Post-traumatic Pneumonia Research Articles

A RARE CASE OF MINIMALLY INVASIVE REMOVAL OF A VERTEBRAL FOREIGN BODY AFTER A GUNSHOT FRAGMENT PENETRATING WOUND OF THE CHEST AND SPINE

Objective. To demonstrate the possibilities of minimally invasive technologies in the diagnosis and treatment of gunshot wounds of the chest and spine. Methods. Patient N., 42, was wounded in the chest during mortar fire. From the diagnosis: gunshot fragment blind penetrating wound chest on the right with a gunshot fracture of the right scapula, III–V ribs on the right, damage to the right lung with the presence of a metal fragment paravertebrallyon the right at the level ThV–ThVI vertebrae, right-sided hemopneumothorax, right-sided post-traumatic pulmonitis, spinal cord injury, lower paraplegia. Results. The final is established diagnosis: gunshot fragment blind penetrating wound chest on the right with a gunshot fracture of the right scapula,III–V ribs on the right, damage to the right lung with the presence of a metal fragment paravertebrally on the right at the level ThV vertebra, right-sided hemopneumothorax. right-sided post-traumatic pneumonia, spinal cord injury, lower paraplegia. The operation was performed: video-assisted thoracoscopy on the right, revision of the pleural cavity, removal of a metal fragment from the body of the ThV vertebra, sanitation and redrainingof the right pleural cavity according to Bulau, which lasted 40 min. In the future, after 2 weeks, the stitches and signs were removed neurological deficit regressed, the wounded was sent to the military medical commission and discharged to parts. Conclusions. Gunshot wounds to the chest with spinal injuryare rare. The use of modern magnetic surgical instrument allows to remove ferromagnetic foreign bodies during vertebral injury. The use of minimally invasive operative interventions for gunshot wounds of the chest with spinal cord injury reduces operative trauma and can be applied to the third level of medical care.

Early Internal Fixation of Concomitant Clavicle Fractures in Severe Thoracic Trauma Prevents Posttraumatic Pneumonia.

Severe thoracic trauma can lead to pulmonary restriction, loss of lung volume, and difficulty with ventilation. In recent years, there has been increasing evidence of better clinical outcomes following surgical stabilization of clavicle fractures in the setting of this combination of injuries. The aim of this study was to evaluate surgical versus non-surgical treatment of clavicle fractures in severe thoracic trauma in terms of clinical and radiological outcomes in order to make a generalized treatment recommendation based on the results of a large patient cohort. This retrospective study included 181 patients (42 women, 139 men) from a European level I trauma centre with a median of 49.3 years in between 2005 and 2021. In 116 cases, the clavicle fracture was stabilized with locking plate or hook plate fixation (group 1), and in 65 cases, it was treated non-surgically (group 2). Long-term functional outcomes at least one year postoperatively using the disabilities of the arm, shoulder and hand (DASH) questionnaire and the Nottingham Clavicle Score (NCS) as well as radiological outcomes were collected in addition to parameters such as hospital days, intensive care days, and complication rates. The Injury Severity Score (ISS) was 17.8 ± 9.8 in group 1 and 19.9 ± 14.4 in group 2 (mean ± SEM; p = 0.93), the time in hospital was 21.5 ± 27.2 days in group 1 versus 16 ± 29.3 days in group 2 (p = 0.04). Forty-seven patients in group 1 and eleven patients in the group 2 were treated in the ICU. Regarding the duration of ventilation (group 1: 9.1 ± 8.9 days, group 2: 8.1 ± 7.7 days; p = 0.64), the functional outcome (DASH group 1: 11 ± 18 points, group 2: 13.7 ± 18. 4 points, p = 0.51; NCS group 1: 17.9 ± 8.1 points, group 2: 19.4 ± 10.3 points, p = 0.79) and the radiological results, no significant differences were found between the treatment groups. With an overall similar complication rate, pneumonia was found in 2% of patients in group 1 and in 14% of patients in group 2 (p = 0.001). This study could demonstrate that surgical locking plate fixation of clavicle fractures in combination with CWI significantly reducing the development of posttraumatic pneumonia in a large patient collection and, therefore, can be recommended as standard therapeutic approach for severe thoracic trauma.

