Thank you, Dr. Diaz. My name is Sean Diefenbacher. I'm coming from Atrium Health in Charlotte. So my colleagues here have presented all the background data. My task is sort of depart from the data a little bit and go through what our algorithm is for managing severe chest wall trauma, both in the mechanically ventilated and the non-mechanically ventilated patients. My only disclosure is I am a prior educational consultant for Johnson & Johnson teaching this operation. My objectives here, again, discuss the algorithms for the management of complex chest wall injury, both the perioperative, intraoperative, and postoperative protocols. And then we'll describe the multi-professional engagement to really build a successful chest wall injury program. Again, these are the classic indications that we employ for surgical fixation. And this is all based in the literature. Again, mostly popularized by the non-flail study to include that non-flail with impaired physiology done by Peracci and his team. So classically, again, clinical flail, radiographic flail, significant chest wall deformity, and non-flail with at least partial displacement. You can't do any of these talks without showing some of the best pictures that you have. So I personally don't like the 3D recons that much, but they do provide some meaningful pictures to at least look at. If you look in the middle of the picture, I think this was about an 80-year-old female who had fallen. And you can see she's got a complete chest wall deformity of the right side of her chest with everything caved in. I personally use the axial images the most, which you can see sort of in the bottom middle here. And again, you can see significant displacement. Again, we've already talked about the taxonomy. So my typical process is fracture mapping. So I tell our residents all the time that their first task is to map the morphology. The second task is to evaluate the physiology. And so I usually use just a spreadsheet like this with the rib fractures labeled out. I'll have them scroll through the scan and mark and characterize in each level. And so you can very quickly see multiple fractures on the same level, some with displacement, some offset, some non-displaced. You get a very quick sense of how you can, how you can map that morphology. It's a good tool to use to direct the approach. It's an intraoperative reference to make sure that you are on the level that you think you are. And I think it actually makes things move much smoother in the operating room when you're communicating back and forth with your team. And then we move on to evaluating the physiology. We use the modified PIC scoring, which assigns points for the cough, the incentive spirometry volumes, and pain scores. And again, all of those total up to give us a better idea of what the patient's physiology is. We've talked a lot about the indications for timing. I'm gonna kind of go through this quickly just because the short version is the sooner the better. We even are trying to do ER to OR if there are no other competing injuries. And so patients very frequently will be posted for the operating room on the same day as their admission. Typically the standard will be less than 72 hours. That leads to decreased operating room times, decreased length of stay, and improved outcomes. And that's all based on the amount of inflammation and other injuries that you encounter. The key for that is early team evaluation. And so if you only have a rib surgeon that's on every other day or periodically, it makes it difficult to sort of employ that. And so building out a team where you have continuous coverage is a main part of that. And then last in the bottom, you've gotta evaluate and prioritize. Obviously a patient in shock or significant other injury from trauma, some of those things gain priority above others. And we communicate with our consultants on how we proceed when there are multiple complex issues at play. Couple populations traditionally have scared us. One is the octogenarian or nonagenarians, meaning our 80 and 90 year old patients. And so this is a CEWA study that demonstrates, again, improved outcomes in the octogenarian and older cohort. It's a decreased mortality, but interestingly it was increased risk of pneumonia and a longer ICU length of stay. And so you're gonna be in that population, but you do have to be alive to be able to get a pneumonia or have a longer stay in the ICU. And so the mortality was significantly different. And then in the bottom, the TBI population was another one that sort of scares us a little bit. We weren't sure, should we be operating on the moderate to severe TBIs and what are the benefits? And again, decreased risk of complications, no significant change in length of stay or ventilator duration, but significant decrease in mortality. And so both of those populations, again, it's not a global blanket statement, but we should not be as reticent to operate on those patients as we might have historically. I'm gonna quickly go through the adjuncts that have been described and go through each of those individually here. So you can see an X-ray with complete opacification of the right hemithorax, the bronchoscopic findings. Again, clearly complete mucus plugging of that right side, which is cleared. We've talked a lot about cryoablation and I would agree with my colleagues that there's not great data out there. This is some data that we presented previously at a conference last year and is awaiting final publication. The short answer is we believe it helps. It's fewer ventilator days, shorter ICU length of stay and nearly a 50% reduction in the opioid consumption. The last comment I'll make is that we have an open randomized control trial that we are currently about a third of the way through our enrollment as a single center for cryoablation by itself and that goes to your point previously where some of these techniques aren't all that well studied but we believe in them. VATS is a routine part of my operation. You can see the CT scans with significant fluid within the left hemithorax. Some operative findings of adhesions and fibrothorax, which all can be lysed. In the bottom screen with the white arrow, you see a hole through the diaphragm from an adjacent rib fracture with the liver parenchyma visible. And so a VATS component to this is to clean up