Category Archives: Procedures

EAST 2017 #10: A Simple Way To Predict Complications After Rib Fracture?

Rib fractures are a common injury, and a very common cause of morbidity. Every time I admit an elderly patient with rib fractures, I debate whether they should go to the ICU or a ward bed. Could there be a more objective way of determining the likelihood of complications, aggressiveness of treatment, and admission unit?

A group at West Virginia University implemented a rib fracture pathway in 2009, and have been collecting data on patients ever since. It was based on the measurement of forced vital capacity (FVC) on admission. This is the total amount of air that can be exhaled during a forced breath.

The authors subdivided their patients into two groups based on the total volume exhaled (<1.5L, and >1.5L). They retrospectively reviewed 6 years of data, looking at specific injuries, complications, and unexpected transfer to ICU. They hypothesized that patients in the highest FVC group would have fewer complications.

Here are the factoids:

  • There was a nearly even split in groups, with 678 patients who had FVC > 1.5L, and 682 with FVC < 1.5
  • There were significantly fewer complications and pneumonia, as well as fewer readmissions in the FVC > 1.5 group
  • Higher FVC was not associated with fewer unexpected transfers to ICU
  • Length of stay was half as long (4d vs 8d) in the high FVC group, but no p value was provided
  • The authors conclude that patients with FVC much greater than 1.5 are at lower risk for complications regardless of the number of fractures (???!)
  • They even suggest that patients with FVC > 1.5 could be discharged from the ED rather than be admitted (!)

Bottom line: Well, it started out good! The abstract showed that the high FVC patients had fewer complications and readmissions. And the length of stay was shorter, although significance was not noted. But the jump to correlating complication risk with number of fractures was not addressed in the abstract. And I can’t quite grasp the leap to suggesting possible discharge from the ED. 

FVC may be an inexpensive and simple test to administer in new rib fracture patients. But it’s ability to predict who goes to ICU and who goes home from the ED was not really identified in the study. 

Questions and comments for the authors/presenters:

  1. A minor point, but the upper limit was defined as > 1.5L in some parts of the abstract, and > 1.5L in  others. Small point, but keep it clean. Make sure all the greater than, less than, and equals signs are consistent.
  2. Was the shorter length of stay significantly different between the groups?
  3. Did you do any stratification by age?
  4. How did you make the conclusion that patients could be sent home from the ED?
  5. And did you do any correlations with your FVC data and the number of fractures? It’s not in the abstract.

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related post:

Reference: Is an FVC of 1.5 adequate for predicting respiratory sufficiency in rib fractures? Paper #4, EAST 2017.

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EAST 2017 #7: Pigtail vs Chest Tube – Does Size Matter?

I’ve been somewhat old school when it comes to chest tubes. Unlike some, I don’t believe that you have any control of where a chest tube goes if you are placing it in a closed chest. Only in the OR with an open one. And I’ve got plenty of x-rays to prove it.

And I used to think that chest tube size mattered when dealing with hemothorax. In theory, you need a big tube to get clots out, right?

Well, maybe not! The trauma group at the University of Arizona Tucson has previously done work on using 14 French pigtail catheters in lieu of a full-size tube. They will be presenting their extended experience with this concept at EAST 2017.

They have maintained a prospectively collected database of information on trauma patients with chest tubes for many years. This study focused only on those who had blood in their chest, either hemothorax (HTX) or hemopneumothorax (HPTX). They also looked at trends in their selection of chest drain tubes.

Here are the factoids:

  • Nearly 500 patients were treated with a tube for HTX or HPTX during the 7 year study period, 2/3 with a chest tube and 1/3 with a pigtail
  • Pigtails had more fluid drain initially (430cc vs 300cc, significant), and 1 less treatment day (4 vs 5, also significant)
  • Failure rate and insertion-related complications were the same (about 22% and 6%, respectively)
  • The group found that their use of pigtails steadily and significantly increased over the years

Bottom line: I’m coming around. The literature does appear to be tilting toward smaller tubes, and this longer-term study helps confirm that. How can this be? Although this is speculation on my part, it probably has to do with the fact that any size tube will drain liquid blood. And probably no size of tube will successfully get all the clot out. 

And certainly, smaller tubes are much better tolerated and do not require the degree of sedation that a mega-tube does. The authors suggest that a multi-center trial should be carried out to confirm this. For my part, I’m going to review the literature we have to date and consider modifying my own chest tube policy (see links below).

Questions and comments for the authors/presenters:

  • Where did you typically insert the pigtails? Anterior chest or classic chest tube position? Was it consistent?
  • Was/is the selection of tube type an attending surgeon specific choice, or did you implement a policy to direct them?
  • Did patient injury pattern or body habitus have any part in tube selection?
  • What about removal failures? That is, how many had to have a tube replaced, and how many went on to require VATS or other surgical procedure for drainage?
  • I enjoyed this provocative paper!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: A prospective study of 7-year experience of using percutaneous 14-French pigtail catheter for traumatic hemothorax at a Level I trauma – size still does not matter. Quick Shot #4, EAST 2017.

