Predictors of mortality in pulmonary contusion

doi:10.1016/S0002-9610(05)80140-0

The American Journal of Surgery

Volume 168, Issue 6, 1994, Pages 659-664

https://doi.org/10.1016/S0002-9610(05)80140-0 Get rights and content

background:

Associated injuries and central nervous system (CNS) trauma are historically associated with poor outcome in patients with pulmonary contusions, but the value of specific factors reflecting shock, fluid resuscitation requirement and pulmonary parenchymal injury in predicting mortality in this population is not well established.

methods:

The medical records of 100 consecutive patients with pulmonary contusion, admitted over a 5-year period, were retro-spectively reviewed. Survivors and nonsurvivors were compared in terms of age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), PaO₂/FiO₂ (oxygenation ratio), the severity and adequacy of shock resuscitation reflected in plasma lactate, resuscitation volume and transfusion requirements, using oneway ANOVA. To determine the contribution of individual, interdependent variables to mortality, the data were then analyzed using multivariable analysis.

results:

ISS and transfusion requirement were significantly higher, and GCS and PaO₂/FiO₂ at 24 and 48 hours after admission were significantly lower in nonsurvivors than in survivors. After multiple regression analysis, the factors most strongly associated with mortality included patient age, oxygenation ratio at 24 hours after admission, and resuscitation volume.

conclusions:

Outcome in patients with pulmonary contusion is dependent upon a number of variables including the severity of pulmonary parenchymal injury as reflected in PaO₂/FiO₂ ratio.

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Cited by (44)

