1
|
Bauman ZM, Khan H, Cavlovic L, Todd S, Cemaj S, Daubert T, Raposo-Hadley A, Matos M, Sheppard O, Berning B, Kamien A, Evans CH, Cantrell E. Better late than never-a single-center review of delayed rib fixation for symptomatic rib fractures and nonunions. J Trauma Acute Care Surg 2023; 95:880-884. [PMID: 37697466 DOI: 10.1097/ta.0000000000004136] [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: 09/13/2023]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRFs) has become an emerging therapy for treatment of patients with rib fractures. More commonly, it is used in the acute setting; however, delayed SSRF can be utilized for symptomatic rib fracture nonunions. Here, we describe our institution's experience with delayed SSRF, hypothesizing it is safe and resolves patient symptoms. METHODS This is a retrospective review of patients presenting to our Level I trauma center to undergo delayed SSRF for symptomatic nonunions from January 2017 to September 2022. Delayed SSRF was defined as SSRF over 2 weeks in the outpatient setting. Basic demographics were obtained. Outcomes of interest included mean pain score (preoperatively and postoperatively), intensive care unit (ICU) and hospital length of stay (LOS), and resolution of preoperative symptoms, specifically chest wall instability, with return to activities of daily living (ADLs). RESULTS Forty-four patients met inclusion criteria with a total of 156 symptomatic nonunion rib fractures that received delayed SSRF. The average age was 59.2 ± 11.9 years and median number of days from injury to SSRF was 172.5 (interquartile range, 27.5-200). The average number rib fractures plated per patient 3.5 ± 1.8. Only three patients required ICU admission postoperatively for no longer than 2 days. Median hospital LOS was 2 days (interquartile range 1-3 days). Average preoperative and postoperative pain score was 6.8 ± 1.9 and 2.02 ± 1.5, respectively ( p < 0.001). Chest wall instability and preoperative symptoms resolved in 93.2% of patients postoperatively ( p < 0.001). Two patients (4.5%) had postoperative complications that resolved after additional surgical intervention. Rib fracture healing was demonstrated on radiographic imaging during postoperative follow-up. CONCLUSION Delayed SSRF is safe and demonstrates significant resolution of preoperative symptoms by decreasing pain, improving chest wall stability, and allowing patients to return to activities of daily living. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
Collapse
Affiliation(s)
- Zachary M Bauman
- From the Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Bethlahmy JM, Hanst BA, Giafaglione SM, Elia JM. Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review. J Clin Anesth 2023; 91:111275. [PMID: 37797395 DOI: 10.1016/j.jclinane.2023.111275] [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: 07/14/2023] [Revised: 09/12/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Abstract
Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.
Collapse
Affiliation(s)
- Jessica M Bethlahmy
- UC Irvine School of Medicine, 1001 Health Sciences Road Irvine, CA 92617, USA
| | - Brian A Hanst
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Sarah M Giafaglione
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Jennifer M Elia
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA.
| |
Collapse
|
3
|
O'Connor LA, Houseman B, Cook T, Quinn CC. Intercostal cryonerve block versus elastomeric infusion pump for postoperative analgesia following surgical stabilization of traumatic rib fractures. Injury 2023; 54:111053. [PMID: 37741705 DOI: 10.1016/j.injury.2023.111053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE Patients with blunt thoracic trauma requiring surgical stabilization of rib fractures (SSRF) frequently experience severe pain. Further, a rising prevalence of opioid-tolerant patients sustain traumatic injuries. The optimal pain management adjunct for concurrent use with SSRF remains uncertain. This study compared outcomes in patients undergoing SSRF with concomitant cryonerve block (CryoNB) or ropivacaine 0.2% elastomeric infusion pump (EIP). METHODS A single-center retrospective comparative analysis was performed at a level II trauma center. A query of our institution's trauma registry of consecutive patients undergoing SSRF from October 2017 to November 2020 with either intercostal CryoNB or ropivacaine 0.2% EIP was conducted. Opioid consumption in oral morphine equivalents (OME), patient-reported pain scores by numerical rating scale, and pulmonary function measured by incentive spirometry effort (mL) were collected at baseline and on postoperative days 1-3. Results were analyzed using a linear-mixed-effects model. Length of stay (LOS), complications, and hospital charges were assessed as secondary outcomes. RESULTS Twenty-six patients meeting inclusion criteria were evaluated. Patient demographics, injury, and surgical variables were similar between groups. The estimated effect for patients treated with CryoNB (n = 14) compared to EIP (n = 12) demonstrated a 25% (estimated -1.37 OME, 95% CI, -2.411 to -0.335, p = 0.01) reduction in hospital opioid requirements, fewer discharge opioids (41.3 mg (37.5-45) versus 175 mg (150- 200), p = 0.03), 22% (estimated -1.506, 95% CI, -2.722 to -0.290, p = 0.02) reduction in pain scores, and shorter postoperative LOS (4 days (4-5) versus 6 days (5-9.5), p = 0.04). Pulmonary function (estimated -48.8 mL, 95% CI, -312.74 to 215.05, p = 0.71), total hospital costs (CryoNB: $90,224 ± 34,633; EIP: $131,498 ± 73,072, p = 0.07), and complications were no different between cohorts. CONCLUSION The addition of intercostal CryoNB as an adjunct to multimodal pain management in trauma patients undergoing surgical fixation of rib fractures may be of benefit. Based on our early data, this technique appears to be promising in reducing opioid requirements and providing an extended duration of pain control without increased costs or complications.
