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Eriksson EA, Wijffels MME, Kaye A, Forrester JD, Moutinho M, Majerick S, Bauman ZM, Janowak CF, Patel B, Wullschleger M, Clevenger L, Van Lieshout EMM, Tung J, Woodfall M, Hill TR, White TW, Doben AR. Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1). Eur J Trauma Emerg Surg 2024; 50:417-423. [PMID: 37624405 DOI: 10.1007/s00068-023-02343-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions. METHODS A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis. RESULTS Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001). CONCLUSION Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities.
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Affiliation(s)
- Evert Austin Eriksson
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Drive CSB 420, MSC 613, Charleston, SC, 29425, USA.
| | - Mathieu Mathilde Eugene Wijffels
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Adam Kaye
- Department of Trauma, Overland Park Regional Medical Center, 10500 Quivira Rd., Overland Park, KS, 66215, USA
| | - Joseph Derek Forrester
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Manuel Moutinho
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
| | - Sarah Majerick
- Department of Trauma, Intermountain Health, Salt Lake City, USA
| | - Zachary Mitchel Bauman
- Trauma Surgery, Surgical Critical Care, Emergency General Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, TraumaOmaha, NE, 68198-3280, USA
| | - Christopher Francis Janowak
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Bhavik Patel
- Gold Coast University Hospital, Gold Coast, QLD, 4215, Australia
| | - Martin Wullschleger
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Griffith University, Gold Coast, Australia
| | - Leanna Clevenger
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Drive CSB 420, MSC 613, Charleston, SC, 29425, USA
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jamie Tung
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Michelle Woodfall
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Thomas Russell Hill
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
| | | | - Andrew Ross Doben
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
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Hoffman RJ, Garner HW, Rojas CA, Grage RA, Sonavane SK, Johnson EM, Mergo PJ, Walker CM, Stowell JT. Atypical Causes of Dyspnea: A Review of Neuromuscular and Chest Wall Disorders that Compromise Ventilation. J Thorac Imaging 2022; 37:W45-W55. [PMID: 35213124 DOI: 10.1097/rti.0000000000000641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dyspnea is a common presenting symptom among patients with cardiopulmonary diseases. However, several neuromuscular and chest wall conditions are often overlooked and under-recognized causes of dyspnea. These disorders frequently adversely affect the structure and function of the ventilatory pump (diaphragm, accessory muscles of ventilation) and can precipitate respiratory failure despite normal lung parenchyma. Weakened musculature impairs clearance of airway secretions leading to aspiration and pneumonia, further compromising respiratory function. Radiologists should be aware of the pathophysiology and imaging manifestations of these conditions and might suggest them to be causes of dyspnea which otherwise may not have been considered by referring clinicians.
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Affiliation(s)
| | | | | | - Rolf A Grage
- Department of Radiology, Mayo Clinic, Jacksonville, FL
