The “Backward Finochietto” Problem

Resuscitative thoracotomy is a (sometimes) life-saving procedure reserved for trauma patients in extremis. Thankfully, most trauma centers do very few of these a year. However, that makes it one of those “high severity – low frequency” procedures that generate many, many quality improvement problems. Many of these issues are due to operator unfamiliarity or equipment availability.

Today, I’ll highlight a problem that crops up occasionally at various trauma centers across the US: the “backward Finochietto.” One of the most essential components of the resuscitative thoracotomy is rapid access to the chest. A large skin incision is typically made, the thoracic wall and intercostal musculature are divided, and the pleural space is entered.

It’s not easy to insinuate your arm between the ribs in an average person. But, of course, there’s a retractor for that! Von Mikulicz presented the first rib spreader at a German surgical society meeting in 1904.  Various versions of this instrument were devised over the next three decades to make it easier and faster to use.

The Finochietto retractor was introduced in 1936 and boasted several enhancements. It used a rack and pinion system to make it easier for the surgeon to spread the chest wall and made it unlikely to close on its own. The turning lever was hinged so it could flattened and placed out of the surgical field. The blades contained fenestrations so chest wall tissue could protrude into them and keep it from slipping when opened. It remains a workhorse instrument for us today and is found in most instrument packs for resuscitative thoracotomy.

But there is a potential problem. Some Finochietto retractors consist of only two pieces: a blade with the linear gear teeth (the rack) and another blade that fits onto it with the turning handle (the pinion). See the image below:

Looks great, right? However, there is one downside. The retractor parts that hook into the soft tissue are of a fixed depth. What if your patient has a more generous body habitus? Placing multiple sets of this retractor into the thoracotomy pack is not practical.

The solution is to allow detachable blades of various sizes. Here’s a modern-day example:

The good news is that the retractor tips are interchangeable. The bad news is that they are sometimes interchangeable with the wrong arm of the retractor! Hence the “backward Finochietto” problem. It’s impossible to use the retractors with the blades on the wrong side, and it takes time the trauma professional does not have to figure out how to snap them off and switch them around.

So what’s the solution? This is clearly an instrument reprocessing quality issue. These instruments are expensive, so your hospital may not be excited about purchasing new ones just for the trauma bay. It all boils down to foolproofing it in as many ways as possible.  Here are some tips:

  • Provide an educational session for all of the reprocessing techs. Unfortunately, this effect will wear off as staff turnover occurs.
  • Post a photograph of a properly assembled retractor for the techs to use when processing the tray.
  • Use colored instrument marking tape on each piece of the instrument. For example, a green tape strip should be placed on both the rack arm of the retractor and the left blade. Use red tape for the pinion arm and the right blade. All the tech needs to do now is match the colors as they assemble the retractor.

Bottom line: This problem is more common than you may think. Ask one of your old-timer trauma surgeons and I’ll bet they can tell you some stories. But it is easily avoided with a little creativity and some tape! Be sure to do it now so it doesn’t pop up in the heat of a resuscitative thoracotomy .

NFTI And STAT: Can They Replace The Cribari Grid?

In my last post, I reviewed using the Cribari grid to evaluate over- and under-triage at your trauma center.  This technique has been a mainstay for nearly two decades but has shortcomings. The most important one is that it relies only on the Injury Severity Score (ISS) to judge whether some type of mistriage occurred.  The ISS is usually calculated after discharge, so it can only be applied after the fact. And its correlation with outcomes varies.

What is NFTI, Exactly?

Five years ago, the Baylor University in Dallas group sought to develop an alternate method of determining who needed a full trauma team activation. They chose resource utilization as their surrogate to select these cases. They reviewed 2.5 years of their registry data (Level I center).  After several iterations, they settled on six “need for trauma intervention” (NFTI) criteria:

  • blood transfusion within 4 hours of arrival
  • discharge from ED to OR within 90 minutes of arrival
  • discharge from ED to interventional radiology (IR)
  • discharge from ED to ICU AND ICU length of stay at least three days
  • require mechanical ventilation during the first three days, excluding anesthesia
  • death within 60 hours of arrival

Patients who had at least one NFTI criterion were considered candidates for full trauma activation, and if an activation did not occur, the encounter would be regarded as undertriage. On the flip side, if no NFTI criteria were present and an activation did occur, it would be overtriage.