Short-term effects of low-volume resuscitation with hypertonic saline and hydroxyethylstarch in an experimental model of lung contusion and haemorrhagic shock
2018, Anaesthesia Critical Care and Pain Medicine
Citation Excerpt :
Batchinsky et al. [16] found similar results using the multiple inert gas elimination technique. In clinical settings, large fluid resuscitation volume is associated with higher mortality in patients with pulmonary contusion [17]. Massive crystalloid infusion after haemorrhagic shock is also, by itself, responsible for an inflammatory response and pulmonary oedema [18].
This study aimed to assess the short-term respiratory tolerance and haemodynamic efficiency of low-volume resuscitation with hypertonic saline and hydroxyethylstarch (HS/HES) in a pig model of lung contusion and controlled haemorrhagic shock. We hypothesised that a low-volume of HS/HES after haemorrhagic shock did not impact contused lungs in terms of extravascular lung water 3 hours after trauma.
A lung contusion resulting from blunt chest trauma was induced in 28 anaesthetised female pigs with five bolt-shots to the right thoracic cage, followed by haemorrhagic shock and fluid resuscitation. Pigs were randomly allocated into two groups: fluid resuscitation by 4 ml/kg of HS/HES, or fluid resuscitation by 10 ml/kg of normal saline (NS). Monitoring was based on transpulmonary thermodilution and a pulmonary artery catheter. After 3 h, animals were euthanized to measure extravascular lung water (EVLW) by gravimetry.
Blunt chest trauma was followed by a transient collapse and hypoxaemia in both groups. Post-mortem gravimetric assessment demonstrated a significant difference between EVLW in the NS-group (8.1 ± 0.7 ml/kg) and in the HS/HES-group (6.2 ± 0.6 ml/kg, P = 0.038). Based on a pathological EVLW threshold of > 7 ml/kg, results indicated that only the NS-group experienced moderate pulmonary oedema, contrary to the HS/HES-group. After haemorrhagic shock, HS/HES infusion enabled the restoration of effective mean arterial pressure and cardiac index. Intrapulmonary shunting increased transiently after fluid resuscitation but there was no significant impairment of oxygenation.
In this pig model of lung contusion, the short-term assessment of fluid resuscitation after haemorrhagic shock with 4 ml/kg of HS/HES showed that pulmonary oedema was avoided compared to fluid resuscitation with 10 ml/kg of NS.
Effects of early administration of dexamethasone, N-acetylcysteine and aprotinin on inflammatory and oxidant-antioxidant status after lung contusion in rats
2009, Injury
Citation Excerpt :
As such, it constitutes quite an important cause of morbidity and mortality. About 25% of the patients require invasive mechanical ventilation.4,9,18 We think that novel pharmacological agents and/or developing better resuscitative strategies can diminish the need for mechanical ventilation as well as improve the prognosis of the multiple-injured patients with associated PC.
This experimental setting was undertaken to elucidate and confirm the role of inflammatory and oxidant–antioxidant mechanisms on blunt injury induced moderate pulmonary contusion (PC). We intended to determine the effects of dexamethasone (DXM), N-acetylcysteine (NAC) and aprotinin (APR) in terms of their ability to diminish the consequences of acute lung injury due to PC.
Rats were allocated to five subgroups. Except for the control, all subgroups had a moderate pulmonary contusion. Following 45 min of observation, animals in groups I and II received intraperitoneal saline, group III 10 mg/kg DXM, group IV 500 mg/kg NAC and group V 30,000 kIU/ml APR. After the procedure, 6 h after contusion, blood gas analysis, lung tissue nitric oxide (NO) and malondialdehyde (MDA) levels, superoxide dismutase (SOD) and catalase (CAT) activity, bronchoalveolar lavage (BAL) fluid and histopathological examination were performed.
All PaO₂ values decreased significantly in contused rats as compared with the control group (p < 0.05). DXM, NAC and APR resulted in a slight increase in PaO₂ values compared with group II (p < 0.05). Lung tissue levels of MDA and NO were higher in the contusion group than in the control (p < 0.05). DXM, NAC and APR all decreased the levels of MDA and NO (p < 0.05), however the decrease in NO was not found to be significant with APR (p > 0.05). SOD and CAT activities increased significantly after contusion compared to control group (p < 0.05). There was no significant difference even though SOD levels were elevated in groups III, IV and V compared with contused animals (p > 0.05). Neutrophils in BAL fluid significantly increased in contused animals (p < 0.05). Only DXM significantly decreased neutrophil population in BAL fluid (p < 0.05). Scores for alveolar haemorrhage/oedema were higher in all contusion-performed rats than those in the control (p < 0.05). Compared with the other drugs, only APR significantly improved the haemorrhage/oedema scores compared to sham animals (p = 0.024).
