Severe Pulmonary Contusion Research Articles

Experimental study of a novel mouse model of tibial shaft fracture combined with blunt chest trauma.

Thoracic Trauma and Limb Fractures Are the Two most Common Injuries in Multiple Trauma. However, there Is Still a Lack of Mouse Models of Trauma Combining Tibial Shaft Fracture (TSF) and Thoracic Trauma. In this Study, we Attempted to Develop a Novel Mouse Model of TSF Combined with Blunt Chest Trauma (BCT). A total of 84 C57BL/6J male mice were used as the multiple trauma model. BCT was induced by hitting the chests of mice with heavy objects, and TSF was induced by hitting the tibia of mice with heavy objects after intramedullary fixation. Serum specimens of mice were received by cardiac puncture at defined time points of 0, 6, 12, 24, 48, and 72 h. Body weight and body temperature tended to decrease within 24 h after multiple trauma. Hemoglobin analyses revealed a decrease during the first 24 h after multiple trauma. Some animals died by cardiac puncture immediately after chest trauma. These animals exhibited the most severe pulmonary contusion and hemorrhage. The level of lung damage varied in diverse mice but was apparent in all animals. Classic hematoxylin and eosin (H&E)-stained paraffin pulmonary sections of mice with multiple trauma displayed hemorrhage and an immunoinflammatory reaction. Bronchoalveolar lavage fluid (BALF) and serum samples of mice with multiple trauma showed an upregulation of interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-1α (TNF-1α) compared with the control group. Microimaging confirmed the presence of a tibia fracture and pulmonary contusion. The novel mouse multiple trauma model established in this study is a common trauma model that shows similar pathological mechanisms and imaging characteristics in patients with multiple injuries. This study is useful for determining whether blockade or intervention of the cytokine response is beneficial for the treatment of patients with multiple trauma. Further research is needed in the future.

The Immunoadsorption Effect of Veno-arterial Extracorporeal Membrane Oxygenation in Refractory Septic Shock, Ventilator-associated Pneumonia, and Acute Respiratory Distress Syndrome Following Severe Pulmonary Contusions

Background: The utilization of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for immunoadsorption has proven efficacious in reducing mortality rates among neonatal and pediatric patients afflicted with severe sepsis and septic shock. However, the effectiveness of this treatment in adult patients with septic shock remains controversial. Objective: This study was designed to assess the potential of VA-ECMO as an immunoadsorption therapy in patients with severe sepsis and septic shock. The primary objective of this study is to evaluate the efficacy of VA-ECMO in improving clinical outcomes, including acute respiratory distress syndrome (ARDS) and ventilator-associated pneumonia (VAP), weaning from mechanical ventilation, the length of intensive care unit (ICU) stay, and mortality rates in patients with concurrent severe pulmonary contusions, septic shock, and respiratory failure resulting from ARDS and VAP. Methods: This study enrolled a cohort of 100 adult patients with severe pulmonary contusions resulting in persistent respiratory failure despite ten days of mechanical ventilation. These patients subsequently developed severe sepsis, VAP with ARDS presentation, and high Murray score (>3 points), Sequential Organ Failure Assessment (SOFA) score (> 12 points), and Clinical Pulmonary Infection Score (CPIS) (> 6 points). The patients were then divided into two groups: group A (n = 50) received conventional management, while group B (n = 50) underwent VA-ECMO. Moreover, the outcomes, including improvement in ARDS and VAP, successful weaning from mechanical ventilation, length of ICU stay, improvement of one or all parameters of Murray, SOFA, and CPIS scores, morbidity rate, and mortality rate were compared between the two groups and recorded after 14 days of treatment. Results: This study revealed that patients in group B showed significant improvement in Murray, SOFA, and CPIS scores. Furthermore, a large percentage of patients in group B were successfully weaned from both inotropic support and mechanical ventilation and were discharged from ICU. However, no significant difference in the mortality rate was observed between the two groups. Conclusion: VA-ECMO notably impedes the progression of sepsis, shortens ICU stay, and expedites the weaning from inotropic support and mechanical ventilation. However, it has no impact on the mortality rate of adult patients with septic shock.

