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Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion
American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion☆ Yuan Zhang, MD, Xue Tang, MD, Hui Xie, MD, Rui Lan Wang, MD, PhD ⁎ Department of Emergency and Intensive Care Unit, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
a r t i c l e
i n f o
Article history: Received 23 December 2014 Received in revised form 5 April 2015 Accepted 6 April 2015 Available online xxxx
a b s t r a c t Objective: The objective of this study is to compare the clinical efficacy of surgical fixation and nonsurgical management of flail chest and pulmonary contusion (FC-PC) and to compare the diverse timings of surgery to discuss case management in FC-PC. Methods: The data of 39 patients diagnosed with FC-PC were obtained from the intensive care unit of Shanghai First People's Hospital and analyzed retrospectively from July 2010 to Dec 2013. The patients required ventilator support and were divided into a surgical group and a nonsurgical group, according to the treatment method. The clinical data, such as mortality, the duration of mechanical ventilation (DMV), intensive care unit length of stay, hospital length of stay (HLOS), days of antibiotic use, transfusion volume, medical expense as well as the incidence of tracheotomy, pleural effusion, and incidence of ventilator associated pneumonia, were collected for all subjects. The surgical group was further divided into 2 groups according to the surgery timing. Surgery within 7 days of admission was defined as early surgery, and all other times were defined as late surgery. The clinical data and incidence of incision infection were collected and compared. Results: The patients in the surgical group had a slightly shorter HLOS. No differences were noted in mortality and the other clinical data between the groups. The early surgical group had a shorter DMV and less incidence of tracheotomy. The other parameters had no differences. Conclusions: Surgery for FC-PC could reduce the HLOS, and early surgery could decrease the DMV and the need for tracheotomy. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Blunt chest injury is a common trauma that accounts for 10% of the total trauma cases in emergency departments worldwide. The mortality rate is 4% to 20% [1]. Flail chest (FC), which defines multiple adjacent ribs broken in multiple places, is the most serious chest injury, and it damages the chest wall integrity and causes "paradoxical motion" from the detachment of a segment from the rest of the chest wall (Fig. 1). Pulmonary contusion (PC) is the most common chest injury (Fig. 2). These conditions frequently exist at the same time. Currently, a deeper understanding of FC pathophysiology exists, and its management has evolved substantially over the past 6 decades. The earliest treatment for FC was surgery. With the increasing technological advancements available in the intensive care unit (ICU), conservative management, based on mechanical ventilation supplemented with intensive pain control, has become more common [2]. Using positive airway pressure to reduce the asynchronous movement of FC could avoid surgical risks and postoperative complications. Conservative treatment
☆ There is no source of support in this study. ⁎ Corresponding author at: 650 Xin-Songjiang Road, post code 201620, Shanghai, China. Tel.: +86 21 37798528; fax: +86 21 37798527. E-mail address: [email protected] (R.L. Wang).
has been administered frequently in previous years. A growing number of researchers have found that surgery for FC could reduce the duration of mechanical ventilation (DMV), the ICU length of stay (ICULOS), the hospital length of stay (HLOS), the incidence of pneumonia and tracheostomy, and mortality. Additional benefits included decreased doses of analgesic and sedative drugs and avoidance of thoracic deformity, and patients could return to previous employment quicker than could those treated conservatively [3-10]. Although patients could incur additional costs, surgery remains the most cost-effective strategy because it could avoid the risks of pneumonia and reduce the length of stay (LOS) days [11]. However, some researchers have disagreed with the current practice and have considered that the studies in support of surgery were predominantly small, single center, and retrospective, with nonrandom patient selection [4,6,7,10]. These conclusions are neither persuasive nor convincing. Nirula et al [12] found that the ICULOS and total HLOS were similar for the surgical and nonsurgical groups in a matched case-control study. Although several meta-analyses have supported surgery [8,9], the Eastern Association for the Surgery of Trauma suggested that improvement in any outcome parameter has not been definitely shown after surgical fixation of FC, and limited studies were found concerning the timing of the surgery [13]. We retrospectively investigated the patients with FC and PC (FC-PC) who were admitted to our ICU to compare the clinical efficacy of surgical fixation and nonsurgical management as well as the diverse timings of the surgery.
