Impact of blunt pulmonary contusion in polytrauma patients with rib fractures

Exogenous surfactant for lung contusion causing ARDS: A systematic review of clinical and experimental reports

This systematic review aimed to summarize the available data on the treatment of pulmonary contusions with exogenous surfactants, determine whether this treatment benefits patients with severe pulmonary contusions, and evaluate the optimal type of surfactant, method of administration, and drug concentration. Three databases (MEDline, Scopus, and Web of Science) were searched using the following keywords: pulmonary surfactant, surface-active agents, exogenous surfactant, pulmonary contusion, and lung contusion for articles published between 1945 and February 2023, with no language restrictions. Four reviewers independently rated the studies for inclusion, and the other four reviewers resolved conflicts. Of the 100 articles screened, six articles were included in the review. Owing to the limited number of papers on this topic, various types of studies were included (two clinical studies, two experiments, and two case reports). In all the studies, surfactant administration improved the selected ventilation parameters. The most frequently used type of surfactant was Curosurf® in the concentration of 25 mg/kg of ideal body weight. In most studies, the administration of a surfactant by bronchoscopy into the segmental bronchi was the preferable way of administration. In both clinical studies, patients who received surfactants required shorter ventilation times. The administration of exogenous surfactants improved ventilatory parameters and, thus, reduced the need for less aggressive artificial lung ventilation and ventilation days. The animal-derived surfactant Curosurf® seems to be the most suitable substance; however, the ideal concentration remains unclear. The ideal route of administration involves a bronchoscope in the segmental bronchi.

Management of Blunt Chest Trauma

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe?

BACKGROUND

Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions.

METHODS

This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses.

RESULTS

A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries ( p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted β , -2.511 [95% confidence interval, -4.87 to -0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted β , -5.19 [95% confidence interval, -10.2 to -0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management.

CONCLUSION

In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Imaging findings of pulmonary contusions on multidetector CT: A retrospective study comparing adults and children

To describe imaging findings of pulmonary contusions (PC) in adults and children using multidetector computed tomography (CT) scanners. We conducted a retrospective single center study. All chest multidetector computed tomography (MDCT) scans of victims of blunt trauma admitted to the emergency unit of a reference trauma center of Brazil between January 2015 and December 2016 were reviewed in search of opacities compatible with PC. The CT images were analyzed in conjunction with medical records, that provided demographic and clinical data. The obtained data were analyzed in the overall population and comparing children and adults. Significant P value was defined as <.05. 52.7% of patients presented bilateral opacities. Middle third, posterior and peripheral portions of the lungs were more frequently affected, in the craniocaudal, anteroposterior and axial axes, respectively. A vast majority of patients (80.6%) presented multiple opacities, whereas a minority showed subpleural sparing (26.9%) and fissure crossing (22.6%), with similar frequencies in children and adults. Children, although, more frequently presented consolidation and more diffuse lesions in the anteroposterior axis compared to adults, with statistically significant differences. PC usually are multiple and predominate in middle, posterior and peripheral portions of the lungs. Subpleural sparing and fissure crossing seems to be infrequent and have similar frequencies between children and adults. Although, there are differences between these age groups, as younger people tend to have more consolidation and diffuse opacities in the anteroposterior axis than older ones.

Evaluating the Limits in the Biomechanics of Blunt Lung Injury

Thoracic blunt trauma is evident in up to one fifth of all hospital admissions, and is second only to head trauma in motor vehicle crashes. One of the most problematic injury mechanisms associated with blunt thoracic trauma is pulmonary contusion, occurring in up to 75% of blunt thoracic trauma cases. The source and effects of pulmonary contusion caused by blunt lung injury are not well defined, especially within the field of continuum biomechanics. This, paired with unreliable diagnostics for pulmonary contusion, leads to uncertainty in both the clinical entity and mechanics of how to predict presence of injury. There is a distinct need to combine the clinical aspects with mechanical insights through the identification and mitigation of blunt lung trauma and material testing and modeling. This is achieved through using the mechanical insights of lung tissue behavior in order to better understand the injurious mechanisms and courses of treatment of blunt-caused pulmonary contusion. This paper hopes to act as a step forward in connecting two perspectives of blunt lung injury, the clinical entity and mechanical testing and modeling, by reviewing the known literature and identifying the unknowns within the two related fields. Through a review of related literature, clinical evidence is correlated to mechanical data to gain a better understanding of what is being missed in identification and response to blunt lung injury as a whole.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021)

Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.

Lungs from polytrauma donors with significant chest trauma can be safely used for transplantation

BACKGROUND

The use of organs from polytrauma donors for lung transplantation is controversial in the literature. For many centers, the radiologic manifestation of lung contusions is a clear reason to reject an organ offer. This results in the loss of potentially viable organs for the donor pool.

METHODS

We analyzed 1152 donor lungs procured by our transplant center between January 2010 and June 2018. These included 118 lungs with a history of polytrauma involving the chest. Sixteen polytrauma donor lungs were rejected after procurement. A total of 102 lungs were transplanted, divided into 2 groups: the polytrauma contusion group (n = 44), comprising polytrauma donors with radiologic signs of lung contusion at the time of offer, and the polytrauma clear group (n = 58), comprising polytrauma donors without lung contusion. Nontrauma donor lungs transplanted during the study period were assigned to a polytrauma control group (n = 650). Short- and long-term outcomes of the 3 groups were compared.