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

Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions. This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses. A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries ( p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted β , -2.511 [95% confidence interval, -4.87 to -0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted β , -5.19 [95% confidence interval, -10.2 to -0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management. In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions. Therapeutic/Care Management; Level IV.

Oxygenation and Respiratory System Compliance Associated With Pulmonary Contusion.

Blunt pulmonary contusions are associated with severe chest injuries and are independently associated with worse outcomes. Previous preclinical studies suggest that contusion progression precipitates poor pulmonary function; however, there are few current clinical data to corroborate this hypothesis. We examined pulmonary dynamics and oxygenation in subjects with pulmonary contusions to evaluate for impaired respiratory function. A chest injury database was reviewed for pulmonary contusions over 5 years at an urban trauma center. This database was expanded to capture mechanical ventilation parameters for the first 7 days on all patients with pulmonary contusion and who were intubated. Daily [Formula: see text]:[Formula: see text], oxygenation indexes (OI), and dynamic compliances were calculated. Pulmonary contusions were stratified by severity. The Fisher exact and chi square tests were performed on categorical variables, and Mann-Whitney U-tests were performed on continuous variables. Significance was assessed at a level of 0.05. 1,176 patients presented with pulmonary contusions, of whom, 301 subjects (25.6%) required intubation and had available invasive mechanical ventilation data. Of these, 144 (47.8%) had mild-moderate pulmonary contusion and 157 (52.2%) had severe pulmonary contusion. Overall injury severity score was high, with a median injury severity score of 29 (interquartile range, 22-38). The median duration of mechanical ventilation for mild-moderate pulmonary contusion was 7 d versus 10 d for severe pulmonary contusion (P = .048). All the subjects displayed moderate hypoxemia, which worsened until day 4-5 after intubation. Severe pulmonary contusion was associated with significantly worse early hypoxia on day 1 and day 2 versus mild-moderate pulmonary contusion. Severe pulmonary contusion also had a higher oxygenation index than mild-moderate pulmonary contusion. This trend persisted after adjustment for other factors, including transfusion and fluid administration. Pulmonary contusions played an important role in the course of subjects who were acutely injured and required mechanical ventilation. Contusions were associated with hypoxemia not fully characterized by [Formula: see text]: [Formula: see text], and severe contusions had durable elevations in the oxygenation index despite confounders.

Factors related to clinical outcomes in blunt thoracic injuries.

This study aims to reduce mortality and morbidity by analyzing the factors associated with blunt chest trauma. In this study, 1020 patients with blunt thoracic trauma were analyzed retrospectively. Major surgeries, complications, admission to intensive care unit, intubation, mortality, prolonged hospital stay were considered poor clinical outcomes. Independent variables were compared with clinical outcomes and analyzed. The mean age was 52.7 ± 19.1. Complications (p = 0.028) and mortality (p < 0.001) were higher in patients aged 65years and older than those aged 65years and younger. Severe chest wall injuries, hemopneumothorax, and pulmonary contusions were associated with poor clinical outcomes (OR = 2474, p = 0.001, OR = 2229, p < 0.001 and OR = 2229, p < 0.001, respectively). The variable most related to poor clinical outcomes was New Injury Severity Score (p < 0.001, OR = 8.37). The most associated factor with poor clinical outcomes was injury severity. Prompt treatment of blunt chest trauma with timely chest tube thoracostomy or surgical treatment when necessary, optimal pain control, and chest physiotherapy will reduce mortality.

Posttraumatic pneumonectomy and management of severely contaminated pleural space.

Posttraumatic pneumonectomy and management of severely contaminated pleural space.