http://dx.doi.org/10.1016/j.ajem.2015.04.005 0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Zhang Y, et al, Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.005
2
Y. Zhang et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
2. Methods We retrospectively analyzed all the patients with FC-PC admitted to the ICU in Shanghai First People's Hospital from July 2010 to December 2013 to determine the clinical effects of different management procedures for FC-PC. The human research ethics committee of Shanghai First People's Hospital approved this clinical study. 2.1. Inclusion and exclusion criteria We screened all the ICU patients diagnosed with FC-PC. The inclusion criteria were (1) age older than 16, (2) multiple rib fractures and PC confirmed by 3-dimensional computed tomography imaging, (3) paradoxical movement in the physical exam, and (4) requirement for mechanical ventilation. The exclusion criteria were (1) age older than 80 or younger than 16, (2) combined spine injury or other fracture that precluded a proper surgical position, (3) combined severe brain injury that caused prolonged DMV because of central nerve system damage, (4) other conditions that exclude the use of general anesthesia, and (5) an uncorrected coagulopathy disorder that would exclude the patient from surgery. There were 39 patients, according to the above criteria. Informed consent was obtained from the patients or their lineal relatives after our explanations of the study. 2.2. Group definitions The patients were divided into a surgical group and a nonsurgical group according to the therapeutic approach taken in each case. The patients who underwent open fixation of the fractured ribs were in the surgical group, and the remaining patients were in the nonsurgical group. The surgical group was further divided into an early surgical group (surgery performed within 7 days after admission) and a late surgical group (surgery performed after 7 days). 2.3. Measured parameters We collected the patient demographic characteristics such as the sex, age, number of fractured ribs, Apache Physiology And Chronic Health Evaluation (APACHE II) score, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, and combined injuries. The primary outcome parameter was mortality. The secondary outcome parameters were the DMV, ICULOS, HLOS, days of antibiotic use, transfusion volume, medical expense, incidence of tracheotomy,
Fig. 1. Multiple rib fractures. Three-dimensional computed tomography showing multiple adjacent ribs fractured in multiple places, fracture of the left fourth through 10th ribs. The displacement of the rib fractures was obvious.
Fig. 2. Pulmonary contusion. Computed tomographic imaging showing PC and pneumothorax involving the left lobe of the lung, and there was subcutaneous emphysema on the left side. The bright spots are the implanted bone plates.
incidence of pleural effusion, incidence of ventilator associated pneumonia (VAP), and incision infection. 2.4. Statistical analysis Because the number of patients included was small, the data were considered to be non-normally distributed. The continuous variables were compared using nonparametric tests and were reported as the median (25%, 75%). The group comparisons of the categorical variables
Table 1 Comparison of the demographic characteristics and combined injuries of the surgical and nonsurgical groups
Sex Male Female Age No. of fractured ribs APACHE II score ISS GCS Combined injuries ARDS Hemorrhagic shock Pneumothorax Pleural effusion Sternum fracture Scapula fracture Clavicle fracture Femoral fracture Other fracture Pelvic fracture Transverse/spinous process fracture Blunt liver/spleen Head trauma Diaphragmatic hernia
Surgical group (n = 24)
Nonsurgical group (n = 15)
72.9% (19/24) 20.8% (5/24) 42.5 (34, 49.5) 11.5 (8, 15.25) 7 (5, 14) 38 (34, 43) 15 (14, 15)
93.3% (14/15) 6.7% (1/15) 47 (35, 55) 11 (7, 16) 9 (6, 19) 38 (35, 43) 14 (6, 15)
P .376
.544 .948 .125 .699 .079
1 (4.2%) 2 (8.3%) 18 (75%) 16 (66.7%) 5 (20.8%) 9 (37.5%) 6 (25%) 6 (25%) 7 (29.2%) 5 (20.8%) 6 (25%)
0 2 (13.3%) 9 (60%) 7 (46.7%) 1 (6.7%) 4 (26.7%) 4 (26.7%) 5 (33.3%) 2 (13.3%) 6 (40%) 7 (46.7%)
1.000 .631 .478 .318 .376 .728 1.000 .718 .437 .277 .185
8 (33.3%) 7 (29.2%) 2 (8.3%)
7 (46.7%) 5 (33.3%) 3 (20%)
.505 1.000 .354
Abbreviation: ARDS, acute respiratory distress syndrome.
Please cite this article as: Zhang Y, et al, Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.005
Y. Zhang et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx Table 2 Comparison of the demographic characteristics of the early surgical and late surgical groups
Sex Male Female Age No. of fractured ribs APACHE II score ISS GCS
Early surgical (n = 12)
Late surgical (n = 12)
75% (9/12) 25% (3/12) 38 (31.25, 47) 11 (7.75, 16.25) 7 (5, 14) 38 (34, 38) 15 (14.25, 15)
83.3% (10/12) 16.7% (2/12) 45.5 (41, 61.5) 12 (8.25, 15) 7 (4.25, 15.5) 42 (35, 43) 14.5 (11.5, 15)
P 1.000
.057 .974 .908 .193 .121
were made using Fisher exact test, and P b .05 was considered statistically significant. All the statistical analysis was performed with SPSS 20.0 (SPSS, Chicago, IL).
3. Results A total of 39 patients were identified according to the criteria. There were 24 patients in the surgical group and 15 patients in the nonsurgical group as well as 12 patients in the early surgical group and 12 patients in the late surgical group.
3.1. Patient characteristics There were no differences between the surgical group and the nonsurgical group in sex, age, number of ribs fractured, APACHE II score, ISS, GCS, and all types of combined injuries. The 2 groups were comparable (Table 1). There was also no difference between the early and late surgical groups in sex, age, number of ribs fractured, APACHE II score, ISS, and GCS (Table 2).