Collapse
Affiliation(s)
- Lizabeth A O'Connor
- Elliot Health System, Division of Thoracic Surgery, 1 Elliot Way, Manchester, NH 03103, United States.
| | - Bryan Houseman
- Elliot Health System, Division of Orthopedic Trauma, 1 Elliot Way, Manchester, NH 03103, United States
| | - Thomas Cook
- University of Massachusetts Amherst, Department of Mathematics and Statistics, Lederle Graduate Research Tower, 1623D, University of Massachusetts Amherst, 710N. Pleasant Street, Amherst, MA 01003, United States
| | - Curtis C Quinn
- Elliot Health System, Division of Thoracic Surgery, 1 Elliot Way, Manchester, NH 03103, United States
| |
Collapse
|
4
|
Lai K, Eldredge RS, Zobel M, Hargis-Villanueva A, Ostlie A, Padilla BE. Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review. J Laparoendosc Adv Surg Tech A 2023; 33:994-1004. [PMID: 37462727 DOI: 10.1089/lap.2023.0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.
Collapse
Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Michael Zobel
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, USA
| | | | - Andrew Ostlie
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
| |
Collapse
|
5
|
Marturano MN, Thakkar V, Wang H, Cunningham KW, Lauer C, Sachdev G, Ross SW, Jordan MM, Dieffenbaugher ST, Sing RF, Thomas BW. Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use, ventilation days, and intensive care days. Injury 2023; 54:110803. [PMID: 37193637 DOI: 10.1016/j.injury.2023.05.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 04/16/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF). METHODS SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation. RESULTS 241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05). CONCLUSION Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.
Collapse
Affiliation(s)
- Matthew N Marturano
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Vandan Thakkar
- Campbell University School of Osteopathic Medicine, Lillington NC, USA
| | - Huaping Wang
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Kyle W Cunningham
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Cynthia Lauer
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Gaurav Sachdev
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Samuel W Ross
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Mary M Jordan
- Department of Trauma and Acute Care Surgery, Atrium Health Cabarrus, Concord NC, USA
| | - Sean T Dieffenbaugher
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Ronald F Sing
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Bradley W Thomas
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA.
| |
Collapse
|
6
|
Caparrelli DJ. Case Report of Cryo Nerve Block in a Patient Undergoing Full Sternotomy: A Novel Approach to Pain Control in Cardiac Surgery. A A Pract 2023; 17:e01654. [PMID: 36735851 PMCID: PMC9951789 DOI: 10.1213/xaa.0000000000001654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 02/05/2023]
Abstract
We present the case of a 65-year-old man undergoing open-heart surgery through a full sternotomy with the use of bilateral intercostal cryo nerve block (cryoNB) as adjunctive therapy for postoperative analgesia. CryoNB has been previously demonstrated as safe and effective for pain control in thoracotomy procedures as well as bilaterally in adolescent patients with pectus excavatum undergoing Nuss procedure. Herein, we describe for the first time, the cryoNB procedure for postoperative pain management in a patient undergoing full sternotomy.
Collapse
Affiliation(s)
- David J Caparrelli
- From the Division of Cardiovascular and Thoracic Surgery, The New England Heart and Vascular Institute, Manchester, New Hampshire
| |
Collapse
|
7
|
Early application of cryoanalgesia to the brachial plexus prevents development of phantom limb pain after traumatic forequarter amputation: A case report. Trauma Case Rep 2022; 41:100678. [PMID: 35864840 PMCID: PMC9294552 DOI: 10.1016/j.tcr.2022.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/20/2022] Open
Abstract
Background Amputation of an extremity frequently results in significant phantom limb pain. The etiology of which is not well understood. Central and peripheral factors appear to play a role. Pain relief interventions often are attempted several weeks to months later. Peripheral nerve injury can rapidly result in cortical somatosensory changes potentially making early intervention important in preventing any permanent changes in nerve pathways. Case report We present a case of traumatic forequarter (interscapulothoracic) amputation treated with cryoanalgesia of the brachial plexus for pain control <72 h after injury. The patient denied painful phantom limb pain and postoperative pain at the surgical site immediately following surgery and over a six month follow up period. Conclusion Cryoanalgesia facilitates extended duration of pain control of the affected peripheral nerve which may be of particular benefit in patients sustaining either surgical or traumatic amputations, particularly when applied early to prevent the transmission of noxious signals to the central nervous system.