Feasibility of pleural and perilesional subcutaneous microdialysis to assess porcine experimental pulmonary contusion

Background: Severe thoracic trauma affects 55% of patients with multiple traumatic injuries and may lead to acute lung injury or acute respiratory distress syndrome. Pulmonary trauma differs clinically and biologically from lung injury of other origins and carries a mortality rate of 10%. Treatment options are limited, and it is not possible to monitor the progression of lung injury with specific biomarkers. Microdialysis of pleural fluid may offer a viable entry to monitor the lung directly and specifically. Bronchial microdialysis has been described, but not pleural microdialysis. We therefore investigated the feasibility of microdialysis of pleural fluid, and its ability to detect pulmonary injury and inflammation in the pleural cavity after traumatic acute lung injury.Methods: 16 pigs (mean weight 64 kg) were randomized to groups “exposed with MD”, receiving a focally severe pulmonary contusion and microdialysis (n = 7), “control with MD”, receiving only microdialysis and no pulmonary contusion (n = 5), “normal no MD” receiving only anesthesia (n = 2) and “naïve no MD” (no instrumentation) (n = 2). Microdialysate from the pleura and the perilesional subcutis, plasma and bronchoalveolar lavage were collected for 5 hours.Results: Pleura lactate, plasma lactate and pleura lactate/pyruvate ratio increased in injured lungs (p < 0.05). Subcutis and plasma glucose increased after trauma (p < 0.05). Pleura glycerol increased although not reaching statistical significance. IL-6 and IL-8 were dissimilar in plasma, bronchoalveolar lavage and pleural fluid, while IL-1 did not differ. Neutrophils increased in bronchoalveolar lavage (p < 0.001) after trauma, and in pleural fluid, although not when the microdialysis catheter was omitted.Conclusion: Pleural microdialysis was technically feasible and detected signs of cellular injury and anaerobic metabolism after focally severe pulmonary contusion and may be of interest for future clinical applications. The microdialysis catheter triggered a recruitment of neutrophils to the pleura which needs to be elucidated further before taking the technique into clinical practice.

Complex chest wall injury and repair complicated by empyema

A 24-year-old man presented to the emergency department after blunt thoracic trauma. As a vested rider, he was competing in a rodeo bull riding competition when he was thrown and...

Surgical Stabilization of Rib Fractures: Indications, Techniques, and Pitfalls.

Background:Rib fractures are a common thoracic injury that is encountered in 20% to 39% of patients with blunt chest trauma and is associated with substantial morbidity and mortality1,2. Traditionally, the majority of patient with rib fractures have been managed nonoperatively. Recently, the utilization of surgical stabilization of rib fractures has increased considerably because the procedure has shown improved outcomes3-5.Description:Surgical stabilization should be considered in cases of multiple bicortically displaced rib fractures, especially in those with a flail chest and/or a concomitant ipsilateral displaced midshaft clavicular fracture or sternal fracture, as such cases may result in thoracic wall instability. For surgical stabilization of rib fractures, we classify rib fractures by location, type of fracture, and degree of displacement after obtaining thin-sliced chest computed tomography (CT) scans. The incision is selected depending on the fracture location, and the surgical technique is chosen relevant to the type of fracture. Single-lung intubation is preferred if there is no severe contralateral pulmonary contusion. We favor performing video-assisted thoracoscopy if possible to control bleeding, evacuate hematomas, repair a lung, and perform cryoablation of the intercostal nerves. A lateral approach is considered to be the main surgical approach because it allows access to the majority of rib fractures. A curvilinear skin incision is made overlying the fractured ribs. Posterior rib fractures are exposed through a vertical incision within the triangle of auscultation, and anterior fractures, through a transverse inframammary incision. The muscle-sparing technique, splitting alongside fibers without transection, should be utilized if possible and supplemented by muscle retraction. For surgical stabilization of rib fractures, we currently prefer precontoured side and rib-specific plates with threaded holes and self-tapping locking screws. Polymer cable cerclage is used to enhance plating of longitudinal fractures, rib fractures near the spine, osteoporotic ribs, and injuries of rib cartilage. The third to eighth ribs are plated most often. Intercostal muscle deficit, if present, is repaired with a xenograft patch. In comminuted rib fractures, the bone gap is bridged with bone graft. Surgical stabilization of rib fractures is recommended within the first 7 days after trauma, preferably within the first 3 days6-8.Alternatives:Nonoperative treatment alternatives include (1) epidural analgesia when not contraindicated because of anticoagulant venous thromboembolism prophylaxis9,10; (2) thoracic paravertebral blockage, e.g., serratus anterior or erector spinae plane nerve block11,12; (3) intercostal nerve block; (4) intravenous or enteral analgesics, e.g., opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs); (5) intrapleural analgesia, e.g., bupivacaine infusion; and (6) multimodal analgesia that incorporates regional techniques, systemic analgesics, and analgesic adjuncts9.Rationale:Surgical stabilization of rib fractures is a safe and effective method to treat displaced rib fractures. The procedure provides definitive stabilization of fractures, improves pulmonary function, lessens pain medication requirements, prevents deformity formation, and results in reduced morbidity and mortality.