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Efficacy Of Preperitoneal Packing For Pelvic Fractures

A multi-center trial published in 2015 showed an astounding 32% mortality rate for patients with shock from pelvic fracture. And as I continue to preach, going any place but the OR is dangerous for the patient. Unfortunately, it’s generally not feasible to operatively fix the pelvis acutely, and external fixation has limited impact on ongoing hemorrhage.

If the patient can be stabilized to some degree, interventional radiology can be very helpful. Unfortunately, access after hours involves some degree of time delay. Ideally, the team arrives in 30 minutes or less. But the patient may not be ready, so time to procedure may increase significantly.

So preperitoneal packing of the pelvis (PPP) has now become popular. Years ago, we tried to pack the pelvis from the inside (peritoneal cavity), but it never worked very well. You can push sponges deep into the pelvis as firmly as you want, but the intestines will not keep them from expanding back out of the pelvis.

PPP entails making a lower midline incision, but not entering the peritoneal cavity. A hand is then slid along the anterior surface of the peritoneum around the inside of the iliac wing. Sponges can then be pushed around toward the sacrum, applying direct pressure over bleeding fracture sites and the overlying tissues.

preperitoneal-packing

Image courtesy of ACSSurgery.com

But does it work? Denver Health performed an 11 year retrospective review of their experience with 2293 patients with pelvic fractures. They looked at time to intervention, blood product usage, and mortality.

Here are the factoids:

  • A total of 128 patients underwent PPP
  • Most were younger (mean age 43) and badly injured (mean ISS 48)
  • Median time from door to OR was 44 minutes
  • Patients received an average of 8 units of RBCs intraop, and an additional 3 units in the ensuing 24 hours
  • Overall mortality was 21% (27 of 128), but 9 (7%) were due to severe head injury

Bottom line: Compared to other published studies, time to “definitive management” with PPP was very short. Blood usage also dropped quickly after the procedure. Mortality seems to be much better than expected at about 13%. These results suggest that if you have to wait for angio, or your patient is too unstable to go there, run to the OR first to do some PPP.

And don’t forget these other important management tips:

  • If you see any posterior pelvic fracture on the initial pelvic x-ray, call for blood
  • If the blood pressure softens at any point activate your massive transfusion protocol
  • Apply a binder, especially for open book type fractures
  • Always get a CT in stable patients to help your orthopedic surgeons plan, and to identify contrast blushes
  • If the patient has to go to OR first to stabilize them, consider angio afterwards. You’ll probably find something they can fix.
  • Think about using your hybrid OR!

Reference: Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. AAST 2016, Paper 32.

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Once Again: Leg Fasciotomy With Less Than Two Incisions

It seems like this topic keeps on coming up! This is the second article I’ve seen this year that describes a variation on the single-incision leg fasciotomy. In the classic two-incision approach, the lateral incision gives access to the anterior and lateral compartments, and the medial incision to the posterior and deep posterior. See below.

The more “standard” single-incision approaches either go through (i.e. removes part of) or around, the fibula. In the diagram below, the arrows point to the access points into the anterior, lateral, posterior and deep posterior from top to bottom.

In the “new” variation described, the authors slide along the lateral edge of the tibia to get to the deep posterior compartment.

This approach requires stripping the tibialis

anterior muscle away from the tibia, which some orthopods may argue interferes with healing. And, as with the other single-incision technique, the procedure may take additional time.

Bottom line: I’m still not a big fan of single-incision fasciotomy. My main reason is that most surgeons are not as familiar with the technique. And patients who have a potentially limb threatening process are not the best to learn on. I have seen too many incomplete fasciotomies with persistent compartment syndrome in my career. 

So unless you are being mentored by someone who is well versed in the technique, use the two incision technique and use a cadaver to practice your single incision operation.

Reference:  A Single-Incision Fasciotomy for Compartment Syndrome
of the Lower Leg. J Ortho Surg 30(7):e252-e255, 2016.

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REBOA: The References

Here are a few references for some of the significant work on REBOA. Be aware that new research is now being published every month! Good luck keeping up!

References:

1. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma 71(6):1869-1872, 2011.

2. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma 75(1):122-128, 2013.

3. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma 78(4):721-728, 2015.

4. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma 78(5):897-023, 2015.

5. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma 78(5):1054-1058, 2015.

6. Resuscitative endovascular balloon occlusion of the aorta. Resuscitation 96:275-279, 2015.

Direct links to the REBOA series:

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