Admission Lymphopenia is Associated With Discharge Disposition in Blunt Chest Wall Trauma Patients

Background. Blunt chest wall trauma accounts for over 10% of all trauma patients presenting to emergency departments worldwide. When the injury is not as severe, deciding which blunt chest wall trauma patients require a higher level of clinical input can be difficult. We hypothesized that patient factors, injury patterns, analgesia, postural condition, and positive airway pressure influence outcomes.Methods. The study population consisted of patients hospitalized with at least 3 rib fractures (RF) and at least one pulmonary contusion and/or at least one pneumothorax lower than 2 cm.Results. A total of 140 patients were retrospectively analyzed. Ten patients (7.1%) were admitted to intensive care unit (ICU) within the first 72 hours, because of deterioration of the clinical conditions and gas exchange with worsening of chest X-ray/thoracic ultrasound/chest computed tomography. On univariable analysis and multivariable analysis, obliged orthopnea (p=0.0018) and the severity of trauma score (p<0.0002) were associated with admission to ICU.Conclusions. Obliged orthopnea was an independent predictor of ICU admission among patients incurring non-life-threatening blunt chest wall trauma. The main therapeutic approach associated with improved outcome is the prevention of pulmonary infections due to reduced tidal volume, namely, upright postural condition and positive airway pressure.

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Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: systematic review

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000690 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000690

Author(s):

Peter I Cha ◽

Jung Gi Min ◽

Advait Patil ◽

Jeff Choi ◽

Nishita N Kothary ◽

...

Keyword(s):

Systematic Review ◽

Chest Wall ◽

Rib Fractures ◽

Hospital Length Of Stay ◽

Cochrane Library ◽

Trauma Patients ◽

Qualitative Synthesis ◽

Thoracic Pain ◽

Level Of Evidence ◽

Chest Wall Trauma

BackgroundThere is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma.MethodsA systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed.ResultsTwenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low.ConclusionsGiven the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence.Level of evidenceLevel IV systematic reviews and meta-analyses.

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A multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL Trial

BMJ Open ◽

10.1136/bmjopen-2019-029187 ◽

2019 ◽

Vol 9 (7) ◽

pp. e029187 ◽

Cited By ~ 3

Author(s):

Ceri Battle ◽

Hayley A Hutchings ◽

Timothy Driscoll ◽

Claire O’Neill ◽

Sam Groves ◽

...

Keyword(s):

Quality Of Life ◽

Chest Wall ◽

Prognostic Model ◽

Clinical Decision Making ◽

Healthcare Resource ◽

Feasibility Trial ◽

Trauma Patients ◽

Chest Wall Trauma ◽

The Impact

ObjectiveA new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). The aim of this trial is to assess the feasibility and acceptability of a definitive impact trial investigating the clinical and cost-effectiveness of a new prognostic model for the management of patients with blunt chest wall trauma in the ED.DesignStepped wedge feasibility trial.SettingFour EDs in England and Wales.ParticipantsAdult blunt chest wall trauma patients presenting to the ED with no concurrent, life-threatening injuries.InterventionA prognostic model (the STUMBL score) to guide clinical decision-making.Outcome measuresPrimary: participant recruitment rate and clinicians’ use of the STUMBL score. Secondary: composite outcome measure (mortality, pulmonary complications, delayed upgrade in care, unplanned representations to the ED), physical and mental components of quality of life, clinician feedback and health economic data gathering methodology for healthcare resource utilisation.ResultsQuantitative data were analysed using the intention-to-treat principle. 176 patients were recruited; recruitment targets were achieved at all sites. Clinicians used the model in 96% of intervention cases. All feasibility criteria were fully or partially met. After adjusting for predefined covariates, there were no statistically significant differences between the control and intervention periods. Qualitative analysis highlighted that STUMBL was well-received and clinicians would support a definitive trial. Collecting data on intervention costs, health-related quality of life and healthcare resource use was feasible.DiscussionWe have demonstrated that a fully powered randomised clinical trial of the STUMBL score is feasible and desirable to clinicians. Minor methodological modifications will be made for the full trial.Trial registration numberISRCTN95571506; Post-results.

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12 A multi-centre randomised feasibility study evaluating the impact of a prognostic model for management of blunt chest wall trauma patients: stumbl trial

Emergency Medicine Journal ◽

10.1136/emermed-2017-207308.12 ◽

2017 ◽

Vol 34 (12) ◽

pp. A868.2-A868

Author(s):

Ceri Battle ◽

Hayley Hutchings ◽

Zoe Abbott ◽

Claire O’neill ◽

Sam Groves ◽

...

Keyword(s):

Chest Wall ◽

Feasibility Study ◽

Prognostic Model ◽

Trauma Patients ◽

Chest Wall Trauma ◽

The Impact

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Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma

The American Surgeon ◽

10.1177/00031348211011115 ◽

2021 ◽

pp. 000313482110111

Author(s):

Krista L. Haines ◽

Benjamin P. Nguyen ◽

Ioana Antonescu ◽

Jennifer Freeman ◽

Christopher Cox ◽

...

Keyword(s):

Mechanical Ventilation ◽

End Of Life ◽

Hospice Care ◽

Private Insurance ◽

Future Research ◽

Trauma Patients ◽

Improvement Program ◽

Advanced Directives ◽

Logistic Regression Models ◽

Discharge Disposition

Introduction Advanced directives (ADs) provide a framework from which families may understand patient’s wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes. Methods Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes. Results 44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO −.74, CI −1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64). Conclusion Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.

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