RESULTS

Basic demographic data and preoperative factors were similar in the 3 groups. Rates of primary graft dysfunction grade 3 at 72 hours did not differ among the 3 groups (0.0% vs 3.4% vs 3.9%; P = .409). The duration of ventilation was similar the 3 groups: 45 hours (interquartile range [IQR], 28-94 hours), 37 hours (IQR, 22-71 hours), and 42 hours (IQR, 22-96 hours), respectively (P = .674). Long-term graft survival was not impaired in the trauma groups compared with controls. One-year survival rates were 84.1% for the polytrauma contusion group, 93.1% for the polytrauma clear group, and 83.1% for the no polytrauma group. Five-year graft survival in the 3 groups was 74.7%, 87.2%, and 70.0%, respectively.

CONCLUSIONS

Lung transplantation using organs from polytrauma donors is associated with similar short- and long-term results as transplantation from nontrauma donors. The presence or absence of radiologic signs of lung contusion at the time of offer has no impact on primary graft function and long-term survival.

IL-17 is a potential biomarker for predicting the severity and outcomes of pulmonary contusion in trauma patients

Pulmonary contusion (PC) is very common in blunt chest trauma, and always results in negative pulmonary outcomes, such as pneumonia, acute respiratory distress syndrome (ARDS), respiratory failure or even death. However, there are no effective biomarkers which can be used to predict the outcomes in these patients. The present study aimed to determine the value of interleukin (IL)-17 and IL-22 in predicting the severity and outcomes of PC in trauma patients. All trauma patients admitted to The First Affiliated Hospital of Guangxi Medical University between January 2015 and December 2017, were studied. Patients aged >14 years old with a diagnosis of PC upon their admission to the emergency department were included. Patients with PC were enrolled as the PC group, patients without PC were enrolled as the non-PC group, and healthy individuals were selected as the control group. Clinical information, including sociodemographic parameters, clinical data, biological findings and therapeutic interventions were recorded for all patients who were enrolled. Blood samples were collected and stored according to the established protocols. PC volume was measured by computed tomography and plasma cytokine levels were assayed by ELISA. A total of 151 patients with PC (PC group) and 159 patients without PC (non-PC group) were included in the present study. In addition, 50 healthy individuals were used as the control group. The primary cause of PC was motor vehicle crashes. PC patients had more rib fractures, but similar injury severity scores compared with other patients. More patients received Pleurocan drainage treatment and had pneumonia complications in the PC group compared with the other two groups. PC patients had a high incidence of ARDS and admission to the intensive care unit (ICU). PC patients also experienced longer periods on mechanical ventilation and had longer stays in the ICU and hospital. PC volume was effective in predicting the outcomes of PC patients. IL-22 levels were similar in the PC group and non-PC group. However, IL-17 could be used as a biomarker to predict the severity of PC, and was strongly associated with PC volume. IL-17 was significantly associated with pro-inflammatory complications in PC patients and could be used as a biomarker for predicting in-patient outcomes of patients with PC. In conclusion, IL-17 is a potential biomarker for predicting the severity and outcomes of PC in trauma patients.

Pulmonary contusions in patients with rib fractures: The need to better classify a common injury

BACKGROUND

Pulmonary contusions are common injuries. Computed tomography reveals vast contused lung volume spectrum, yet pulmonary contusions are defined dichotomously (unilateral vs bilateral). We assessed whether there is stepwise increased risk of pulmonary complications among patients without, with unilateral, and with bilateral pulmonary contusion.

METHODS

We identified adults admitted with rib fractures using the largest US inpatient database. After propensity-score-matching patients without vs with unilateral vs bilateral pulmonary contusions and adjusting for residual confounders, we compared risk for pneumonia, ventilator-associated pneumonia (VAP), respiratory failure, intubation, and mortality.

RESULTS

Among 148,140 encounters of adults with multiple rib fractures, 19% had concomitant pulmonary contusions. Matched patients with pulmonary contusions had increased risk of pneumonia 19% [95%CI:16-33%], respiratory failure 40% [95%CI: 31-50%], and intubation 46% [95%CI: 33-61%]. Delineation showed bilateral contusions, not unilateral contusions, attributed to increased risk of complications.

CONCLUSIONS

There is likely a correlation between contused lung volume and risk of pulmonary complications; dichotomously classifying pulmonary contusions is insufficient. Better understanding this correlation requires establishing the clinically significant contusion volume and a correspondingly refined classification system.

Assessment of thoracic volume changes after the collapse of lateral rib fractures based on chest computed tomography data: computer simulation and a multiple variable linear regression analysis

Background

Chest blunt trauma (CBT) and the resultant rib fractures often lead to thoracic collapse. The purpose of this study was to explore the effect of displacement of the rib fracture and thoracic collapse on the thoracic volume by using normal chest CT data.

