Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society

BACKGROUND

Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.

METHODS

Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.

RESULTS

Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.

CONCLUSION

We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level IV.

Revision of the AAST grading scale for acute cholecystitis with comparison to physiologic measures of severity

BACKGROUND

Grading systems for acute cholecystitis are essential to compare outcomes, improve quality, and advance research. The American Association for the Surgery of Trauma (AAST) grading system for acute cholecystitis was only moderately discriminant when predicting multiple outcomes and underperformed the Tokyo guidelines and Parkland grade. We hypothesized that through additional expert consensus, the predictive capacity of the AAST anatomic grading system could be improved.

METHODS

A modified Delphi approach was used to revise the AAST grading system. Changes were made to improve distribution of patients across grades, and additional key clinical variables were introduced. The revised version was assessed using prospectively collected data from an AAST multicenter study. Patient distribution across grades was assessed, and the revised grading system was evaluated based on predictive capacity using area under receiver operating characteristic curves for conversion from laparoscopic to an open procedure, use of a surgical "bail-out" procedure, bile leak, major complications, and discharge home. A preoperative AAST grade was defined based on preoperative, clinical, and radiologic data, and the Parkland grade was also substituted for the operative component of the AAST grade.

RESULTS

Using prospectively collected data on 861 patients with acute cholecystitis the revised version of the AAST grade has an improved distribution across all grades, both the overall grade and across each subscale. A higher AAST grade predicted each of the outcomes assessed (all p ≤ 0.01). The revised AAST grade outperformed the original AAST grade for predicting operative outcomes and discharge disposition. Despite this improvement, the AAST grade did not outperform the Parkland grade or the Emergency Surgery Score.

CONCLUSION

The revised AAST grade and the preoperative AAST grade demonstrated improved discrimination; however, a purely anatomic grade based on chart review is unlikely to predict outcomes without addition of physiologic variables. Follow-up validation will be necessary.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level IV.

The influence of damage distribution on serious brain injury in occupants in frontal motor vehicle crashes

In spite of improvements in motor vehicle safety systems and crashworthiness, motor vehicle crashes remain one of the leading causes of brain injury. The purpose of this study was to determine if the damage distribution across the frontal plane affected brain injury severity of occupants in frontal impacts. Occupants in "head on" frontal impacts with a Principal Direction of Force (PDOF) equal to 11, 12, or 1o'clock who sustained serious brain injury were identified using the Crash Injury Research Engineering Network (CIREN) database. Impacts were further classified based on the damage distribution across the frontal plane as distributed, offset, and extreme offset (corner). Overall, there was no significant difference for brain injury severity (based on Glasgow Coma Scale<9, or brain injury AIS>2) comparing occupants in the different impact categories. For occupants in distributed frontal impacts, safety belt use was protective (odds ratio (OR)=0.61) and intrusion at the occupant's seat position was four times more likely to result in severe (Glasgow Coma Scale (GCS)<9) brain injury (OR=4.35). For occupants in offset frontal impacts, again safety belt use was protective against severe brain injury (OR=0.25). Possibly due to the small number of brain-injured occupants in corner impacts, safety belts did not significantly protect against increased brain injury severity during corner impacts. This study supports the importance of safety belt use to decrease brain injury severity for occupants in distributed and offset frontal crashes. It also illustrates how studying "real world" crashes may provide useful information on occupant injuries under impact circumstances not currently covered by crash testing.

Plunging ranula as a complication of intraoral removal of a submandibular sialolith

Mucous cysts in the submandibular region--so-called 'plunging' ranula--are relatively uncommon. We report a case of a plunging ranula that complicated excision of an intraductal sialolith of the submandibular gland.

[Comparison of echograms by a microscanner and histological findings of the common bile duct, in vitro study]

To confirm the relationship between the layer structure of the common bile duct by a microscanner (MS) and its histological features, we performed a study using the pinning method with needles and catgut. The locations of 67 needles inserted at random depths in 29 slices of the resected common bile duct from 18 patients were confirmed both by a MS and a microscope. The wall of the common bile duct was delineated as a two- (42 points) or three-layer structure (25 points); "low and high" or "high, low, and high echoic layers" from the mucosal side. A fibrotic layer (ss 1) was often (56/67 points, 16/18 patients) seen in the subserosa (ss) containing nerves and vessels larger than 100 mu in diameter. Among the 51 needle echoes demonstrated in the inner hypoechoic layer, 2 were located in the mucosa (m), 12 in the fm, 19 in the af, 17 in the ss 1, and 1 in the fatty layer of the ss (ss 2). Five of the 6 needles in the outer hyperechoic layer were in the ss 2, and 1 was in the pancreatic parenchyma (pa). Four of the 8 needles at the border between the inner hypoechoic layer and the outer hyperechoic layer histologically corresponded to fm, af, ss 1, and pa, respectively, and the other four corresponded to ss 2. From these results, we conclude that the inner hypoechoic layer contains not only m, fm, and af, but also ss 1. Therefore, this should be kept in mind for the preoperative assessment of the depth of bile duct carcinoma by MS.

[Ultrasonographic study of rectal carcinoid tumors]

To compare intraluminal ultrasonographic (ILUS) findings with histological findings of rectal carcinoid tumors, 35 patients with rectal carcinoid tumors were reviewed. The results were as follows: 1) The rectal wall was visualized as a seven- or nine-layer structure by means of ILUS in 81% of the patients. 2) The possibility that the thin hyperechoic third layer above the tumor on ILUS corresponds to the muscularis mucosae and fibrointerstitium above the tumor histologically. 3) In cases with relatively high internal echoes, the amount of fibrointerstitium exceeded that of tumor cells histologically. 4) In cases with nonuniform internal echo patterns, tumor cells were separated by thick fibrointerstitium forming nodular nests.

[Diagnosis of superficial-type early carcinoma of the gallbladder by endoscopic ultrasonography--comparison with ultrasonography]

The detectability of superficial-type carcinoma of the gallbladder by ultrasonography (US) and endoscopic ultrasonography (EUS) were investigated. Eight patients with such carcinoma of the gallbladder were reviewed. They had undergone both US and EUS previous to surgery. The tumor was detected in 3 patients by US, 2 patients with IIa + IIb-type carcinoma and 1 patient with IIa-type carcinoma. Those lesions were visualized as localized thickening of the gallbladder wall or as broad-based tumor. In 2 patients, lesions were not initially detected by US, but were shown by US after the examination by EUS. The tumor was detected by EUS also in 1 case of IIb + IIa-type carcinoma besides those 3 patients mentioned above. All four of these lesions were visualized as broad-based tumor by EUS. It was difficult to detect pure IIb-type or small IIa-type carcinoma even by EUS. In patients with concomitant acute cholecystitis or gallbladder stone, it was difficult to evaluate the abnormal findings of the gallbladder wall.

Expression of S-100 protein and glial fibrillary acidic protein in cultured submandibular gland epithelial cells and salivary gland tissues. Histogenetic implication for salivary gland tumors

S-100 protein and glial fibrillary acidic protein (GFAP) were studied in human salivary gland tissues and human cultured submandibular gland epithelial cells. Immunohistochemically, ductal cells in normal salivary gland tissues were positive for S-100 protein and GFAP, but myoepithelial cells were uniformly negative. Immunocytochemically, cultured submandibular gland ductal cells were positive for S-100 protein and GFAP. By immunoblotting analysis of the cultured cell lysates, a 6.5-kd S-100 protein was detected. This band corresponded to S-100 protein purified from bovine brain. The cultured submandibular gland cells expressed 49- and 54-kd GFAP polypeptides. These results have important implications for the histogenesis of salivary gland tumors.

Should Critical Care Medicine be a Formal Part of the Undergraduate Curriculum?

Medical students were surveyed shortly after completing the third year of medical school. The survey was designed to identify those areas of critical care medicine students had been exposed to and expressed interest in learning more about. In addition, the surveys sought to discern the level of confidence students felt with respect to different critical illnesses and intensive care unit (ICU) therapeutic modalities. Finally, the students were asked their opinion regarding the possibility or need for critical care medicine as part of their medical school curriculum. The three most common topics of interest among medical students who had recently finished their third year in medical school were shock, hemodynamic monitoring, and mechanical ventilation. Less than 30% of the students surveyed felt “better-than-average” confidence on any one of a number of critical care topics and treatment modalities. Of the 80% of students (n = 70) who completed the survey, 91% (n = 64) felt that critical care medicine should be made a part of the medical school curriculum, 6% (n = 4) felt it should not, and 3% (n = 2) were undecided. The survey results and the finding that most of the relevant literature acknowledges the need for critical care medicine in medical school has led us to conclude that a national core clerkship or a didactic lecture series in critical care medicine should be carefully designed and implemented into the undergraduate curriculum.

Orotracheal intubation in trauma patients with cervical fractures

OBJECTIVE

To evaluate orotracheal intubation with in-line stabilization of the cervical spine for emergency airway treatment of trauma patients with cervical spine injuries.

DESIGN

Of 7518 trauma patients examined, 81 patients with cervical spine injuries received emergency orotracheal intubation. All intubations were performed by experienced anesthesiologists, with a separate individual maintaining in-line stabilization. Neurologic examination was documented before and after intubation.

