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

Abstract

BACKGROUND:The presence of six or more rib fractures or a displaced rib fracture due to cardiopulmonary resuscitation (CPR) has been associated with longer hospital and intensive care unit (ICU) length of stay (LOS). Evidence on the effect of surgical stabilization of rib fractures (SSRF) following CPR is limited. This study aimed to evaluate outcomes after SSRF versus nonoperative management in patients with multiple rib fractures after CPR. METHODS:An international, retrospective study was performed in patients who underwent SSRF or nonoperative management for multiple rib fractures following CPR between January 1, 2012, and July 31, 2020. Patients who underwent SSRF were matched to nonoperative controls by cardiac arrest location and cause, rib fracture pattern, and age. The primary outcome was ICU LOS. RESULTS:Thirty-nine operatively treated patient were matched to 66 nonoperatively managed controls with comparable CPR-related characteristics. Patients who underwent SSRF more often had displaced rib fractures (n = 28 [72%] vs. n = 31 [47%]; p = 0.015) and a higher median number of displaced ribs (2 [P 25 -P 75 , 0-3] vs. 0 [P 25 -P 75 , 0-3]; p = 0.014). Surgical stabilization of rib fractures was performed at a median of 5 days (P 25 -P 75 , 3-8 days) after CPR. In the nonoperative group, a rib fixation specialist was consulted in 14 patients (21%). The ICU LOS was longer in the SSRF group (13 days [P 25 -P 75 , 9-23 days] vs. 9 days [P 25 -P 75 , 5-15 days]; p = 0.004). Mechanical ventilator-free days, hospital LOS, thoracic complications, and mortality were similar. CONCLUSION:Despite matching, those who underwent SSRF over nonoperative management for multiple rib fractures following CPR had more severe consequential chest wall injury and a longer ICU LOS. A benefit of SSRF on in-hospital outcomes could not be demonstrated.A low consultation rate for rib fixation in the nonoperative group indicates that the consideration to perform SSRF in this population might be associated with other nonradiographic or injury-related variables.

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.…”

“…There are no existing guidelines concerning surgical stabilization of CPR-related CWIs. Selective patients are operated in an attempt to wean patients of ventilator, but it is unclear what effect surgery has in this patient group 19,30–32 . Patient selection is important as the post-CPR patient is already vulnerable, and usually on vital anticoagulants, which increase the risk of perioperative bleeding.…”

“…It is unclear if patients with CPR-related CWIs benefit from surgical fixation in the same way as traumatic non–CPR-related CWI 16–18 . A retrospective multicenter study found that surgical fixation of chest wall injuries after CPR did not show any benefit concerning hospital outcome and mortality 19 …”

“…[16][17][18] A retrospective multicenter study found that surgical fixation of chest wall injuries after CPR did not show any benefit concerning hospital outcome and mortality. 19 There is a need for a better understanding of the incidence of CPR-related CWIs in patients surviving OHCA and how these injuries influence morbidity and mortality. The extent of injury to the chest wall has previously been shown to impact outcome in trauma patients but it is unclear if the same applies to CPR-related chest wall injuries.…”

Hardware failure for anterior chest wall and costal cartilage injuries: A single-center experience

“…Costal cartilage injuries, which are often missed radiographically, contribute to refractory pain and instability particularly when seen in an anterior (or sternal) flail chest. This latter injury pattern is seen following high-energy blunt trauma to the anterior chest or at times following high-quality cardiopulmonary resuscitation 12 . Surgical stabilization of anterior chest wall and costal cartilage injuries is unique in that this requires bridging of titanium hardware to the cartilaginous portion of the chest wall or application of hardware to the cartilage alone (Figs.…”