The First NFTI Paper

In their first published paper, the Baylor group analyzed nearly 5,000 trauma activations, split roughly in half for full versus partial trauma activations. Two-thirds of the full activations met at least one NFTI criterion. This means that about a third might be considered overtriage since they did not require one of the critical resources or die within 60 hours of arrival. And looking at the partial activations, fully 75% did not meet any NFTI criteria. There were 561 deaths in the overall group (12%). Of those, only 13 did not meet any NFTI criteria, but every one had a DNR order in place.

Now let’s translate all this into under- and overtriage numbers:

  • Undertriage: 22% (partial activations that were NFTI +)
  • Overtriage: 58% (any level of activation in a NFTI – patient)

The authors concluded that NFTI assesses anatomy and physiology using only measures of early resource utilization. They believe that it self-adjusts for age, frailty, and comorbidities and is a simple and effective tool for identifying major trauma patients.

But is it better for evaluating over- and undertriage than the Cribari grid? I’ve had several people tell me that it is. But if you look at the numbers above, overtriage is in the usual range, and undertriage is higher than the usual raw Cribari numbers. Even the authors suggest that it might be used to determine if the patient needed a trauma activation. Up to this point, NFTI is interesting, but not better than Cribari on its own.

The following year, these authors published a paper that further refined their concept. They rolled NFTI into something called the Standardized Triage Assessment Tool (STAT). Basically, the Cribari matrix is applied to the trauma activation data as usual. The fallouts (over- and undertriage groups) are then tested against the NFTI criteria. Cribari undertriage patients who were NFTI negative were now considered appropriate triage, as were Cribari overtriage who were NFTI positive. NFTI was basically used to do another level of screening on the outliers before resorting to individual chart review.

Once again, let’s look at over- and undertriage experience in the paper:

  • Undertriage: 9.1% undertriage (Cribari) reduced to 3.3% by adding STAT
  • Overtriage: 50% overtriage (Cribari) reduced to 31% by adding STAT

The authors concluded that adding STAT to the review process tightens up the numbers, reducing the number of charts that need to be reviewed individually. It also standardizes comparisons between hospitals that use STAT. This may be helpful for future triage-related research.

What Does It All Mean?

The Cribari grid has been around a long time, and people are both comfortable and facile using it. But it does tend to overestimate undertriage. In my experience, the raw Cribari undertriage rate is usually 12-22%. Individual chart analysis reduces this by about 10%. Overtriage rates are anywhere from 40% to 90%, and most centers do not review those charts because they don’t care much about reducing it.

Applying NFTI criteria to the over- and undertriage fallouts from Cribari makes sense. It appears to appropriately reduce both rates significantly. Undertriage remains the most significant factor to monitor. If you choose to adopt the use of the STAT technique, consider manually reviewing the undertriage charts that are being reclassified as appropriate for a few cycles. This should help confirm that STAT is really working for you.

One last thing. Using Cribari or NFTI or STAT does not absolve you of having good triage criteria for trauma activations. It is not possible to know a patient’s ISS or NFTI status as they are rolling through the door. The quality of your activation criteria are the first screen to try to ensure appropriate triage. If you keep finding undertriage events occurring, first look at your criteria. If those seem to be fine, then it’s time to scrutinize the people applying them!

Helpful Tools

The authors of the STAT paper provided some Excel spreadsheets to help add the Cribari matrix, NFTI, or STAT to your registry. Note that this only works for TraumaBase! If you use a different registry, contact your vendor for assistance.

The spreadsheets consist of three tabs/pages. On the first, enter the specific field names from your TraumaBase implementation. This fills in the code on the second tab which will be added to TraumaBase. The third tab gives explicit directions on how to add the feature to your registry.

Here are the downloadable file links provided by the authors:


  1. Asking a Better Question: Development and Evaluation of the Need For Trauma Intervention (NFTI) Metric as a Novel Indicator of Major Trauma. J Trauma Nursing 24(3):150-157, 2017.
  2. Avoiding Cribari gridlock: The standardized triage assessment tool improves the accuracy of the Cribari matrix method in identifying potential overtriage and undertriage. J Trauma Acute Care Surg. 2018 May;84(5):718-726.

Undertriage And Overtriage: The Cribari Grid

Any trauma performance improvement professional understands the importance of undertriage and overtriage. Overtriage occurs when a patient who does not meet trauma activation criteria gets one anyway. And undertriage is the converse, where no activation is called despite criteria being met. As you may expect, the latter is much more dangerous for the patient.

