Chest injuries - what is new?

Club cell protein (CC)16 as potential lung injury marker in a porcine 72 h polytrauma model

BACKGROUND

Polytrauma and respiratory tract damage after thoracic trauma cause about 25% of mortality among severely injured patients. Thoracic trauma can lead to the development of severe lung complications such as acute respiratory distress syndrome, and is, therefore, of great interest for monitoring in intensive care units (ICU). In recent years, club cell protein (CC)16 with its antioxidant properties has proven to be a potential outcome-related marker. In this study, we evaluated whether CC16 constitutes as a marker of lung damage in a porcine polytrauma model.

METHODS

In a 72 h ICU polytrauma pig model (thoracic trauma, tibial fracture, hemorrhagic shock, liver laceration), blood plasma samples (0, 3, 9, 24, 48, 72 h), BAL samples (72 h) and lung tissue (72 h) were collected. The trauma group (PT) was compared to a sham group. CC16 as a possible biomarker for lung injury in this model, and IL-8 concentrations as known indicator for ongoing inflammation during trauma were determined by ELISA. Histological analysis of ZO-1 and determination of total protein content were used to show barrier disruption and edema formation in lung tissue from the trauma group.

RESULTS

Systemic CC16 levels were significantly increased early after polytrauma compared vs. sham. After 72 h, CC16 concentration was significantly increased in lung tissue as well as in BAL in PT vs. sham. Similarly, IL-8 and total protein content in BAL were significantly increased in PT vs. sham. Evaluation of ZO-1 staining showed significantly lower signal intensity for polytrauma.

CONCLUSION

The data confirm for the first time in a larger animal polytrauma model that lung damage was indicated by systemic and/or local CC16 response. Thus, early plasma and late BAL CC16 levels might be suitable to be used as markers of lung injury in this polytrauma model.

Initial Experiences of Extracorporeal Membrane Oxygenation for Trauma Patients at a Single Regional Trauma Center in South Korea

Purpose For severe lung injuries or acute respiratory distress syndrome that occurs during critical care due to trauma, extracorporeal membrane oxygenation (ECMO) may be used as a salvage treatment. This study aimed to describe the experiences at a single center with the use of ECMO in trauma patients. Methods We enrolled a total of 25 trauma patients who were treated with ECMO between January 2015 and December 2019 at a regional trauma center. We analyzed and compared patients’ characteristics between survivors and non-survivors through a medical chart review. We also compared the characteristics of patients between direct and indirect lung injury groups. Results The mean age of the 25 patients was 45.9±19.5 years, and 19 patients (76.0%) were male. The mean Injury Severity Score was 26.1±10.1. Ten patients (40.0%) had an Abbreviated Injury Scale (AIS) 3 score of 4, and six patients (24.0%) had an AIS 3 score of 5. There were 19 cases (76.6%) of direct lung injury. The mortality rate was 60.0% (n=15). Sixteen patients (64.0%) received a loading dose of heparin for the initiation of ECMO. There was no significant difference in heparin use between the survivors and non-survivors (70% in survivors vs. 60% in non-survivors, p=0.691). When comparing the direct and indirect lung injury groups, there were no significant differences in variables other than age and ECMO onset time. Conclusions If more evidence is gathered, risk factors and indications will be identified and we expect that more trauma patients will receive appropriate treatment with ECMO.

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

Lung Contusion in Polytrauma: An Analysis of the TraumaRegister DGU

Background Thorax trauma frequently occurs in which injuries to the bony chest, lung contusions (LCs), and others are diagnosed. The significance of this violation is described very differently and is mostly based on monocentric data.

Methods A retrospective analysis of the TraumaRegister DGU® (TR-DGU) dataset (Project 2014–062) was performed between 2009 and 2014 (injury severity score [ISS] ≥ 16, primary admission to a trauma center, no isolated traumatic brain injury). Patients with LC (Abbreviated Injury Scale [AIS] 3 + 4) were compared with the control group, and an analysis of different age groups was performed.

Results A total of 49,567 patients were included, thereunder 14,521 (29.3%) without relevant thoracic trauma (TT); 95.9% blunt traumas. 18,892 patients (38.1%) had LC and 14,008 (28.3%) had severe LC with AIS 3 + 4; thereunder 72.7% males. For severe LC, the average age was the lowest (44.7 ± 19.7 years) and ISS the highest (30.4 ± 12.1 points).

Intubation, intensive care, (multi-) organ failure, sepsis, and extrathoracic injuries were most common in severe LC. Shock, chest tubes, further thoracic injuries, and patient death occurred most frequently in TT without LC.

Younger patients showed a higher incidence of LC than the older ones; however, high patient age was a highly significant risk factor for the development of complications and poor outcome.

Conclusion Since LC was present in almost 40% of the severely injured and was related to higher morbidity, LC should be detected and managed at the earliest possible time. Proper follow-ups employing chest X-rays and computed tomography (CT) scans are recommended.

