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Background: Although surgical stabilization for rib fractures (SSRF) has been adopted widely over the past decade, little information is available regarding the prevalence and outcomes of post-operative surgical site infection (SSI). We hypothesized that SSI after SSRF is uncommon but morbid. Patients and Methods: Patients undergoing SSRF at a level 1 trauma center from 2010-2020 were reviewed. The primary outcome was the prevalence of SSI, documented by clinical examination, radiography, systemic markers of infection, and microbiology. Results: Of 228 patients undergoing SSRF, 167 (73.2%) were male, the median age was 53 years (P25-P75; 41-63 years), injury severity score (ISS) was 19 (P25-P75, 13-26), with a median of eight fractured ribs (P25-P75, 6-11). All stabilization plates were titanium. SSRF was typically performed on post-injury day one (P25-P75, 0-2 days) after trauma. All patients received antibiotic agents within 30 minutes of incision, and a median of four ribs (P25-P75, 3-6) were repaired. Four (1.8%) patients developed an SSI and all underwent implant removal. Two patients required implant removal within 30 days (on post-operative day seven and 17) and two for chronic infection at seven and 17 months after SSRF. The causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) bacteria in all patients. After implant removal, three patients received intravenous and oral antibiotic agents, ranging from two to six weeks, without recurrent infection. No patient required additional SSRF. Conclusions: Surgical site infection after SSRF is rare but morbid and can become symptomatic within one week to 17 months. Implant removal results in complete recovery.

BACKGROUND Geriatric trauma rates are increasing, yet trauma centers often struggle to provide autonomy regarding decision making to these patients. Advance care planning can assist with this process. Currently, there are limited data on the impact of advance directives (AD) in elderly trauma patients. The purpose of this study was to evaluate the prevalence of pre-injury AD in geriatric trauma patients and its impact on outcomes, with the hypothesis that ADs would not be associated with an increase in mortality. METHODS A multi-center retrospective review was conducted on patients older than 65 with traumatic injury between 2017 and 2019. Three level I trauma centers and one level II trauma center were included. Exclusion criteria were readmission, burn injury, transfer to another facility, discharge from emergency department, and mortality prior to being admitted. RESULTS There were 6,135 patients identified; 751 (12.2%) had a pre-injury AD. Patients in the AD+group were older (86 vs 77 years, p < 0.0001), more likely to be female (67% vs 54.8%, p < 0.0001), and had more comorbidities. Hospital length of stay and ventilator days were similar. In-hospital mortality occurred in 236 patients and 75.4% of them underwent withdrawal of care (WOC). The mortality rate was higher in AD+ group (10.5% vs 2.9%, p < 0.0001). No difference was seen in the rate of AD between the WOC+ and WOC- group (31.5% vs 39.6%, p = 0.251). A pre-injury AD was identified as an independent predictor of mortality, but not a predictor of WOC. CONCLUSION Despite a high WOC rate in patients over 65, most patients did not have an AD prior to injury. As the elderly trauma population grows, advance care planning should be better integrated into geriatric care to encourage a patient-centered approach to end-of-life care. LEVEL OF EVIDENCE Level IV. STUDY TYPE Prognostic and epidemiological.

Stroke secondary to blunt cerebrovascular injury (BCVI) most often occurs before initiation of antithrombotic therapy. Earlier treatment, especially in multiply injured patients with relative contraindications to antithrombotic agents, could be facilitated with improved risk stratification; furthermore, the relationship between BCVI-attributed stroke and hypercoagulability remains unknown. We hypothesized that patients who suffer BCVI-related stroke are hypercoagulable compared with those with BCVI who do not stroke.Rapid thromboelastography (TEG) was evaluated for patients with BCVI-attributed stroke at an urban Level I trauma center from 2011 to 2018. Contemporary controls who had BCVI but did not stroke were selected for comparison using propensity-score matching with 20% caliper that accounted for age, sex, injury severity, and BCVI location and grade.During the study period, 15,347 patients were admitted following blunt trauma. Blunt cerebrovascular injury was identified in 435 (3%) patients, of whom 28 experienced associated stroke and had a TEG within 24 hours of arrival. Forty-nine patients who had BCVI but did not suffer stroke served as matched controls. Stroke patients formed clots faster as evident in their larger angle (77.5 degrees vs. 74.6 degrees, p = 0.03) and had greater clot strength as indicated by their higher maximum amplitude (MA) (66.9 mm vs. 61.9 mm, p0.01). Activated clotting time was shorter among stroke patients but not significantly (113 seconds vs. 121 seconds, p0.05). Increased angle and elevated MA were significant predictors of stroke with odds ratios of 2.97 for angle greater than 77.3 degrees and 4.30 for MA greater than 63.0 mm.Patients who suffer BCVI-related stroke are hypercoagulable compared with those with BCVI who remain asymptomatic. Increased angle or MA should be considered when assessing the risk of thrombosis and determining the optimal time to initiate antithrombotic therapy in patients with BCVI.Prognostic, Level III.

INTRODUCTION Locoregional analgesia (LRA) remains underused in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF. METHODS Noninferiority, single-center, randomized clinical trial (2017-2020) was performed. Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space), and LB involved thoracoscopic intercostal blocks of ribs 3 to 8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function score, measured daily for 5 days postoperatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality. RESULTS Thirty-four patients were enrolled: 16 IC and 18 LB. Age, Injury Severity Score, RibScore, Blunt Pulmonary Contusion Score, and use of nonnarcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p = 0.23). There was no significant difference in Sequential Clinical Assessment of Respiratory Function score between the IC and LB groups. On postoperative days 2 to 4, narcotic requirements were less than half in the LB, as compared with the IC group; however, this difference was not statistically significant. Average wholesale price was US $605 for IC and US $434 for LB. CONCLUSION In this noninferiority trial, LB provided at least comparable and potentially superior LRA as compared with IC among patients undergoing SSRF. LEVEL OF EVIDENCE Therapeutic, level II.

Background We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT). Methods Retrospective review of all trauma patients undergoing TT from 6/30/2016–6/30/2019. Multivariable logistic regression identified independent predictors of complications. Results Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m2 were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%–53.5%), and early complication increased the likelihood of late complication (4.3%–13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication. Conclusion TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m2. We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes.