NSAIDs And Fracture Healing Revisited – Yet Again!

I’ve written so many posts about the use of non-steroidal anti-inflammatory drugs (NSAIDs) it’s practically getting old. To summarize, some old animal studies suggested that using NSAIDs during fracture healing could impair the process. However, human studies were not so convincing.

Over the years, there has been quite a bit of conflicting evidence. This generally means the association between healing and NSAID use is weak. However, after this period of time, we should have become aware of a significant cause/effect relationship.

The Eastern Association for the Surgery of Trauma recently released a practice management guideline regarding the use of NSAIDs for the treatment of acute pain after orthopedic trauma. They used a standard methodology to identify and analyze published research. They focused on human studies specifically relating to this drug class’s use in fractures. The group ultimately identified 19 pertinent research papers for analysis, 10 of which were prospective, randomized studies.

Here are the three questions they asked, with their answers:

  • Should NSAIDs be used in analgesic regimens for adult patients
    (≥18 years old) with traumatic fracture versus routine analgesic
    regimens that do not include NSAIDs to improve analgesia and
    reduce opioid use without increases in non-union and acute kidney
    injury rates? Although the quality of the studies for this question was low, EAST conditionally recommended using NSAIDs in pain control regimens. In the higher-quality studies in this group, there was no increased risk of non-union.
  • Should ketorolac be used in analgesic regimens for adult patients with traumatic fracture versus routine analgesic regimens that do not include ketorolac to improve analgesia and reduce opioid use without increasing non-union
    rates? This is the same question asked above, but with a specific drug rather than the class in general. The answer was basically the same.
  • Should selective NSAIDs (COX-2 inhibitors) be used in analgesic
    regimens for adult patients (≥18 years old) with traumatic fracture versus routine analgesic regimens that include non-selective NSAIDs to improve analgesia and reduce opioid use without increasing non-union rates?
    COX-2 inhibitors are a subset of NSAIDs that are more selective in their action, blocking only the COX-2 receptor. Several years ago, there was a scandal regarding the COX-2 inhibitor rofecoxib (Vioxx). These selective drugs tended to have a higher incidence of cardiac complications. The manufacturer covered up this fact for several years, resulting in many unneeded deaths before it was removed from the market. The only COX-2 inhibitor available in the US is celecoxib. Only a few studies were performed using this drug during bone healing. There were not enough to make a recommendation.

Bottom line: EAST made conditional recommendations for using NSAIDs in general and ketorolac specifically in adults with fractures. “Conditional” only means that the authors did not have a consensus. Some voted to strongly recommend, and the remainder to conditionally recommend. There were no votes to recommend against their use.

The use of NSAIDs should complement a well-thought-out opioid regimen, which should also be combined with other non-narcotic medications and appropriate mobilization and therapy.

Reference: Efficacy and safety of non-steroidal anti-inflammatory
drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open. 2023 Feb 21;8(1):e001056. doi: 10.1136/tsaco-2022-001056. PMID: 36844371; PMCID: PMC9945020.

What Is: The Tripod Fracture?

The tripod fracture (officially known as the zygomaticomaxillary complex fracture, and sometimes called a malar fracture) is the most common one seen after trauma. Fundamentally, the zygoma is separated from the rest of the face in a tripod fracture.

As you might imagine (tripod fracture), there are three components to this fracture. The first is a fracture through the zygomatic arch (1). Next, the fracture extends across the floor of the orbit and includes the maxillary sinus (2). Finally, the fracture includes the lateral orbital rim and wall (3).

Extraocular muscles may become trapped in the fracture line, leading to diplopia. It is very important to do a good eye exam to try to detect entrapment. The infraorbital nerve also passes through the orbital floor and may be injured, leading to numbness along the lower eyelid and upper lip.

Nondisplaced fractures are treated symptomatically and reevaluated after a week or so to see if surgery would be beneficial. Displaced or symptomatic fractures require early open reduction. The pictures below show the anatomy of these fractures. They are derived from teaching materials provided by the Radiology Department at the University of Washington.



Emergency Intubation: ED or OR?

Decades ago, intubation of trauma patients only took place in the operating room, and only anesthesiologists performed it. As the discipline of Emergency Medicine came into being in the 1980s, emergency physicians became skilled in this procedure. Occasional trauma intubations had to occur in the ED, and typically anesthesia was called for it.

As the emergency physicians became more comfortable and improved their skills, they also started intubating. I distinctly remember a paper from the time (which I unfortunately do not have a reference to) stating that ED and OR intubation were equally safe if the ED intubation field could be made to look like the OR.  This thinking has become commonplace, and in most trauma centers, intubation is now provided nearly exclusively by emergency physicians. Anesthesia is called only for extremely difficult cases.

But we have all been involved in cases where the patient is severely injured, usually hypotensive, and crashes and burns during or immediately after the procedure. This is likely due to a combination of loss of sympathetic tone due to the drugs administered, increased vagal tone from instrumenting the airway, and hypovolemia.

Authors from the University of Wisconsin, University of Pennsylvania, and Johns Hopkins hypothesized that ED intubation for patients requiring urgent operation for hemorrhage control was associated with adverse outcomes. They performed a three-year registry study from the National Trauma Program Databank of patients requiring laparotomy for hemorrhage control within 60 minutes of arrival. They excluded the dead and nearly dead (DOA, ED thoracotomy) and patients with immediate indications for intubation (head, neck, or facial trauma). They compared mortality, ED dwell time, blood transfusions, and major complications between patients with ED vs. OR intubation.