ТРАВМАТИЧНИЙ ПНЕВМОНІТ ВНАСЛІДОК ВІЙСЬКОВОЇ ТРАВМИ ГРУДНОЇ КЛІТКИ ЯК ФАКТОР РИЗИКУ ПНЕВМОНІЇ

The relevance of the problem of gunshot wounds and injuries as a result of the war with Russia continues to grow. Gunshot wounds and chest injury can cause several life-threatening conditions: bleeding, airway obstruction, tension pneumothorax with pericardial tamponade, open pneumothorax, massive hemothorax, chest dissection, tracheobronchial injury, diaphragm damage, myocardial injury, rupture thoracic aorta, esophageal damage and lung contusion. Lung contusion or traumatic pneumonitis is characterized by hemorrhage and swelling in the alveoli. This causes respiratory distress which develops 24 hours after lung injury, causing perfusion/ventilation mismatch by increasing pulmonary vascular resistance and decreasing lung compliance. From February 24, 2022 to February 18, 2023, in the Pulmonology Department of Volyn Regional Clinical Hospital, the rate of hospitalized military patients with chest injury due to mine-explosive wounds, shrapnel wounds, gunshot bullet wounds, and stub-cut wounds of the chest amounted to 19.3% of all pulmonary cases among military, admitted this year (n=88). Penetrating chest injury occurred in 41.1% of cases, nonpenetrating blunt chest injury (including behind armor blunt trauma) in 23.5 % of cases, chest trauma with soft tissue injury in 35.2 % of cases. Chest injury with fractured chest bones was detected in 47% of cases. In 52.9 % of cases, chest injuries and one stab-cut wound were on the side surface and chest, which was not protected by a bulletproof vest. Lung contusion or traumatic pneumonitis was observed in 70.5% of cases, including destruction in 29.4 %. Post-traumatic pneumonia was observed in 58.8 % of cases, that was caused by a non-hospital and hospital infection, pleurisy was observed in 17.6 % of cases. After chest injury, infiltrative-destructive pulmonary tuberculosis was detected in 5.8 % of cases and invasive pulmonary aspergillosis in 5.8 % of cases. Thus, the occurrence of a specific infection that can lead to destruction and aggravate destructive changes in the lung parenchyma should also be taken into account. Also, in 64.7 % of cases, metal, fragmentary, foreign bodies of the chest organs were found, and required further surgical removal. The article presents clinical cases of patients with chest injuries received as a result of military operations in Ukraine. Key words: traumatic pneumonitis, lung contusion, gunshot wound, chest injury, behind armor blunt trauma, pneumonia.

Лечение пострадавших с сочетанной травмой органов нескольких полостей и опорно-двигательной системы

The aim of the study was to improve the results of treatment of patients with severe combined trauma of the organs of several cavities (skull, thoracic and abdominal cavities, retroperitoneal space) and of the musculoskeletal system. Materials and research methods. The study involved 72 patients treated between 2013 and 2017 in a Level I trauma center established at the Republican Clinical Hospital of the Ministry of Health of the Kabardino-Balkarian Republic. The Injury Severity Score (ISS) index was used to determine the severity of injury; “department of military field surgery, condition, admission” scale was used to assess the state of the injured. Results of the study and their analysis. Analysis of the findings showed the following: in severe combined injuries the main causes of death are: shock, cerebral edema and dislocation, posttraumatic pneumonia, multiple organ failure, acute respiratory failure, pulmonary embolism and DIC syndrome. The most satisfactory treatment outcomes can be achieved only with the use of a care tactic based on the principles of staged surgical treatment “Damage control”. The time frame and the sequence of surgical treatment of injuries depend on their severity, degree of life threatening and prevailing injury.

RESULTS OF SURGICAL TREATMENT OF FIRE WOUNDS OF COLON

The aim of the study. Evaluate the results of surgical treatment of wounded with gunshot wounds of the colon.
 Materials and methods of research. A retrospective analysis of the results of surgical treatment of 32 wounded with gunshot wounds of the colon, who were treated in the Central Medical Center and area of responsibility (II–IV level of medical care) from 2014 to 2017. Damage to the right half of the colon was observed in 12 wounded (37.4 %), the left half — in 17 (53.2 %), the rectum — in 3 (9.4 %). A differentiated approach to surgical treatment of colon injuries of different localization is applied.
 Results and discussion. The method of multi-stage surgical treatment “Damage Control Surgery” was used in 12.5 % of patients. The most common complications of the injury were adhesive intestinal obstruction in 6.3 % of cases, the formation of intestinal abscesses — in 6.3 %, the development of post-traumatic pneumonia in 25 % of patients.
 Conclusions. If the tactics of “Damage Control Surgery” are followed, it is possible to improve the results of surgical treatment of colon injuries in severe and extremely severe patients.

