Achieving adequate pain control for rib fractures remains challenging; prescription of alternatives to narcotics is imperative to curtail the current opioid epidemic. Although gabapentin has shown ...promise following elective thoracic procedures, its efficacy in patients with rib fractures remains unstudied. We hypothesized that gabapentin, as compared to placebo, would both improve acute pain control and decrease narcotic use among critically ill patients with rib fractures.
Adult patients admitted to the trauma surgery service from November 2016 – November 2017 at an urban, Level I trauma center with one or more rib fractures were randomized to either gabapentin 300mg thrice daily or placebo for one month following their injury. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings during the index admission, as well as and one-month quality of life survey data were abstracted.
Forty patients were randomized. The groups were well matched with respect to age, gender, prior narcotic use, tobacco use, and prior respiratory disease. Although the median RibScore did not differ between groups, the gabapentin group had a higher median number of ribs fractured as compared to the placebo group (7 vs. 5, respectively). Degree of pulmonary contusion and injury severity score were similar between groups. Use of loco-regional anesthetic modalities did not differ between groups. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings were similar between both groups. No benefit was observed when adding gabapentin to a multi-modal analgesic regimen for rib fractures. There were no instances of pneumonia, respiratory failure, or mortality in either group. Hospital and intensive care unit length of stay were similar between groups. Both overall and chest-specific quality of life was equivalent between groups at one month follow-up.
In this group of critically ill patients with rib fractures, gabapentin did not improve acute outcomes for up to one month of treatment.
Controversy exists about the preferred initial treatment of appendicitis. We sought to compare the two treatments for initial management of simple appendicitis.
In this post hoc analysis of the ...Multicenter Study for the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, subjects were divided into appendectomy or nonoperative management (NOM; antibiotics only or percutaneous drainage) cohorts. A novel topic-specific hierarchical ordinal scale was created with eight mutually exclusive categories: mortality, reoperation, other secondary interventions, readmission, emergency department visit, wound complication, surgical site infection, and no complication. Pairwise comparisons of American Association for the Surgery of Trauma Imaging Severity Grade 1 (simple appendicitis) patients were compared using win-lose-tie scoring and the sums of appendectomy/NOM groups were compared.
A total 3,591 subjects were included: 3,262 appendectomy and 329 NOM, with significant differences in baseline characteristics between groups. Across 28 sites, the rate of NOM ranged from 0% to 48%, and the loss to follow-up rate was significantly higher for NOM compared with appendectomy (16.5% vs. 8.7%, p = 0.024). In the simple appendicitis hierarchical ordinal scale analysis, 2,319 subjects resulted in 8,714,304 pairwise comparisons; 75% of comparisons resulted in ties. The median (interquartile range) sums for the two groups are as follows: surgical, 400 (400-400), and NOM, 400 (-2,427 to 400) (p < 0.001). A larger proportion of appendectomy subjects (88.1%) had an outcome that was equivalent (or better) than at least half of the subjects compared with NOM subjects (NOM, 70.5%; OR 95% confidence interval, 0.3 0.2-0.4).
In contemporary American practice, appendectomy (compared with NOM) for simple appendicitis is associated with lower odds of developing clinically important unfavorable outcomes in the first year after illness.
Therapeutic/Care Management; Level III.
We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT).
Retrospective review of all trauma patients undergoing TT from 6/30/2016–6/30/2019. ...Multivariable logistic regression identified independent predictors of complications.
Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m2 were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%–53.5%), and early complication increased the likelihood of late complication (4.3%–13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication.
TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m2. We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes.
•Increased TT complication rates are independently associated with placement in the ED.•Urgency, i.e. time to placement, is not associated with increased complication rates.•EM Physician TT placement is associated with increased complication rates.•Malpositioning and early complications are associated with subsequent complications.•TT complications impact hospital length of stay and patient outcomes.
INTRODUCTIONResuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing ...preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODSRetrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTSDuring the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSIONPPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
Introduction
The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and ...outcomes of SSRF between patients with and without non-urgent operative pelvic injuries.
Patients and Methods
In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups.
Results
Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups.
Conclusions
SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.
Venous thromboembolism (VTE) in patients with major pelvic fractures who undergo preperitoneal pelvic packing (PPP) has not been investigated. We hypothesized that patients who undergo PPP are at ...high risk for VTE, thus early prophylactic anticoagulation and screening duplex are warranted.
All patients requiring PPP from 2015 to 2019 were reviewed. Management and outcomes were analyzed.
During the study period, 79 patients underwent PPP. Excluding the early deaths, 17 patients had deep venous thrombosis (DVT) and 6 had pulmonary emboli (PE); 4 patients had both DVT/PE. Overall mortality was 15%. Thirty-two patients underwent screening duplex within 72 h of admission and 10 were positive for DVT.