3.2. Clinical outcomes The 24 patients in the surgical group survived, whereas 2 patients in the nonsurgical group died. However, there was no significant difference in mortality. The surgical group had slightly shorter HLOS (38 days [33, 54.25] for the surgical group vs 60 days [38, 99.75] for the nonsurgical group, P = .049). The other measured parameters had no significant difference (Table 3). The early surgical group had shorter DMV (8 days [2.25, 12.75] for the early surgical group vs 15.5 days [11.25, 19.5] for the late surgical group, P = .016) and less incidence of tracheotomy (odds ratio, 0.111; 95% confidence interval, 0.018-0.705; P = .039]. The other measured parameters had no significant difference (Table 4).
3
4. Discussion Flail chest and pulmonary contusion occurs at a rate of approximately 15 per 10000 patients in America. According to this ratio, 1 or 2 patients are admitted to each level I or II trauma center per month [14], which is similar to the rate of management of FC-PC in our ICU. The treatment strategy primarily includes mechanical ventilation with positive end-expiratory pressure, aggressive pain control, and surgical fixation to rebuild the chest wall integrity. The debate continues to focus on whether to treat the patient conservatively with mechanical ventilation or whether to perform surgical fixation of the ribs. There are positive and negative aspects in both management strategies. Thoracic integrity could be restored in a short time after surgical fixation, avoiding restrictive lung ventilation, and thoracic movement would be stable and without malunion. Previous literature has shown that stability after surgery could reach 87.5% to 100% [15-17], which coincides with our study. Our results showed 91.9% stability (22/24). The general anesthesia required for the surgery is a great risk for patients with severe multiple trauma, and some patients could not tolerate the procedure. The surgery is a difficult and time- and effort-consuming procedure. The additional dissection of the muscle is a second trauma for the patients, and the pain caused by the surgery is severe. The foreign implantation could easily cause connective tissue infection [18]. In our study, 6 of the 24 surgery patients had an incision infection that led to prolonged HLOS and antibiotic administration. The surgical procedure is dangerous for patients who are in an unstable condition. Using conservative management could stabilize the chest wall and relieve respiratory failure without imposing any additional stress on the patients but ensuring the possibility of treating other combined injuries simultaneously [19]. Conservative management has limitations. Progressive rib displacement could occur with conservative treatment and could lead to malunion. Thus, thoracic expansion would be limited, and ventilation would be decreased [5]. Another disadvantage is that mechanical ventilation could easily cause VAP. Long-term intravenous administration of sedatives is harmful to the liver and could result in jaundice [19] or affect patient consciousness. In the previous 10 years, surgical fixation has been increasingly supported by studies worldwide. In 2013, Slobogean et al [9] suggested in a meta-analysis that surgery for FC could reduce the DMV and ICULOS as well as the incidence of pneumonia, mortality, sepsis, and tracheostomy. A meta-analysis by Leinicke et al [8] showed that surgical fixation could decrease the DMV, ICULOS, and HLOS and reduce mortality, the incidence of pneumonia and the requirement for a tracheotomy. Although surgery is more expensive, it is the most cost-effective strategy because it decreases the incidence of VAP [11]. In our study, we found that surgical fixation could reduce the HLOS. The other parameters showed no difference between the surgical and nonsurgical groups. We found that the number of patients included was small, with heterogeneous timing of the surgeries. In addition, multiple trauma patients had different combined injuries that could have
Table 3 Comparison of the clinical outcomes of the surgical and nonsurgical groups
Mortality DMV ICULOS HLOS Antibiotic use (d) RBC trans (u) Plasma trans (u) Expense Tracheotomy Pleural effusion VAP
Surgical group (n = 24)
Nonsurgical group (n = 15)
OR (95%CI)
P
0 12 (7.5, 17.75) 24.5 (21.25, 30.75) 38 (33, 54.25) 30 (26, 36.5) 4 (0.25, 13.75) 12 (2,18) 241667 (189567, 290195) 12 (50%) 3 (12.5%) 16 (66.7%)
2 (13.3%) 7 (4, 14) 21.5 (18, 33.5) 60 (38, 99.75) 36.5 (25.5, 41) 8 (0,18) 15 (0, 24) 182632 (97177, 270052) 7 (46.7%) 1 (6.7%) 7 (46.7%)
–
.142 .233 .719 .049⁎ .472 .520 .450 .053 1.000 1.000 .318
1.143 (0.314-4.160) 2 (0.188-21.225) 2.286 (0.609-8.579)
Abbreviations: OR, odds ratio; CI, confidence interval; RBC, red blood cell; trans, transfusion. ⁎ The surgical group has shorter HLOS than the nonsurgical group, P b .05.
Please cite this article as: Zhang Y, et al, Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.005
4
Y. Zhang et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Table 4 Comparison of the clinical outcomes of the early surgical and late surgical groups
Mortality DMV ICULOS HLOS Antibiotic use (d) RBC trans (U) Plasma trans (U) Expense Tracheostomy Pleural effusion VAP Incision infection
Early surgical group (n = 12)
Late surgical group (n = 12)
OR (95%CI)
P
0 8 (2.25, 12.75) 21.5 (12.75, 30.75) 38.5 (31.5, 48.75) 30 (25.75, 42) 5 (0, 8.75) 12 (0.5, 18.75) 207341 (169501, 314051) 3 (25%) 2 (16.7%) 7 (58.3%) 3 (25%)
0 15.5 (11.25, 19.5) 26 (23.25, 32.25) 37 (33, 56.75) 30 (26, 33) 3 (1.25, 17) 10 (3.5, 17.75) 261236 (193905, 288869) 9 (75%) 1 (8.3%) 9 (75%) 3 (25%)
–
– .016⁎ .088 .862 .724 .705 .642 .299 .039⁎ 1.000 .667 1.000
0.111 (0.018-0.705) 2.2 (0.172-28.137) 0.467 (0.082-2.656) 1 (0.158-6.346)
⁎ The early surgical group had a shorter DMV and lower rate of tracheotomy, P b .05.