Evaluation of Cytokine Dynamics in Patients With Multiple and Concomitant Closed Chest Injuries

Aim of the study. An actual problem of the modern approach to the management of patients in the post-traumatic period with the aim of predicting, preventing and treating complications of post-traumatic pneumonia is the assessment of the dynamics of the cytokine profile in this period.Material and methods. Investigations were carried out at the time of hospitalization prior medical interventions. During the research the following methods were used: clinical, physical, instrumental, follow-up, radiation (MRI, CT, X-Ray), endoscopic, laboratory. Blood was taken from the peripheral vein on the first, third, fifth, seventh and ninth day of hospitalization to determine the interlikin profile. The definition of Proinflammatory cytokines: IL-1, IL-6 and IL-10 in the blood serum performed by ELISA on the immunofermental analyzer Abbott AXSYM using standard kits ProCon (“Protein contour”, St. Petersburg, Russia). Data were processed statistically using Student’s t-test.Results. Analysis of the results of determination of IL-1 in the serum of patients DK showed that in all stages of the disease, in addition to IV, the contents of this cytokine exceeded the control values in varying degrees of severity. While the levels of IL-1 in the serum of patients with the 1ststage of the disease was 4.0 times; stage 2–3.4 times; the third stage is 1.5 times higher than normal. And only in patients with very severe stage of pneumonia contents IL-1 did not differ from the norm. A similar picture was observed when determining the serum content of patients with a very severe stage of pneumonia, and only in contrast to the level of IL-1 in patients with a very severe stage of pneumonia, the IL-6 content remained significantly higher than normal. So, the content of IL-10 in patients with a very severe stage of pneumonia of stage I, II, III and IV of the disease averaged 330.7±24.5, respectively; 210.5±17.3; 123.4±15.3 and 98.5±12.7 pg/ml (in all cases p<0.05). CONCLUSION The results obtained in a comparative study of contents of proinflammatory cytokines (IL-1, IL-6 and TNF-a) in the blood serum showed that the determination of the spectrum of cytokines in peripheral blood, in our opinion, is the most perspective and can be a key marker for early detection of inflammation. Key words: post-traumatic pneumonii, interlikin profile, peripheral blood serum>˂0.05).Conclusion. The results obtained in a comparative study of contents of proinflammatory cytokines (IL-1, IL-6 and TNF-a) in the blood serum showed that the determination of the spectrum of cytokines in peripheral blood, in our opinion, is the most perspective and can be a key marker for early detection of inflammation.

Direct Airway Instillation of Neutrophils Overcomes Chemotactic Deficits Induced by Injury.

Trauma induces neutrophil migration toward injury sites, both initiating wound healing and protecting against local bacterial infection. We have previously shown that mitochondrial formyl peptides (mtFPs) released by injured tissues act as chemoattractants by ligating neutrophil (PMN) formyl peptide receptor 1 (FPR1). But this process can also internalize multiple neutrophil chemoattractant receptors and thus might limit neutrophil migration to the lung in response to bacteria. Our objective was to better understand susceptibility to pneumonia after injury and thus find ways to reverse it. We modeled the alveolar chemotactic environment in pulmonary infections by incubating Staphylococcus aureus or Escherichia coli with peripheral blood mononuclear cells. Survey of the chemotactic mediators in the resultant conditioned media (CM) showed multiple potent chemoattractants. Pretreating PMN with mtFPs to mimic injury potently reduced net migration toward CM and this net effect was mostly reversed by an FPR1 antagonist. Using an established mouse model of injury-dependent lung infection, we then showed simple instillation of exogenous unstimulated human neutrophils into the airway resulted in bacterial clearance from the lung. Injury-derived mtFPs suppress global PMN localization into complex chemotactic environments like infected alveoli. Transplantation of naive exogenous human neutrophils into the airway circumvents that pathologic process and prevents development of post-traumatic pneumonia without injury noted to the recipients.