Early Local Inhibition of Club Cell Protein 16 Following Chest Trauma Reduces Late Sepsis-Induced Acute Lung Injury

Blunt thoracic trauma (TxT) deteriorates clinical post-injury outcomes. Ongoing inflammatory changes promote the development of post-traumatic complications, frequently causing Acute Lung Injury (ALI). Club Cell Protein (CC)16, a pulmonary anti-inflammatory protein, correlates with lung damage following TxT. Whether CC16-neutralization influences the inflammatory course during ALI is elusive. Ninety-six male CL57BL/6N mice underwent a double hit model of TxT and cecal ligation puncture (CLP, 24 h post-TxT). Shams underwent surgical procedures. CC16 was neutralized by the intratracheal application of an anti-CC16-antibody, either after TxT (early) or following CLP (late). Euthanasia was performed at 6 or 24 h post-CLP. Systemic and pulmonary levels of IL-6, IL-1β, and CXCL5 were determined, the neutrophils were quantified in the bronchoalveolar lavage fluid, and histomorphological lung damage was assessed. ALI induced a significant systemic IL-6 increase among all groups, while the local inflammatory response was most prominent after 24 h in the double-hit groups as compared to the shams. Significantly increased neutrophilic infiltration upon double hit was paralleled with the enhanced lung damage in all groups as compared to the sham, after 6 and 24 h. Neutralization of CC16 did not change the systemic inflammation. However, early CC16-neutralization increased the neutrophilic infiltration and lung injury at 6 h post-CLP, while 24 h later, the lung injury was reduced. Late CC16-neutralization increased neutrophilic infiltration, 24 h post-CLP, and was concurrent with an enhanced lung injury. The data confirmed the anti-inflammatory potential of endogenous CC16 in the murine double-hit model of ALI.

Contributing factors in the development of acute lung injury in a murine double hit model

OBJECTIVES

Blunt chest (thoracic) trauma (TxT) is known to contribute to the development of secondary pulmonary complications. Of these, acute lung injury (ALI) is common especially in multiply injured patients and might not only be due to the direct trauma itself, but seems to be caused by ongoing and multifactorial inflammatory changes. Nevertheless, the exact mechanisms and contributing factors of the development of ALI following blunt chest trauma are still elusive.

METHODS

60 CL57BL/6N mice sustained either blunt chest trauma combined with laparotomy without further interventions or a double hit (DH) including TxT and cecal ligation puncture (CLP) after 24 h to induce ALI. Animals were killed either 6 or 24 h after the second procedure. Pulmonary expression of inflammatory mediators cxcl1, cxcl5, IL-1β and IL-6, neutrophil infiltration and lung tissue damage using the Lung Injury Score (LIS) were determined.

RESULTS

Next to a moderate increase in other inflammatory mediators, a significant increase in CXCL1, neutrophil infiltration and lung injury was observed early after TxT, which returned to baseline levels after 24 h. DH induced significantly increased gene expression of cxcl1, cxcl5, IL-1β and IL-6 after 6 h, which was followed by the postponed significant increase in the protein expression after 24 h compared to controls. Neutrophil infiltration was significantly enhanced 24 h after DH compared to all other groups, and exerted a slight decline after 24 h. LIS has shown a significant increase after both 6 and 24 h compared to both control groups as well the late TxT group.

CONCLUSION

Early observed lung injury with moderate inflammatory changes after blunt chest trauma recovered quickly, and therefore, may be caused by mechanical lung injury. In contrast, lung injury in the ALI group did not undergo recovery and is closely associated with significant changes of inflammatory mediators. This model may be used for further examinations of contributing factors and therapeutic strategies to prevent ALI.

Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome

BACKGROUND

Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course.

METHODS

We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview.

RESULTS

From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB^® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49-63] with a median ISS of 21 [IQR 16-29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12-68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred.

CONCLUSIONS

In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule. Trial registration number KEK BASEC Nr. 2016-01679.

Rotational therapy in thoracic injuries: what is the evidence?

PURPOSE OF REVIEW

To review the current use of continuous lateral rotational therapy (CLRT) in patients with thoracic injuries and its impact on clinical course, complications and outcome.

RECENT FINDINGS

Patient positioning is a key factor in the treatment of severe thoracic injuries and CLRT, and intermittent supine and prone position are basic options. There is a lack of randomized controlled studies for trauma patients with chest injury undergoing kinetic therapy as standard of care. A positive effect of kinetic therapy for prevention of secondary respiratory complications has been reported; nevertheless, no positive effect on mortality or length of hospital stay could be affirmed so far. In general, standardized therapeutic regimes for treatment of chest trauma have been implemented, including ventilator settings and positioning therapy. However, the available data do not allow a clear recommendation for rotational/kinetic therapy or prone positioning as superior or inferior.

SUMMARY

The benefit of changing the patients' position for secret mobilization and recruitment of atelectasis after chest trauma and therefore preventing secondary complications seems to be self-evident. Since only few studies report about the utility of CLRT in critically ill chest trauma patients, randomized controlled multicenter trials are necessary to analyze the overall benefit of such means.