I frequently get questions on the “Cribari Grid” or “Cribari Method” for calculating these numbers. Dr. Chris Cribari was a previous chair of the Verification Review Committee of the ACS Committee on Trauma. He developed a table-format grid that provides a simplified method for calculating these numbers.

But remember, the gold standard for calculating over- and undertriage is examining each admission to see if they actually met any of your trauma activation triage criteria. The Cribari method is designed for those programs that do not or cannot check these on every admission. And since most programs have too many trauma admissions to verify every single one, the grid technique can be very helpful. It is a surrogate for chart review that helps reduce the workload to identify patients with higher ISS that might have benefited from a trauma activation.

If you use the Cribari method, use it as a first pass to identify potential undertriage. In most trauma programs, the raw undertriage number using the grid will be around 10-20%. Obviously, this is unacceptably high. It requires the second pass: manually examining the chart of every patient in the undertriage list to see if they meet any of your activation criteria. If they did not, they would most likely not have been undertriaged. The second pass process usually decreases the undertriage rate by about 10%, usually reducing it below the acceptable threshold of 5%

But now you need to do a third pass. Look at each patient’s injuries and overall condition to ask yourself if they might have been better cared for by your entire trauma team. Even though they don’t meet any of your existing criteria, should they have? If so, you may need to add a new activation criterion. Then, count that patient as undertriage, of course.

I’ve simplified the Cribari Grid calculation process as much as possible and have provided a Microsoft Word document that automates the task. Just download the file, fill in the four highlighted values in the table, update the formulas using the instructions, and voila! You’ve got your numbers! Instructions for manual calculations are also included. Download it by clicking the image below or the link at the end of this post.

In my next post, I’ll examine how the NFTI score (Need For Trauma Intervention) fits into your undertriage calculations.

Click here to download the calculator.

Preperitoneal Packing Vs Angioembolization: Part 3

In the previous post in this series, I described an early review article summarizing several older studies comparing these two hemorrhage control techniques for pelvic fractures. Today, I’ll review another paper fresh off the press, published just this month.

This paper comes from the orthopedics and neurosurgical groups at the University of Texas-San Antonio. They scanned five years of data from the National Inpatient Sample, which included data from 35 million inpatient admissions in the US. They separated all patients with acetabular and pelvic ring fractures using ICD-10 codes.

They further narrowed their dataset to patients with angioembolization (AE) or peri-pelvic packing (PPP) as their primary procedure. This eliminated patients who might have received other additional management that could cloud the data. Various hospital outcomes were tabulated, including hospital charges, mortality, and discharge location.

Here are the factoids:

  • Of the 3,780 patients identified, only 160 underwent PPP, and the remaining 3,620 had AE. This is probably a function of PPP’s newer and more novel nature.
  • The AE patients were significantly older than the PPP patients (66 vs 53 years). This suggests that trauma professionals have a lower threshold to order AE in older patients.
  • Time to procedure start was similar for both interventions
  • Overall, there was no difference in mortality between the AE and PPP patients
  • There was no difference in unfavorable discharge (other than home)
  • Hospital charges were significantly lower in the AE group ($369K vs $250K)!

Bottom line: This is the largest comparison of AE and PPP to date. It mostly confirms earlier work and adds significant insights about cost and discharge status.

AE and PPP have equivalent outcomes. This is true even though the AE group is larger and significantly older. However, it is possible that the number of PPP cases was too low for the authors to demonstrate any significant differences. 

What should you do when faced with these patients? First, hemodynamic instability means that PPP is the only choice. You can feel comfortable that outcomes will be the same as AE. If there is concern that there could be ongoing bleeding, PPP can be followed by a trip to the interventional radiology suite. This is a common practice.

I shouldn’t have to say it, but AE should never even be considered in an unstable patient. 

What about stable patients? AE seems to be the way to go. It is tolerated even by older patients. And it ends up saving a lot of money when compared to PPP. 

There is still room for research in this space. As our PPP experience grows, we should hopefully be able to confirm the conclusions  in this paper. If any are refuted, I’ll revisit this post and make the needed updates. Which is what you should also do in your practice!

Reference: Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures. J Orthop Trauma 38(5):254-258, 2024.