Incidence of post-traumatic pneumonia in poly-traumatized patients: identifying the role of traumatic brain injury and chest trauma.

PurposeTraumatic brain injury (TBI) and chest trauma are common injuries in severely injured patients. Both entities are well known to be associated with severe post-traumatic complications, including pneumonia, a common complication with a significant impact on the further clinical course. However, the relevance of TBI, chest trauma and particularly their combination as risk factors for the development of pneumonia and its impact on outcomes are not fully elucidated.MethodsA retrospective analysis of poly-traumatized patients treated between 2010 and 2015 at a level I trauma centre was performed. Inclusion criteria were: Injury Severity Score ≥ 16 and age ≥ 18 years. TBI and chest trauma were classified according to the Abbreviated Injury Scale. Complications (i.e. acute respiratory distress syndrome (ARDS), multi-organ dysfunction syndrome (MODS) and pneumonia) were documented by a review of the medical records. The primary outcome parameter was in-hospital mortality.ResultsOver the clinical course, 19.9% of all patients developed pneumonia, and in-hospital mortality was 25.3%. Pneumonia (OR 5.142, p = 0.001) represented the strongest independent predictor of in-hospital mortality, followed by the combination of chest injury and TBI (OR 3.784, p = 0.008) and TBI (OR 3.028, p = 0.010). Chest injury alone, the combination of chest injury and TBI, and duration of ventilation were independent predictors of pneumonia [resp. OR 4.711 (p = 0.004), OR 4.193 (p = 0.004), OR 1.002 (p < 0.001)].ConclusionsChest trauma alone and especially its combination with TBI represent high-risk injury patterns for the development of pneumonia, which forms the strongest predictor of mortality in poly-traumatized patients.

The role of natural resistance factors in the development of inflammatory complications in patients with closed thoracic trauma

In recent years, the upward trend in closed severe chest injuries has increased. Closed chest injury with fractures of the ribs is often accompanied by the occurrence of purulent-inflammatory complications. So, the ability of blood serum to lysis Escherichia coli (bactericidal activity of blood serum), micrococcus (indicator of lysozyme content), bacillus subtilis (indicator of beta-lysine content) in 54 patients with a closed chest injury was studied. The indicators of factors of natural resistance were compared with those of 40 healthy people. In addition, the indicators of patients whose trauma proceeded with and without an inflammatory complication were compared with each other. Inflammatory complications in the form of post-traumatic pleurisy and pneumonia were observed in 34 (62.9%) of the examined patients with fractures of 1-3 ribs. In patients with these injuries, we revealed a slight decrease in the bactericidal activity of blood serum: on the first day in the group of patients with a smooth flow to 75.92 + 3.22%, and in the group of patients with complication of the trauma, the inflammatory process (pleurisy, pneumonia) to 72, 83 + 2.65%. On the second day, in the first group, BABS decreases even more to 70.79 + 3.11%, and on the second day it increases to 87.32 + 1.91% (p &lt;0.05). All subsequent days of observation, the bactericidal activity of the blood serum of patients with a favorable flow remained normal or close to normal.The concentration of serum beta-lysine in patients is also subject to large changes depending on the course of the post-traumatic period. In cases of smooth flow, on the first day we noted an increase in the content of beta-lysine in 52.87 + 2.51% (with a norm of 39.3 + 1.4%). Starting from the second day there is a clear downward trend in this indicator. From 4 to 5 days, he approaches the norm (44.32 + 2.40%) and remains within these limits throughout the entire observation period. Thus, a decrease in serum lysozyme and an increase in beta-lysine concentration from the first day after an injury in patients with fractures of 1-3 ribs can serve as a prognostic sign of an inflammatory complication.resistance, which were already registered with minor injuries. However, in cases of the development of the inflammatory process, there is a more significant decrease in the lysozyme content and an increase in the concentration of beta-lysine in the blood serum from the first day after the injury, remaining on all subsequent days.

