Shao-wen Xu

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.

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.

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.

Invasive pulmonary and central nervous system aspergillosis following slops aspiration in a trauma patient.

Cerebral aspergillosis is a rare complication of multiple trauma. In this report, we present a remarkable case of multiple lung and brain lesions caused by aspergillosis after a falling incident. A 54-year-old male was admitted with multiple trauma (brain contusion, aspiration pneumonitis with pulmonary contusion, right humerus fracture and right scapular fracture) due to a 6-m fall and aspiration of slops. In view of aspiration pneumonitis (Figure ​(Figure1,1, day 1), intravenous antibiotic treatment (tazocin, moxifloxacin hydrochloride and metronidazole) was started. Brain computerized tomography (CT) on day 12 indicated a focus of encephalomalacia in the left frontal lobe, which was thought to be the progress of brain contusion (Figure ​(Figure1,1, day 12). On the same day, chest CT showed a pulmonary halo sign on the left upper lung (Figure ​(Figure1,1, day 12), and voriconazole therapy was used because of high suspicion of invasive pulmonary fungal infection. Voriconazole treatment had to be stopped, however, due to severe rash 5 days later. Anti-fungus therapy was continued with caspofungin. On day 19, the brain CT showed signs of fungus infection (Figure ​(Figure1,1, day 19). Twenty-two days after injury, the central venous catheter culture grew aspergillus species and established the diagnosis of invasive aspergillosis in this patient; liposomal amphotericin B was then also added to the patients treatment. On day 34, enhanced CT imaging of the brain showed progression of multiple lesions of fungus infection (Figure ​(Figure1,1, day 34). Unfortunately, the patient died 40 days after injury. Figure 1 Chest and brain computerized tomography on days 1, 12, 19, 28, and 34. Aspiration pneumonitis with pulmonary contusion was shown on day 1. Black arrows, multiple lesions of fungus infection in both the lung and the brain. White arrows, progression of ... We have described invasive aspergillosis with a rapidly progressive and fatal pulmonary and cerebral course in a previously healthy man. Neuroaspergillosis is an uncommon infection associated with an exceedingly high mortality. The diagnosis of neuroaspergillosis is difficult, often made at the terminal stage of disease or on autopsy [1]. Perhaps due to the greater penetration into the central nervous system (CNS), voriconazole treatment greatly improved clinical outcomes with a survival rate of 30% in high-risk patients [2,3]. According to the guidelines for treating invasive pulmonary aspergillosis, voriconazole is recommended for primary treatment [4]. Unfortunately, this patient was refractory to voriconazole because of severe rash, and then caspofungin was selected for salvage therapy. Owing to the large molecular mass, high protein binding and water solubility of caspofungin, its penetration into the CNS was limited [5]; this invasive pulmonary aspergillosis was then further complicated by dissemination to the CNS on day 19. In conclusion, we report a rare trauma case accompanied with invasive pulmonary and CNS aspergillosis following slops aspiration. This case highlights the diagnostic challenge presented by invasive aspergillosis in non-neutropenic patients and underscores its poor prognosis.

Novel double-superior-trunk injury of the brachial plexus: a case report.

Brachial plexus injuries are generally rare and a double-superior-trunk injury of the brachial plexus has never been reported before. We report the first case of a brachial plexus injury in a 43-year-old Chinese male with a double superior trunk. This was observed incidentally during an operation 1 month after initial traction injury sustained in a car accident. The double superior trunk of the brachial plexus was formed by the double roots of C5 and C6, respectively. Six months after discharge, the patient reported the recovery of most of the function of his left arm except the muscles innervated by the radial nerve. Two years after discharge, he reported almost full functional recovery of his left arm. We discuss what is known about anatomical variations of the brachial plexus, and the possible association between this novel brachial plexus anatomy and the almost complete functional recovery of the arm.