RESULTS

Peripheral neurologic deficit was present from the outset in 20 patients. There were unstable cervical fractures in 38 patients with no neurologic deficit. Twenty-three patients were neurologically intact with fractures that were later judged stable. In no instance was there a deterioration of neurologic status following intubation. Peripheral neurologic deficits improved after intubation in four patients.

CONCLUSION

Orotracheal intubation, performed with manual in-line stabilization by trained and experienced personnel, is a safe emergency procedure in patients with cervical fractures.

Tumor necrosis factor and monocytes are released during hemorrhagic shock

Tumor necrosis factor (TNF) is a key mediator involved in many physiologic processes including immunity, inflammation, and metabolism. A relationship between TNF and hemorrhagic shock has not been clearly demonstrated. To help understand the role of TNF in hemorrhagic shock we developed a hemorrhagic shock model to measure TNF and monocyte levels during hemorrhage and resuscitation. Male Sprague-Dawley rats were anesthetized and subjected to a 50% blood loss (30 ml/kg) over 2 min and left in shock for 58 min. The animals were then resuscitated with two times blood loss (60 ml/kg) using lactated Ringers over 1 h. This model results in 75% mortality within 3 days (LD 75). Blood samples (2 ml) were obtained at intervals during shock and resuscitation, and assayed for TNF concentrations and white blood cell counts. Despite a marked fall in total leukocytes (24,600 pre-hemorrhage to 11,300 post-hemorrhage, P < 0.005), monocytes increased in percentage and in total count. Blood levels of TNF were initially undetectable but rose within 10 min after hemorrhage, peaked at 30 min after hemorrhage, and then became undetectable during resuscitation. In this model, macrophages and TNF are released into the circulation after hemorrhagic shock. TNF may play a role as a mediator in the pathophysiology of hemorrhagic shock.

Pneumatosis intestinalis associated with needle catheter jejunostomy tubes: CT findings and implications

The CT findings of pneumatosis intestinalis (PI) associated with needle catheter jejunostomy tubes (NCT) are described in two patients. Each case had cyst-like intramural gas collections associated with the NCT. Neither case had focal bowel wall thickening or portal or mesenteric free air, and there was no evidence of intestinal necrosis. Our findings suggest that cyst-like intramural gas collections associated with NCT represent a benign form of PI.

Superoxide dismutase polyethylene glycol improves survival in hemorrhagic shock

Oxygen free radicals are known to form after reperfusion of ischemic tissue. To test the role and importance of oxygen free radicals in hemorrhagic shock, an animal model of hemorrhagic shock and resuscitation was utilized. Sprague-Dawley rats were anesthetized with halothane and then subjected to approximately 50 per cent blood volume hemorrhage (30 cc/kg), followed by a 60 min shock period. Resuscitation was performed over 1 hour with lactated ringers (LR) at a volume of two times blood loss (60 cc/kg). This model results in a survival rate of 25 per cent over 72 hrs. Using this model, animals were randomized to receive either LR, Superoxide Dismutase-Polyethylene Glycol (SOD-PEG) (15,000 units/kg) with LR or Catalase-Polyethylene Glycol (CAT-PEG) (175,000 units/kg) with LR. The group treated with SOD-PEG demonstrated significantly increased survival rates vs the group treated with LR (67% vs 25%, P = 0.02). The group treated with CAT-PEG demonstrated no significant improvement in survival when compared to the LR-treated group (20% vs 24%). These data suggest that treatment directed toward oxygen free radicals and reperfusion injury may play an important role in hemorrhagic shock resuscitation.

Hemodynamic and oxygen transport effects of pentastarch in burn resuscitation

If nonprotein colloid plasma expanders could be demonstrated to be safe and efficacious in burn resuscitation, a significant cost benefit would result. This study was a randomized cross-over comparison of 500 ml of 5% albumin and 500 ml of 10% pentastarch, a new hydroxyethyl starch, in acute burn resuscitation. Pentastarch was an effective plasma expander, resulting in increases of preload, cardiac output, oxygen delivery, and oxygen consumption; the hemodynamic effects of pentastarch infusion were equal or superior to those of albumin. Both albumin and pentastarch infusions resulted in increased bleeding and clotting times; these effects were most likely dilutional. Pentastarch is a promising plasma substitute for burn resuscitation; the effects of a 500 ml infusion are equal or superior to those of albumin. Further study is necessary to assess the safety of larger infusion volumes.

