Jian-Xin Gan

Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma.

IntroductionEarly detection of pneumothorax in multiple trauma patients is critically important. It can be argued that the efficacy of ultrasonography (US) for detection of pneumothorax is enhanced if it is performed and interpreted directly by the clinician in charge of the patients. The aim of this study was to assess the ability of emergency department clinicians to perform bedside US to detect and assess the size of the pneumothorax in patients with multiple trauma.MethodsOver a 14 month period, patients with multiple trauma treated in the emergency department were enrolled in this prospective study. Bedside US was performed by emergency department clinicians in charge of the patients. Portable supine chest radiography (CXR) and computed tomography (CT) were obtained within an interval of three hours. Using CT and chest drain as the gold standard, the diagnostic efficacy of US and CXR for the detection of pneumothorax, defined as rapidity and accuracy (sensitivity, specificity, positive predictive value, negative predictive value), were compared. The size of the pneumothorax (small, medium and large) determined by US was also compared to that determined by CT.ResultsOf 135 patients (injury severity score = 29.1 ± 12.4) included in the study, 83 received mechanical ventilation. The time needed for diagnosis of pneumothorax was significantly shorter with US compared to CXR (2.3 ± 2.9 versus 19.9 ± 10.3 minutes, p < 0.001). CT and chest drain confirmed 29 cases of pneumothorax (21.5%). The diagnostic sensitivity, specificity, positive and negative predictive values and accuracy for US and radiography were 86.2% versus 27.6% (p < 0.001), 97.2% versus 100% (not significant), 89.3% versus 100% (not significant), 96.3% versus 83.5% (p = 0.002), and 94.8% versus 84.4% (p = 0.005), respectively. US was highly consistent with CT in determining the size of pneumothorax (Kappa = 0.669, p < 0.001).ConclusionBedside clinician-performed US provides a reliable tool and has the advantages of being simple and rapid and having higher sensitivity and accuracy compared to chest radiography for the detection of pneumothorax in patients with multiple trauma.

Penehyclidine hydrochloride attenuates LPS-induced acute lung injury involvement of NF-κB pathway

To investigate the protective effects of penehyclidine hydrochloride (PHC) in lipopolysaccharide (LPS)-induced acute lung injury (ALI) and the underlying molecular mechanism. ALI was induced by intravenous injection of LPS (5mg/kg). Male Sprague-Dawley (SD) rats challenged with or without LPS were pretreated with varied doses of PHC 0.5h before injection of LPS or saline. Blood gas in arterial blood, lung weight gain, bronchoalveolar lavage fluid (BALF), and neutrophils sequestration were examined 6h after administration of LPS. Pathological changes of lung tissue were measured by light microscopy. Phosphorylation of mitogen-activated protein kinase (MAPK) family and NF-kappaB were detected by western blot. All animals demonstrated drops in arterial oxygen tension (PaO(2)) after LPS application, which were significantly reversed by PHC pretreatment. Administration of PHC reduced lung water gain, bronchoalveolar lavage protein content, infiltration of neutrophils, malondialdehyde (MDA) content, and lactate dehydrogenase (LDH) activity and enhanced superoxide dismutase (SOD) activity. Histopathological study also indicated that PHC treatment markedly attenuated lung histopathological changes, alveolar hemorrhage, and inflammatory cells infiltration with evidence of decreasing of myeloperoxidase (MPO) activity. Furthermore, p38MAPK, ERK, and NF-kappaB were activated in 6h after LPS treatment, which could be blunted by PHC, while JNK remained unchanged. These findings confirmed significant protection by PHC against LPS-induced lung vascular leak and inflammation and implicated inhibition of p38MAPK activation signaling a potential role for PHC in the management of ALI.

The analysis of risk factors of impacting mortality rate in severe multiple trauma patients with posttraumatic acute respiratory distress syndrome