Prevention and treatment of infectious complications of penetrating thoracic injuries

Results of treatment of 325 wounded are analyzed with penetrating wounds of the chest and identify risk factors for the development of infectious complications. Found that infectious complications of the chest organs developed in 49 (15,1%) cases. It has been established that the most frequent infectious complications of penetrating wounds of the chest are post-traumatic pneumonia (67,3% of cases) and acute empyema of the pleura (26,5% of cases). The most prognostic significant risk factors for the development of infectious complications were identified: the type of injury (odds ratio - 2,48;95% confidence interval - 1,34-3,76), the severity of injuries (odds ratio - 7,88; 95% confidence interval - 3,9-15,92), blood loss (odds ratio - 3,09; 95% confidence interval - 1,6-5,94), duration of stay in the intensive care unit (odds ratio - 9,25;95% confidence interval - 4,57-18, 74), the intersection of chest wall structures (odds ratio - 2,84; 95% confidence interval- 1,24-6,47). Measures aimed at the prevention of infectious complications should be started from the moment the woundedperson enters the hospital. The priority tasks are to maintain the patency of the tracheobronchial tree, expanding the lung,adequate drainage and debridement of the pleural cavity. A high risk of developing infectious complications in penetratingwounds of the chest is expected in the wounded in a severe and extremely serious condition (according to the scale of fieldsurgery - condition at admission more than 31 points). The duration of stay in the intensive care unit for more than 4 daysincreases the probability of infectious complications 9 times.

Early hydrocortisone for multiple trauma patients may lower the incidence of nosocomial pneumonia

Background Early post-traumatic pneumonia increases the duration of mechanical ventilation (MV), hospitalization, and risk of death. In this study, the efficacy of hydrocortisone therapy in the prevention of nosocomial pneumonia in multiple trauma patients has been assessed. Patients and methods Six hundred patients who were admitted with multiple trauma were randomly assigned into two groups. The early hydrocortisone (EH) group consisted of 300 patients who received intravenous hydrocortisone 200 mg/day within 24 h from admission or trauma for 5 days and 100 mg, 50 mg on the following 2 days, respectively. The no early hydrocortisone group consisted of 300 patients who received placebo. All patients were followed up for the incidence of noscomial pneumonia. The days of ICU stay, MV, and mortality rates were calculated in both groups as secondary outcomes. Results The incidence of nosocomial pneumonia in the EH group was significantly lower than the no early hydrocortisone group [120 (40%) vs. 240 (80%), P Conclusion The use of early intravenous stress dose of hydrocortisone in patients with multiple trauma may be associated with lower incidence of nosocomial pneumonia but with no difference in mortality.

Hydrocortisone prevents immunosuppression by interleukin-10+ natural killer cells after trauma-hemorrhage.

Trauma induces a state of immunosuppression, which is responsible for the development of nosocomial infections. Hydrocortisone reduces the rate of pneumonia in patients with trauma. Because alterations of dendritic cells and natural killer cells play a central role in trauma-induced immunosuppression, we investigated whether hydrocortisone modulates the dendritic cell/natural killer cell cross talk in the context of posttraumatic pneumonia. Experimental study. Research laboratory from an university hospital. Bagg Albino/cJ mice (weight, 20-24 g). First, in an a priori substudy of a multicenter, randomized, double-blind, placebo-controlled trial of hydrocortisone (200 mg/d for 7 d) in patients with severe trauma, we have measured the blood levels of five cytokines (tumor necrosis factor-α, interleukin-6, interleukin-10, interleukin-12, interleukin-17) at day 1 and day 8. In a second step, the effects of hydrocortisone on dendritic cell/natural killer cell cross talk were studied in a mouse model of posttraumatic pneumonia. Hydrocortisone (0.6 mg/mice i.p.) was administered immediately after hemorrhage. Twenty-four hours later, the mice were challenged with Staphylococcus aureus (7 × 10 colony-forming units). Using sera collected during a multicenter study in patients with trauma, we found that hydrocortisone decreased the blood level of interleukin-10, a cytokine centrally involved in the regulation of dendritic cell/natural killer cell cluster. In a mouse model of trauma-hemorrhage-induced immunosuppression, splenic natural killer cells induced an interleukin-10-dependent elimination of splenic dendritic cell. Hydrocortisone treatment reduced this suppressive function of natural killer cells and increased survival of mice with posthemorrhage pneumonia. The reduction of the interleukin-10 level in natural killer cells by hydrocortisone was partially dependent on the up-regulation of glucocorticoid-induced tumor necrosis factor receptor-ligand (TNFsf18) on dendritic cell. These data demonstrate that trauma-induced immunosuppression is characterized by an interleukin-10-dependent elimination of dendritic cell by natural killer cells and that hydrocortisone improves outcome by limiting this immunosuppressive feedback loop.