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Prospective validation of the Rib Injury Guidelines for traumatic rib fractures. J Trauma Acute Care Surg 2022; 92:967-973. [PMID: 35125449 DOI: 10.1097/ta.0000000000003535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The Rib Injury Guidelines (RIG) were developed to guide triage of traumatic rib fracture patients to home, regular floor, or intensive care unit (ICU) and standardize care. The RIG score is based on patient history, physical examination, and imaging findings. The aim of this study was to evaluate triage effectiveness and health care resources utilization following RIG implementation. METHODS This is a prospective analysis at a level I trauma center from October 2017 to January 2020. Adult (18 years or older) blunt trauma patients with a diagnosis of at least one rib fracture on computed tomography imaging were included. Patients before (PRE) and after (POST) implementation of RIG were compared. In the POST group, patients were divided into RIG 1, RIG 2, and RIG 3 based on their RIG score. Outcomes were readmission for RIG 1 patients, unplanned ICU admission for RIG 2 patients, and overall ICU admission. Secondary outcomes were hospital length of stay (LOS) and mortality. RESULTS A total of 1,100 patients were identified (PRE, 754; POST, 346). Mean ± SD age was 56 ± 19 years, 788 (71.6%) were male, and median Injury Severity Score was 14 (range, 10-22). The most common mechanism of injury was motor vehicle collision (554 [50.3%]), 253 patients (22.9%) had ≥5 rib fractures, and 53 patients (4.8%) had a flail chest. In the POST group, 74 patients (21.1%) were RIG 1; 121 (35.2%), RIG 2; and 151 (43.7%), RIG 3. No patient in RIG 1 was readmitted following initial discharge, and two patients (1.6%) in RIG 2 had an unplanned ICU admission (both for alcohol withdrawal syndrome). Patients after implementation of RIG had shorter hospital LOS (3 [1-6] vs. 4 [1-7] days; p = 0.019) and no difference in mortality (5.8% vs. 7.7%; p = 0.252). On multivariate analysis, RIG implementation was associated with decreased ICU admission (adjusted odds ratio, 0.55 [0.36-0.82]; p = 0.004). CONCLUSION Rib Injury Guidelines are safe and effectively define triage of rib fracture patients with an overall reduction in ICU admissions, shorter hospital LOS, and no readmissions. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Stopenski S, Binkley J, Schubl SD, Bauman ZM. Rib Fracture Management: A Review of Surgical Stabilization, Regional Analgesia, and Intercostal Nerve Cryoablation. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bakir MS, Langenbach A, Pinther M, Lefering R, Krinner S, Grosso M, Ekkernkamp A, Schulz-Drost S. The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU ®. Eur J Trauma Emerg Surg 2021; 48:3623-3634. [PMID: 34739544 PMCID: PMC9532310 DOI: 10.1007/s00068-021-01819-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022]
Abstract
Purpose Isolated clavicle fractures (CF) rarely show complications, but their influence in the thorax trauma of the seriously injured still remains unclear. Some authors associate CF with a higher degree of chest injuries; therefore, the clavicle is meant to be a gatekeeper of the thorax. Methods A retrospective analysis of the TraumaRegister DGU® (project 2017-10) was carried out involving the years 2009–2016 (ISS ≥ 16, primary admission to a trauma center). Cohort formation: unilateral and bilateral flail chest injuries (FC), respectively, with and without a concomitant CF. Results 73,141 patients (26.5% female) met the inclusion criteria and 12,348 had flail chest injuries (FC; 20.0% CF; 67.7% monolateral FC), 25,425 other rib fractures (17.7% CF), and 35,368 had no rib fractures (6.5% CF). On average, monolateral FC patients were 56.0 ± 17.9 years old and bilateral FC patients were 57.7 ± 19 years old. The ISS in unilateral and bilateral FC were 29.1 ± 11.7 and 42.2 ± 12.9 points, respectively. FC with a CF occurred more frequently with bicycle and motorbike injuries in monolateral FC and pedestrians in bilateral FC injuries and less frequently due to falls. Patients with a CF in addition to a FC had longer hospital and ICU stays, underwent artificially respiration for longer periods, and died less often than patients without a CF. The effects were highly significant in bilateral FC. CF indicates more relevant concomitant injuries of the lung, scapula, and spinal column. Moreover, CF was associated with more injuries of the extremities in monolateral CF. Conclusion Due to the relevance of a concomitant CF fracture in FC, diagnostics should focus on finding CFs or rule them out. Combined costoclavicular injuries are associated with a significantly higher degree of thoracic injuries and longer hospital stays.