Our findings demonstrate that moderate bilateral PC induced by blunt chest trauma leads to an early inflammatory process which is clearly associated with activation of the oxidant–antioxidant cascade. On this basis, early supportive treatment with DXM, NAC and APR may yield favourable results on pulmonary pathophysiological parameters which are adversely affected due to PC.
Prognostic analysis of patients with blunt chest trauma admitted to an intensive care unit
2007, Journal of the Formosan Medical Association
Predictors of mortality in blunt chest trauma patients have mostly been studied by univariate analysis. This study used multivariate analysis to identify the independent predictors in these patients admitted to a surgical intensive care unit (SICU).
One hundred and twenty-seven blunt thoracic trauma patients consecutively admitted to a SICU were enrolled and evaluated by quantified injury severity scores including Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), Therapeutic Intervention Scoring System (TISS) and Injury Severity Score (ISS). Incidence of thoracic and extrathoracic injuries, transfusion and resuscitation volumes, PaO₂/F_IO₂ ratio and the presence of shock were also evaluated.
In the univariate analysis, clinical characteristics of survivors (n = 113) and non-survivors (n = 14) at admission were similar regarding age, gender, incidence of intrathoracic injuries and extrathoracic injuries and ISS. The following variables were higher for non-survivors: APACHE II score, 19 ± 6 vs. 12 ± 6 (p = 0.002); TISS points, 39 ± 13 vs. 29 ± 15 (p = 0.019); the presence of shock, 93% vs. 42% (p < 0.001). Non-survivors also had lower GCS, 8 ± 5 vs.14 ± 3 (p < 0.001), and PaO₂/F_IO₂ ratio, 211 ± 124 vs. 340 ± 145 (p = 0.002). Of the shock patients, they had significantly higher volumes of blood transfusions and fluid resuscitations (p < 0.001) and a higher incidence of abdominal injuries (p = 0.031) and mortality rate (p < 0.001) than non-shock patients. Multivariate logistic regression analysis identified three independent risk factors of mortality: GCS (adjusted odds ratio [OR], 0.76; 95% confidence interval [CI], 0.64-0.89; p = 0.001), PaO₂/F_IO₂ ratio (adjusted OR, 0.75; 95% CI, 0.58-0.98; p = 0.036) and shock (adjusted OR, 3.8; 95% CI, 1.24-11.69; p = 0.020).
Blunt chest trauma was usually associated with injuries of other organ systems, especially of the abdomen and head. Besides a decreased PaO₂/F_IO₂, a lower GCS and a presence of shock were also independent prognostic predictors of mortality for these patients admitted to the ICU.
Pulmonary contusions: physiopathology and management
2007, Reanimation
Les contusions pulmonaires sont des lésions traumatiques pulmonaires rencontrées dans environ 50 % des traumatismes thoraciques graves. Il s'agit dans la majorité des cas de polytraumatismes. En dehors d'une destruction pulmonaire étendue, la lésion traumatique primitive (zone contuse), caractérisée par des ruptures alvéolocapillaires hémorragiques et des lacérations parenchymateuses, est souvent peu symptomatique. L'évolution est marquée par une réaction inflammatoire, d'origine pulmonaire et systémique ; son importance conditionne la survenue d'un œdème pulmonaire lésionnel diffus dont dépend le pronostic. Maximale au troisième jour, l'insuffisance respiratoire s'améliore vers la fin de la première semaine en l'absence de complication. Le diagnostic repose sur le scanner thoracique qui peut permettre d'aider à apprécier le risque de recours à la ventilation mécanique. Il n'existe pas de traitement médicamenteux spécifique. La prise en charge de la détresse respiratoire est symptomatique ; en cas d'atteinte pariétale une analgésie optimale doit être assurée pour permettre une kinésithérapie efficace.
Pulmonary contusions are common traumatic lung injury in 50% of severe thoracic traumas. Most of the patients are multi-injured. Except in cases of massive parenchymal destruction, the primitive lesion (contused area) is poorly symptomatic. Alveolocapillar ruptures characterize contused lung with haemorrhage in air spaces. In the hours following the trauma, an inflammatory reaction develops secondary to the pulmonary initial insult and to the general trauma. Its intensity depends on the occurrence of a diffuse acute lung injury, which impacts the prognosis. Maximal about the third day, the respiratory distress usually resolves in 8 days in absence of complications. Computed tomography is the reference diagnostic technique and may help to predict the need for mechanical ventilation. Although the management of the respiratory distress is supportive and non-specific, special attention should be provide to analgesia and physiotherapy in cases of parietal injuries.
Lung contusion: Relevance of initial injured pulmonary volume measurement by computed tomography
2003, Annales Francaises d'Anesthesie et de Reanimation
