Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study. O'Connell KM, Patel KV, Powelson E, Robinson BRH, Boyle K, Peschman J, Blocher-Smith EC, Jacobson L, Leavitt J, McCrum ML, Ballou J, Brasel KJ, Judge J, Greenberg S, Mukherjee K, Qiu Q, Vavilala MS, Rivara F, Arbabi S. J Trauma Acute Care Surg. 2021 Aug 1;91(2):265-271.
Blunt chest trauma in the elderly may result in rib fractures. Greater than 3 fractures may result in severe pain, hypoventilation, and respiratory complications. Uncontrolled pain and the use of opioids are risk factors for delirium, especially in the vulnerable older population. This study investigated whether older adults with rib fractures who received regional anesthesia (RA) have a lower risk of delirium.
Seven US trauma centers participated in this retrospective, cohort study of adults greater than 65 years of age with 3 or more rib fractures from blunt trauma being admitted to an ICU. Patients were excluded with significant head/spine injuries (AIS>=3), history of dementia and death within 24 hours. The primary outcome was incidence of delirium within the first 7 days, defined as a positive CAM-ICU assessment. Secondary outcomes included respiratory complications, mortality, and length of stay. Patients receiving thoracic regional anesthesia (RA) via epidural or paravertebral catheters were compared to those who did not receive RA. All other care was provided base on institutional practice patterns.
Four-hundred sixty-three (80.7%) patients without RA were compared to 111 individuals receiving RA (99 epidural and 12 paravertebral catheters). Demographics, injury characteristics and ISS were similar between groups. Patients receiving RA had significantly higher chest AIS scores, more flail segments (28% vs. 11%), more hemo/pneumothoraces (68% vs. 41%) and tube thoracostomies (48% vs. 27%). The 7-day incidence of delirium and complications were not different in the unadjusted analysis. Patients receiving RA had longer ICU length of stay (4 vs. 3 days) and were more likely to undergo thoracic procedures (23% vs. 8%) than those with no RA. Multivariate analysis demonstrated a 35% decreased risk of delirium for patients receiving RA compared to those with no RA.
Older adults with severe blunt chest trauma are at elevated risk for ICU admission and delirium.
This study demonstrated a reduced risk of delirium in those patients receiving thoracic regional anesthesia. While promising, further investigation is needed to evaluate the role of opioids and other pain management strategies in the multidisciplinary treatment of elderly patients with rib fractures.
Implications of the national Stop the Bleed campaign: The swinging pendulum of prehospital tourniquet application in civilian limb trauma. Mikdad S, Mokhtari AK, Luckhurst CM, Breen KA, Liu B, Kaafarani HMA, Velmahos G, Mendoza AE, Bloemers FW, Saillant N. J Trauma Acute Care Surg. 2021 Aug 1;91(2):352-360.
Uncontrolled extremity hemorrhage is a recognized source of preventable mortality in trauma patients. The efficacy of prehospital tourniquets (TQ) in the civilian setting has been demonstrated and the Stop the Bleed campaign was initiated in 2015 to train bystanders in basic hemorrhage control. The frequency of TQ use has increased, thus the purpose of this study was to characterize the efficacy, appropriateness and complications associated with TQ placement since the launch of Stop the Bleed.
This is a 5-year retrospective review of adults requiring prehospital TQ placement for extremity injury at 2 US trauma centers. Patients were excluded if the TQ was placed in the hospital or for non-traumatic bleeding. Datasets included demographics, TQ characteristics, injury data and outcomes. Patients were evaluated for indicated TQ use (limb amputation, hard vascular signs, injuries requiring OR within 2 hours, or massive blood loss on scene) and appropriate TQ placement (with inappropriate defined as a venous TQ, prolonged duration or inappropriate anatomic placement). The primary outcome was complications related to prehospital TQ placement.