influenced the final results. The meta-analysis by Slobogean et al and Lenicke et al did not consider PC, and the included patients had single FC instead of FC-PC cases. Their analysis did not report whether patients diagnosed as FC combined with PC could benefit from surgery. As early as 1998, Voggenreite et al [20] separately analyzed patients with FC with or without PC and found that, in patients with FC and respiratory failure without PC, surgery permits early extubation. Patients with FCPC did not benefit from surgery. The literature regarding the timing of surgery is limited. Kakegawa et al [6] suggested that patients using internal pneumatic stabilization for more than 10 days had no flail improvement and should undergo surgery. Surgery could reduce DMV and the incidence of pneumonia. Our study found that earlier surgery permitted earlier fixation of the chest wall to reduce DMV and the tracheotomy incidence. Medical institutions have not agreed on the surgical indication. Voggenreite et al [20] suggested that FC and respiratory insufficiency without PC is the indication. Most institutions and our hospital have agreed that, in single FC cases, surgery should be performed. When patients with severe FC-PC fail to wean from the ventilator or when a thoracotomy is required for other reasons, such as progressive hemothorax or intercostal vascular rupture, for which open chest surgery is needed, surgery is necessary [13,14]. Every institution is trying to determine the optimal timing for surgery. Our study has several limitations. This study is a single-center, retrospective study, and the cases included are limited. This study did not involve function tests as a parameter and had no standard score system for PC. In addition, the study does not have the follow-up information for the discharged patients because patients in our country do not typically have regular follow-ups, the time points for follow-ups were inconsistent, or patients went to a hospital near their homes for reexamination. The data comparison error would be huge if we had compared the 2 groups. We emphasized the in-hospital data in our study, particularly for the objective variables. A limited amount of data was missing in our study, which we tried to avoid, and the missing data were managed with listwise deletion by SPSS. Additional larger, multiple-center, prospective randomized controlled studies are required to determine the ideal management for FC-PC and the optimal timing for the surgery.
5. Conclusions Our experience in treating 39 patients with FC-PC showed that surgical fixation could reduce the HLOS. Early surgery permits a shorter DMV and lower incidence of tracheotomy.
Acknowledgment We thank Xue Tang for assistance with the writing and Re Na Zhou for helping in the performance of the statistical analysis. References [1] Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury 2012;43(1): 8–17. [2] Davignon K, Kwo J, Bigatello LM. Pathophysiology and management of the flail chest. Minerva Anestesiol 2004;70(4):193–9. [3] Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52(4):727–32 [discussion 32]. [4] Balci AE, Eren S, Cakir O, Eren MN. Open fixation in flail chest: review of 64 patients. Asian Cardiovasc Thorac Ann 2004;12(1):11–5. [5] Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005;4(6):583–7. [6] Kakegawa S, Kamiyoshihara M, Ohtaki A, Ohki S, Morishita Y. Surgical fixation of the ribs for flail chest injuries. Kyobu Geka 2006;59(11):974–9. [7] Marasco S, Cooper J, Pick A, Kossmann T. Pilot study of operative fixation of fractured ribs in patients with flail chest. ANZ J Surg 2009;79(11):804–8. [8] Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis. Ann Surg 2013;258(6):914–21. [9] Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg 2013;216 (2):302–11 [e1]. [10] Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Faknry SM, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care 2014;29(1):139–43. [11] Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg 2012;215(2):201–5. [12] Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg 2006;72:307–9. [13] Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward T, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73(5 Suppl. 4):S351–61. [14] Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg 2008;20(1):39–45. [15] Reber P, Ris HB, Inderbitzi R, Stark B, Nachbur B. Osteosynthesis of the injured chest wall. Use of the AO (Arbeitsgemeinschaft fur Osteosynthese) technique. Scand J Thorac Cardiovasc Surg 1993;27(3–4):137–42. [16] Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 1995;110(6): 1676–80. [17] Fabbri C, Mazieri M, Cirocchi R, Bisacci R, Cagini L. Flail chest. Minerva Chir 1996;51 (9):669–73. [18] Carbognani P, Cattelani L, Bellini G, Rusca M. A technical proposal for the complex flail chest. Ann Thorac Surg 2000;70(1):342–3. [19] Nishiumi N, Fujimori S, Katoh N, Iwasaki M, Inokuchi S, Inoue H. Treatment with internal pneumatic stabilization for anterior flail chest. Tokai J Exp Clin Med 2007;32(4):126–30. [20] Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest–outcomes of patients with or without pulmonary contusion. J Am Coll Surg 1998;187(2):130–8.
Please cite this article as: Zhang Y, et al, Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.005
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion☆ Yuan Zhang, MD, Xue Tang, MD, Hui Xie, MD, Rui Lan Wang, MD, PhD ⁎ Department of Emergency and Intensive Care Unit, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
a r t i c l e
i n f o
Article history: Received 23 December 2014 Received in revised form 5 April 2015 Accepted 6 April 2015 Available online xxxx
a b s t r a c t Objective: The objective of this study is to compare the clinical efficacy of surgical fixation and nonsurgical management of flail chest and pulmonary contusion (FC-PC) and to compare the diverse timings of surgery to discuss case management in FC-PC. Methods: The data of 39 patients diagnosed with FC-PC were obtained from the intensive care unit of Shanghai First People's Hospital and analyzed retrospectively from July 2010 to Dec 2013. The patients required ventilator support and were divided into a surgical group and a nonsurgical group, according to the treatment method. The clinical data, such as mortality, the duration of mechanical ventilation (DMV), intensive care unit length of stay, hospital length of stay (HLOS), days of antibiotic use, transfusion volume, medical expense as well as the incidence of tracheotomy, pleural effusion, and incidence of ventilator associated pneumonia, were collected for all subjects. The surgical group was further divided into 2 groups according to the surgery timing. Surgery within 7 days of admission was defined as early surgery, and all other times were defined as late surgery. The clinical data and incidence of incision infection were collected and compared. Results: The patients in the surgical group had a slightly shorter HLOS. No differences were noted in mortality and the other clinical data between the groups. The early surgical group had a shorter DMV and less incidence of tracheotomy. The other parameters had no differences. Conclusions: Surgery for FC-PC could reduce the HLOS, and early surgery could decrease the DMV and the need for tracheotomy. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Blunt chest injury is a common trauma that accounts for 10% of the total trauma cases in emergency departments worldwide. The mortality rate is 4% to 20% [1]. Flail chest (FC), which defines multiple adjacent ribs broken in multiple places, is the most serious chest injury, and it damages the chest wall integrity and causes "paradoxical motion" from the detachment of a segment from the rest of the chest wall (Fig. 1). Pulmonary contusion (PC) is the most common chest injury (Fig. 2). These conditions frequently exist at the same time. Currently, a deeper understanding of FC pathophysiology exists, and its management has evolved substantially over the past 6 decades. The earliest treatment for FC was surgery. With the increasing technological advancements available in the intensive care unit (ICU), conservative management, based on mechanical ventilation supplemented with intensive pain control, has become more common [2]. Using positive airway pressure to reduce the asynchronous movement of FC could avoid surgical risks and postoperative complications. Conservative treatment
☆ There is no source of support in this study. ⁎ Corresponding author at: 650 Xin-Songjiang Road, post code 201620, Shanghai, China. Tel.: +86 21 37798528; fax: +86 21 37798527. E-mail address: [email protected] (R.L. Wang).
has been administered frequently in previous years. A growing number of researchers have found that surgery for FC could reduce the duration of mechanical ventilation (DMV), the ICU length of stay (ICULOS), the hospital length of stay (HLOS), the incidence of pneumonia and tracheostomy, and mortality. Additional benefits included decreased doses of analgesic and sedative drugs and avoidance of thoracic deformity, and patients could return to previous employment quicker than could those treated conservatively [3-10]. Although patients could incur additional costs, surgery remains the most cost-effective strategy because it could avoid the risks of pneumonia and reduce the length of stay (LOS) days [11]. However, some researchers have disagreed with the current practice and have considered that the studies in support of surgery were predominantly small, single center, and retrospective, with nonrandom patient selection [4,6,7,10]. These conclusions are neither persuasive nor convincing. Nirula et al [12] found that the ICULOS and total HLOS were similar for the surgical and nonsurgical groups in a matched case-control study. Although several meta-analyses have supported surgery [8,9], the Eastern Association for the Surgery of Trauma suggested that improvement in any outcome parameter has not been definitely shown after surgical fixation of FC, and limited studies were found concerning the timing of the surgery [13]. We retrospectively investigated the patients with FC and PC (FC-PC) who were admitted to our ICU to compare the clinical efficacy of surgical fixation and nonsurgical management as well as the diverse timings of the surgery.
