Surgical stabilization of rib fractures in conjunction with veno-venous ECMO for traumatic chest wall injury: a multi-institutional case series from the Chest Wall Injury Society (CWIS).

Abstract

Introduction: Rib fractures are prevalent in 10% of blunt injury admissions and contribute significantly to trauma-related mortality. Severe cases, such as flail segments or multiple displaced fractures, frequently necessitate surgical stabilization of rib fractures (SSRF) to mitigate pain and improve outcomes. Pulmonary contusions, present in about 25% of chest wall injuries, can be exacerbated by severe rib fractures, leading to acute respiratory distress syndrome. These cases can lead to a combination of therapies-SSRF and veno-venous extracorporeal membrane oxygenation (VV-ECMO)-that is rarely reported and without guidelines. Here we present the identified cases of patients undergoing SSRF on VV-ECMO highlighting the potential synergy of these two therapies to achieve favorable outcomes.

Methods: The Chest Wall Injury Society queried its membership to identify cases where both SSRF and VV-ECMO were used concurrently. Five patients from three trauma centers were identified. Data on patient demographics, injury mechanisms, treatment timelines, and outcomes were collected. Descriptive analysis was planned given the low number of anticipated patients. IRB approval was sought and determined exempt by the Stanford IRB as no identifiable information was presented.

Results: The cohort comprised five male patients aged 20-50s, primarily injured in vehicular collisions. Median Injury Severity Score was 34. Median number of fractured ribs was 11 (range: 9-15) and four patients had clinical flail chest. ECMO cannulation occurred on median day 0, and SSRF was performed on median day 4 postinjury. Median duration of ECMO was 19 days, and hospital stay was 49 days. All patients underwent tracheostomy, and four developed pulmonary infections. Despite these complications, all patients survived, with three discharged home and two to skilled nursing facilities. No rib-related readmissions were reported.

Conclusion: Integration of SSRF and VV-ECMO presents a viable therapeutic strategy for severely injured trauma patients. Although further research is needed, this approach holds promise for improving outcomes in selected patients.