Pentoxifylline improves survival following hemorrhagic shock

Pentoxifylline is an agent which improves microcirculatory blood flow, but its use as therapy for shock has not been reported. We performed this study to determine if pentoxifylline improves survival following experimental hemorrhagic shock. Anesthetized Sprague-Dawley rats were studied; the animals were subjected to hemorrhage and then resuscitated using lactated Ringer's solution, with either placebo or pentoxifylline added by random selecting. Animals were then observed for 3 days. There was significantly increased survival in pentoxifylline-treated animals (p less than .05). In additional experiments, animals received more aggressive fluid resuscitation; improved survival in the pentoxifylline group was noted almost immediately and persisted through the 72-h period. This was significant at the p less than .01 level. We conclude that pentoxifylline improves survival from hemorrhagic shock in this experimental model, and has additive survival value to fluid resuscitation.

Protective effect of pentoxifylline on gastric mucosa

Pentoxifylline (PF) has been shown to increase tissue oxygen tension. This study was performed to determine if PF has a protective effect on the gastric mucosa against alcohol (EtOH)-induced injury. Fasted Sprague-Dawley rats were pretreated with randomized test solution (control, normal saline, or PF, 75 mg/kg) intraperitoneally (ip). At 30 min, 100% EtOH (pH 8.5) was given intragastric. At 90 min, laparotomy was performed and gastric serosal stomach surface oxygen tensions (pO2) were measured. Stomachs were excised and opened and pH was measured. Photographs were taken and sections were obtained for histologic analysis to determine mucosal injury. The PF-pretreated rats had significantly higher serosal pO2 and significantly lower intragastric pH than control animals. There was significantly less gross and histologic mucosal injury in PF-treated animals. We conclude that PF is protective against EtOH gastric mucosal injury. This effect correlates with increased gastric serosal pO2 and is likely due to improved microcirculatory blood flow following PF administration.

Laser Doppler velocimetry in critically ill patients

Cutaneous blood flow may be an indirect measure of circulatory function estimated by continuous, noninvasive laser Doppler velocimetry (LDV). It has been postulated that LDV may be a useful monitor of cardiac output changes. To test this hypothesis, LDV was evaluated in 67 critically ill adult patients with simultaneous measurements of cardiac index (CI) and other physiologic variables. Heated and unheated laser probes were utilized. The results indicate that LDV reflects acute directional changes of CI. Further, with the heated laser probe, the magnitude of acute CI change is reflected. However, there are gradual changes over time of LDV which may occur independently of CI or other monitored variables. Hence, absolute LDV values are not predictive of absolute CI values.

Pentoxifylline improves tissue oxygenation after hemorrhagic shock

This randomized and blinded study was performed to determine whether pentoxifylline significantly improves tissue oxygenation after hemorrhagic shock. Hepatic surface oxygen tension was measured in anesthetized rats before and after hemorrhage. Rats were then randomly assigned to either a placebo group (n = 21) receiving 1 ml of intravenous saline solution or to a treatment group (n = 23) receiving intravenous 25 mg/kg of pentoxifylline in 1 ml of saline solution. Investigators were blinded as to which solution was injected. Five minutes after injection of pentoxifylline, there was significant increase in hepatic surface oxygen tension; this increase persisted throughout 1 hour of observation and was significantly greater than in placebo-treated animals. Further study of the effects of pentoxifylline on tissue perfusion and oxygenation after hemorrhagic shock is warranted.

Pulmonary complications after Fluosol administration to patients with life-threatening blood loss

Fluosol-DA 20% (Fluosol), a perfluorochemical emulsion capable of improving oxygen transport, was used to treat three patients with life-threatening hemorrhage. In each case a decreased partial pressure of oxygen, an increased alveolar-arterial oxygen gradient, fever, an increased white blood cell count, and chest x-ray abnormalities occurred at similar time intervals after treatment with Fluosol. In one patient, pulmonary complications were fatal. Similar adverse reactions to treatment with Fluosol have not been previously reported. Possible explanations for these pulmonary complications are the adult respiratory distress syndrome, oxygen toxicity, or direct toxic effects of Fluosol.

Development of gallstone pancreatitis. The role of the common channel

Whether bile reflux through a common channel into the pancreatic duct is a causative factor in the development of gallstone pancreatitis is controversial. To address this issue, we have reviewed a consecutive series of cholecystectomies performed with intraoperative cholangiograms. The cholangiograms and the patients' charts were reviewed independently to determine the incidence of a common channel in patients both with and without pancreatitis and to analyze their clinical courses. The group of patients who had pancreatitis showed a common channel in 19 (90%) of 20 cases, while those patients who did not have pancreatitis showed a common channel in 23 (35%) of 66 cases. The patients who had pancreatitis were less likely to have choledocholithiasis than were those patients who did not have pancreatitis, and these patients were less likely to require exploration of the common bile duct.