http://dx.doi.org/10.1016/j.ajem.2015.04.005 0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Zhang Y, et al, Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.005
2
Y. Zhang et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
2. Methods We retrospectively analyzed all the patients with FC-PC admitted to the ICU in Shanghai First People's Hospital from July 2010 to December 2013 to determine the clinical effects of different management procedures for FC-PC. The human research ethics committee of Shanghai First People's Hospital approved this clinical study. 2.1. Inclusion and exclusion criteria We screened all the ICU patients diagnosed with FC-PC. The inclusion criteria were (1) age older than 16, (2) multiple rib fractures and PC confirmed by 3-dimensional computed tomography imaging, (3) paradoxical movement in the physical exam, and (4) requirement for mechanical ventilation. The exclusion criteria were (1) age older than 80 or younger than 16, (2) combined spine injury or other fracture that precluded a proper surgical position, (3) combined severe brain injury that caused prolonged DMV because of central nerve system damage, (4) other conditions that exclude the use of general anesthesia, and (5) an uncorrected coagulopathy disorder that would exclude the patient from surgery. There were 39 patients, according to the above criteria. Informed consent was obtained from the patients or their lineal relatives after our explanations of the study. 2.2. Group definitions The patients were divided into a surgical group and a nonsurgical group according to the therapeutic approach taken in each case. The patients who underwent open fixation of the fractured ribs were in the surgical group, and the remaining patients were in the nonsurgical group. The surgical group was further divided into an early surgical group (surgery performed within 7 days after admission) and a late surgical group (surgery performed after 7 days). 2.3. Measured parameters We collected the patient demographic characteristics such as the sex, age, number of fractured ribs, Apache Physiology And Chronic Health Evaluation (APACHE II) score, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, and combined injuries. The primary outcome parameter was mortality. The secondary outcome parameters were the DMV, ICULOS, HLOS, days of antibiotic use, transfusion volume, medical expense, incidence of tracheotomy,
Fig. 1. Multiple rib fractures. Three-dimensional computed tomography showing multiple adjacent ribs fractured in multiple places, fracture of the left fourth through 10th ribs. The displacement of the rib fractures was obvious.
Fig. 2. Pulmonary contusion. Computed tomographic imaging showing PC and pneumothorax involving the left lobe of the lung, and there was subcutaneous emphysema on the left side. The bright spots are the implanted bone plates.
incidence of pleural effusion, incidence of ventilator associated pneumonia (VAP), and incision infection. 2.4. Statistical analysis Because the number of patients included was small, the data were considered to be non-normally distributed. The continuous variables were compared using nonparametric tests and were reported as the median (25%, 75%). The group comparisons of the categorical variables
Table 1 Comparison of the demographic characteristics and combined injuries of the surgical and nonsurgical groups
Sex Male Female Age No. of fractured ribs APACHE II score ISS GCS Combined injuries ARDS Hemorrhagic shock Pneumothorax Pleural effusion Sternum fracture Scapula fracture Clavicle fracture Femoral fracture Other fracture Pelvic fracture Transverse/spinous process fracture Blunt liver/spleen Head trauma Diaphragmatic hernia
Surgical group (n = 24)
Nonsurgical group (n = 15)
72.9% (19/24) 20.8% (5/24) 42.5 (34, 49.5) 11.5 (8, 15.25) 7 (5, 14) 38 (34, 43) 15 (14, 15)
93.3% (14/15) 6.7% (1/15) 47 (35, 55) 11 (7, 16) 9 (6, 19) 38 (35, 43) 14 (6, 15)
P .376
.544 .948 .125 .699 .079
1 (4.2%) 2 (8.3%) 18 (75%) 16 (66.7%) 5 (20.8%) 9 (37.5%) 6 (25%) 6 (25%) 7 (29.2%) 5 (20.8%) 6 (25%)
0 2 (13.3%) 9 (60%) 7 (46.7%) 1 (6.7%) 4 (26.7%) 4 (26.7%) 5 (33.3%) 2 (13.3%) 6 (40%) 7 (46.7%)
1.000 .631 .478 .318 .376 .728 1.000 .718 .437 .277 .185
8 (33.3%) 7 (29.2%) 2 (8.3%)
7 (46.7%) 5 (33.3%) 3 (20%)
.505 1.000 .354
Abbreviation: ARDS, acute respiratory distress syndrome.
Please cite this article as: Zhang Y, et al, Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.005
Y. Zhang et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx Table 2 Comparison of the demographic characteristics of the early surgical and late surgical groups
Sex Male Female Age No. of fractured ribs APACHE II score ISS GCS
Early surgical (n = 12)
Late surgical (n = 12)
75% (9/12) 25% (3/12) 38 (31.25, 47) 11 (7.75, 16.25) 7 (5, 14) 38 (34, 38) 15 (14.25, 15)
83.3% (10/12) 16.7% (2/12) 45.5 (41, 61.5) 12 (8.25, 15) 7 (4.25, 15.5) 42 (35, 43) 14.5 (11.5, 15)
P 1.000
.057 .974 .908 .193 .121
were made using Fisher exact test, and P b .05 was considered statistically significant. All the statistical analysis was performed with SPSS 20.0 (SPSS, Chicago, IL).
3. Results A total of 39 patients were identified according to the criteria. There were 24 patients in the surgical group and 15 patients in the nonsurgical group as well as 12 patients in the early surgical group and 12 patients in the late surgical group.
3.1. Patient characteristics There were no differences between the surgical group and the nonsurgical group in sex, age, number of ribs fractured, APACHE II score, ISS, GCS, and all types of combined injuries. The 2 groups were comparable (Table 1). There was also no difference between the early and late surgical groups in sex, age, number of ribs fractured, APACHE II score, ISS, and GCS (Table 2).