Heparin-free extracorporeal membrane oxygenation in a patient with severe pulmonary contusions and bronchial disruption.

Pulmonary contusion complicated with endobronchial hemorrhage is potentially life-threatening, particularly in patients with tracheobronchial tree disruption and severe airway bleeding after blunt trauma, and pose a high mortality risk. In such cases, extracorporeal membrane oxygenation (ECMO) can be used as a salvage treatment modality. However, the use of ECMO for moribund trauma patients with respiratory failure may be limited for several reasons, such as intractable bleeding. In this case report, we describe a patient with severe bilateral pulmonary contusions with tracheobronchial tree disruption that was successfully treated using heparin-free venovenous ECMO.

Risk Factors for Pneumonia in Ventilated Trauma Patients with Multiple Rib Fractures.

BackgroundVentilator-associated pneumonia (VAP) is a common disease that may contribute to morbidity and mortality among trauma patients in the intensive care unit (ICU). This study evaluated the associations between trauma factors and the development of VAP in ventilated patients with multiple rib fractures.MethodsWe retrospectively and consecutively evaluated 101 patients with multiple rib fractures who were ventilated and managed at our hospital between January 2010 and December 2015, analyzing the associations between VAP and trauma factors in these patients. Trauma factors included sternal fracture, flail chest, diaphragm injury, traumatic aortic dissection, combined cardiac injury, pulmonary contusion, pneumothorax, hemothorax, hemopneumothorax, abbreviated injury scale score, thoracic trauma severity score, and injury severity score.ResultsForty-six patients (45.5%) had at least 1 episode of VAP, 10 (21.7%) of whom died in the ICU. Of the 55 (54.5%) patients who did not have pneumonia, 9 (16.4%) died in the ICU. Using logistic regression analysis, we found that VAP was associated with severe lung contusion (odds ratio, 3.07; 95% confidence interval, 1.12 to 8.39; p=0.029).ConclusionSevere pulmonary contusion (pulmonary lung contusion score 6–12) is an independent risk factor for VAP in ventilated trauma patients with multiple rib fractures.

Club cell protein 16 as a biomarker in pulmonary contusion.

The aim of the present study was to investigate the variation and clinical significance of the 16-kDa club cell protein (CC16) in patients with pulmonary contusion. A total of 42 patients with pulmonary contusion were divided into experimental groups I (n=24, moderate pulmonary contusion) and II (n=18, severe pulmonary contusion). An enzyme-linked immunosorbent assay was used to detect the serum levels of CC16 in the two groups of patients within 24 h after the incident and at days 1, 3, 7 and 14 after treatment. The results were compared with another 16 healthy subjects included as the controls. The serum CC16 level at each time point was higher in the two experimental groups compared to the controls (P<0.01). The difference was significant when regarding the levels of CC16 measured within 24 h after contusion and at days 1, 3, 7 and 14 after treatment (P<0.01); however, the levels appeared to decline. In addition, the levels at each time point in experimental group II were significantly higher compared to group I (P<0.01). In conclusion, serum CC16 levels are markedly elevated at the early stage of pulmonary contusion and appear to decrease following treatment. An increase of the CC16 levels is associated with the degree of injury, for which measurement of the levels may serve as a biomarker for evaluation of the serious condition of this pulmonary contusion.