One-hundred forty-seven patients were included in the review, predominantly men (93%) and with penetrating injuries (63%). Frequency of TQ use and commercial TQs increased over time; while placement by EMS personnel decreased (52% applied prior to EMS arrival). Seventy-four (51%) had a clear indication for TQ placement. GSWs had the highest frequency of placement without clear indication (19%). Indicated TQs had longer duration of application that non-indicated (60 vs. 44 min). Thirty-nine patients (27%) had inappropriate TQ placement (20 indicated and 19 non-indicated), most frequently prolonged TQ time (over 2 hours, n=20), followed by venous TQs (13), placement distal to injury (4), prolonged duration + venous (1), and prolonged duration + distal (1). Of the inappropriate TQ placements, 2 resulted in nerve palsies, 2 required fasciotomies and 1 presented in extremis with significant blood loss from a distal / prolonged TQ. Cases with indicated TQs were more likely to require blood transfusion (58% vs 29%), be admitted to ICU (51% vs 15%), go directly to the OR (81% vs. 44%) and have a longer length of stay (5.5 vs 2 days). Mortality was not different.
Over this 5-year study, TQ use and placement by non-EMS personnel increased. Nearly 50% did not have a clear indication for placement and over 25% were applied inappropriately. Further research is needed to improve education and training in the proper indications and application of tourniquets.
Enhanced recovery after surgery (ERAS) in patients undergoing emergency laparotomy after trauma: a prospective, randomized controlled trial. Purushothaman V, Priyadarshini P, Bagaria D, et al. Trauma Surgery & Acute Care Open 2021;6:e000698.
Summary: ERAS protocol is safe and may have better outcomes after trauma laparotomy in select patients.
Enhanced recovery after surgery (ERAS) has been adopted in multiple surgical disciplines for the perioperative care of patients and has had been shown to carry a benefit in outcomes, mainly hospital length of stay, with no increase in complications. The authors’ aim was to test the applicability and outcomes of ERAS in trauma laparotomy.
In a single-center, prospective, randomized controlled trial, patient undergoing trauma laparotomy were randomized to ERAS vs conventional care. Inclusion criteria included ASA class I and II. Excluded were patient with ASA class III, IV, and V, those requiring post-operative inotrope or ventilatory support, pre-existing liver, hematological, or immune-compromised patients, and those with solid organ injuries. Sixty patients were randomized to the two groups.
Most patients had an ASA of I (95%), were moderately injured (Mean ISS 11 vs 9) and underwent bowel repair (93%). Intraoperatively, both groups had comparable usage of crystalloids, blood transfusion and intraoperative inotropes, and comparable blood loss and operative duration. Bowel injury patterns and operative interventions were comparable. ERAS patients had higher usage of colloids, and epidural placement (19 vs 11).
Post-operatively, time to removal of NG tube, urinary catheters, and drains were significantly shorter in ERAS group, as well as time to liquid and solid diet initiation. However, time to return of bowel function did not differ. There was no difference in post-operative opioid usage or pain scores. ERAS patients received more NSAIDs and DVT prophylaxis.
Examining their outcomes, the authors found hospital stay to be shorter in ERAS group (3.3 vs 5 days) with no increase in readmission or post-operative complications compared to conventional care. The rate of failure of ERAS protocol was found to be 13% in this study, due to paralytic ileus and vomiting in four patients.
The study was mainly limited with its stringent inclusion and exclusion criteria. This was due to the study being the first in the trauma population. However, this RCT proves feasibility of implementing ERAS protocols in trauma and further studies will help delineate the appropriate inclusion criteria for traumatically injured patients that can be safely managed with those protocols.
AAST Patient Assessment Committee Organ Injury Scaling 2020 update: Bowel and mesentery.
Tominaga,GT, Crandall M, Cribari C, Zarzaur B, Bernstein M, Kozar RA. Journal of Trauma and Acute Care Surgery: September 2021 - Volume 91 - Issue 3 - p e73-e77.
The authors provide an update from the American Association for the Surgery of Trauma (AAST) to the Organ Injury Scale (OIS) for small bowel and colon, originally developed in 1990.
This OIS provides, for the first time, a separate grading system for blunt and penetrating injuries to each of the small bowel and the colon and adds an OIS for mesenteric injuries.
Given the advances in imaging technology since the development of the original OIS, and the ensuing changes in diagnostic and management guidelines, this new bowel OIS includes imaging findings and provides the appropriate definitions to ensure objective scoring of radiologic findings. The new OIS is also formatted similar to the recent OIS for solid organs, and provides a scale for each of the imaging, operative, and pathologic findings.
Another novel addition to this OIS is considering the delay in diagnosis in the grading by upgrading the OIS by one grade for a delay of or greater than 8 hours between the time of injury and diagnosis.
This revision brings the bowel OIS up to date with current practice patterns and guidelines. The authors invite future studies to validate it.