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Sat Jan 31 18:24:16 GMT 2009

AGREED!!!  IF we do this study, patient selection is going to have to be VERY carefully proscribed, and the parameters studied will - as Karim has pointed out earlier - need to be studied out to a year or better so as to study not just the immediacy of success, but the long term effects - if any - on ventilatory function.  If two "identical" patients are studied, and early rib fixation enables the patients to be extubated earlier, and they are then to have improved long term ventilatory function when compared to their counterparts, my guess is that everyone is going to reexamine their predetermined biases!

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of John E. Sutton Jr.
Sent: Saturday, January 31, 2009 9:49 AM
To: trauma-list at trauma.org
Subject: Re: trauma-list Digest, Vol 67, Issue 52

--- You wrote:
Having said that, I would LOVE any input from the group as to what y'all think is the appropriate patient for early rib fixation.  As Karim said, it probably should be done later (towards the 5-7 post admission day), and perhaps earlier on the "stoved-in" (is that really the correct way to say that??) chest.
--- end of quote ---

Ron,
 I think you are right that the main problem is one of patient selection. Shackford and Trinkle showed in the 70's and 80's that the number of rib fxs, degree of flail,etc. was not the issue of prolonged ,or any , ventilatory requirements but it was the degree of underlying pulmonary injury and contusion. Thus the clinical observation that often after 7-10 days the pt. with a flail segment and underlying contusion gets extubated. The flail is no better but the contused lung has improved. The ideal pt. would be someone with a crushed chest who has no underlying lung injury. There early fixation might help with pain management and improve pulmonary mechanics. However, a pt. with such a combination of chest injury is rare and perhaps accounts for Dr. Mattox's observation that they have done the procedure infrequently.
John

John E. Sutton, Jr., M.D. , F.A.C.S
Professor of Surgery,  Dartmouth Medical School
Division Chief, Trauma and Acute Surgical Care
phone: 603-650-8022
fax :     603-650-8030
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trauma-list Digest, Vol 67, Issue 52