Objectif. – Déterminer l’intérêt de la quantification tomodensitométrique du volume pulmonaire lésé lors de l’évaluation de la sévérité des patients souffrant de contusions pulmonaires (CP).
Type d’étude. – Étude d’observation rétrospective.
Patients et méthodes. – Les dossiers de 49 patients victimes de traumatisme thoracique avec CP ont été revus. Recueil des données clinicobiologiques dont l’index d’oxygénation (PaO₂/FIO₂), et des traitements à visée respiratoire appliqués pendant les 5 premiers jours d’hospitalisation : pression expiratoire positive (PEP) et monoxyde d’azote (NO). Le volume pulmonaire lésé (CP et atélectasie) a été quantifié sur le scanner thoracique initial par une double lecture, par 2 radiologues expérimentés indépendants. Une corrélation significative a été recherchée entre le volume pulmonaire non fonctionnel initial, le rapport PaO₂/FIO₂ et les modalités de traitement.
Résultats. – Une atteinte parenchymateuse pulmonaire, supérieure à 37,75 % du volume pulmonaire total a été associée à la vingt-quatrième heure, à un rapport PaO₂/FIO₂ < 300, et au cinquième jour, à un maintien d’une PEP > 6 cmH₂O et/ou de l’administration de NO.
Conclusion. – La quantification tomodensitométrique du volume pulmonaire lésé ou non fonctionnel apparaît être un critère de gravité des CP. Le scanner thoracique initial donne une information pronostique supplémentaire parmi d’autres paramètres lors du bilan des traumatismes thoraciques avec atteinte parenchymateuse.
Objective. – To evaluate computed tomography quantification of injured pulmonary volume after thoracic trauma and its relevance for severity grade of patients with lung contusion.
Study design. – Retrospective study in a major French Level I university trauma center.
Patients and methods. – Clinical and biological data including oxygenation index (PaO₂/FIO₂) and therapeutics modalities during the first 5 days: positive end expiratory pressure (Peep) and nitric oxide (NO), were collected on 49 patients with lung contusion resulting from thoracic trauma. Injured pulmonary volume was evaluated on initial thoracic tomodensitometry by 2 senior radiologists. The correlation between oxygenation index, therapeutics modalities and initial injured pulmonary volume was assessed for signification.
Results. – Injured pulmonary volume larger than 37.75% of total lung volume is associated with both hypoxemia at the twenty-fourth hour (PaO₂/FIO₂ <300), and need for Peep >6 cm H₂O and /or ongoing NO administration on day 5.
Conclusion. – Injured parenchymal pulmonary volume evaluation on initial tomodensitometry seems to be an important indicator of lung contusion severity. Thoracic computed tomography provides additional prognostic information in the initial evaluation of thoracic trauma with parenchymal injury.
A rat model for isolated bilateral lung contusion from blunt chest trauma
2005, Anesthesia and Analgesia
Lung contusion affects 17%–25% of adult blunt trauma patients, and is the leading cause of death from blunt thoracic injury. A small animal model for isolated bilateral lung contusion has not been developed. We induced lung contusion in anesthetized rats by dropping a 0.3-kg weight onto a precordial protective shield to direct the impact force away from the heart and toward the lungs. Lung injury was characterized as a function of chest impact energy (1.8–2.7 J) by measurements of arterial oxygenation, bronchoalveolar lavage (BAL) albumin and cytology, pressure-volume mechanics, and histopathology. Histology confirmed bilateral lung contusion without substantial cardiac muscle trauma. Rats receiving 2.7 J of chest impact energy had 33% mortality that exceeded prospectively defined limits for sublethal injury. Hypoxemia in rats with maximal sublethal injury (2.45 J) met criteria for acute lung injury at ≤24 h, improving by 48 h. BAL albumin levels were highest at ≤24 h, and remained elevated along with increased BAL leukocytes and decreased lung volumes at 48 h. We concluded that an impact energy of 2.45 J induces isolated, bilateral lung contusion and provides a useful model for future mechanistic pathophysiological assessments.

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^*: This work was supported in part by NIH grant 1 RO HD 30455-01.

^**: Presented at the 46th Annual Meeting of the Southwestern Surgical Congress, Tucson, Arizona, April 17–20, 1994.

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Jack A. Barney Resident AwardPredictors of mortality in pulmonary contusion*,**

background:

methods:

results:

conclusions:

Surg Clin North Am

Lancet

Injury

Am J Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Preface

Blunt chest trauma: the intensivist's perspective

J Int Care Med

Determinants of outcome after pulmonary contusion

J Trauma

Survival in trauma victims with pulmonary contusion

Am Surg

Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion

J Trauma

Injuries of the chest wall, the lungs and the pleura

Jack A. Barney Resident Award
Predictors of mortality in pulmonary contusion*,**