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Affiliation(s)
- Mustafa Sinan Bakir
- Department of Trauma and Reconstructive Surgery and Rehabilitative Medicine, Medical University Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany. .,Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.
| | - Andreas Langenbach
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.,Department of Orthopaedics and Trauma Surgery, Klinikum Forchheim, Krankenhausstraße 10, 91301, Forchheim, Germany
| | - Melina Pinther
- Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany
| | - Rolf Lefering
- Department of Medicine, Institute for Research in Operative Medicine (IFOM), Faculty of Health, Universität Witten-Herdecke, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Sebastian Krinner
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Marco Grosso
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Axel Ekkernkamp
- Department of Trauma and Reconstructive Surgery and Rehabilitative Medicine, Medical University Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany.,Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany
| | - Stefan Schulz-Drost
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.,Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.,Department for Trauma Surgery, Helios Hospital Schwerin, Wismarsche Strasse 393-397, 19049, Schwerin, Germany
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Tran A, Fernando SM, Brochard LJ, Fan E, Inaba K, Ferguson ND, Calfee CS, Burns KEA, Brodie D, McCredie VA, Kim DY, Kyeremanteng K, Lampron J, Slutsky AS, Combes A, Rochwerg B. Prognostic factors for development of acute respiratory distress syndrome following traumatic injury - a systematic review and meta-analysis. Eur Respir J 2021; 59:13993003.00857-2021. [PMID: 34625477 DOI: 10.1183/13993003.00857-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/17/2021] [Indexed: 11/05/2022]
Abstract
PURPOSE To summarise the prognostic associations between various clinical risk factors and the development of the acute respiratory distress syndrome (ARDS) following traumatic injury. METHODS We conducted this review in accordance with the PRISMA and CHARMS guidelines. We searched six databases from inception through December 2020. We included English language studies describing the clinical risk factors associated with the development of post-traumatic ARDS, as defined by either the American-European Consensus Conference or the Berlin definition. We pooled adjusted odds ratios for prognostic factors using the random effects method. We assessed risk of bias using the QUIPS tool and certainty of findings using GRADE methodology. RESULTS We included 39 studies involving 5 350 927 patients. We identified the amount of crystalloid resuscitation as a potentially modifiable prognostic factor associated with the development of post-traumatic ARDS (adjusted odds ratio [aOR] 1.19 for each additional liter of crystalloid administered within first 6 h after injury, 95% CI 1.15 to 1.24, high certainty). Non-modifiable prognostic factors with a moderate or high certainty of association with post-traumatic ARDS included increasing age, non-Hispanic white race, blunt mechanism of injury, presence of head injury, pulmonary contusion, or rib fracture; and increasing chest injury severity. CONCLUSION We identified one important modifiable factor, the amount of crystalloid resuscitation within the first 24 h of injury, and several non-modifiable factors associated with development of post-traumatic ARDS. This information should support the judicious use of crystalloid resuscitation in trauma patients and may inform the development of a risk-stratification tools.
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Affiliation(s)
- Alexandre Tran
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Dennis Y Kim
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM Unite Mixte de Recherche (UMRS) 1166, Paris, France.,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Paris, France
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
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Kawai Y, Konishi H, Miyazaki K, Kogeichi Y, Takano K, Okuda A, Maegawa N, Urisono Y, Fukushima H. A new quantitative assessment method for predicting pneumonia caused by chest wall injury. J Trauma Acute Care Surg 2021; 91:521-526. [PMID: 34137745 DOI: 10.1097/ta.0000000000003314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The severity of rib fractures has been previously evaluated by combining categorical data, but these methods have only low predictive capability for respiratory complications and mortality. This study aimed to establish a more accurate method for predicting the development of pneumonia, a frequent complication in chest injuries, using anatomical relationships. METHODS We analyzed three-dimensional reconstructed images of 644 consecutive trauma patients who underwent whole-body computed tomography (CT) in our institution within a 36-month study period from April 2017. The anatomical relationship between the right and left thoracic volumes of non-rib fracture patients was used to estimate thoracic volume changes on the injured side in unilateral rib fracture patients. The predictive capability of changes in thoracic volume for the development of pneumonia was evaluated according to the area under the receiver operating characteristic curve and compared with that of previous chest wall severity evaluation methods. RESULTS Of the 644 patients, 133 and 478 patients had unilateral rib fractures and non-rib fractures, respectively. The amount of change in thoracic volume due to unilateral rib fractures was significantly greater in pneumonia patients (400 mL vs. 160 mL, p < 0.01). The area under the receiver operating characteristic curve for the development of pneumonia was 0.83, which tended to be higher than that of the previous severity scoring methods. CONCLUSION The amount of change in chest volume, which can be estimated using CT images, has better predictive capability for pneumonia than previous severity assessment methods based on categorical data. The amount of change in chest volume measured using whole-body CT can be used to rapidly determine the optimal treatment for severe chest wall injuries. LEVEL OF EVIDENCE Prognostic study, level IV.