OBJECTIVE We hypothesize that not all of the traditional risk factors of impacting mortality rate in commonly traumatic populations with posttraumatic acute respiratory distress syndrome (ARDS) are independently associated with those patient populations identified with severe multiple trauma. Rather, we postulate that there may exist significantly different impacting degrees of specific risk factors in stratified patients (surviving beyond 24 and 96 hours)--more severe multiple trauma with higher injury score and long-term mechanical ventilation as well. METHODS This is a retrospective cohort study regarding trauma as a single cause for emergency intensive care unit admission. Twenty-two items of potential risk factors of impacting mortality rate were calculated by univariate and multivariate logistic analyses to find distinctive items in these severe multiple trauma patients. RESULTS The unadjusted odds ratio and 95% confidence intervals of mortality rate were found to be associated with 6 (out of 22) risk factors, namely, (1) Acute Physiology and Chronic Health Evaluation II score, (2) duration of trauma factor, (3) aspiration of gastric contents, (4) sepsis, (5) pulmonary contusion, and (6) duration of mechanical ventilation. Significant results also appeared in stratified patients. CONCLUSIONS Impact of pulmonary contusion and Acute Physiology and Chronic Health Evaluation II score contributing to prediction of mortality may exist in the early phase after trauma. Sepsis is still a vital risk factor referring to systemic inflammatory response syndrome, infection, secondary multiple organ dysfunction, etc. Discharging trauma factors as early as possible becomes the critical therapeutic measure. Aspiration of gastric contents in emergency intensive care unit admission could lead to incremental mortality rate due to aspiration pneumonia. Long-standing mechanical ventilation should be constrained because it is likely to cause severe refractory complications.

Prolonged length of stay in the emergency department in high-acuity patients at a Chinese tertiary hospital.

ED overcrowding is a worldwide issue, with most evidence coming from developed countries. Until now, little was known about this subject in China. The aim of this study was to investigate the situation of prolonged lengths of stay (LOS) in the ED for high‐acuity patients in a Chinese tertiary hospital and to identify associated factors.

ANALYSIS OF CLINICAL RISK FACTORS ASSOCIATED WITH THE PROGNOSIS OF SEVERE MULTIPLE-TRAUMA PATIENTS WITH ACUTE LUNG INJURY

BACKGROUND Several clinical risk factors have been reported to be associated with the prognosis of acute lung injury (ALI). However, these studies have included a general trauma patient population, without singling out the severely injured multiple-trauma patient population. OBJECTIVES To identify the potential risk factors that could affect the prognosis of ALI in multiple-trauma patients and investigate the prognostic effects of certain risk factors among different patient subpopulations. METHODS In this retrospective cohort study, severely injured multiple-trauma patients with early onset of ALI from several trauma centers were studied. Potential risk factors affecting the prognosis of ALI were examined by univariate and multivariate logistic analyses. RESULTS There were 609 multiple-trauma patients with ALI admitted to the emergency department and emergency intensive care unit during the study period. The nine risk factors that affected prognosis, as indicated by the unadjusted odds ratios with 95% confidence intervals, were the APACHE II (Acute Physiology and Chronic Health Evaluation II) score, duration of trauma, age, gastrointestinal hemorrhage, pulmonary contusion, disseminated intravascular coagulation (DIC), multiple blood transfusions in 6 h, Injury Severity Score (ISS), and aspiration of gastric contents. Specific risk factors also affected different patient subpopulations in different ways. CONCLUSIONS Patients older than 65 years and with multiple (> 10 units) blood transfusions in the early stage after multiple trauma were found to be independent risk factors associated with deterioration of ALI. The other factors studied, including pulmonary contusion, APACHE II score ≥ 20, ISS ≥ 16, gastrointestinal hemorrhage, and aspiration of gastric contents, may predict the unfavorable prognosis of ALI in the early stage of trauma, with their effects attenuating in the later stage. Duration of trauma ≥ 1 h and the presence of DIC may also indicate unfavorable prognosis during the entire treatment period.

Comparison of the new injury severity score and the injury severity score in multiple trauma patients