[Chest trauma from a surgical perspective]

Patients with multiple injuries in particular frequently also suffer from chest trauma. During the initial phase the identification and treatment of life-threatening injuries is essential and tension pneumothorax is of particular importance during this phase. The Advanced Trauma Life Support (ATLS) algorithm should be followed for structured treatment. In most cases treatment by insertion of a chest tube is sufficient but for some injuries an emergency thoracotomy is unavoidable as a life-saving intervention. In the further treatment especially a flail chest and retained hemothorax are responsible for complications, such as acute lung failure and thoracic empyema. Early operative interventions in the sense of rib fracture stabilization and thoracoscopy-assisted evacuation of hematomas can help to prevent such complications.

Leukotriene B4 indicates lung injury and on-going inflammatory changes after severe trauma in a porcine long-term model

BACKGROUND

Recognizing patients at risk for pulmonary complications (PC) is of high clinical relevance. Migration of polymorphonuclear leukocytes (PMN) to inflammatory sites plays an important role in PC, and is tightly regulated by specific chemokines including interleukin (IL)-8 and other mediators such as leukotriene (LT)B4. Previously, we have reported that LTB4 indicated early patients at risk for PC after trauma. Here, the relevance of LTB4 to indicating lung integrity in a newly established long-term porcine severe trauma model (polytrauma, PT) was explored.

METHODS

Twelve pigs (3 months old, 30 ± 5kg) underwent PT including standardized femur fracture, lung contusion, liver laceration, hemorrhagic shock, subsequent resuscitation and surgical fracture fixation. Six animals served as controls (sham). After 72h lung damage and inflammatory changes were assessed. LTB4 was determined in plasma before the experiment, immediately after trauma, and after 2, 4, 24 or 72h. Bronchoalveolar lavage (BAL)-fluid was collected prior and after the experiment.

RESULTS

Lung injury, local gene expression of IL-8, IL-1β, IL-10, IL-18 and PMN-infiltration into lungs increased significantly in PT compared with sham. Systemic LTB4 increased markedly in both groups 4h after trauma. Compared with declined plasma LTB4 levels in sham, LTB4 increased further in PT after 72h. Similar increase was observed in BAL-fluid after PT.

CONCLUSIONS

In a severe trauma model, sustained changes in terms of lung injury and inflammation are determined at day 3 post-trauma. Specifically, increased LTB4 in this porcine long-term model indicated a rapid inflammatory alteration both locally and systemically. The results support the concept of LTB4 as a biomarker for PC after severe trauma and lung contusion.

Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials

AIMS

Flail chest from a blunt injury to the thorax is associated with significant morbidity and mortality. Its management globally is predominantly non-operative; however, there are an increasing number of centres which undertake surgical stabilisation. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management.

PATIENTS AND METHODS

A systematic search of the literature was carried out to identify randomised controlled trials (RCTs) which compared the clinical outcome of patients with a traumatic flail chest treated by surgical stabilisation of any kind with that of non-operative management.

RESULTS

Of 1273 papers identified, three RCTs reported the results of 123 patients with a flail chest. Surgical stabilisation was associated with a two thirds reduction in the incidence of pneumonia when compared with non-operative management (risk ratio 0.36, 95% confidence interval (CI) 0.15 to 0.85, p = 0.02). The duration of mechanical ventilation (mean difference -6.30 days, 95% CI -12.16 to -0.43, p = 0.04) and length of stay in an intensive care unit (mean difference -6.46 days, 95% CI 9.73 to -3.19, p = 0.0001) were significantly shorter in the operative group, as was the overall length of stay in hospital (mean difference -11.39, 95% CI -12.39 to -10.38, p < 0.0001).

CONCLUSION

Surgical stabilisation for a traumatic flail chest is associated with significant clinical benefits in this meta-analysis of three relatively small RCTs. Cite this article: Bone Joint J 2016;98-B:1119-25.

Physical function and pain after surgical or conservative management of multiple rib fractures - a follow-up study

Background

There is scarce knowledge of physical function and pain due to multiple rib fractures following trauma. The purpose of this follow-up was to assess respiratory and physical function, pain, range of movement and kinesiophobia in patients with multiple rib fractures who had undergone stabilizing surgery and compare with conservatively managed patients.

Methods

A consecutive series of 31 patients with multiple rib fractures who had undergone stabilizing surgery were assessed >1 year after the trauma concerning respiratory and physical function, pain, range of movement in the shoulders and thorax, shoulder function and kinesiophobia. For comparison, 30 patients who were treated conservatively were evaluated with the same outcome measures.

Results

The results concerning pain, lung function, shoulder function and level of physical activity were similar in the two groups. The patients who had undergone surgery had a significantly larger range of motion in the thorax (p < 0.01) and less deterioration in two items in Disability Rating Index (sitting and standing bent over a sink) (p < 0.05).

Discussion

It is questionable whether the control group is representative since the majority of patients were invited but refused to participate in the follow-up. In addition, this study is too small to make a definitive conclusion if surgery is better than conservative treatment. But we see some indications, such as a tendency for decreased pain, better thoracic range of motion and physical function which would indicate that surgery is preferable. If operation technique could improve in the future with a less invasive approach, it would presumably decrease post-operative pain and the benefit of surgery would be greater than the morbidity of surgery.

