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Seibold T, Schönfelder J, Weeber F, Lechel A, Armacki M, Waldenmaier M, Wille C, Palmer A, Halbgebauer R, Karasu E, Huber‐Lang M, Kalbitz M, Radermacher P, Paschke S, Seufferlein T, Eiseler T. Small Extracellular Vesicles Propagate the Inflammatory Response After Trauma. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2021; 8:e2102381. [PMID: 34713625 PMCID: PMC8693079 DOI: 10.1002/advs.202102381] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/20/2021] [Indexed: 05/03/2023]
Abstract
Trauma is the leading cause of death in individuals under 44 years of age. Thorax trauma (TxT) is strongly associated with trauma-related death, an unbalanced innate immune response, sepsis, acute respiratory distress syndrome, and multiple organ dysfunction. It is shown that different in vivo traumata, such as TxT or an in vitro polytrauma cytokine cocktail trigger secretion of small extracellular nanovesicles (sEVs) from endothelial cells with pro-inflammatory cargo. These sEVs transfer transcripts for ICAM-1, VCAM-1, E-selectin, and cytokines to systemically activate the endothelium, facilitate neutrophil-endothelium interactions, and destabilize barrier integrity. Inhibition of sEV-release after TxT in mice ameliorates local as well as systemic inflammation, neutrophil infiltration, and distant organ damage in kidneys (acute kidney injury, AKI). Vice versa, injection of TxT-plasma-sEVs into healthy animals is sufficient to trigger pulmonary and systemic inflammation as well as AKI. Accordingly, increased sEV concentrations and transfer of similar cargos are observed in polytrauma patients, suggesting a fundamental pathophysiological mechanism.
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Affiliation(s)
- Tanja Seibold
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Jonathan Schönfelder
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Florian Weeber
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - André Lechel
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Milena Armacki
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Mareike Waldenmaier
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Christoph Wille
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Annette Palmer
- Institute of Clinical and Experimental Trauma‐ImmunologyUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Rebecca Halbgebauer
- Institute of Clinical and Experimental Trauma‐ImmunologyUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Ebru Karasu
- Institute of Clinical and Experimental Trauma‐ImmunologyUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Markus Huber‐Lang
- Institute of Clinical and Experimental Trauma‐ImmunologyUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Miriam Kalbitz
- Department of TraumatologyHandPlastic and Reconstructive SurgeryUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Peter Radermacher
- Institute of Anesthesiological Pathophysiology and Process EngineeringUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Stephan Paschke
- Department of General and Visceral SurgeryUniversity HospitalAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Thomas Seufferlein
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
| | - Tim Eiseler
- Department of Internal Medicine IUniversity Hospital UlmAlbert‐Einstein‐Allee 23Ulm89081Germany
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Evaluation of Lung Contusion, Associated Injuries, and Outcome in a Major Trauma Center in Shiraz, Southern Iran. Emerg Med Int 2021; 2021:3789132. [PMID: 33976939 PMCID: PMC8087464 DOI: 10.1155/2021/3789132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 12/29/2020] [Accepted: 04/17/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Blunt chest trauma as one of the most common injuries in trauma cases can cause significant morbidity and mortality. The purpose of this study was to determine the clinical course of traumatic injuries with an initial diagnosis of a pulmonary contusion in patients. Method In this retrospective study, we evaluated the demographic and clinical features of patients who were referred to a major trauma center in southern Iran. In our study, patients were enrolled with the diagnosis of pulmonary contusion. All included patients were above 16 years of age, with an initial CT scan in favor of pulmonary contusion, while patients not being hospitalized for more than 48 hours were excluded from the study. Results Among the 434 patients included in our study, 366 (84%) were male and the mean age was 41.17 (SD = 17.89). Among them, the majority (80.4%) had right side lung contusion and 47 patients (10.8%) had right rib fracture. The most common injuries were head and neck injury (56.9%) and limbs (30%). In 25% of cases, pulmonary contusion was associated with pneumothorax and 15.8% with hemothorax. Also, 49.6% of patients were transferred to the ICU. The mortality rate in our study was 15.2% (n = 66). Conclusion Although recent advances in pulmonary care and ventilator management have been achieved, there is still considerable morbidity and mortality associated with this condition. Therefore, there is a need to provide a national guideline based on native patient information for better management.
