Survey of American College of Surgeons Committee on trauma members on firearm injury: Consensus and opportunities.

BACKGROUND: In the United States, there is a perceived divide regarding the benefits and risks of firearm ownership. The American College of Surgeons Committee on Trauma Injury Prevention and Control Committee designed a survey to evaluate Committee on Trauma (COT) member attitudes about firearm ownership, freedom, responsibility, physician-patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development. METHODS: A 32-question survey was sent to 254 current U.S. COT members by email using Qualtrics. SPSS was used for χ exact tests and nonparametric tests, with statistical significance being less than 0.05. RESULTS: Our response rate was 93%, 43% of COT members have firearm(s) in their home, 88% believe that the American College of Surgeons should give the highest or a high priority to reducing firearm-related injuries, 86% believe health care professionals should be allowed to counsel patients on firearms safety, 94% support federal funding for firearms injury prevention research. The COT participants were asked to provide their opinion on the American College of Surgeons initiating advocacy efforts and there was 90% or greater agreement on 7 of 15 and 80% or greater on 10 of 15 initiatives. CONCLUSION: The COT surgeons agree on: (1) the importance of formally addressing firearm injury prevention, (2) allowing federal funds to support research on firearms injury prevention, (3) retaining the ability of health care professionals to counsel patients on firearms-related injury prevention, and (4) the majority of policy initiatives targeted to reduce interpersonal violence and firearm injury. It is incumbent on trauma and injury prevention organizations to leverage these consensus-based results to initiate prevention, advocacy, and other efforts to decrease firearms injury and death. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level I; therapeutic care, level II.

Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema.

BACKGROUND: Retained hemothorax (RH) is relatively common after chest trauma and can lead to empyema. We hypothesized that patients who have surgical fixation of rib fractures (SSRF) have less RH and empyema than those who have medical management of rib fractures (MMRF). METHODS: Admitted rib fracture patients from January 2009 to June 2013 were identified. A 2:1 propensity score model identified MMRF patients who were similar to SSRF. RH, and empyema and readmissions, were recorded. Variables were compared using Fisher exact test and Wilcoxon rank-sum tests. RESULTS: One hundred thirty-seven SSRF and 274 MMRF were analyzed; 31 (7.5%) had RH requiring 35 interventions; 3 (2.2%) SSRF patients had RH compared with 28 (10.2%) MMRF (P = .003). Four (14.3%) MMRF subjects with RH developed empyema versus zero in the SSRF group (P = .008); 6 (19.3%) RH patients required readmission versus 14 (3.7%) in the non-RH group (P = .002). CONCLUSIONS: Patients with rib fractures who have SSRF have less RH compared with similar MMRF patients. Although not a singular reason to perform SSRF, this clinical benefit should not be overlooked.

Cleared for takeoff: The effects of hypobaric conditions on traumatic pneumothoraces.

BACKGROUND: Current guidelines suggest that traumatic pneumothorax (tPTX) is a contraindication to commercial airline travel, and patients should wait at least 2 weeks after radiographic resolution of tPTX to fly. This recommendation is not based on prospective, physiologic study. We hypothesized that despite having a radiographic increase in pneumothorax size while at simulated altitude, patients with a recently treated tPTX would not exhibit any adverse physiologic changes and would not report any symptoms of cardiorespiratory compromise. METHODS: This is a prospective, observational study of 20 patients (10 in Phase 1, 10 in Phase 2) with tPTX that has been treated by chest tube (CT) or high flow oxygen therapy. CT must have been removed within 48 hours of entering the study. Subjects were exposed to 2 hours of hypobaria (554 mm Hg in Phase 1, 471 mm Hg in Phase 2) in a chamber in Salt Lake City, Utah. Vital signs and subjective symptoms were recorded during the "flight." After 2 hours, while still at simulated altitude, a portable chest radiograph (CXR) was obtained. tPTX sizes on preflight, inflight, and postflight CXR were compared. RESULTS: Sixteen subjects (80%) were male. Mean (SD) age and ISS were 49 (5) years and 10.5 (4.6), respectively. Fourteen (70%) had a CT to treat tPTX, which had been removed 19 hours (range, 4-43 hours) before the study. No subject complained of any cardiorespiratory symptoms while at altitude. Radiographic increase in tPTX size at altitude was 5.6 (0.61) mm from preflight CXR. No subject developed a tension tPTX. No subject required procedural intervention during the flight. Four hours after the study, all tPTX had returned to baseline size. CONCLUSION: Patients with recently treated tPTX have a small increase in the size of tPTX when subjected to simulated altitude. This is clinically well tolerated. Current prohibitions regarding air travel following traumatic tPTX should be reconsidered and further studied. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Rib plating of acute and sub-acute non-union rib fractures in an adult with cystic fibrosis: a case report.