Conclusions

Patients undergoing surgery have a similar long-term recovery to those who are treated conservatively except for a better range of motion in the thorax and fewer limitations in physical function. Surgery seems to be beneficial for some patients, the question remains which patients.

Trial registration

FoU i Sverige (R&D in Sweden), No 106121

Patients with thoracic trauma and concomitant spinal cord injury have a markedly decreased mortality rate compared to patients without spinal cord injury

INTRODUCTION

The present study was performed to compare the clinical outcome, with special focus on the mortality rate of thoracic injuries, in patients with and without spinal cord injury.

MATERIALS AND METHODS

Patients who were treated for thoracic trauma at our institution between January 1998 and December 2007 were included in this retrospective cohort study. Patients were divided into two groups according to whether they had suffered a concomitant spinal cord injury (SCI) (N = 54) or not (N = 61). Survival analysis was performed using the Kaplan-Meier function and the Cox proportional hazards model. Age, sex, injury severity score (ISS), Charlson comorbidity index (CCI), and infection with pneumonia were included as covariates in the final model.

RESULTS

Patients with SCI have a 65 % reduction in the chance of dying compared to patients without SCI following thoracic trauma (HR = 0.35; 95%CI = 0.13-0.96; p = 0.041). Sex (HR = 0.67; 95 % CI: 0.26-1.71, P = 0.141), ISS > =25 (HR = 2.08 95 % CI: 0.58-7.49, P = 2.63) and a Charlson Comorbidity Index of 2 (HR = 1.82; 95 % CI: 0.58-7.22, P = 0.393) had no effect in the risk of dying. However, patients older than 60 years had four times the chance of dying than patients younger than 30 years (HR = 4.39; 95 % CI: 1.02-19, P = 0.048). Patients with pneumonia had a nonsignificant twofold increase in the risk of dying (HR = 2.28; 95 % CI: 0.97-5.34, P = 0.059).

CONCLUSIONS

Our results demonstrate that patients with thoracic trauma and concomitant SCI had markedly decreased mortality compared to patients without SCI, even after adjusting for age, sex, injury severity, comorbidities and pneumonia infection.

The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS

Background

The use of a double lumen cannula for veno-venous extracorporeal membrane oxygenation (v.v. ECMO) offers several advantages such as cannulation with only one cannula, patient comfort and the earlier mobilization and physiotherapy. The cannulation should be performed under visual wire and cannula placement into the right atrium, which is associated with risks of malposition and right ventricular perforation. The aim of this patient series is to describe the use of double lumen cannula in trauma patients with posttraumatic ARDS.

Material and methods

Criteria for the v.v ECMO treatment were defined as hypoxaemia (pO2/FiO2 < 200 mmHg, FiO2 0.8-1,0); tidal volume >4-6 ml/kg ideal body weight; mean inspiratory pressure (Pinsp) >32-34 mmHg; respiratory acidosis pH <7.25; and arterial saturation (SaO2) <90%. The analysis included the Injury Severity Score (ISS), the types of injury, time of treatment, complications and outcomes.

Results

A total of 24 patients with major trauma were treated for posttraumatic ARDS with v.v. ECMO. The double lumen cannula (Avalon®, Fa. Maquet, Rastatt, Germany) was used in six male patients. The mean ISS was 31 (20–48). The ECMO therapy was started in an average on the third day after trauma. The mean ECMO run time was 7 days ± 5 (6–18), and the hospital stay was in mean of 60 days ± 34 (21–105).

Conclusion

The use of double lumen cannula for v.v ECMO therapy in trauma patients is a feasible treatment option. No higher risk of bleeding could be found in this case series. A PTT-controlled heparinization is recommended using double lumen cannula. Therefore the use of this cannula type in trauma patients with high risk of bleeding is to discuss controversially.

Rescue extracorporeal membrane oxygenation in a young man with a stab wound in the chest

A 27-year-old man with haemorrhagic shock and acute cardiac tamponade due to a stab in the chest underwent successful resuscitation and surgical repair of the right ventricular perforation thanks to the use of extracorporeal membrane oxygenation (ECMO) in the emergency department. To the best of the authors' knowledge, this is the first report around the use of ECMO to rescue a victim of a penetrating cardiac trauma. The physicians who have portable ECMO device should be aware of this option when a life-threatening internal bleeding in haemodynamically unstable patients could be quickly controlled by surgery, even if performed in ill-suited settings.

Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience

Introduction

Severe trauma with concomitant chest injury is frequently associated with acute lung failure (ALF). This report summarizes our experience with extracorporeal lung support (ELS) in thoracic trauma patients treated at the University Medical Center Regensburg.

Methods

A retrospective, observational analysis of prospectively collected data (Regensburg ECMO Registry database) was performed for all consecutive trauma patients with acute pulmonary failure requiring ELS during a 10-year interval.