Patients with complex pelvic trauma undergoing PPP have a 23% incidence of DVT and an additional 8% incidence of PE. 31% of screening ultrasounds are positive. The overall mortality was 15%. With a high incidence of VTE in this patient population, we recommend screening duplex ultrasounds.
•Preperitoneal pelvic packing (PPP) controls hemorrhage in pelvic fracture patients.•DVT incidence in PPP patients was 23%, with an additional 8% incidence of PE.•Mortality rate for our PPP patient cohort was 15%, versus published rates of 24–32%.•We recommend screening ultrasound, with packs in place, and early DVT prophylaxis.•Studies should investigate use of IVC filters and alternative packing techniques.
Loco-regional analgesia (LRA) remains underutilized in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under ...direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF.
Non-inferiority, single center, randomized clinical trial (2017-2020). Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space) and LB involved thoracoscopic intercostal blocks of ribs 3-8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function (SCARF) score, measured daily for 5 days post-operatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality.
Thirty-four patients were enrolled; 16 IC and 18 LB. Age, injury severity score, RibScore, Blunt Pulmonary Contusion Score, and use of non-narcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p=0.23). There was no significant difference in SCARF score between the IC and LB groups. On post-operative days 2-4, narcotic requirements were less than half in the LB, as compared to the IC group; however, this difference was not statistically significant. Average wholesale price was $605 for IC and $434 for LB.
In this non-inferiority trial, LB provided at least comparable, and potentially superior LRA as compared to IC among patients undergoing SSRF.
Level II, Therapeutic.
There is a paucity of data describing opioid prescribing patterns for trauma patients. We investigated pain medication regimens prescribed at discharge for patients with traumatic rib fractures, as ...well as potential variables predictive of opioid prescribing.
A single-center, retrospective analysis was performed of 337 adult patients presenting with ≥1 traumatic rib fractures between January and December 2019. The primary outcome was oral morphine milligram equivalents (MME) prescribed on discharge. A multivariable logistic regression analysis was performed to determine factors independently associated with above median (150) MME prescription at discharge.
The majority of patients were male (68.8%) with a median age of 53 y. Blunt trauma accounted for 97.3% of cases with a median Injury Severity Score(ISS) of 10. Locoregional pain procedures were utilized in 16.9% of patients. Opioids were the most common analgesic prescribed at discharge, and 74.1% of patients prescribed opioids on discharge were also prescribed a non-opioid adjunct. On multivariable analysis, daily MME prescribed during hospitalization (OR 1.01, 95% CI 1.01-1.02, P < 0.01) and number of rib fractures (OR 2.26, 95% CI 1.36-3.74, P < 0.01) were predictive of high MME prescribed on discharge.
For patients with traumatic rib fractures, daily MME during hospitalization and number of rib fractures were predictive of high MME prescribing on discharge. Further prospective studies evaluating strategies for pain management and protocolized approaches to opioid prescribing are needed to reduce unnecessary and inappropriate opioid use in this patient population.
Surgical stabilization of rib fractures (SSRF) should be performed early after injury. Factors that influence timing remain unknown. Our objective was to identify inherent variables that allow for ...early identification and treatment. We hypothesized that certain demographic, injury, and logistical factors are associated with SSRF <24 hours from admission.
Retrospective review from an urban level 1 trauma center (10/2010-8/2019). Patients were grouped as SSRF <24 hours from admission
≥24 hours. Demographics, transfer from an outside hospital (OSH), timing documentation, injury descriptors, surgeon on-call, and operative surgeon were collected. SSRF for chronic non-union was excluded.
Data from 173 patients were analyzed. Eighty-five patients (49%) were in the <24 hours group and 88 (51%) were in the ≥24 hours group. Baseline demographics were similar between groups. Injury severity was significantly higher in the late group: increased Injury Severity Score (ISS; 16.5
21.0, P<0.01), lower Glasgow Coma Scale (GCS; 15
14, P<0.01), more rib fractures (7
9, P=0.01), and increased incidence of face (6%
16%, P=0.03), spine (22%
47%, P<0.01), and pelvis fractures (8%
25%, P<0.01). Patients admitted on a Wednesday were more likely to undergo early SSRF as compared to other days of the week (P=0.01) There was also a shorter time from the decision to perform SSRF to the actual operation in the early group, as compared to the late group (13
44 hours, P<0.01). Fifty (28.9%) SSRF cases were performed by the on-call surgeon; this percentage did not differ in the early
late group (33%
25%, P=0.25). Patients needing pelvic fixation were more likely to be in the late group. Patients transferred from an OSH for SSRF were more likely to be in the early group (29%
10%, P<0.01). Finally, likelihood of early surgery increased with increasing study year.
Approximately one-half of SSRF cases were performed within 24 hours of admission. Factors that influence surgery within 24 hours of admission appear related to overall injury severity and systems issues, including day of admission, transfer from another facility, additional urgent pelvic surgery, and institutional experience with SSRF. Surgeon availability did not drive this disparity.
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