Evaluation of Lung Contusion, Associated Injuries, and Outcome in a Major Trauma Center in Shiraz, Southern Iran

Objective. Blunt chest trauma as one of the most common injuries in trauma cases can cause significant morbidity and mortality. The purpose of this study was to determine the clinical course of traumatic injuries with an initial diagnosis of a pulmonary contusion in patients. Method. In this retrospective study, we evaluated the demographic and clinical features of patients who were referred to a major trauma center in southern Iran. In our study, patients were enrolled with the diagnosis of pulmonary contusion. All included patients were above 16 years of age, with an initial CT scan in favor of pulmonary contusion, while patients not being hospitalized for more than 48 hours were excluded from the study. Results. Among the 434 patients included in our study, 366 (84%) were male and the mean age was 41.17 (SD = 17.89). Among them, the majority (80.4%) had right side lung contusion and 47 patients (10.8%) had right rib fracture. The most common injuries were head and neck injury (56.9%) and limbs (30%). In 25% of cases, pulmonary contusion was associated with pneumothorax and 15.8% with hemothorax. Also, 49.6% of patients were transferred to the ICU. The mortality rate in our study was 15.2% (n = 66). Conclusion. Although recent advances in pulmonary care and ventilator management have been achieved, there is still considerable morbidity and mortality associated with this condition. Therefore, there is a need to provide a national guideline based on native patient information for better management.

Frequency and importance of blush in lung contusion in patients with blunt trauma: A retrospective observational study

Background: The high mortality rate in patients with blunt chest trauma remains a problem. The assessment of blush in hepatic and splenic trauma is important because it indicates the need for emergency hemostatic intervention. However, the frequency and importance of blush in lung contusions are unknown. Therefore, this study aimed to evaluate the frequency of blush in the lung contusion and the relationship between blush and the clinical outcome of patients with blunt chest trauma.Methods: In this retrospective observational study, we enrolled patients with an injury severity score of 16 or higher and a chest abbreviated injury scale of 3 or higher who were admitted to the emergency department of Hokkaido University Hospital from January 1, 2003, to December 31, 2016. Blush was defined as an active extravasation image of an intravascular contrast agent recognized on contrast-enhanced computed tomography. Date of trauma severity, various treatments, and outcomes were recorded from the electrical medical records of the patients.Results: During the study period, 83 patients had severe lung contusions and 12 patients had blush. In-hospital mortality of patients with blush was significantly higher than that of patients without blush. Patients with blush required support through mechanical ventilation more frequently and for a longer duration than patients without blush.Conclusion: Our study revealed that blush in the lung contusions was not rare and was associated with a high risk of mortality in patients with severe blunt chest trauma. We should not hesitate to intervene if a blush of the lung contusion was detected in a patient with blunt chest trauma.

Biomechanically Based Correlate for Localized Lung Contusion From Nonlethal Blunt Impact Projectiles

ABSTRACT Introduction Injury mechanics of blunt impact projectiles differ from those experienced in whole body motor vehicle collisions because the effects are localized around the point of impact, and thus, injury thresholds based upon gross chest kinematics (e.g., force, velocity) may not be applicable across impact types. Therefore, knowledge of biomechanically based tissue injury correlates for blunt impact projectiles are needed to better guide design and development of protective systems as well as assess injury risks from blunt impact projectile weapons. Materials and Methods In this study, subject-specific swine finite element models were used to quantify the tissue-level stresses and strains resulting from high speed projectile impact. These tissue-level injury doses were correlated to pathology injury outcomes to produce injury risk curves for lung contusion. Details of the pathology data and finite element results are provided in Appendix 1. Survival analysis regression methods were applied to develop lung injury regression curves and a number of statistical methods were used to evaluate several biomechanical metrics as correlates to lung contusion. Uncertainty and sensitivity analyses were used to further confirm the selection of the correlate. Results Statistical analysis revealed that normalized strain-energy density was the best correlate for prediction of lung tissue damage. Going further, normalized strain-energy density also proved to be suitable for prediction of the percentage of contused lung volume, a more meaningful medical diagnosis. As expected, peak strain-energy density is most sensitive to muscle-skin properties, as quantified through a comprehensive uncertainty and sensitivity analysis over three sets of projectile weights and speeds. Conclusions Normalized strain-energy density was found to be the best correlate for prediction of lung tissue damage and correlate well to extent of contused lung volume.

Comparative Study between the Uses of High Dose Corticosteroid Therapy for Short Duration Versus Low Dose Corticosteroid for Long Duration in Severe Lung Contusion with ARDS

Introduction: Corticosteroids are used in ARDS to prevent lung fibrosis. The best dose, duration and regimen are still the points of debate among physicians. Aim of the Work: The aim of this study is to make a comparison between two corticosteroid regimens, i.e. short-duration high dose versus long- duration low dose corticosteroid use in ARDS due to lung contusion with VAP for lowering both morbidity and mortality rates and early weaning from ventilator. Patients and Methods: Patients who had >3 on Murray score and >6 on CPIS were allocated randomly in two groups of 120 patients each. Group A received 30 mg/kg methyl-prednisolone slowly intravenously in 250 ml normal saline every 8 hours for only 48 hours, while group B received 1 mg/kg/day methyl-prednisolone divided into three doses given every 8 hours for two weeks. The study lasted for 16 days; morbidity was considered if no improvement was observed in any or all clinical parameters of both Murray and CPIS scores and if there was failure in removing patients from the ventilator within the studied period. Results: Significant improvement was observed in patients of group B compared to group A with regard to APACH II <10 score, arterial oxygen saturation>95, hypoxic index >300, lung infiltrate in chest X-ray, lung compliance, response of the lung to recruitment maneuver, the return of core temperature to normal, normal tracheal secretion, the return of leucocytic count to normal, negative qualitative sputum culture and a significantly higher number of patients were removed from the ventilator of group B compared to group A. However, mortality rate was not significant between the two groups. Conclusion: Low dose corticosteroid if used for a long duration significantly lowers morbidity and accelerates recovery, and in turn, accelerates weaning from ventilator compared to high dose corticosteroid used for a short duration. While the difference between the two regimens was not significant with regard to the mortality rate, still further studies are needed to emphasize a fixed corticosteroid dose and regimen in ARDS due to lung contusion.