Collapse
|
8
|
Opioid Requirements After Intercostal Cryoanalgesia in Thoracic Surgery. J Surg Res 2022; 274:232-241. [DOI: 10.1016/j.jss.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 01/12/2022] [Accepted: 01/22/2022] [Indexed: 11/23/2022]
|
9
|
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
|
10
|
Abstract
Chest wall pain affects many patients following chest surgery, fractures, or malignancies, and can be very difficult to manage with normal pharmacologic agents. Intercostal ablation provides one alternative treatment modality for patients suffering from intercostal pain. Intercostal cryoneurolysis involves using extreme cold to cause Wallerian degeneration of the targeted intercostal nerve. This article reviews the patient selection, technique, and complications in the utilization of intercostal neurolysis in the treatment of intractable chest pain.
Collapse
Affiliation(s)
- Junjian Huang
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kevin Delijani
- Georgetown University School of Medicine, Washington, District of Columbia
| | | | - Andrew J Gunn
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
11
|
Cha PI, Min JG, Patil A, Choi J, Kothary NN, Forrester JD. Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: systematic review. Trauma Surg Acute Care Open 2021; 6:e000690. [PMID: 34079913 PMCID: PMC8137159 DOI: 10.1136/tsaco-2021-000690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/04/2021] [Accepted: 04/24/2021] [Indexed: 11/03/2022] Open
Abstract
Background There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma. Methods A systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed. Results Twenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low. Conclusions Given the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence. Level of evidence Level IV systematic reviews and meta-analyses.
Collapse
Affiliation(s)
- Peter I Cha
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Jung Gi Min
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Jeff Choi
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Nishita N Kothary
- Section of Interventional Radiology, Department of Radiology, School of Medicine, Stanford University, Stanford, California, USA
| | | |
Collapse
|
12
|
Bauman ZM, Loftus J, Raposo-Hadley A, Samuel S, Ernst W, Evans CH, Cemaj S, Kaye AJ. Surgical stabilization of rib fractures combined with intercostal nerve cryoablation proves to be more cost effective by reducing hospital length of stay and narcotics. Injury 2021; 52:1128-1132. [PMID: 33593526 DOI: 10.1016/j.injury.2021.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/16/2020] [Accepted: 02/02/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intercostal nerve cryoablation (INCA) coupled with surgical stabilization of rib fractures (SSRF) has been shown to reduce post-operative pain scores but at what monetary cost. We hypothesize that in-hospital outcomes improve with the addition of INCA to SSRF and potential increased hospital charges are justified by patient benefits. METHODS Multi-institutional, retrospective review of patients undergoing SSRF with and without INCA over an 8-year period. Institutions involved were Level II or higher trauma centers. Basic demographics were obtained. Patients were included if SSRF was performed during the index hospitalization. Primary outcomes included total hospital length of stay (HLOS) and HLOS after SSRF, total hospital charges (HC), HC the day of surgery and HC after surgery. Secondary outcome included total narcotic consumption in morphine milliequivalents (MME) after SSRF. Mann-Whitney U test was used for analysis. Statistical significance p < 0.05. RESULTS 136 patients analyzed; 92 underwent SSRF only and 44 underwent SSRF with INCA. Demographics were similar between groups. Number of ribs stabilized was comparable; 4.78 ± 1.64 SSRF only and 4.73 ± 1.66 SSRF with INCA (p = 0.463). Median ISS [16 (IQR 11.5-16) SSRF only and 14 (IQR 9-18.75) SSRF with INCA (p = 0.463)] was not statistically different. The INCA group showed a decrease in the median total HLOS, 9 versus 10 days (U = 1517.5, p = 0.026) and HLOS after SSRF, 4 versus 6 days (U = 1217.5, p < 0.001). HC the day of surgery were higher for the INCA group, $93,932 versus $71,143 (U = 1106, p < 0.001). However, total HC were similar between groups and total HC after SSRF was significantly less for the INCA group, $10,556 versus $20,269 (U = 1327, p = 0.001). Total median narcotic use after SSRF was significantly less for the INCA group, 88.6 vs 113.7 MME (U = 1544.5, p = 0.026). CONCLUSION SSRF with INCA is safe and does not increase overall HC with the added benefit of decreased HLOS post-operatively and decreased narcotic consumption.
Collapse
Affiliation(s)
- Zachary M Bauman
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA 68198.
| | - John Loftus
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA 68198.
| | - Ashley Raposo-Hadley
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA 68198.
| | - Shradha Samuel
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA 68198.
| | - Weston Ernst
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA 68198.
| | - Charity H Evans
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA 68198.
| | - Samuel Cemaj
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA 68198.
| | - Adam J Kaye
- Division of Trauma Surgery, Overland Park Regional Medical Center, Overland Park, KS, USA 66215
| |
Collapse
|