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Affiliation(s)
- Yasuyuki Kawai
- From the Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara City, Nara, Japan
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Taheri Akerdi A, Mousavi SM, Abdolrahimzadehfard H, Borazjani R, Paydar S. Flail chest: Definition and management protocols need to be modified. J Trauma Acute Care Surg 2021; 91:e50. [PMID: 33797491 DOI: 10.1097/ta.0000000000003188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pieracci FM, Schubl S, Gasparri M, Delaplain P, Kirsch J, Towe C, White TW, Whitbeck S, Doben AR. The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures. Injury 2021; 52:1241-1250. [PMID: 33795145 DOI: 10.1016/j.injury.2021.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/20/2021] [Accepted: 02/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Publications investigating the efficacy of surgical stabilization of rib fractures (SSRF) have increased exponentially. However, there is currently no standardized reporting structure for these studies, rendering both comparisons and extrapolation problematic. METHODS A subject matter expert group was formed by the Chest Wall Injury Society. This group conducted a review of the SSRF investigational literature and identified variable reporting within several general categories of relevant parameters. A compliment of guidelines was then generated. RESULTS The reporting guidelines consist of 26 recommendations in the categories of: (1) study type, (2) patient and injury characteristics, (3) patient treatments, (4) outcomes, and (5) statistical considerations. CONCLUSION Our review identified inconsistencies in reporting within the investigational SSRF literature. In response to these inconsistencies, we propose a set of recommendations to standardize reporting of original investigations into the efficacy of SSRF.
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Affiliation(s)
- Fredric M Pieracci
- Department Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO.
| | - Sebastian Schubl
- Department of Surgery, University of California-Irvine, Irvine, CA
| | - Mario Gasparri
- Department of Surgery, Division of CT Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Jordan Kirsch
- Department of Surgery, Section of Acute and Critical Care Surgery, Barnes-Jewish Hospital/Washington University, St. Louis, MI
| | - Christopher Towe
- Department of CT Surgery, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Thomas W White
- Department of Surgery, Intermountain Medical Center, Murray, UT
| | | | - Andrew R Doben
- Department of Surgery, St. Francis Medical Center, Hartford, CT
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Pieracci FM, Leasia K, Hernandez MC, Kim B, Cantrell E, Bauman Z, Gardner S, Majercik S, White T, Dieffenbaugher S, Eriksson E, Barns M, Benjamin Christie D, Lasso ET, Schubl S, Sauaia A, Doben AR. Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes? J Trauma Acute Care Surg 2021; 90:1014-1021. [PMID: 34016925 DOI: 10.1097/ta.0000000000003140] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. METHODS Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. RESULTS Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. CONCLUSION Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians. LEVEL OF EVIDENCE Therapeutic, Level IV.
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Affiliation(s)
- Fredric M Pieracci
- From the Department of Surgery (F.M.P., K.L.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (M.C.H., B.K.), Mayo Clinic, Rochester, Minnesota; Department of Surgery (E.C., Z.B.), University of Nebraska Medical Center, Omaha, Nebraska; Department of Surgery (S.G., S.M., T.W.), Intermountain Medical Center, Murray, Utah; Department of Surgery (S.D., E.E.), Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.B., D.B.C.), The Medical Center, Navicent Health, Macon, Georgia; Department of Surgery (E.T.L., S.S.), University of California, Irvine, California; Department of Surgery (A.S.), University of Colorado School of Medicine, Aurora, Colorado; and Department of Surgery (A.R.D.), St. Francis Medical Center, Hartford, Connecticut
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