Risk factors for post-traumatic pneumonia in patients with retained haemothorax: Results of a prospective, observational AAST study

IntroductionRetained haemothorax (RH) is a problematic sequela of thoracic trauma, reported in up to 20% of patients following chest injury. RH is associated with a higher severity of thoracic trauma and may portend the onset of other serious post-traumatic complications, including pneumonia. The development of pneumonia has previously been reported to be as high as 19.5% in the setting of traumatic RH. The purpose of this study was to identify risk factors for the development of pneumonia as a complication in RH. MethodsWe utilized the American Association for the Surgery of Trauma Post-Traumatic Retained Haemothorax database. Patients with post-traumatic RH were prospectively enrolled from 2009 to 2011. Inclusion criteria were placement of a thoracostomy tube within 24h of admission for the evacuation of pneumothorax or haemothorax and subsequent chest computed tomography scan chest showing RH. Patients treated with thoracotomy before placement of tube thoracostomy were excluded. For univariate analysis, the Chi-square test with Yates correction was used for comparison of categorical risk factors and the Student's t-test or the Mann–Whitney test for comparison of continuous risk factors. To identify independent risk factors for the development of pneumonia, variables from the univariate analysis significant at p<0.2 were entered into a forward logistic regression model. Adjusted odds ratio and 95% confidence intervals (CI) were derived. Results328 patients with post-traumatic RH from 20 United States centres were enrolled. After stepwise regression analysis, ISS>25 (adjusted OR: 7.1; 95% CI: 3.1, 16.4; p<0.001), blunt mechanism of injury (adjusted OR: 3.5; 95% CI: 1.7, 7.2; p=0.001), and failure to administer peri-procedural antibiotics on the initial thoracostomy tube placement (adjusted OR: 2.6; 95% CI: 1.30, 5.4; p=0.01) were found to be independent predictors of the pneumonia in patients with post-traumatic RH. ConclusionsTo our knowledge, our current study is the largest attempt to identify the independent predictors for pneumonia in this population. Our data show that elevated ISS, blunt thoracic trauma, and failure to administer peri-procedural antibiotics on tube thoracostomy placement are the statistically significant independent risk factors.

Pathogenesis of post-traumatic ventilator-associated pneumonia

Objective To study the role of changes of oropharyngeal microflora in pathogenesis of post-traumatic ventilator-associated pneumonia (VAP). Methods Forty-five patients with post-traumatic VAP treated with intubation and mechanical ventilation were involved in the study.Microbiologic cultures and drug-sensitivity test of oropharyngeal secretions,subglottic secretions,sputum from deep airway and gastric fluid samples were performed at days 1,3,7 and 14 after mechanical ventilation.The stool samples were collected to detect the coccus and bacillus ratio and the fungus.The concordance rate of microflora among subglottic secretions,sputum,gastric fluid and oropharyngeal secretions were compared. Results The main pathogens for VAP patients were gram-negative bacilli.The study showed an increase in aspects of the positive rate of etiology cultures of subglottic secretions,sputum and gastric fluid samples,the concordance rate of microflora among subglottic secretions,sputum,gastric fluid and oropharyngeal secretions and the number of ESBL + and multi-resistant bacteria,along with the prolonged mechanical ventilation. Conclusions The changes of oropharyngeal microflora are closely associated with the development of VAP.The enterobacteria in the gastric cavity always reversely colonize in the oropharynx and the retrograde stomach-pharynx-lower respiratory tract infection is a major infection route of VAP. Key words: Pneumonia, ventilator-associated; Oropharynx; Bacterial infections

Early Onset Pneumonia Following Pulmonary Contusion: The Case of Stonewall Jackson

Confederate Lieutenant General Thomas J. "Stonewall" Jackson was wounded by his own men at the Battle of Chancellorsville during the American Civil War. While being removed from the field, Jackson fell from the litter and struck the right side of his chest on a large stone or stump. Four days following the amputation of his left arm, Jackson developed pneumonia in his right lung. His treating physicians believed the infection developed secondary to a pulmonary contusion that occurred when he fell from the litter. Pulmonary contusions are an independent risk factor in the development of post-traumatic pneumonia and an infection that occurs within 72 to 96 hours of injury is termed an early onset pneumonia. The nature and timing of Stonewall Jackson's illness following his wounding is consistent with the modem diagnosis of early onset pneumonia following chest trauma.