OBJECTIVE To assess whether these characteristics of less misclassification and greater area under receiver operator characteristic (ROC) curve of the new injury severity score (NISS) are better than the injury severity score (ISS) as applying it to our multiple trauma patients registered into the emergency intensive care unit (EICU). METHODS This was a retrospective review of registry data from 2 286 multiple trauma patients consecutively registered into the EICU from January 1,1997 to December 31, 2006 in the Second Affiliated Hospital, Medical School of Zhejiang University in China. Comparisons between ISS and NISS were made using misclassification rates, ROC curve analysis, and the H-L statistics by univariate and multivariate logistic progression model. RESULTS Among the 2 286 patients, 176 (7.7%) were excluded because of deaths on arrival or patients less than 16 years of age. The study population therefore comprised 2 110 patients. Mean EICU length of stay (LOS) was 7.8 days ?2.4 days. Compared with the blunt injury group, the penetrating injury group had a higher percentage of male, lower mean EICU LOS and age. The most frequently injured body regions were extremities and head/neck, followed by thorax, face and abdomen in the blunt injury group; whereas, thorax and abdomen were more frequently seen in the penetrating injury group. The minimum misclassification rate for NISS was slightly less than ISS in all groups (4.01% versus 4.49%). However, NISS had more tendency to misclassify in the penetrating injury group. This, we noted, was attributed mainly to a higher false-positive rate (21.04% versus 15.55% for ISS, t equal to 3.310, P less than 0.001), resulting in an overall misclassification rate of 23.57% for NISS versus 18.79% for ISS (t equal to 3.290, P less than 0.001). In the whole sample, NISS presented equivalent discrimination (area under ROC curve: NISS equal to 0.938 versus ISS equal to 0.943). The H-L statistics showed poorer calibration (48.64 versus 32.11, t equal to 3.305, P less than 0.001) in the penetrating injury group. CONCLUSIONS NISS should not replace ISS because they share similar accuracy and calibration in predicting multiple blunt trauma patients. NISS may be more sensitive but less specific than ISS in predicting mortality in certain penetrating injury patients.

The Impact of Clinical Risk Factors in the Conversion from Acute Lung Injury to Acute Respiratory Distress Syndrome in Severe Multiple Trauma Patients

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are different stages of the same disease, the aggravated stage of ALI leading to ARDS. Patients with ARDS have higher hospital mortality rates and reduced long-term pulmonary function and quality of life. It is, therefore, important to prevent ALI converting to ARDS. This study evaluated 17 risk factors potentially associated with the conversion from ALI to ARDS in severe multiple trauma. The results indicate that the impact of pulmonary contusion, APACHE II score, gastrointestinal haemorrhage and disseminated intravascular coagulation may help to predict conversion from ALI to ARDS in the early phase after multiple-trauma injury. Trauma duration, in particular, strongly impacted the short- and long-term development of ALI. Being elderly (aged ≥ 65 years) and undergoing multiple blood transfusions in the early phase were independent risk factors correlated with secondary sepsis, deterioration of pulmonary function and transfusion-related acute lung injury due to early multiple fluid resuscitation.

Protective effect of raloxifene on lipopolysaccharide and acid- induced acute lung injury in rats

AbstractAim:To evaluate the protective effect of oral raloxifene on acute lung injury.Methods:Thirty adult, male Sprague-Dawley rats each weighing 180–210 g were used and divided into 3 groups: the raloxifene-lipopolysaccharide (LPS)-HCl group (n=10), the LPS-raloxifene-HCl group (n=10), and the placebo group (n=10). All the rats were injected intraperitoneally (ip) with 5 mg/kg LPS, and raloxifene (30 mg/kg) was orally administered 1 h before and 14 h after LPS injection into the raloxifene-LPS-HCl and the LPS-raloxifene-HCl groups, respectively; the placebo group received nothing. Sixteen hours after LPS injection, all the animals were anesthetized and the femoral artery was cannulated. All the rats received a direct intratracheal (IT) injection of HCl (pH 1.2; 0.5 mL/kg). The mean arterial pressure (MAP) and blood gas concentrations were measured. Fifteen rats (5 in each group, respectively) underwent a micro positron emission tomography (microPET) scan of the thorax 4 h after HCl instillation. The wet/dry (W/D) weight ratio determination and histopathological examination were also performed.Results:The rats in the LPS-raloxifene-HCl group had a lower [18F]fluorodeoxyglucose uptake compared with the rats in the placebo group (4.67±1.33 vs 9.01±1.58, respectively, P<0.01). The rats in the LPS-raloxifene-HCl group also had a lower histological lung injury score (8.20±1.23 vs 12.6±0.97, respectively, P<0.01) and W/D weight ratio (5.335±0.198 vs 5.886±0.257, respectively, P< 0. 01) compared to the placebo group. The rats in this group also showed better pulmonary gas exchange and more stable mean arterial pressure (MAP) compared to the placebo group.Conclusion:Raloxifene provides a significant protective effect on acute lung injury in rats induced first by LPS ip injection and then by HCl IT instillation.