Challenges of diagnosis of COVID-19 in trauma patients: A case series

Background Diagnosis of COVID-19 can be challenging in trauma patients, especially those with chest trauma and lung contusion. Methods We present a case series of patients from February and March 2020 who were admitted to our trauma center at Rajaee Hospital Trauma Center, in Shiraz, Iran and had positive SARS-CoV-2 PCR test or chest CT scan suggestive of COVID-19 and were admitted to the specific ICU for COVID-19. Results Eight COVID-19 patients (6 male) with mean age of 40 (SD = 16.3) years old, were presented. All patients were cases of trauma injuries, with multiple injuries including chest trauma and lung contusion, admitted to our trauma center for management of their injuries, but they were diagnosed with COVID-19 as well. Two of them had coinfection of influenza type-B and SARS-CoV-2. All patients were treated for COVID-19 and three of them died; the rest were discharged from hospital. Conclusion Since PCR for SARS-CoV-2 is not always sensitive enough to confirm the cause of pneumonia, chest CT manifestations can be helpful, though, they are not always differentiable from lung contusion. Therefore, both the CT scan and the clinical and paraclinical presentation and course of improvement can be beneficial in diagnosing COVID-19 in the trauma setting.

Chest CT scan in patients with contusion and COVID-19, a comparative study with pure lung contusion

Background: Resource allocation for traumatic patients who are positive/negative for COVID-19 challenges the diagnosis. We designed this study to compare the chest CT appearances of COVID-19 patients associated with lung contusion versus patients with lung contusion only, to determine the differentiation capability of CT scan concerning the two conditions. Methods: CT-scans of 9 RT-PCR positive patients of lung contusion due to motor-vehicle-accident (COVID-19 with contusion group) and 16 consecutive patients with lung contusions of comparable severity scores from the pre-COVID-19 era (contusion only group) were revaluated retrospectively and blindly by three radiologists in consensus. The distribution and characteristics of presenting CT-scan findings; including presence, shape and distribution of Ground Glass Opacities and consolidations, presence of subpleural sparing, crazy-paving and Atoll sign. In addition, presence of effusions and cavities were compared between the two groups. Time course of the opacities was compared. Results: Bilateral distribution of opacities was noted in 100% of COVID-19 with contusion and 87.5% of contusion only group. There was no significant difference between Ground Glass Opacities or consolidation shapes (P=0.44 and P=0.66). Both Ground Glass Opacities and consolidations were more diffusely distributed in COVID-19 with contusion, while a predominantly peripheral distribution was more commonly seen in the contusion only group (P=0.03 and P=0.01 respectively). Subpleural sparing was noted in 93.8% of contusion only as compared to 44% of CC group (p=0.04). Appearance resembling Atoll sign was noted in 12.5% of the contusion only groups and none of the COVID-19 with contusion group (P=0.01). Time to resolution was significantly longer in COVID-19 with contusion (15±6 days) comparing to contusion only patients (P=0.02). Conclusion: 'Typical' chest CT findings including bilateral peripheral Ground Glass Opacities and consolidations, also crazy-paving and Atoll signs, as well as less typical findings such as subpleural sparing is seen in both lung contusion and COVID-19 pneumonitis. Time course of the lesions might be a better radiologic discriminator between the two entities.

Application of non-operative management protocol in pediatric blunt splenic injuries with other associated injuries

Background: Non-operative management (NOM) has become the standard of care for isolated blunt splenic injuries with satisfactory success rates. However, literature is scarce about the non-operative management of blunt splenic injuries (BSI) with other associated injuries (OAI). The main aim of this study is to assess the applicability of protocol-based NOM in BSI with OAI.Methods: Protocol based resuscitative algorithm was followed for the management of patients with BSI and OAI. NOM was taken up in those patients who were hemodynamically stable and was not attempted in patients who remained hemodynamically unstable or developed hemodynamic instability even after the resuscitative efforts. The data was collected and analyzed.Results: Forty patients with the mean age of 7.05±3.9 years were studied. Fall from height formed the commonest mode of injury. The mean AAST grade was 2.55. The most common association was a left lung contusion (20%). Fifteen patients presented with shock among which two failed the protocol-based resuscitative efforts and were hence explored. One of the patients had lung contusion and the other dorsal vertebral fractures (3rd and 4th). Another patient with mesenteric tear and delayed hemorrhage was operated. Two other patients underwent surgical interventions for bowel perforation and fracture of right femur respectively. Spleen was preserved in both of these patients. Though, the NOM was successful in overall 87.5% patients, spleen specific success rate was 92.5%.Conclusions: Application of protocol-based NOM in patients with BSI with OAI is highly successful if instituted in properly selected patients especially those with low grades of injury and also in those with delayed presentation.