Urgent Airways After Trauma: Who Gets Pneumonia?

Several risk factors, including emergent intubation, severe head injury, shock, blunt trauma, and high severity of injury, have been identified as risk factors for the development of pneumonia after trauma. This study assesses the contribution of emergent intubation to the development of pneumonia after injury. A retrospective review of all trauma patients requiring intubation or cricothyroidotomy in the Emergency Department (ED) or in the pre-hospital area (field) over a 41/2 year period. 571 patients comprised the study population. Of these, 80% had airways established in the ED, while 20% were intubated in the field. Field intubation was associated with a lower Glasgow Coma Scale (GCS) score (p <0.0001) and more severe injury (p <0.0001), particularly to the chest and extremities.Twenty-five percent of the population developed pneumonia. Patients diagnosed with pneumonia were older (p=0.009), and had a higher ISS (p <0.0001), lower GCS score, (p <0.008), longer ICU and hospital length of stay (p < 0.0001). Injuries to the head, thorax and extremities were more common (p < 0.05) and more severe (p <0.05) in patients developing pneumonia. The incidence of pneumonia after field airway was significantly higher (35% versus 23%, p=0.048).Multiple logistic regression analysis identified field intubation, age, AIS-head, and AIS-extremity as independent risk factors for pneumonia. Pre-hospital but not ED intubation is an independent risk factor for the development of post-traumatic pneumonia. Other predictors include the severity of injury, specifically head and extremity injuries.

Risk factors for the development of pneumonia in multiple injured patients. Results of a prospective clinical trial

ZusammenfassungDie Pneumonie ist die häufigste infektiöse Komplikation beim mehrfachverletzten Patienten. In einer prospektiven klinischen Kohortenstudie wurden 266 polytraumatisierte Patienten hinsichtlich ihrer posttraumatischen Pneumonieentwicklung untersucht. Verschiedene Risikofaktoren wurden univariat und multivariat analysiert.Dabei wurden drei unterschiedliche Pneumoniedefinitionen verwendet, um die Abhängigkeit der Ergebnisse von der jeweiligen Definition zu überprüfen. Die Inzidenz von Pneumonien (primär 41%) variierte je nach Definition zwischen 30 und 50%.Verletzungen von Thorax, Schädel und Abdomen waren mit einem signifikant erhöhtem Risiko einer Pneumonie assoziiert (adjustierte relative Risiken: 1,77, 1,97 bzw. 1,52). Ein höheres Lebensalter erhöhte ebenfalls signifikant das Pneumonierisiko.Obwohl sich in der Hauptanalyse ein erhöhtes Pneumonierisiko männlicher Patienten fand (relatives Risiko 2,23;95%-Konfidenzintervall 1,43–3,05), ließ sich dieses Ergebnis bei Verwendung anderer Pneumoniedefinitionen nicht sicher reproduzieren.Schwere Verletzungen des Körperstamms und Kopfes sowie das Alter des Patienten sind sichere Risikofaktoren für eine posttraumatische Pneumonie.Der Zusammenhang zwischen männlichem Geschlecht und infektiösen Komplikationen blieb fraglich.

A formula for prediction of posttraumatic pneumonia based on early anatomic and physiologic parameters.