Here are the factoids:

  • Nearly 10,000 patients from 253 Level I or II trauma centers were included in the study
  • About 20% of patients underwent intubation in the ED, and they were more likely to have blunt trauma mechanism and higher ISS (22 vs. 17)
  • Initial vital signs were not clinically significant between the ED and OR groups
  • Mortality in the ED group was significantly higher (17% vs. 7%), the ED dwell time was significantly longer ( 31 vs. 22 minutes), required significantly more blood transfusion (6 vs. 4 units), and had a significantly higher risk of major complications (specifically cardiac arrest, AKI, and ARDS)
  • There was a wide variation in the rate of ED intubation across all the hospitals. Centers with the highest rate of ED intubations were 5x more likely to intubate than the lowest rate centers. The patient case mix could not explain this difference.
  • The lower ED intubation rate hospitals tended to be nonprofit Level I university hospitals
  • Centers with high levels of hemorrhage control surgery were more likely to intubate in the OR

Bottom line: From a purely technical perspective, the old dogma about patient location not making a difference is basically true. The process of getting an airway safely into the patient and secured is equivalent wherever it is done as long as the lighting, equipment, and skill levels are equivalent. 

But when one considers the physiologic aftermath of this process, things are obviously more nuanced. Actively bleeding patients are extremely challenged, down to their organ and cellular levels. Disrupting their normal compensatory mechanisms is clearly associated with a significant downside. 

We should clearly distinguish the patient who needs an airway for airway’s sake or cerebral protection from one who needs to be in the OR for bleeding control. Other papers have shown that mortality increases as each minute ticks by in the hemorrhaging patient. Trauma programs need to monitor these patients and do a performance improvement deep dive into all trauma patients intubated in the ED to ensure appropriate decision-making.

Reference: Emergency Department Versus Operating Room Intubation of Patients Undergoing Immediate Hemorrhage Control Surgery. Journal of Trauma and Acute Care Surgery, Publish Ahead of Print
DOI: 10.1097/TA.0000000000003907

In The Next Trauma MedEd Newsletter: Popular Topics

The March issue of the Trauma MedEd newsletter will be sent out soon! It’s chock full of general stuff of interest to all you trauma professionals.

This issue is being released on April Fool’s Day, but it’s not a joke! If you sign up any time before then, you will receive it, too. Otherwise, you’ll have to wait until it goes out to the general public a week later. Click this link right away to sign up now and/or download back issues.

In this issue, get some tips on:

  • Should I Apply Compression Devices To Patients With Known DVT?
  • Why Do They Call It The Surgical Neck Of The Humerus?
  • You’ve Been Pimped!
  • Nursing: When Is Drain Output Too Bloody?

As always, this month’s issue will go to all of my subscribers first. If you are not yet one of them, click this link right away to sign up now and/or download back issues.

Management Of Penetrating Neck Trauma: The Way We Were/Are

The management of penetrating injuries to the neck has changed very little over the years. Could it be time? Today, I’ll review some of the basics of classic diagnosis and treatment. In my next post, I’ll discuss an alternative way to approach it.

First, lets look at the time-honored zones of the neck. Here’s a nice diagram from EMDocs.net:

The zones are numbered in reverse, from bottom to top, and in Roman numerals.

The area below the cricoid cartilage is considered Zone I and contains many large vascular and aerodigestive structures that are relatively difficult to approach surgically. For this reason, diagnostic testing is recommended to assist in determining if an operation is actually needed and what the best surgical exposure would be. Obviously, this can only be considered in the stable patient. Unstable patients must go straight to the OR and the trauma surgeon will determine the surgical approach on the fly.

Similarly, the area above the angle of the mandible is Zone III, and is also difficult to expose. Injuries to this area may involve the distal carotid and vertebral arteries near the base of the skull, as well as the distal jugular vein. Surgical approach may require dislocation of or fracturing the mandible to get at this area. This is  challenging and not that desirable, and few surgeons are familiar with the technique. For this reason, imaging is very desirable and often demonstrates that no significant injury is present. And endovascular / angiographic techniques are now available that may obviate the need for surgery.

Zone II is everything in-between the mandibular angle and cricoid cartilage. This is the surgical Easy Button. Exposure is simple and the operation is fun. In the old days, an injury to this area went straight to the OR regardless of whether there were signs or symptoms of injury. Yes, there were quite a few negative explorations. But we’ve become more selective now with the advent of improved resolution of our CT scans.

Currently, we usually follow a two-step approach to penetrating neck trauma:

  1. Are there hard signs of injury present? These tell us that a structure that absolutely needs to be fixed has been injured. The patient should be taken directly to OR after control of the airway, if appropriate. Typical hard signs are:
    1. Airway compromise
    2. Active air bubbling from wound
    3. Expanding or pulsatile hematoma
    4. Active bleeding
    5. Hematemesis
  2. What zone is the injury in? And don’t just look at the obvious entry point. Gunshots (and long knives) may enter multiple zones. The zone then determines what happens next:
    1. Zone I – CT angio of neck and chest. If positive, proceed to OR for repairs, and perform EGD and/or bronchoscopy as needed
    2. Zone II – Old days: proceed to operating room for exploration, or angiogram, EGD, direct laryngoscopy, and bronchoscopy. Most chief residents chose the former. Current day: CTA of neck, followed by OR, EGD, bronchoscopy only if indicated.
    3. Zone III – CT angio of the neck. If positive, consider angiography/endovascular consultation vs operation.

Changes from old days to more current thinking have been made possible by improvements in speed and resolution of our CT scanners. But why can’t we take this another step forward and streamline this process even more? I’ll propose some changes in my next post!

Reference: Western Trauma Association Critical Decisions in Trauma:
Penetrating neck trauma. J Trauma 75(6):936-940, 2013.