Rapid sequence versus early surgical stabilization of severe chest wall injuries: a propensity score-matched analysis from a multicenter trauma registry

BACKGROUND: The optimal timing for post traumatic Chest Wall Reconstruction (CWR) in severely injured / polytraumatized patients with severe chest wall instability remains a subject of debate. While early surgery within 72 h is associated with improved outcomes, the efficacy and safety of an even earlier "rapid sequence" approach on the day of admission are unclear. This study aims to compare outcomes of severely injured patients undergoing rapid sequence surgery (Day 0) versus early surgery (Days 1-3). METHODS: ≥3), an Injury Severity Score (ISS) ≥ 9, who survived the first 48 h and underwent CWR were included. Patients were stratified into a "Rapid Sequence" group (surgery on Day 0) and an "Early" group (surgery on Days 1-3). Propensity score matching (PSM) was performed to balance baseline characteristics, including injury patterns, demographics, and initial physiological status. Primary outcome was in-hospital mortality. Secondary outcomes included sepsis, multi-organ failure (MOF), and length of stay. RESULTS: From an initial cohort of 34,659 patients with severe chest wall injuries, 2,498 operatively treated patients with a known date of surgery were analyzed. 1,168 (46.8%) underwent rapid sequence surgery (Day 0) and 567 (22.7%) underwent early surgery (Days 1-3). Before matching, the Rapid Sequence group had a higher ISS (27.7 vs. 26.0), a higher incidence of severe head trauma (14.4% vs. 9.2%), and significantly higher mortality (8.4% vs. 4.1%). PSM yielded 500 matched pairs. Despite matching, the Rapid Sequence group retained a higher baseline injury burden (mean ISS: 28.1 vs. 26.2; mortality prognosis (Revised Injury Severity Classification, Version III (RISC III) Score): 16.2% vs. 10.7%). The primary outcome showed a nearly threefold higher mortality rate in the Rapid Sequence group (10.6% vs. 3.6%; p < .001). Rates of sepsis (14.6% vs. 12.0%) and MOF (33.6% vs. 28.3%) were also higher in the rapid group, though not statistically significant. CONCLUSION: In this large registry analysis, rapid sequence CWR on the day of admission identified a distinct subgroup of patients with more severe concomitant injuries and higher baseline risk. The higher mortality in this group likely reflects residual confounding by indication and survivorship bias, rather than a detrimental effect of rapid surgery per se. This suggests that the decision for immediate surgery is likely driven by life-threatening concomitant injuries not fully captured in the matching model, identifying a patient population with an intrinsically higher risk of death. Our findings therefore do not justify a blanket Day-0-for-all strategy, but are consistent with the broader literature suggesting that CWR performed within 72 h is beneficial when timing is individualized to overall injury severity and physiological stability.