3.2. Clinical outcomes The 24 patients in the surgical group survived, whereas 2 patients in the nonsurgical group died. However, there was no significant difference in mortality. The surgical group had slightly shorter HLOS (38 days [33, 54.25] for the surgical group vs 60 days [38, 99.75] for the nonsurgical group, P = .049). The other measured parameters had no significant difference (Table 3). The early surgical group had shorter DMV (8 days [2.25, 12.75] for the early surgical group vs 15.5 days [11.25, 19.5] for the late surgical group, P = .016) and less incidence of tracheotomy (odds ratio, 0.111; 95% confidence interval, 0.018-0.705; P = .039]. The other measured parameters had no significant difference (Table 4).
3
4. Discussion Flail chest and pulmonary contusion occurs at a rate of approximately 15 per 10000 patients in America. According to this ratio, 1 or 2 patients are admitted to each level I or II trauma center per month [14], which is similar to the rate of management of FC-PC in our ICU. The treatment strategy primarily includes mechanical ventilation with positive end-expiratory pressure, aggressive pain control, and surgical fixation to rebuild the chest wall integrity. The debate continues to focus on whether to treat the patient conservatively with mechanical ventilation or whether to perform surgical fixation of the ribs. There are positive and negative aspects in both management strategies. Thoracic integrity could be restored in a short time after surgical fixation, avoiding restrictive lung ventilation, and thoracic movement would be stable and without malunion. Previous literature has shown that stability after surgery could reach 87.5% to 100% [15-17], which coincides with our study. Our results showed 91.9% stability (22/24). The general anesthesia required for the surgery is a great risk for patients with severe multiple trauma, and some patients could not tolerate the procedure. The surgery is a difficult and time- and effort-consuming procedure. The additional dissection of the muscle is a second trauma for the patients, and the pain caused by the surgery is severe. The foreign implantation could easily cause connective tissue infection [18]. In our study, 6 of the 24 surgery patients had an incision infection that led to prolonged HLOS and antibiotic administration. The surgical procedure is dangerous for patients who are in an unstable condition. Using conservative management could stabilize the chest wall and relieve respiratory failure without imposing any additional stress on the patients but ensuring the possibility of treating other combined injuries simultaneously [19]. Conservative management has limitations. Progressive rib displacement could occur with conservative treatment and could lead to malunion. Thus, thoracic expansion would be limited, and ventilation would be decreased [5]. Another disadvantage is that mechanical ventilation could easily cause VAP. Long-term intravenous administration of sedatives is harmful to the liver and could result in jaundice [19] or affect patient consciousness. In the previous 10 years, surgical fixation has been increasingly supported by studies worldwide. In 2013, Slobogean et al [9] suggested in a meta-analysis that surgery for FC could reduce the DMV and ICULOS as well as the incidence of pneumonia, mortality, sepsis, and tracheostomy. A meta-analysis by Leinicke et al [8] showed that surgical fixation could decrease the DMV, ICULOS, and HLOS and reduce mortality, the incidence of pneumonia and the requirement for a tracheotomy. Although surgery is more expensive, it is the most cost-effective strategy because it decreases the incidence of VAP [11]. In our study, we found that surgical fixation could reduce the HLOS. The other parameters showed no difference between the surgical and nonsurgical groups. We found that the number of patients included was small, with heterogeneous timing of the surgeries. In addition, multiple trauma patients had different combined injuries that could have
Table 3 Comparison of the clinical outcomes of the surgical and nonsurgical groups
Mortality DMV ICULOS HLOS Antibiotic use (d) RBC trans (u) Plasma trans (u) Expense Tracheotomy Pleural effusion VAP
Surgical group (n = 24)
Nonsurgical group (n = 15)
OR (95%CI)
P
0 12 (7.5, 17.75) 24.5 (21.25, 30.75) 38 (33, 54.25) 30 (26, 36.5) 4 (0.25, 13.75) 12 (2,18) 241667 (189567, 290195) 12 (50%) 3 (12.5%) 16 (66.7%)
2 (13.3%) 7 (4, 14) 21.5 (18, 33.5) 60 (38, 99.75) 36.5 (25.5, 41) 8 (0,18) 15 (0, 24) 182632 (97177, 270052) 7 (46.7%) 1 (6.7%) 7 (46.7%)
–
.142 .233 .719 .049⁎ .472 .520 .450 .053 1.000 1.000 .318
1.143 (0.314-4.160) 2 (0.188-21.225) 2.286 (0.609-8.579)
Abbreviations: OR, odds ratio; CI, confidence interval; RBC, red blood cell; trans, transfusion. ⁎ The surgical group has shorter HLOS than the nonsurgical group, P b .05.
Please cite this article as: Zhang Y, et al, Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.005
4
Y. Zhang et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Table 4 Comparison of the clinical outcomes of the early surgical and late surgical groups
Mortality DMV ICULOS HLOS Antibiotic use (d) RBC trans (U) Plasma trans (U) Expense Tracheostomy Pleural effusion VAP Incision infection
Early surgical group (n = 12)
Late surgical group (n = 12)
OR (95%CI)
P
0 8 (2.25, 12.75) 21.5 (12.75, 30.75) 38.5 (31.5, 48.75) 30 (25.75, 42) 5 (0, 8.75) 12 (0.5, 18.75) 207341 (169501, 314051) 3 (25%) 2 (16.7%) 7 (58.3%) 3 (25%)
0 15.5 (11.25, 19.5) 26 (23.25, 32.25) 37 (33, 56.75) 30 (26, 33) 3 (1.25, 17) 10 (3.5, 17.75) 261236 (193905, 288869) 9 (75%) 1 (8.3%) 9 (75%) 3 (25%)
–
– .016⁎ .088 .862 .724 .705 .642 .299 .039⁎ 1.000 .667 1.000
0.111 (0.018-0.705) 2.2 (0.172-28.137) 0.467 (0.082-2.656) 1 (0.158-6.346)
⁎ The early surgical group had a shorter DMV and lower rate of tracheotomy, P b .05.
