Tag Archives: repair

Complications, Thorax

Early Vs Delayed Thoracic Endovascular Repair

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Back in the day, the only way to fix a broken thoracic aorta was via left thoracotomy.  This was a big procedure, with the possibility of several major complications, with postop paraplegia being one of them. At the time, there was a debate about whether the procedure should be done immediately versus waiting until the patient was well-resuscitated. The concern was that death was nearly certain if the aortic lesion progressed.

We learned that temporizing with strict blood pressure control worked wonders at protecting the patient. Although many of these injuries were managed within hours, a growing number were delayed by a few days to improve outcomes.

Nowadays, thoracic endovascular aortic repair (TEVAR) is routine and much less morbid than the open procedure. However, the same question arises: do it early or wait a while? Interestingly, not one but two analyses have been published on this very topic in the last four months!

The first is from an international research group that searched the usual databases and initially found 921 records. They included only clinical trials or cohort studies with ten or more adult patients that could be stratified as early (within 24 hours) or late (after 24 hours) intervention. After applying these criteria, only seven studies remained for analysis.

There were 3,757 patients with early repairs, compared to 1,238 undergoing late repair. The presenting demographics and injury grades were similar in each group. However, the short-term mortality was significantly higher (1.9x) in the early TEVAR group. Additionally, ICU length of stay was significantly longer (3 days) in the late TEVAR group.

The second paper was presented as a quick-shot at last year’s AAST meeting. It is from a group of researchers from our big Boston trauma centers and the Netherlands. They used four years of data from the TQIP database, giving them extra information unavailable in the first study. They specifically looked at patients with grade II or III injuries. Here is the grading scale:

Here are the factoids:

  • A total of 1,339 patients were studied, with about three-quarters in the early TEVAR group
  • Median time to TEVAR was 4 hours in the early group and 65 hours in the late group
  • Patients in the early group were significantly less likely to have brain or liver injuries
  • ISS was similar in both groups
  • The early TEVAR group had significantly higher in-hospital mortality (16% vs. 5%), significantly higher risk of ARDS (7.6% vs. 2.1%), but significantly shorter ICU stay (7 vs 10 days)
  • When patients who died within the first 24 hours were excluded, the in-hospital mortality remained significantly higher, and the ICU and hospital lengths of stay were significantly shorter

Bottom line: Some society guidelines began recommending delayed TEVAR in 2015. This study did not detect any trend toward this, however. Using different methods and databases, these two studies identified nearly identical mortality and ICU trends in large groups of patients. The mortality trends do not appear to be related to injury grade, overall injury severity, or the presence of head injury. 

Taken together, this suggests that we need to rethink the timing of TEVAR in patients with grade II or III injuries. The best timing still needs to be defined, but it appears to be beyond 24 hours. Centers performing this procedure should review their results and consider extending procedure timing as additional research is done to define the ideal time interval.

References:

  1. Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Traumatic Aortic Injury: A Systematic Review and Meta-Analysis. Cureus. 2023 Jun 28;15(6):e41078. doi: 10.7759/cureus.41078. PMID: 37519486; PMCID: PMC10375940.
  2. Early Versus Delayed Thoracic Endovascular Aortic Repair for
    Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis. Ann Surg 278:e848-e854, 2023.

 

General

Wounds: When Are They Too Old To Close?

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At some point in their training, every trauma professional is taught that there is a certain period time during which a wound can be safely closed. The exact number varies, but is usually somewhere between 6 and 24 hours. After that, we are told, “bad things happen.”

Always question dogma, I say. Is this true, or is it another one of those “facts” that have been propagated through the ages? Two emergency medicine groups recently performed a meta-analysis to try to answer my question. As usual, they found that much of the published literature is not very good. Out of 418 papers in their original search, only 4 fully met their criteria (laceration repaired primarily, in the ED, with clear early vs delayed criteria.

With the exception of one study with a very limited focus, there was no correlation between wound age and infection or dehiscence after primary closure. None of the studies could reliably provide a specific time beyond which closure was destined to fail. And the use of antibiotics in some of the studies also confounded the results.

Bottom line: It is more likely that infection-prone wounds get infected, not old ones. Although leaving a wound open to heal by secondary intention usually avoids the problem, it’s a big patient dissatisfier, especially with large wounds. Since many patients don’t present to the ED until their wound is “old”, it may be reasonable to try primary closure in all but infection-prone wounds. (The meaning of that phrase is not exactly clear, but most of us know it when we see it.) 

Reference: The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury 43(11):1793-1798, 2012.

General

Wounds: When Are They Too Old To Close?

Leave a comment

At some point in their training, every trauma professional is taught that there is a certain period time during which a wound can be safely closed. The exact number varies, but is usually somewhere between 6 and 24 hours. After that, we are told, “bad things happen.”

Always question dogma, I say. Is this true, or is it another one of those “facts” that have been propagated through the ages? Two emergency medicine groups recently performed a meta-analysis to try to answer my question. As usual, they found that much of the published literature is not very good. Out of 418 papers in their original search, only 4 fully met their criteria (laceration repaired primarily, in the ED, with clear early vs delayed criteria.

With the exception of one study with a very limited focus, there was no correlation between wound age and infection or dehiscence after primary closure. None of the studies could reliably provide a specific time beyond which closure was destined to fail. And the use of antibiotics in some of the studies also confounded the results.

Bottom line: It is more likely that infection-prone wounds get infected, not old ones. Although leaving a wound open to heal by secondary intention usually avoids the problem, it’s a big patient dissatisfier, especially with large wounds. Since many patients don’t present to the ED until their wound is “old”, it may be reasonable to try primary closure in all but infection-prone wounds. (The meaning of that phrase is not exactly clear, but most of us know it when we see it.) 

Reference: The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury 43(11):1793-1798, 2012.

General

Which Lacerations Can I Close?

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There is always debate about which lacerations can be closed, but not a lot of literature to back it up. Here are some good rules to follow:

  • In general, close all face and scalp lacerations. They almost never get infected. Complicated ones may need extra care, debridement, or involvement of a plastic surgeon. 
  • Closing lacerations that are more than 24 hours old is risky (except for the face). They tend to be colonized with skin flora and become infected much more frequently.
  • Most other lacerations can be closed primarily within 24 hours. For the most part, it doesn’t matter what the cutting instrument was. One exception is an object that is heavily contaminated (e.g. freshly used pitchfork). Most knives don’t fall into this category. They are clean, but not sterile and the risk of infection is low.

All wounds should be inspected for foreign bodies. On occasion, this may require an xray. But remember that many foreign objects (wood, glass) are not radiopaque and will be invisible. Next, the wound should be copiously irrigated with sterile saline to flush out any small particles and reduce bacterial counts. Finally, if the edges are ragged the wound should be sharply debrided.

Antibiotics are not usually needed, since the few bacteria left will be rapidly taken care of by the patient’s immune system. If there are worries about contamination or the patient is immunocompromised, a very brief course of antibiotic is recommended. Tetanus toxoid should be given if indicated.

The most important issue is patient education. The signs and symptoms of early wound infection should be explained, and a phone number or location for followup should be clearly listed.

Bottom line: All lacerations can be safely closed within 24 hours, with a few exceptions.