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Miller C, Stolarski A, Ata A, Pfaff A, Nadendla P, Owens K, Evans L, Bonville D, Rosati C, Stain SC, Tafen M. Impact of blunt pulmonary contusion in polytrauma patients with rib fractures. Am J Surg 2019; 218:51-55. [PMID: 30791991 DOI: 10.1016/j.amjsurg.2019.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/13/2018] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND We investigated the impact of blunt pulmonary contusion (BPC) in patients with rib fractures. METHODS Adult patients with rib fractures caused by blunt mechanisms were enrolled over 3 years at a Level 1 trauma center. BPC was defined according to percentage of lung affected as: moderate (1-19% contusion) or severe (≥20% contusion). RESULTS In total, 1448 of the 7238 admitted patients had rib fractures. Of these, 321 (22.2%) had BPC: 236 moderate and 85 severe. Patients with BPC were more likely to be admitted to the ICU (moderate: OR 1.55, 95% CI 1.10-2.19; severe: OR 2.74, 95% CI 1.41-5.32). Significantly increased rates of pneumonia (OR 2.52, 95% CI 1.43-4.90) and empyema (OR 4.80, 95% CI 1.07-21.54) were found for moderate and severe BPC, respectively. CONCLUSIONS ICU admission and infectious pulmonary complications were more likely with BPC. The presence of BPC on admission CT is also prognostic of increased resource utilization.
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Affiliation(s)
- Claire Miller
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - Allan Stolarski
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - Ashar Ata
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - Ashley Pfaff
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
| | | | - Kimberly Owens
- Department of Radiology, Albany Medical Center, Albany, NY, USA
| | - Lauren Evans
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Bonville
- Division of Acute Care Surgery and Surgical Critical Care, Houston Methodist Hospital, Houston, TX, USA
| | - Carl Rosati
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - Steven C Stain
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - Marcel Tafen
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA.
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Rittayamai N, Katsios CM, Beloncle F, Friedrich JO, Mancebo J, Brochard L. Pressure-Controlled vs Volume-Controlled Ventilation in Acute Respiratory Failure: A Physiology-Based Narrative and Systematic Review. Chest 2015; 148:340-355. [PMID: 25927671 DOI: 10.1378/chest.14-3169] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Mechanical ventilation is a cornerstone in the management of acute respiratory failure. Both volume-targeted and pressure-targeted ventilations are used, the latter modes being increasingly used. We provide a narrative review of the physiologic principles of these two types of breath delivery, performed a literature search, and analyzed published comparisons between modes. METHODS We performed a systematic review and meta-analysis to determine whether pressure control-continuous mandatory ventilation (PC-CMV) or pressure control-inverse ratio ventilation (PC-IRV) has demonstrated advantages over volume control-continuous mandatory ventilation (VC-CMV). The Cochrane tool for risk of bias was used for methodologic quality. We also introduced physiologic criteria as quality indicators for selecting the studies. Outcomes included compliance, gas exchange, hemodynamics, work of breathing, and clinical outcomes. Analyses were completed with RevMan5 using random effects models. RESULTS Thirty-four studies met inclusion criteria, many being at high risk of bias. Comparisons of PC-CMV/PC-IRV and VC-CMV did not show any difference for compliance or gas exchange, even when looking at PC-IRV. Calculating the oxygenation index suggested a poorer effect for PC-IRV. There was no difference between modes in terms of hemodynamics, work of breathing, or clinical outcomes. CONCLUSIONS The two modes have different working principles but clinical available data do not suggest any difference in the outcomes. We included all identified trials, enhancing generalizability, and attempted to include only sufficient quality physiologic studies. However, included trials were small and varied considerably in quality. These data should help to open the choice of ventilation of patients with acute respiratory failure.
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Affiliation(s)
- Nuttapol Rittayamai
- Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Christina M Katsios
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - François Beloncle
- Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Medical Intensive Care Unit, Hospital of Angers, Université d'Angers, Angers, France
| | - Jan O Friedrich
- Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital Sant Pau, Barcelona, Spain
| | - Laurent Brochard
- Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, St. Michael's Hospital, Toronto, ON, Canada.