Delayed diagnosis of tooth aspiration in three multiple trauma patients with mechanical ventilation

Tooth aspiration is a critical and rare complication in trauma patients. It can remain undetected and misdiagnosed. Here we present three mechanically ventilated multiple trauma cases with delayed diagnosis of bronchial tooth aspiration. Case 1 A 23-year-old man was severely injured in a car accident and had multiple trauma, with an injury severity score (ISS) of 50 and a head abbreviated injury score (AIS) of 5. Three days later he was transferred to our hospital and chest CT showed a tooth-like foreign body in the right bronchial tree, which was confirmed to be a bicuspid ( according to the Palmer notation method) by flexible bronchoscopy. As the tooth was psilate and firmly embedded, many attempts with either flexible or rigid bronchoscopy could not extract it. The patient died of sepsis 70 days after the accident. Case 2 A 26-year-old man was presented to a local hospital with multiple trauma (ISS 54, head AIS 5) following a motorcycle accident. On the next day when he was transferred to our hospital, a chest film and fibreoptic bronchoscopy confirmed a lateral incisor () in the left lobe. We failed to extract the tooth, but fortunately it was expectorated via the tracheotomy tube following a vigorous cough on day 12. Case 3 A 25-year-old man was presented with multiple trauma (ISS 41, head AIS 4) after a motorcycle accident. He was transferred to our hospital 9 hours later. Chest CT and flexible bronchoscopy confirmed a central incisor () in the right bronchial tree. It was extracted by flexible bronchoscopy on day 8 (Figure ​(Figure11). Figure 1 CT images of lung and maxillofacial bones, inspired tooth in case 3. (a-d) CT scan on day 1 showed the tooth-like foreign body (white/black arrow) in the right bronchus. (e) Reconstructed CT images on day 2 showed fracture of mandible and left zygomatic ... Early diagnosis of tooth aspiration in coma patients is difficult because aspiration is rarely considered in the absence of an acute clinical presentation. Thus, an endobronchial tooth can remain undetected for a long time and result in serious complications [1]. In all three cases reported here, tooth aspiration was missed by the local hospitals. Doctors should suspect that any tooth that has been avulsed and not found as possibly aspirated in trauma patients, especially for those in a coma status. The medical history, clinical signs and radiological findings should be carefully checked. CT is more accurate than chest radiography in detecting endobronchial foreign bodies. When negative chest radiography or doubtful clinical findings are presented, bronchoscopy should be performed to confirm the diagnosis [2]. Both flexible and rigid bronchoscopy can be used for the diagnosis and removal of teeth [3]. Tracheotomy may facilitate the removal of an aspirated tooth.

Evaluation of the inflammatory response in a two-hit acute lung injury model using [18F]FDG microPET

The aim of this study was to investigate whether a two-hit acute lung injury (ALI) model is better than a one-hit model in simulating ALI, and to evaluate the inflammatory response in the lungs in these two models using micro-positron emission tomography (microPET) with [18F]fluorodeoxyglucose (FDG). Sprague Dawley rats were divided into four groups; rats in the lipopolysaccharide (LPS; n=10) and LPS-HCl (n=10) groups were challenged by the intraperitoneal administration of 5 mg/kg LPS, while rats in the normal saline (NS; n=3) and HCl (n=10) groups received the same volume of normal saline solution. Sixteen hours following the administration, the rats in the HCl and LPS-HCl groups received an acid instillation (IT) of 0.5 ml/kg HCl (pH=1.2), while the rats in the remaining two groups received the same volume of normal saline solution. The mean arterial blood pressure (MAP) and blood gas concentrations were measured in all four groups. MicroPET was performed 4 h following HCl IT and the lungs were excised for histopathological examination. The rats in the LPS-HCl group exhibited a higher arterial PaO2 and a lower arterial PaCO2 compared with the rats in the remaining groups. The MAP decreased markedly in the LPS-HCl group, but remained stable in the LPS, HCl and NS groups. MicroPET results identified that the region of interest ratio in the LPS-HCl group (9.00±1.41) was significantly higher compared with those in the LPS (4.01±0.60) and HCl (3.33±0.55) groups (P<0.01). In addition, histological examination showed that the mean lung injury score in the LPS-HCl group (12.70±0.95) was significantly higher compared with those in the HCl (8.40±1.26) and LPS (7.00±0.82) groups (P<0.01). The present study demonstrates that LPS pretreatment significantly magnifies and prolongs the inflammatory response to subsequent acid IT in the lungs. Moreover, it is simpler to induce ALI using the two-hit model than with the one-hit model, and [18F]FDG microPET is a useful tool for evaluating the inflammatory reaction during ALI.