Results

Between April 2002 and April 2012, 52 patients (49 male, three female) with severe thoracic trauma and ALF refractory to conventional therapy required ELS. The mean age was 32 ± 14 years (range, 16 to 72 years). Major traffic accident (73%) was the most common trauma, followed by blast injury (17%), deep fall (8%) and blunt trauma (2%). The mean Injury Severity Score was 58.9 ± 10.5, the mean lung injury score was 3.3 ± 0.6 and the Sequential Organ Failure Assessment score was 10.5 ± 3. Twenty-six patients required pumpless extracorporeal lung assist (PECLA) and 26 patients required veno-venous extracorporeal membrane oxygenation (vv-ECMO) for primary post-traumatic respiratory failure. The mean time to ELS support was 5.2 ± 7.7 days (range, <24 hours to 38 days) and the mean ELS duration was 6.9 ± 3.6 days (range, <24 hours to 19 days). In 24 cases (48%) ELS implantation was performed in an external facility, and cannulation was done percutaneously by Seldinger's technique in 98% of patients. Cannula-related complications occurred in 15% of patients (PECLA, 19% (n = 5); vv-ECMO, 12% (n = 3)). Surgery was performed in 44 patients, with 16 patients under ELS prevention. Eight patients (15%) died during ELS support and three patients (6%) died after ELS weaning. The overall survival rate was 79% compared with the proposed Injury Severity Score-related mortality (59%).

Conclusion

Pumpless and pump-driven ELS systems are an excellent treatment option in severe thoracic trauma patients with ALF and facilitate survival in an experienced trauma center with an interdisciplinary treatment approach. We encourage the use of vv-ECMO due to reduced complication rates, better oxygenation and best short-term outcome.

Use of extracorporeal membrane oxygenation in combination with high-frequency oscillatory ventilation in post-traumatic ARDS

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life-threatening complications in trauma patients. Despite the implantation of a veno-venous extracorporeal membrane oxygenation (vv ECMO), sufficient oxygenation (arterial SaO(2)  > 90%) is not always achieved. The additive use of high-frequency oscillation ventilation (HFOV) and ECMO in the critical phase after trauma could prevent the occurrence of life-threatening hypoxaemia and multi-organ failure. We report on a 26-year-old female (Injury Severity Score 29) who had multiple injuries as follows: an unstable pelvic fracture, a blunt abdominal trauma, a blunt trauma of the left thigh, and a thoracic injury. Three days after admission, the patient developed fulminant ARDS (Murray lung injury score of 11 and Horovitz-Index <80 mmHg), and vv ECMO therapy was initiated. The Horovitz-Index was <80 mm Hg, and the lung compliance was minimal. With HFOV, almost complete recruitment of the lung was achieved, and the fraction of inspired oxygen (FiO(2) ) was significantly reduced. The pelvic fracture was treated non-operatively. The HFOV was terminated after 3 days, and the ECMO was stopped after 19 days.

A structured autopsy-based audit of 370 firearm fatalities: Contribution to inform policy decisions and the probability of the injured arriving alive at a hospital and receiving definitive care

The objectives of this autopsy-based audit of firearm-related fatalities were to acquire data to inform policy decisions and to assess the probability of the injured arriving alive at a hospital and receiving definitive care.

EVALUATED VARIABLES

Demographics; co-morbidities; location and intention of the injury; toxicology; types of firearms; Abbreviated Injury Scale; Injury Severity Score (ISS); transfer means and time; and location of death.

RESULTS

Of a total of 370 fatalities, 85.7% were male. The median age was 38 (9-95) years. Suicides (47%) and assaults (45.1%) were the most common underlying intentions. The most seriously injured regions were the head (44.5%), thorax (25.7%), abdomen (10.7%), and spine (5.7%). Of the 370 total subjects, 4.9% had an ISS<16 and 59.5% had an ISS≤74; both groups were classified as potentially preventable deaths. The majority (84%) died at the scene, and only 9.8% left the emergency department alive for further treatment. Multivariate analyses documented that postmortem ISS is an independent factor that predicts the probability of the injured reaching a hospital alive and receiving definitive care. Individuals injured in greater Athens and those most seriously injured in the face, abdomen or spine had significantly greater chances of reaching a hospital alive and receiving definitive care, whereas those injured by a shotgun and the positive toxicology group were significantly less likely to. In conclusion, this study provides data to inform policy decisions, calls for a surveillance network and establishes a baseline for estimating the probability regarding the location of firearm-related deaths.

[Chest trauma: who, how and what?]

A chest-trauma management system, tagged as the "Pécs model" in a tertiary referral center is described with extensive references to the state of the art in thoracic trauma. Chest drainage has utmost importance in primary therapy as well as in surgical decision making (diagnosis). Thoracotomy is a general surgical competence, just as damage control is. Definitive treatment and management of sequelae, however, requires competence in thoracic surgery. Multidisciplinarity is underscored.

Lung Organ Failure Score (LOFS): probability of severe pulmonary organ failure after multiple injuries including chest trauma

BACKGROUND

Pulmonary complications are common in multiple trauma patients with chest injury. Factors predisposing these critically ill patients to respiratory organ failure are not fully understood.

