Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR.

METHODS

A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able.

RESULTS

Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home.

CONCLUSION

Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed.

LEVEL OF EVIDENCE

Therapeutic, Level V.

Surgical stabilization of rib fractures in symptomatic COVID-19: A case report

Severe chest wall injury following trauma is a significant contributing factor to respiratory failure and need for mechanical ventilation in multiply injured patients. Surgical stabilization of rib fractures (SSRF) is increasingly considered to be advantageous in this population. Surgical stabilization has been shown to improve multiple outcomes including ventilator avoidance, liberation from mechanical ventilation, and diminished pulmonary complications in the trauma population, particularly when performed early. During the coronavirus disease 2019 (COVID-19) pandemic, ventilators have become a scarce resource, and conservative strategies have become a critical component of intensive care. We present a report of the perioperative outcome of SSRF in a geriatric polytrauma patient who initially presented after a mechanical fall and co-existing symptomatic COVID-19.

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