Rib Fractures, Flail Chest, and Pulmonary Contusion

Blunt chest trauma accounts for a significant proportion of debilitating and life-threatening injuries. Rib fractures are notoriously painful and can lead to prolonged hospitalization, contribute to the development of pneumonia and respiratory failure, and delay outpatient recuperation significantly. Flail chest, along with chest wall deformity, the most severe of chest wall injuries, is associated with significant acute morbidity and mortality. Pulmonary contusion often accompanies blunt chest wall trauma and when diffuse will result in respiratory failure regardless of other injuries. Pulmonary lacerations, pneumatoceles, and even lobar infarction can occur. In this review, we describe the development of current principles of management of rib fractures, flail chest, and pulmonary contusion. Emerging or unclarified strategies include the importance of acute pain control of rib fractures to alleviate the development of chronic pain, the role of rib fracture operative reduction/internal fixation (ORIF) in severe chest wall trauma, and the use of surfactant and dual lung ventilation for severe pulmonary contusion.

Severe cardiac trauma or myocardial ischemia? Pitfalls of polytrauma treatment in patients with ST-elevation after blunt chest trauma

IntroductionThoracic injuries are the third most common injuries in polytrauma patients. The mechanism of injury and the clinical presentation are crucially important for adequate emergency treatment.Presentation of caseHere we present a case of a 37-year-old male who was admitted to our level-1 trauma center after motor vehicle accident. The emergency physician on scene presented the patient with a myocardial infarction. During initial clinical trauma assessment the patient developed circulatory insufficiency so that cardiopulmonary resuscitation was necessary. Considering the preclinical and clinical course it was decided to proceed with thrombolysis. Despite consistently sufficient resuscitation measures circulatory function was not restored and the patient remained in asystole and passed away.DiscussionThe initial assessment showed cardiopulmonary instability. After applying thrombolysis a therapeutic point of no return was reached because surgical intervention was impossible but autopsy findings showed severe myocardial and pulmonary contusions likely due to shear forces.ConclusionThis case outlines the importance of understanding the key mechanism of injury and the importance of communication at each stage of healthcare transfer. A transesophageal echocardiography can help to identify injuries after myocardial contusion.

Effect of early mechanical ventilation with continuous vacuum suction in treatment of serious pulmonary contusion

Objective To summarize the value of early mechanical ventilation plus continuous vacuum suction in treatment of serious pulmonary contusion. Methods Forty-eight cases of severe pulmonary contusion were assigned to mechanical ventilation plus continuous vacuum suction (observation group, n=20) and mechanical ventilation plus discontinuous vacuum suction (control group, n=28) according to the random number table. Modes of mechanical ventilation were synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), and positive and expiratory pressure (PEEP). Changes in blood gas analysis, mechanical ventilation time, and associated complications were compared between groups. Results At ventilation time of 6 and 24 hours, PaO2 in observation group was (100.36±5.90)mmHg and (105.34±7.40)mmHg respectively, with significant differences from (75.36±8.95)mmHg and (76.36±8.35)mmHg in control group (P 0.05). Conclusion Early mechanical ventilation with sustained vacuum suction is effective to keep airway clear, improve oxygenation index, decrease PEEP level, and control the duration of mechanical ventilation, but may not lower the risks of ventilator-associated pneumonia and pulmonary atelectasis. Key words: Lung injury; Ventilators, negative-pressure; Treatment outcome