METHODS

Univariate and multivariate logistic regression analyses were used to assess the prognostic value of clinical and laboratory variables (2002-2008; n = 30,616) from the Trauma Registry of the German Trauma Society (DGU). Data from patients admitted to the ICU with lung contusion/lacerations, an Injury Severity Score ≥ 16 and age ≥ 18 were included in the study. Severe pulmonary organ failure was defined as PaO(2)/FiO(2)<200 for ≥ 3 days and based on the odds ratios (ORs) a simplified Lung Organ Failure Score (LOFS) was developed using integer values.

RESULTS

21.3% (1254) of the 5892 patients analysed developed severe pulmonary organ failure. We identified seven independent predictors with significant correlation: age, gender, head injury, fluid therapy, injury severity, degree of chest trauma and surgical interventions. The highest ORs were observed in cases of Abbreviated Injury Scale (AIS)(Thorax) = 5 (1.58), surgical intervention (1.71) and multiple surgeries (2.41). We found that patients with simplified score values ≥ 21 points were at a maximum risk (>30%) for developing severe pulmonary complications.

CONCLUSION

This scoring method could help trauma surgeons determine which multiple trauma patients are at risk for pulmonary complications after trauma. Efficacy analyses of prophylactic PEEP ventilation or rotational bed therapy in subgroups with comparable risks for respiratory complication could be based on the LOFS.

Does gastric volume in trauma patients identify a population at risk for developing pneumonia and poor outcomes?

BACKGROUND

Trauma patients may have full stomachs or impaired airway reflexes that place them at risk for aspiration and pneumonia. Our hypothesis was that trauma patients with larger gastric volumes as measured by abdominal computed tomography (CT) at admission have higher rates of pneumonia and worse outcomes.

METHODS

We matched an initial cohort of 81 trauma patients with an admission CT of the abdomen and a diagnosis of pneumonia by Injury Severity Score and Abbreviated Injury Score of the head and chest with a control group of 81 trauma patients without pneumonia. We estimated gastric volumes on CT and compared variables using chi-square, t-tests, receiver operating curve analysis, and regression analysis.

RESULTS

Patients with pneumonia had larger gastric volumes than those without pneumonia (879 cm(3)versus 704 cm(3); P = 0.04). Receiver operating curve analysis gave a gastric volume threshold value of 700 cm(3) as a predictor of pneumonia. Patients with a gastric volume ≥ 700 cm(3) had more pneumonia (61% versus 41%; P = 0.01), stayed longer in the hospital (27.6 versus 19.7 d; P < 0.05) and the intensive care unit (18.4 versus 12.5 d; P = 0.01), required more days on the ventilator (18.1 versus 12.0 d; P = 0.02), and had a trend toward increased mortality (17% versus 11%; P = 0.2). On multivariate analysis, nasogastric or orogastric tube (odds ratio 3.0; P = 0.004) and gastric volume >700 cm(3) (odds ratio 2.7; P = 0.004) were independent predictors of pneumonia.

CONCLUSIONS

Trauma patients who developed pneumonia had larger initial gastric volumes. A straightforward estimate of gastric volume on admission abdominal CT may predict patients at risk for developing pneumonia and poor outcomes. Clinicians should be especially vigilant in taking precautions against pneumonia and have a lower threshold for suspecting pneumonia in patients with abdominal CT gastric volumes ≥ 700 cm(3).

Thin Chest Wall is an Independent Risk Factor for the Development of Pneumothorax after Chest Tube Removal

The factors contributing to the development of pneumothorax after removal of chest tube thoracostomy are not fully understood. We hypothesized that development of post pull pneumothorax (PPP) after chest tube removal would be significantly lower in those patients with thicker chest walls, due to the “protective” layer of adipose tissue. All patients on our trauma service who underwent chest tube thoracostomy from July 2010 to February 2011 were retrospectively reviewed. Patient age, mechanism of trauma, and chest Abbreviated Injury Scale score were analyzed. Thoracic CTs were reviewed to ascertain chest wall thickness (CW). Thickness was measured at the level of the nipple at the midaxillary line, as perpendicular distance between skin and pleural cavity. Chest X-ray reports from immediately prior and after chest tube removal were reviewed for interval development of PPP. Data are presented as average ± standard deviation. Ninety-one chest tubes were inserted into 81 patients. Patients who died before chest tube removal (n = 11), or those without thoracic CT scans (n = 13) were excluded. PPP occurred in 29.9 per cent of chest tube removals (20/67). When PPP was encountered, repeat chest tube was necessary in 20 per cent of cases (4/20). After univariate analysis, younger age, penetrating mechanism, and thin chest wall were found to be significant risk factors for development of PPP. Chest Abbreviated Injury Scale score was similar in both groups. Logistic regression showed only chest wall thickness to be an independent risk factor for development of PPP.

Multidetector-row computed tomography of thoracic trauma

Imaging in trauma patients has dramatically evolved since the advent of computed tomography (CT), particularly multidetector CT (MDCT) technology. Axial MDCT images of the body can be acquired in seconds and shown any plane, allowing immediate viewing and interpreting. These factors make CT an invaluable means to detect many injuries not previously visible by any other noninvasive imaging techniques. Potentially subtle, but significant, thoracic injuries such as pneumothorax, haemothorax, aortic injury, sternal and spinal fractures can be detected on MDCT easily. In this article, the author will discuss the use of MDCT in the diagnosis of various thoracic injuries.