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Blunt pulmonary contusion: admission computed tomography scan predicts mechanical ventilation. ACTA ACUST UNITED AC 2012; 71:1543-7. [PMID: 21857256 DOI: 10.1097/ta.0b013e31822c4a8b] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blunt pulmonary contusion (BPC) evolves over 12 to 24 hours, and the initial plain radiographs fail to reliably identify patients at risk of clinical deterioration. Admission computed tomography (CT) may offer accurate characterization of BPC and early prediction of the need for mechanical ventilation (MV). METHODS This was a combination of a 5-year retrospective study (January 2002 to April 2007) and a 6-month prospective study (September 2007 to February 2008) of adult blunt trauma (BT) patients with thoracic injuries and a chest CT upon hospital arrival. The primary outcome was MV due to thoracic trauma. To ensure that MV was required for BPC and not for associated injuries, all patients with significant extrathoracic injuries (Abbreviated Injury Scale score >2) were excluded. The extent of BPC was measured by two scoring systems. RESULTS Of 392 patients (67% males; age, 48 years ± 21 years; Abbreviated Injury Scale score chest, 3 ± 1; and Injury Severity Score [ISS], 13 ± 6), 243 (62%) had BPC. Twenty-five (6%) patients required MV and two (0.5%) died. The combination of Glasgow Coma Scale (GCS) score <14, BPC score >2, and >4 ribs fractured predicted MV in 100% of the cases, and the absence of all factors precluded MV in 100%. In the prospective period of 6 months, 55 patients had BPC and we confirmed our finding that the absence of the three factors precludes MV. CONCLUSION A simple score derived by the initial chest CT, in combination with GCS and the number of fractured ribs, can predict the need for MV early. In the presence of these predictors, patients should be admitted to a high level of monitoring.
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Hernandez G, Fernandez R, Lopez-Reina P, Cuena R, Pedrosa A, Ortiz R, Hiradier P. Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial. Chest 2009; 137:74-80. [PMID: 19749006 DOI: 10.1378/chest.09-1114] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Guidelines for noninvasive mechanical ventilation (NIMV) recommend continuous positive airway pressure in patients with thoracic trauma who remain hypoxic despite regional anesthesia. This recommendation is rated only by level C evidence because randomized controlled trials in this specific population are lacking. Our aim was to determine whether NIMV reduces intubation in severe trauma-related hypoxemia. METHODS This was a single-center randomized clinical trial in a nine-bed ICU of a level I trauma hospital. Inclusion criteria were patients with Pao(2)/Fio(2)<200 for >8 h while receiving oxygen by high-flow mask within the first 48 h after thoracic trauma. Patients were randomized to remain on high-flow oxygen mask or to receive NIMV. The interface was selected based on the associated injuries. Thoracic anesthesia was universally supplied unless contraindicated. The primary end point was intubation; secondary end points included length of hospital stay and survival. Statistical analysis was based on multivariate analysis. RESULTS After 25 patients were enrolled in each group, the trial was prematurely stopped for efficacy because the intubation rate was much higher in controls than in NIMV patients (10 [40%] vs 3 [12%], P = .02). Multivariate analysis adjusted for age, gender, chronic heart failure, and Acute Physiology and Chronic Health Evaluation II at admission revealed NIMV as the only variable independently related to intubation (odds ratio, 0.12; 95% CI, 0.02-0.61; P = .01). Length of hospital stay was shorter in NIMV patients (14 vs 21 days P = .001), but no differences were observed in survival or other secondary end points. CONCLUSION NIMV reduced intubation compared with oxygen therapy in severe thoracic trauma-related hypoxemia.
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Affiliation(s)
- Gonzalo Hernandez
- Critical Care Medicine, Hospital Virgen de la Salud, Toledo, Mezquite n degrees 12, 6 degrees A, 28045, Madrid, Spain.
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Abstract
Thoracic trauma is an important cause of morbidity and mortality in the UK, frequently found in drivers of motor vehicles following high-speed accidents. One of the more serious injuries is a flail chest, particularly when there are also underlying pulmonary contusions. For many years the optimal therapeutic regimen for the management of this condition has remained somewhat controversial. More recently, the role of epidural analgesia, the use of non-invasive techniques of ventilation and identification of those who may benefit from surgical stabilisation have been more clearly defined.