Identification of risks for development of ventilator-associated pneumonia (VAP), which might be identified early after injury, would allow for prognostic estimates and targeting of high-risk cohorts for clinical trials of preventive strategies. This study was performed to develop an equation that can be applied to estimate the probability of pneumonia based on parameters collected in the early postinjury interval. Over a 28-month period, patient admissions were reviewed for mechanism and severity of injury, patterns of injury, shock, and need for emergent intubation. Early deaths (<48 hours) were excluded. VAP diagnosis required > or = 10(5) colony-forming units/mL organisms in the bronchoalveolar lavage effluent. Multiple logistic regression analysis was used to develop the prediction equation and estimate odds ratios. The equation was then tested on consecutive patients admitted over a 2-month period. We reviewed 9,721 admissions (77% blunt, 23% penetrating). VAP incidence was 5.6%. Overall mortality was 2% (21% for patients with VAP vs. 1% for no VAP; p < 0.0001). Multiple logistic regression analysis for all patients produced the following equation: f(x) = -3.08 - 1.56 (MOI) - 0.12 (GCS) + 1.37 (SCI) + 0.30 (chest AIS) + 1.87 (lap) + 0.67 (tx) + 0.05 (ISS) + 0.66 (int), where MOI is mechanism of injury (penetrating = 1, blunt = 0), GCS is Glasgow Coma Scale score, SCI is spinal cord injury (yes = 1, no = 0), lap is emergent laparotomy (yes = 1, no = 0), ISS is Injury Severity Score, tx is units of blood transfused in the resuscitation room, and int is intubation in either the field or the resuscitation room (yes = 1, no = 0). The probability of VAP was calculated as follows: P(VAP) = e(f)(x)/1 + e(f)(x). This formula was concordant in 95% and discordant in 5%. It is possible to accurately predict risk for VAP in trauma patients based on data available early after injury. This calculation could be useful for counseling families relative to prognosis and research protocols, and addressing hospitalization issues with third-party payors.

Identification of Early Predictors for Post-Traumatic Pneumonia

We demonstrated that the standard clinical criteria of fever, leukocytosis, purulent sputum, and infiltrate on chest radiograph are nonspecific for the diagnosis of post-traumatic pneumonia, and only approximately 50 per cent of patients with these conditions have pneumonia. Quantitative cultures of bronchoalveolar lavage effluent will differentiate pneumonia (requiring antibiotic therapy) from systemic inflammatory response syndrome (not requiring antibiotics). Early identification of patients at risk for pneumonia can target populations for clinical research. Because risk factors for pneumonia when diagnosed by quantitative cultures have not been defined we reviewed our recent experience to identify variables predictive of pneumonia. Patients over a 22-month period who survived > 48 hours were identified from the trauma registry. Pneumonia was defined as growth of > or = 10(5) organisms per milliliter in the bronchoalveolar lavage effluent. Risk factors evaluated included injury severity and severity of shock. There were 7503 patients (75% with blunt and 25% with penetrating injuries). The incidence of pneumonia was 6 per cent (7% of patients with blunt and 2% of patients with penetrating injuries). Logistic regression analysis identified age; Glasgow Coma Scale score; Injury Severity Score; transfusion requirements during resuscitation; spinal cord injury; chest injury severity; and emergent femur fixation, craniotomy, and laparotomy as being independent predictors of pneumonia. We conclude that multiple risk factors, which are all able to be determined early after injury, are predictive of post-traumatic pneumonia. Prompt identification of this high-risk group of patients allows prognostic considerations relative to patient management schemes and targets populations for prophylactic measures or immunomodulation.

Hemorrhagic Shock Impairs Mucosal Immunity to Gut-Derived Antigens

Secretory immunoglobulin A (sIgA) is the principal antibody protecting against pathogens in the respiratory tract and other mucosal surfaces. Nosocomial pneumonias are frequent after injury and critical illness and are often due to enteric pathogens. The aim of this study was to assess the relative effect of hemorrhagic shock (HS) on mucosal immunity at intestinal and respiratory mucosal sites. Fisher rats were immunized intragastrically with dinitrophenylated (DNP) Pneumococcus (Pn). Three weeks later, animals were subjected to sham treatment or HS. The animals were then rechallenged with DNP-Pn 1 or 3 days later. Animals were sacrificed 7 days later, and bronchoalveolar and gastric lavage was performed. Total and anti-DNP-specific sIgA were quantitated from these secretions by enzyme-linked immunosorbent assay. There was a significant decrease in DNP-Pn-specific sIgA at 72 hours after HS, which was not present in animals at 24 hours after HS. This was most profound in bronchoalveolar lavage specimens. We conclude that impaired mucosal defense against gut-derived antigens after HS may be important mechanistically for the development of posttraumatic pneumonia and other mucosally related infectious complications.