influenced the final results. The meta-analysis by Slobogean et al and Lenicke et al did not consider PC, and the included patients had single FC instead of FC-PC cases. Their analysis did not report whether patients diagnosed as FC combined with PC could benefit from surgery. As early as 1998, Voggenreite et al [20] separately analyzed patients with FC with or without PC and found that, in patients with FC and respiratory failure without PC, surgery permits early extubation. Patients with FCPC did not benefit from surgery. The literature regarding the timing of surgery is limited. Kakegawa et al [6] suggested that patients using internal pneumatic stabilization for more than 10 days had no flail improvement and should undergo surgery. Surgery could reduce DMV and the incidence of pneumonia. Our study found that earlier surgery permitted earlier fixation of the chest wall to reduce DMV and the tracheotomy incidence. Medical institutions have not agreed on the surgical indication. Voggenreite et al [20] suggested that FC and respiratory insufficiency without PC is the indication. Most institutions and our hospital have agreed that, in single FC cases, surgery should be performed. When patients with severe FC-PC fail to wean from the ventilator or when a thoracotomy is required for other reasons, such as progressive hemothorax or intercostal vascular rupture, for which open chest surgery is needed, surgery is necessary [13,14]. Every institution is trying to determine the optimal timing for surgery. Our study has several limitations. This study is a single-center, retrospective study, and the cases included are limited. This study did not involve function tests as a parameter and had no standard score system for PC. In addition, the study does not have the follow-up information for the discharged patients because patients in our country do not typically have regular follow-ups, the time points for follow-ups were inconsistent, or patients went to a hospital near their homes for reexamination. The data comparison error would be huge if we had compared the 2 groups. We emphasized the in-hospital data in our study, particularly for the objective variables. A limited amount of data was missing in our study, which we tried to avoid, and the missing data were managed with listwise deletion by SPSS. Additional larger, multiple-center, prospective randomized controlled studies are required to determine the ideal management for FC-PC and the optimal timing for the surgery.
5. Conclusions Our experience in treating 39 patients with FC-PC showed that surgical fixation could reduce the HLOS. Early surgery permits a shorter DMV and lower incidence of tracheotomy.
Acknowledgment We thank Xue Tang for assistance with the writing and Re Na Zhou for helping in the performance of the statistical analysis. References [1] Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury 2012;43(1): 8–17. [2] Davignon K, Kwo J, Bigatello LM. Pathophysiology and management of the flail chest. Minerva Anestesiol 2004;70(4):193–9. [3] Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52(4):727–32 [discussion 32]. [4] Balci AE, Eren S, Cakir O, Eren MN. Open fixation in flail chest: review of 64 patients. Asian Cardiovasc Thorac Ann 2004;12(1):11–5. [5] Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005;4(6):583–7. [6] Kakegawa S, Kamiyoshihara M, Ohtaki A, Ohki S, Morishita Y. Surgical fixation of the ribs for flail chest injuries. Kyobu Geka 2006;59(11):974–9. [7] Marasco S, Cooper J, Pick A, Kossmann T. Pilot study of operative fixation of fractured ribs in patients with flail chest. ANZ J Surg 2009;79(11):804–8. [8] Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis. Ann Surg 2013;258(6):914–21. [9] Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg 2013;216 (2):302–11 [e1]. [10] Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Faknry SM, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care 2014;29(1):139–43. [11] Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg 2012;215(2):201–5. [12] Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg 2006;72:307–9. [13] Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward T, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73(5 Suppl. 4):S351–61. [14] Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg 2008;20(1):39–45. [15] Reber P, Ris HB, Inderbitzi R, Stark B, Nachbur B. Osteosynthesis of the injured chest wall. Use of the AO (Arbeitsgemeinschaft fur Osteosynthese) technique. Scand J Thorac Cardiovasc Surg 1993;27(3–4):137–42. [16] Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 1995;110(6): 1676–80. [17] Fabbri C, Mazieri M, Cirocchi R, Bisacci R, Cagini L. Flail chest. Minerva Chir 1996;51 (9):669–73. [18] Carbognani P, Cattelani L, Bellini G, Rusca M. A technical proposal for the complex flail chest. Ann Thorac Surg 2000;70(1):342–3. [19] Nishiumi N, Fujimori S, Katoh N, Iwasaki M, Inokuchi S, Inoue H. Treatment with internal pneumatic stabilization for anterior flail chest. Tokai J Exp Clin Med 2007;32(4):126–30. [20] Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest–outcomes of patients with or without pulmonary contusion. J Am Coll Surg 1998;187(2):130–8.
Please cite this article as: Zhang Y, et al, Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.005