Curative effect of Xuebijing injection on severe pulmonary contusion

ObjectiveTo investigate the curative effects of Xuebijing (XBJ) injection, a Chinese patent medicine, on severe pulmonary contusion (PC). MethodsSixty-three patients with PC were randomized to conventional therapy plus XBJ injection (n=33) or conventional therapy alone (n=30). Between groups differences in corticosteroid treatment, immune regulation therapy, hemofiltration, infusion volume, transfusion volume and antibiotic period were measured, as were intensive care unit (ICU)-free time, ventilation time, 28-day mortality rate and incidence of ventilation-associated pneumonia (VAP). Serum concentrations of procalcitonin (PCT), tumor necrosis factor-α (TNF-α), interleukin (IL)-6, and IL-10, white blood cell (WBC) counts and percentages of human leukocyte antigen DR/CD14+ (HLA-DR/CD14+) peripheral blood mononuclear cells were compared. Markers of ventilation were determined by blood gas analysis and ventilator parameters. ResultsWBC counts and serum concentrations of PCT, TNF-α, IL-6 and IL-10 were reduced significantly more quickly, and CD14+ percentage was increased significantly earlier, in the XBJ group than in the control group (P<0.05 each). The level of ventilation and oxygenation index were ameliorated earlier in the XBJ than in the control group (P< 0.05). XBJ treatment significantly reduced ICU-stay time, ventilation time and incidence of VAP (P<0.05 each), but had no effect on 28-day mortality rate (P>0.05). ConclusionXBJ treatment can shorten ICU-free and ventilation times and reduce the incidence of VAP, improving outcomes in patients with severe PC. XBJ may act by regulating inflammation and immunity, alleviating systemic inflammatory response syndrome induced by trauma.

Management of pulmonary contusion and flail chest

Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

Predicting outcome of patients with chest wall injury

BackgroundRib fractures occur in 10% of injured patients, are associated with morbidity and mortality, and frequently necessitate intensive care unit (ICU) care. A scoring system that identifies the risk for respiratory failure early in the evaluation process may allow early intervention to improve outcomes. The aim of this study was to test the hypothesis that a scoring system based on initial clinical findings can identify patients with rib fractures at greatest risk for morbidity and mortality. MethodsA simple scoring system to stratify risk was developed and applied to patients through a retrospective trauma registry review. Points were assigned as follows: age < 45 years = 1 point, age 45 to 65 years = 2 points, age > 65 years = 3 points; <3 fractures = 1 point, 3 to 5 fractures = 2 points, >5 fractures = 3 points; no pulmonary contusion = 0 points, mild pulmonary contusion = 1 point, severe pulmonary contusion = 2 points, bilateral pulmonary contusion = 3 points; and bilateral rib fracture absent = 0 points, bilateral rib fracture absent present = 2 points. A review of trauma registry patients with rib fractures (June 2008 to February 2010) at a state-designated level 1 trauma center was performed. Data reviewed included age, number of fractures, bilateral injury, presence of pulmonary contusion, classification of the contusion, length of hospital stay, mechanical ventilation, ICU admission, and length of stay. The scoring system was retrospectively applied to 649 patients to determine validity. ResultsA score ≤ 7 indicated lower mortality (24 of 579 [4.2%]) compared with patients with scores > 7 (10 of 70 [14.3%]) (Fisher's 2-sided P = .0018). Patients with scores ≤ 6 were less likely to be admitted to an ICU (29.7%) compared with those with scores ≥ 7 (56.7%) (P < .0001). Patients with total scores < 7 were less likely to require intubation (20.6%) compared with those with scores ≥ 7 (40.0%) (P < .0001). Patients with scores ≤ 4 had shorter lengths of stay (36.0% <5 days) compared with those who had scores > 4 (59.7%) (P < .0001). ConclusionsA simple scoring system predicts the likelihood that patients will require mechanical ventilation and prolonged courses of care. A score of 7 or 8 predicted increased risk for mortality, admission to the ICU, and intubation. A score > 5 predicted a longer length of stay and a longer period of ventilation. This scoring system may assist in the earlier implementation of treatment strategies such epidural anesthesia, ventilation, and operative fixation of fractures.

The expression of von Willebrand factor and interleukin-8 in severe pulmonary contusion patients