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Affiliation(s)
- Zaffer Qasim
- Emergency and Critical Care Medicine, Salford Royal Hospitl NHS Foundation Trust, Salford M6 8HD, UK
| | - Carl Gwinnutt
- Department of Anaesthesia, Salford Royal Hospital NHS Foundation Trust, Salford M6 8HD UK,
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Perl M, Gebhard F, Braumüller S, Tauchmann B, Brückner UB, Kinzl L, Knöferl MW. The pulmonary and hepatic immune microenvironment and its contribution to the early systemic inflammation following blunt chest trauma. Crit Care Med 2006; 34:1152-9. [PMID: 16484915 DOI: 10.1097/01.ccm.0000207343.53990.a8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Blunt chest trauma is accompanied by an early increase in plasma cytokine concentrations. However, the local sources of these mediators are poorly defined. We investigated the impact of blunt chest trauma on the inflammatory mediator milieu in different compartments (lung tissue, bronchoalveolar lavage, liver tissue, Kupffer cells, plasma) along with the time course of trauma-induced pulmonary endothelial barrier dysfunction to elucidate potential relationships. In addition, the correlation between intratracheally instilled interleukin-6 and its systemic release were studied. DESIGN Prospective, randomized, controlled animal study. SETTING Basic science laboratory of a university affiliated level 1 trauma center. SUBJECTS Male C3H/HeN mice, 8-9 wks old, n = 141. INTERVENTIONS Blunt chest trauma induced by a focused blast wave, intravenous injection of Evans blue, and intratracheal instillation of recombinant human interleukin-6. MEASUREMENTS AND MAIN RESULTS Two hours after blunt chest trauma, plasma interleukin-6 was markedly increased. Simultaneously, interleukin-6, tumor necrosis factor-alpha, macrophage inflammatory protein-2, monocyte chemotactic polypeptide-1 and neutrophil/monocyte accumulation in bronchoalveolar lavage and interleukin-6, monocyte chemotactic polypeptide-1, and myeloperoxidase activity in lung tissue were significantly increased. This was accompanied by a coinciding elevation in the Evans blue lung-plasma ratio. Recombinant human interleukin-6, instilled intratracheally before blunt chest trauma, was detected in a dose-dependent manner in the plasma of the mice. Additionally, Kupffer cell interleukin-6, tumor necrosis factor-alpha, and interleukin-10 production was significantly augmented as early as 30 mins after the insult. CONCLUSIONS These results indicate that early increased cytokine concentrations in the lung, particularly interleukin-6, are important mediator sources as their local peak coincides with the systemic inflammatory response and is accompanied by a simultaneous impaired function of the pulmonary endothelial barrier. A direct relationship between their local and systemic concentrations can be established. Furthermore, this is the first study to show that Kupffer cells are activated early after blunt chest trauma.
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Affiliation(s)
- Mario Perl
- Department of Trauma, Hand, Plastic, and Reconstructive Surgery, University of Ulm, Germany
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Affiliation(s)
- Riyad Karmy-Jones
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Dunham CM, Barraco RD, Clark DE, Daley BJ, Davis FE, Gibbs MA, Knuth T, Letarte PB, Luchette FA, Omert L, Weireter LJ, Wiles CE. Guidelines for emergency tracheal intubation immediately after traumatic injury. THE JOURNAL OF TRAUMA 2003; 55:162-79. [PMID: 12855901 DOI: 10.1097/01.ta.0000083335.93868.2c] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Keough V, Pudelek B. Blunt chest trauma: review of selected pulmonary injuries focusing on pulmonary contusion. AACN CLINICAL ISSUES 2001; 12:270-81. [PMID: 11759554 DOI: 10.1097/00044067-200105000-00010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pulmonary injuries resulting from blunt chest trauma remain a common clinical entity for critical care and emergency nurses. In this article, the epidemiology and mechanism of injury most often observed in patients with blunt chest trauma are reviewed. Selected pulmonary injuries are discussed in terms of mechanism of injuries, assessment and diagnostic modalities, standard therapies, and cutting-edge therapies used today with a focus on pulmonary contusion. Many advances and experimental therapies currently used in the management of the patient with severe lung injuries are discussed. A case study is presented highlighting a complicated case of a blunt chest injury resulting in severe pulmonary contusion.
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Affiliation(s)
- V Keough
- Loyola University Chicago, Niehoff School of Nursing, Chicago, Illinois, USA
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