Resuscitative emergency thoracotomy in a Swiss trauma centre

BACKGROUND

Resuscitative emergency thoracotomy (ET) is performed as a salvage manoeuvre for selected patients with trauma. However, reports from European trauma centres are scarce.

METHODS

A retrospective analysis was undertaken of injured patients who underwent resuscitative ET in the emergency department (ED) or operating room (OR) between January 1996 and September 2008. Survival in the ED and to hospital discharge was analysed using logistic regression.

RESULTS

During the study interval 121 patients required a resuscitative thoracotomy, of which 49 (40·5 per cent) were performed in the ED and 72 (59·5 per cent) in the OR. Patients in the OR had higher blood pressure on arrival (median 110 versus 60 mmHg; P < 0·001), were less often in severe haemorrhagic shock (63 versus 94 per cent; P < 0·001), had fewer serious head injuries (Abbreviated Injury Score of 3 or above in 33 versus 53 per cent; P = 0·031) and more often had a penetrating stab wound as the dominating mechanism (25 versus 10 per cent; P = 0·042) compared with those in the ED. Ten patients (20 per cent) survived to hospital discharge after ED thoracotomy, compared with 53 (74 per cent) of those treated in the OR. Penetrating injury and Glasgow Coma Scale score above 8 were independent predictors of hospital survival following ED thoracotomy. No patient with a blunt injury and no detectable signs of life on admission survived. Three of 26 patients with blunt trauma and signs of life on admission survived to hospital discharge.

CONCLUSION

Resuscitative ET may be life-saving in selected patients. Location of the procedure is dictated by injury severity and vital parameters. Outcome is best when signs of life are present on admission, even for blunt injuries.

Ventilation in chest trauma

Chest trauma is one important factor for total morbidity and mortality in traumatized emergency patients. The complexity of injury in trauma patients makes it challenging to provide an optimal oxygenation while protecting the lung from further ventilator-induced injury to it. On the other hand, lung trauma needs to be treated on an individual basis, depending on the magnitude, location and type of lung or chest injury. Several aspects of ventilatory management in emergency patients are summarized herein and may give the clinician an overview of the treatment possibilities for chest trauma victims.

Circulating levels of Clara cell protein 16 but not surfactant protein D identify and quantify lung damage in patients with multiple injuries

BACKGROUND

Almost 60% of all patients with severe multiple injuries sustain severe chest trauma with aggravating effect on morbidity and mortality. Diagnosis of lung contusion is performed by early posttraumatic multislice computed tomography. Because this diagnostic procedure requires time, resources, and exposure to radiation, a noninvasive approach with easy follow-up measurements is warranted.

METHODS

Serum levels of Clara cell protein 16 (CC16) and surfactant protein D as lung-specific biomarkers were obtained on admission from 104 patients with multiple injuries using enzyme-linked immunosorbent assay technique. Patients were divided into those with severe lung injury ([LI]; n = 68) and without LI (NLI; n = 36). Nonsmoking healthy volunteers served as controls. In addition, volume of lung contusions were calculated planimetrically on serial multislice computed tomography scans obtained after admission. Factors influencing CC16 serum levels were determined in uni- and multivariate analyses, and Spearman rank coefficients were calculated for correlations.

RESULTS

Patients with LI showed a significant (p < 0.05) elevation of median CC16 levels (10.2 ng/mL) compared with NLI patients (5.4 ng/mL) and controls (5.2 ng/mL). Serum CC16 levels correlated with the volume of lung contusions (r = 0.78, p < 0.0001) and were not influenced by overall injury severity, age, gender, or preclinical ventilation. In contrast, circulating surfactant protein D levels were not associated with the presence of LI or the extent of lung contusions.

CONCLUSIONS

Our results advocate CC16 as a potential biomarker for LI in severely injured patients because of its high correlation with the volume of contused lung parenchyma. Therefore, this parameter may allow a specified initial treatment of patients with multiple injuries.

Reading chest radiographs in the critically ill (Part II): Radiography of lung pathologies common in the ICU patient

This is part II of two series review of reading chest radiographs in the critically ill. Conventional chest radiography remains the cornerstone of day to day management of the critically ill occasionally supplemented by computed tomography or ultrasound for specific indications. In this second review we discuss radiographic findings of cardiopulmonary disorders common in the intensive care patient and suggest guidelines for interpretation based not only on imaging but also on the pathophysiology and clinical grounds.

Accuracy of conventional imaging of penetrating torso injuries in the trauma resuscitation room

OBJECTIVES

Chest X-ray (CXR), abdominal ultrasound, cardiac ultrasound, and abdominal X-ray are the most frequently used imaging modalities to radiologically evaluate patients with penetrating torso trauma. The aim of this study was to evaluate the accuracy of these imaging modalities.