all of that retained hemithorax, to lyse and clean up the fibrothorax and then finally to make sure you have adequately positioned chest tube for drainage and evaluate for any additional injuries. We've talked a lot about multimodal, sorry, about regional anesthetics. Again, I think two things that make this important, number one, our emergency department physicians are willing to do single shot blocks and that's on arrival in the emergency bay. And our rib fracture algorithms automatically have an acute pain management consult for our regional team who has seven day coverage for placement of catheters. We briefly talked previously about the multimodal non-narcotic sparing medication regimen and again, every institution has a little bit different but the main things here are you tailor it to your patient, you tailor it to their age, their renal function, all again with the goal of avoiding significant narcotic exposure. I wanna spend a little bit of time talking about our respiratory therapy protocols. I think this is probably the most critical part, the way that we do it, meaning we have standardized protocols for bronchial hygiene and mucus clearance for bronchodilators in the COPD protocol and then the third protocol is our lung expansion protocol. On admission, the order is placed for respiratory to evaluate and they automatically initiate and then work through these pathways with periodic check-ins with the physician for escalations or for failure to progress. And so that immediately comes with the admission order set. Ventilatory strategies, again, standard ventilatory strategies, nothing in particular other than to say that we're trying to extubate all of our patients in the operating room at the conclusion of the case. And so limiting continuous additives, avoiding continuous IV narcotics like fentanyl drips allows us to more aggressively get patients to pressure support and extubated, again, with lots of communication with our anesthesiologist to try and extubate immediately in the operating room. In terms of mobilization from a physical therapy standpoint, this is a handout that we give our patients post-operatively but mobilization starts on hospital day one with physical therapy evaluations and a mobility metric in our ICU where we have to have two documented mobility occurrences. Again, takes a huge team, including physical therapy and nurses to be able to accomplish that. So the algorithms, just to kind of bring it home here so we have a little bit of time for questions, again, it's a systematic preoperative evaluation. That means you map the morphology, you characterize the physiology, you stratify the additional injuries and you make a decision on operative fixation. We utilize the intraoperative adjuncts that we've all talked about, bronchoscopy, a VATS for evaluation of the pleural space and cryoablation for additional pain adjuncts. And finally, we leverage our relationships with our multi-professional teams. And so I wanted to leave you with this slide. This is the busy slide intentionally because really building a chest wall injury program requires you to have so many additional components to it. That means working with our multi-professional teams, including physical therapy, respiratory therapy, anesthesia, our emergency medicine colleagues, all of those parts of it come into play to allow us to have a successful chest wall program. And again, the tenants there are early intervention, whether that's surgical or non-surgical, and then appropriate follow-up, which you see down in the bottom, which means a dedicated rib clinic that we have significant development of order sets so that we maintain a lack of variability. And then also, all of our rib processes are subject to our QI and PI and peer review processes. Just a quick list of references there. And notably, we're the host city for the chest wall injury meeting this year. And finally, just a quick acknowledgement of my mentors. You can see some grates on the wall there. Somebody said we all stand on the shoulders of giants, but I think it's probably better to say we unknowingly walk amongst them most of the time. Thank you. So with that, we have just under 10 minutes, so the floor is open for questions. So I'll initially ask a question to Joe. As far as physical therapy, we haven't actually mentioned it. How do you incorporate the physical therapy program in your chest wall injury program? I would tend to agree. I mean even from the perspective of just creating a program for chest wall injury, I think if you define it like that doesn't necessarily mean that everybody's going to get stabilized, but the fact that you can improve the pulmonary, the physical therapy, the pain management to everyone who has rib fractures I think is beneficial to your entire local trial I have a bias. We all have biases, right? I saw it when it was initially being developed and I did a few cases and I was not very excited. There is yet to actually be a whole lot of actual studies in living people. I've done it in cadavers looking at different plating systems in terms of the physics associated with how the anterior plates and posterior plates and U-plates and bone density and et cetera. I don't think that we know yet what type of plate is better other than plating is better than no plating. I think a lot of it may have to do from the privileges standpoint. Whether or not if you can't get intrathoracic elective rib plating privileges, then you may end up having to just continue to do external plating. Definitely at this point, the goal is to try to minimize the surgical trauma associated with rib plating. So coming up with various different techniques which is why all the systems have right angle drivers today. The other is the advancement on exposure, trying not to divide muscle when you don't have to. Creating elevation of the, just the muscle bundle and the shoulder girdle to be able to get exposure. And then appropriate positioning. But the one thing that I have heard from those who do use that technique more is that you can get closer to the spine to try to stabilize it. I feel I can get pretty close on the external without doing, getting inside. But that's just my skill set. Do you guys have a favorite or bias?

severe chest wall trauma

multimodal approaches

surgical fixation

respiratory therapy

team collaboration