Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation

Abstract

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.

Injury pattern and clinical outcome in patients with and without chest wall injury after cardiopulmonary resuscitation

“…Selective patients are operated in an attempt to wean patients of ventilator, but it is unclear what effect surgery has in this patient group. 19,[30][31][32] Patient selection is important as the post-CPR patient is already vulnerable, and usually on vital anticoagulants, which increase the risk of perioperative bleeding. The clinician contemplating operative intervention needs to be confident that the underlying cause for the CA is reversible and that the patient is neurologically intact.…”

Surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures following cardiopulmonary resuscitation: an international, retrospective matched case-control study (CWIS-CPR)

“…27 In studies describing the post-CPR population, SSRF is mostly used as a late salvage intervention to possibly aid mechanical ventilation liberation with time to SSRF ranging from seven to 38 days after CPR. [19][20][21][22] Early SSRF is advocated by contemporary guidelines in the case of severe posttraumatic rib fractures, as late SSRF has no benefit on in-hospital outcomes over nonoperative management. 17,28,29 In our study, time to SSRF was 5 days after admission, which is considered late.…”

“…This exclusion could be due to similar reasons, as the patient with traumatic brain injury, such as the unclear (neurological) prognosis, assumed increased perioperative risk and confounding of outcomes because of an increased risk of prolonged mechanical ventilation and mortality 27 . In studies describing the post-CPR population, SSRF is mostly used as a late salvage intervention to possibly aid mechanical ventilation liberation with time to SSRF ranging from seven to 38 days after CPR 19–22 . Early SSRF is advocated by contemporary guidelines in the case of severe posttraumatic rib fractures, as late SSRF has no benefit on in-hospital outcomes over nonoperative management 17,28,29 .…”

“…[16][17][18] To date, evidence on SSRF in the post-CPR population is limited to case reports and series without control group. [19][20][21][22] It is hypothesized that restoring chest wall integrity, reducing pain due to fracture stabilization, and improving respiratory capacity through SSRF aid ventilator liberation and improve outcome.…”

“…Traumatic flail chest is currently an indication for surgical stabilization of rib fractures (SSRF), as this has been shown to reduce the occurrence of pneumonia, ICU LOS, and mechanical ventilation duration as compared with nonoperatively managed patients 16–18 . To date, evidence on SSRF in the post-CPR population is limited to case reports and series without control group 19–22 . It is hypothesized that restoring chest wall integrity, reducing pain due to fracture stabilization, and improving respiratory capacity through SSRF aid ventilator liberation and improve outcome.…”