METHODS

From January 2001 until January 2005, all consecutive patients with penetrating torso injuries presenting at the emergency department of a level 1 trauma center were included. Imaging modalities (chest/abdominal X-ray, abdominal/cardiac ultrasound), were compared retrospectively with a 'gold standard' (i.e. computed tomography or surgery within 2 h after arrival) or outcome of conservative treatment. The accuracy of the imaging modalities was calculated.

RESULTS

Three hundred and eighteen patients were included. On the basis of 299 CXRs, the sensitivity for diagnosing pneumothorax, hemothorax, and subcutaneous emphysema was 71, 63, and 61%, respectively. The sensitivity of abdominal ultrasound (N = 229) to detect free abdominal fluid and/or intra-abdominal injury was 65%. The specificity, positive predictive value, negative predictive value, and accuracy of the two imaging modalities to detect any of the diagnoses mentioned were >or=87%. Cardiac ultrasound (N = 31) did not show any false positive or negative results for detecting cardiac effusion. Pneumoperitoneum was not seen on abdominal X-ray in eight of 11 patients with perforation of a hollow organ.

CONCLUSION

Despite high specificity, positive predictive value, and negative predictive value, a considerable number of lesions remain undetected after CXR and abdominal ultrasound because of moderate-to-inadequate sensitivity. Abdominal X-ray hardly provides additional information. Careful clinical monitoring of patients is mandatory, particularly when computed tomography scan or operative treatment is not indicated.

[Treatment of polytrauma in the intensive care unit]

The treatment of severely injured trauma patients (polytrauma) is one of the outstanding challenges in medical care. Early in the initial course the patient's diagnostics have to be scrupulously reevaluated by an interdisciplinary team (tertiary trauma survey) to reduce deleterious sequelae of missed injuries after the initial assessment. Severely injured patients stay in intensive care for an average of 11 days. During this time the patient's therapy has to ensure a high quality evidence-based intensive care treatment and simultaneously has to be tailored to the current individual injuries. Because of the fact that the damage control strategy is gaining increasing acceptance, the intensive care unit plays a pivotal role in the critical time between emergency and elective surgery. Therefore a close cooperation between physicians of the intensive care unit and all surgical disciplines involved is essential to reach the aim of therapeutic efforts. After survival of emergency treatment patients with severe trauma should be reintegrated into social and occupational life as soon as possible.

Exercise-induced cardiac troponin elevation: evidence, mechanisms, and implications

Regular physical exercise is recommended for the primary prevention of cardiovascular disease. Although the high prevalence of physical inactivity remains a formidable public health issue, participation in exercise programs and recreational sporting events, such as marathons and triathlons, is on the rise. Although regular exercise training reduces cardiovascular disease risk, recent studies have documented elevations in cardiac troponin (cTn) consistent with cardiac damage after bouts of exercise in apparently healthy individuals. At present, the prevalence, mechanism(s), and clinical significance of exercise-induced cTn release remains incompletely understood. This paper will review the biochemistry, prevalence, potential mechanisms, and management of patients with exercise-induced cTn elevations.

Selective medicated (saline + natural surfactant) bronchoalveolar lavage in unilateral lung contusion. A clinical randomized controlled trial

OBJECTIVE

Open lung and low tidal volume ventilation appear to be a promising ventilation for chest trauma as it can reduce ARDS and improve outcome. Local therapy (e.g. BAL) can be synergic to remove from the lung the debris, mitigate inflammatory cascade and avoid damage spreading to not compromised lung areas.

MATERIALS AND METHODS

44 pulmonary contused patients were randomized to receive broncho-suction and volume controlled low tidal volume ventilation-VCLTVV (Control Group) or the same ventilation plus medicated (saline + surfactant) BAL (Treatment Group). Tidal volume <10 ml/kg, PEEP of 10-12 cm H(2)O and PaO(2) 60-100 mm Hg and PaCO(2) 35-45 mm Hg were used in both groups. BAL was performed using a fiberscope. 4 boluses of 25 ml saline with 2.4 mg/ml of surfactant were introduced into each contused lobe in which, subsequently, 240 mg of surfactant was instilled.

RESULTS

All patients survived. In the Control Group 18 patients developed pneumonia, 5 ARDS and days of intubation were 11.50 (3.83) compared to 5.05 (1.21) of Treatment Group in which OI and PaO(2)/FiO(2) significantly improved from 36 h.

CONCLUSIONS

VCLTVV alone was not able to prevent ARDS and infection in the Control Group as the reduction of intubation. In the Treatment Group, VCLTVV and medicated BAL facilitated the removal of degradated lung material and recruited the contused lung regions, enabling the healing of the lung pathology.

Cardiac and Pulmonary Injury

Cardiac and pulmonary injuries present major challenges in diagnosis and treatment. Distinct differences between penetrating and blunt trauma of these organs exist. Outcomes for severe injuries are still grave. Organized trauma systems can provide optimal care by minimizing prehospital time, allowing easy access to imaging modalities, and offering state-of-the-art treatment strategies. A multidisciplinary approach, including surgeons, intensivists, and others, is absolutely necessary.