Objective To study the clinical changes of von Willebrand factor( vWF) and interleukin-8 (IL-8) in patients with severe pulmonary contusion. Methods Sixty-three patients with severe pulmonary contusion were divided into three different classifications for the sake of comparison in different respects, namely (1) severe pulmonary contusion with ARDS group and severe pulmonary contusion without ARDS group, (2) survival group and non-survival group, and (3) ISS score <20 group and ISS scored 20 group. In addition, the normal control group was set up. The levels of plasma vWF and serum IL-8 were respectively detected by double-antibody sandwich enzyme-linked immunosorbent assay (ELISA) within 24 hours of injury and 1,3,5 and 7days after injury. The regularity of their changes was observed and the correlation factors were analyzed from the data. Results Compared with normal controls, the concentrations of plasma vWF and serum IL-8 were significantly increased in patients with severe pulmonary contusion in all intervals of detection. The concentrations of plasma vWF escalated gradually in severe pulmonary contusion with ARDS, and reached significantly higher levels in 5 days and 7 days after injury compared with those without ARDS group (P <0. 05). The increase in concentrations of serum IL-8 peaked in 5day after injury, and then declined. The levels of serum IL-8 were higher in patients with severe pulmonary contusion with ARDS group than those in this kind of patients without ARDS group. The levels of plasma vWF and serum IL-8 were higher in non - survival group than those in survival group (P < 0.05). The increase in levels of plasma vWF and serum IL-8 peaked and then declined in 5 days in ISS score 3:20 group, whereas it peaked and declined in 3 days after injury in ISS score < 20 group. The level of plasma vWF was positively correlated with platelets and negatively correlated with oxygenation index. The levels of serum IL-8 was positively correlated with white blood cell count and ISS score, and negatively correlated with oxygenation index. Conclusions The levels of plasma vWF and serum IL-8 were increased in patients with severe pulmonary contusion, reflecting the severity of pulmonary injury. The levels of plasma vWF and serum IL-8 were the sensitive markers for evaluating the severity of pulmonary injury and the prognosis of ARDS caused by severe pulmonary contusion. Key words: Trauma; Pulmonary contusion; vWF; ARDS; IL-8

Expression patterns of plasma von Willebrand factor and serum interleukin-8 in patients with early-stage severe pulmonary contusion

von Willebrand factor (vWF) is only released from endothelial cells and platelets and is an in vivo and in vitro marker of endothelial injury in septic patients with acute lung injury (ALI). Interleukin-8 (IL-8), as a proinflammatory mediator causing recruitment of inflammatory cells, induces an increase in oxidant stress mediators and makes it as a key parameter for localized inflammation. However, it has not been well established whether the level of serum IL-8 is associated with the severity of lung injury and whether it is a prognosis marker for severe lung contusion. This study was to investigate the expression of plasma vWF and IL-8 and their association with the severity and outcomes of severe pulmonary contusion. A total of 63 patients were divided into a severe pulmonary contusion with acute respiratory distress syndrome (ARDS) group and a non-ARDS group, or a survivor group and a non-survivor group, or an injury severity score (ISS) <20 group and an ISS ≥20 group. Another 20 healthy volunteers served as controls. The levels of plasma vWF and serum IL-8 were measured by enzyme-linked immunosorbent assay (ELISA) at 1, 3, 5 and 7 days after injury. The expression patterns of the plasma vWF and serum IL-8 were compared between different groups. The concentrations of plasma vWF and serum IL-8 were significantly increased in all severe pulmonary contusion patients at all time points in comparison with the control group. The concentrations of plasma vWF in patients with ARDS increased during the whole study period, but vWF in patients with non-ARDS increased gradually until day 5 and then decreased at day 7. The concentration of serum IL-8 showed a similar expression pattern in both groups, but the expression increased more significantly in the ARDS group than in the non-ARDS group. Interestingly, both plasma vWF and serum IL-8 levels steadily increased in the non-survivor group. Furthermore, the level of plasma vWF was higher in the ISS≥20 group than in the ISS<20 group. The level of serum IL-8 in the ISS≥20 group was consistently high, while that in the ISS<20 group peaked at day 3 and decreased at day 5. In addition, the level of plasma vWF was positively correlated with platelet count, but negatively correlated with oxygen index. The level of serum IL-8 was positively correlated with white blood cell count and ISS score, and inversely correlated with oxygen index. The elevated levels of plasma vWF and serum IL-8 in severe pulmonary contusion patients reflect the severity of pulmonary injury and patients outcomes, suggesting that the plasma vWF and serum IL-8 are sensitive markers for clinical evaluation of the severity of pulmonary injury and predication of patient prognosis.