Methods

In this retrospective study, seven consecutive normal participants were selected from our hospital between June and July 2018. Normal thoracic models were reconstructed, followed by simulation of lateral fractures through the 4th to 9th ribs under three collapse modes with 1–5 cm of collapse. The thoracic collapse models (n = 630) were reconstructed using 3Dmax 2014. We calculated the thoracic volume and reduction percentage for each thoracic collapse model. Linear regression-based comparisons of thoracic volume reductions were performed.

Results

In all three collapse modes, the degree of the collapse was linearly correlated with the mean thoracic volume reduction. The reduction percentage in the posterior collapse mode was higher than that in the anterior collapse mode (P < 0.001). The largest volume reductions in the anterior, posterior, and simultaneous collapse models were in the 6th rib fracture model (P < 0.001), 8th rib fracture model (P < 0.001), and 7th rib fracture model (P < 0.001), respectively.

Conclusions

The influences of rib fracture displacement and collapse on the thoracic volume in the 6th through 8th ribs are critical in lateral rib fractures. For patients with 6th to 8th rib fractures and posterior rib collapse, surgical intervention to restore thoracic volume may be more essential.

Early Versus Late Tracheostomy in Trauma Patients With Rib Fractures

BACKGROUND

Patients with blunt chest trauma with multiple rib fractures (RF) may require tracheostomy. The goal was to compare early (≤7 d) versus late (>7 d) tracheostomy patients and to analyze clinical outcomes, to determine which timing is more beneficial.

METHODS

This retrospective review included 124 patients with RF admitted to trauma ICU at two level 1 trauma centers who underwent tracheostomy. Analyzed variables included age, gender, injury severity score, Glasgow Coma Scale, number of ribs fractured, total fractures of the ribs, prevalence of bilateral RF, flail chest, maxillofacial injuries, cervical vertebrae trauma, traumatic brain injuries (TBI), coinjuries, epidural analgesia, surgical stabilization of RF, failure to extubate, hospital LOS, intensive care unit LOS (ICULOS), duration of mechanical ventilation, mortality, and timing and type of tracheostomy.

RESULTS

Mean number of RF in all tracheostomized patients with blunt chest trauma was 5.2 and 85% of patients had pulmonary co-injuries. Mean tracheostomy timing was 9.9 d. Early tracheostomy (ET) was correlated with statistically significant reduction in ICULOS and duration of mechanical ventilation. The dominant cause of mortality in all groups was TBI and it was more pronounced in the ET patients. Most deaths were encountered between 3 and 5 wk after admission. ET was more often performed in the operating room with an open technique, whereas late tracheostomy was more often implemented with percutaneous technique at bedside.

CONCLUSIONS

ET could be beneficial in chest trauma patients with multiple RF as it reduces ICULOS and ventilation requirements. Mortality benefits are not correlated with tracheostomy timing.

Tracheostomy in trauma patients with rib fractures

PURPOSE

Patients with rib fractures (RF) may require prolonged mechanical ventilation and tracheostomy. Indications for tracheostomy in trauma patients with RF remain debatable. The goal was to delineate characteristics of patients who underwent tracheostomy due to thoracic versus extra-thoracic causes, such as maxillofacial-mandibular injury (MFM), traumatic brain injury (TBI), and cervical vertebrae trauma (CVT), and to analyze clinical outcomes. The predictive values of chest trauma scoring systems for tracheostomy were also evaluated. We hypothesized that tracheostomized patients were more severely injured with more ribs fractured and had more pulmonary co-injuries.

METHODS

Retrospective review included 471 patients with RF admitted to two Level 1 trauma centers. Patients with tracheostomy (n = 124, 26.3%) were compared to patients with endotracheal intubation (n = 347, 73.7%). Analyzed variables included age, gender, injury severity score (ISS), Glasgow Coma Scale, number of ribs fractured, total fractures of ribs, prevalence of bilateral rib fractures, flail chest, clavicle fractures, MFM, TBI, CVT, co-injuries, comorbidities, RF treatment options, hospital length of stay (HLOS), intensive care unit LOS (ICULOS), duration of mechanical ventilation (DMV).

RESULTS

Tracheostomized compared to intubated patients had statistically higher ISS, more ribs fractured, total fractures of the ribs, bilateral and clavicle fractures, MFM, spine, chest, and orthopedic co-injuries and longer HLOS, ICULOS and DMV. Tracheostomy for thoracic reasons was performed in 64 patients (51.6%) and for extra-thoracic reasons in 60 patients (48.4%). Mean tracheostomy timing was 9.9 days and was significantly shorter in the extra-thoracic compared to the thoracic group (8.0 versus 11.6 days, p < 0.001). All chest trauma scoring system values were significantly higher in tracheostomized patients. Predictive values of scoring systems for tracheostomy increased in patients with thoracic trauma only.

CONCLUSIONS

A quarter of mechanically ventilated patients with RF required tracheostomy. Tracheostomized compared to intubated patients were more severely injured with more ribs fractured and were intubated longer. An increased amount of RF was associated with an increase in tracheostomies, especially for thoracic reasons.