BACKGROUND: Rib fractures associated with osteoporosis have been reported to occur ten times more frequently in adults with cystic fibrosis. Fractures cause chest pain, and interfere with cough and sputum clearance leading to worsened lung function and acute exacerbations which are the two main contributors to early mortality in cystic fibrosis. Usual treatment involves analgesics and time for healing; however considerable pain and disability result due to constant re-injury from chronic repetitive cough. Recently, surgical plating of rib fractures has become commonplace in treating acute, traumatic chest injuries. We describe here successful surgical plating in a White cystic fibrosis patient with multiple, non-traumatic rib fractures. CASE PRESENTATION: A-37-year old White male with cystic fibrosis was readmitted to Intermountain Medical Center for a pulmonary exacerbation. He had developed localized rib pain while coughing 2 months earlier, with worsening just prior to hospital admission in conjunction with a "pop" in the same location while bending over. A chest computerized tomography scan at admission demonstrated an acute 5th rib fracture and chronic non-united 6th and 7th right rib fractures. An epidural catheter was placed both for analgesia and to make secretion clearance possible in preparation for the surgery performed 2 days later. Under general anesthesia, he had open reduction and internal fixation of the right 5th, 6th and 7th rib fractures with a Synthes Matrix rib set. After several days of increased oxygen requirements, fever, fluid retention, and borderline vital signs, he stabilized. Numerical pain rating scores from his ribs were lower post-operatively and he was able to tolerate chest physical therapy and vigorous coughing. CONCLUSIONS: In our case report, rib plating with bone grafting improved rib pain and allowed healing of the fractures and recovery, although the immediate post-op period required close attention and care. We believe repair may be of benefit in selected cystic fibrosis patients, such as our patient who had suffered multiple rib fractures that were healing poorly.

Medial scapular winging associated with rib fractures and plating corrected with pectoralis major transfer.

INTRODUCTION: Rib plating is becoming increasingly common as a method for stabilizing a flail chest resulting from multiple rib fractures. Recent guidelines recommend surgical stabilization of a flail chest based on consistent evidence of its efficacy and lack of major safety concerns. But complications of this procedure can occur and are wide ranging. PRESENTATION OF CASE: We report an interesting case of a 58-year-old male patient that worked as a long-distance truck driver and had a flail chest from multiple bilateral rib fractures that occurred when his vehicle was blown over in a wind storm. He underwent open reduction with internal fixation (ORIF) of the bilateral rib fractures and they successfully healed. However, he had permanent long thoracic nerve injury on the side with the most severe trauma. This resulted in symptomatic scapular winging that impeded him from long-distance truck driving. The scapular winging was surgically corrected nearly two years later with a pectoralis major transfer augmented with fascia lata graft. The patient had an excellent final result. DISCUSSION: We report this case to alert surgeons who perform rib fracture ORIF that long thoracic nerve injury is a potential iatrogenic complication of that procedure or might be a result of the chest wall trauma. CONCLUSION: Although the specific cause of the long thoracic nerve injury could not be determined in our patient, it was associated with chest wall trauma in the setting of rib fracture ORIF. The scapular winging was surgically corrected with a pectoralis major transfer.

A role in trauma care for advanced practice clinicians.

Advanced practice clinicians (APCs) are increasingly being utilized to care for patients on trauma services, but the quality of care provided by these alternate delivery models has been questioned. We hypothesized that APCs could safely administer trauma care that had traditionally been provided by surgical residents. Outcomes from an APC trauma-care delivery model were compared with those reported in the National Trauma Data Bank (NTDB). Parameters included in the comparison were mechanism of injury (MOI), length of hospital stay (LOS), injury severity score (ISS), and mortality. When MOI was used as the basis of comparison, the percentage of patients treated at the trauma center and the percentage of patients with information in the NTDB were similar. Despite having more seriously injured patients, the APC-staffed trauma center demonstrated a shorter LOS for all ISS categories; comparisons of patients with ISS >24 did not reach statistical significance. In addition, the APC-staffed trauma center had a statistically lower overall combined mortality rate when categorized by ISS. We conclude that an APC trauma-care delivery model provides outcomes at least as good as those reported by the NTDB.