Facteurs de risque d’insuffisance respiratoire aiguë dans les traumatismes thoraciques fermés

Facteurs de risque d’insuffisance respiratoire aiguë dans les traumatismes thoraciques fermés

INTRODUCTION

Chest trauma is the most common injury in severe trauma occurring in more than 50% of cases (1). Isolated chest trauma is rare since more than 80% are associated with other potentially life-threatening injuries (2). A high morbi-mortality rate is reported for chest trauma and a 25% mortality rate is applicable to severe chest trauma (3). After abdominal and brain trauma injuries, it is the third cause of death in traumatology (4,5). Chest trauma is characterized by life-threatening conditions initially caused by direct injury to the lung and related respiratory failure, secondarily by the consequences of hypoxemia and inflammatory reaction on other organ functions. Blunt chest trauma (BCT) may be considered as a major issue in traumatology because of its multiple respiratory complications. Acute Respiratory Failure (ARF) accounts for most of chest trauma complications. During the past decade, mechanical invasive ventilation (MIV) was the first-line treatment for such patients. Now, noninvasive ventilation (NIV) and multimodal analgesia reduce MIV rate in these situations (1) according the national guidelines (6). Various factors lead to ARF: atelectasis, early bacterial pneumonia, alveolar hypoventilation and pulmonary inflammation caused by trauma. The complexity of chest trauma management can be explained by the diversity of thoracic injuries, which are mainly bone injuries (ribs, sternal fractures, flail chest), pulmonary contusions, pneumothoraxes and pleural effusions (or aortic dissection, cardiac contusion, diaphragm lesion) with other associated injuries. Clinical presentation of thoracic trauma is heterogenous, ranging from mild to severe forms. Recently, risk factors of mortality for severe chest trauma have been identified: age greater than 65, pre-existing cardiopulmonary diseases, three or more rib fractures (7). Mild trauma is also associated with a significant morbidity. Thus, initial assessment may underestimate the severity of the situation and respiratory status may worsen during the following hours or days after admission. Currently, abundant inhomogeneous literature about chest trauma exists but very few concerning mild chest trauma, especially for stable patients without respiratory distress upon admission, who could benefit from a specific prophylactic management with proper orientation.

Study design and patients

We performed a retrospective observational monocentric study in a regional university hospital ICU (La Timone, France). We collected data over a 5-year period from January 1, 2015 to December 31, 2020. Every included patient with mild BCT was over 16 years old, admitted to the ED and managed in ICU for at least 48 hours with spontaneous breathing at admission. In our cohort, non-life-threatening BCT defined the mild BCT of patients having stable vital parameters at ED admission and without critical impairment requiring urgent surgery. A full body computed-tomography scan (CT-scan) was systematically performed. Exclusion criteria were: mechanically ventilated patients, whether they had been intubated prior or at ICU admission, patient intubated for other reasons than an acute respiratory distress during their hospital stay, minor chest trauma (less than 3 isolated rib fractures or isolated minor hemo-pneumothorax), and penetrating trauma. We screened eligible patients through the local database using the international classification of diseases (ICD), named Cora. The ICD 10th revision codes used were S20.2 for thoracic contusion, S29.8 for other thoracic injury, S27.3 for other lung injury, S27.0 for pneumothorax, S27.1 for traumatic hemothorax, S22.3/S22.4 for multiples fractured ribs, and S22.5 for flail chest. All patients who met the inclusion criteria with such codes were enrolled in the study. 583 patients were screened from database results, 393 patients were excluded and 190 patients were included. Developing an early ARF within the first 72 hours from ED admission to ICU follow-up were screened. The occurrence of ARF was described by the association of a PaFI ratio under 200 with the need of ventilator support: high flow oxygen (HFO), NIV or IMV. Patients requiring ventilator support for another motive than ARF due to thoracic injury were excluded. 

Data collection

The following data were collected from medical files (axigate) of each patient: age, gender, chronic respiratory diseases (smoking, asthma, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and restrictive syndrome), cardiovascular comorbidities (diabetes, High blood pressure, coronary artery disease (stented or not), peripheral arterial obstructive disease (PAOD)), body mass index, 7  anticoagulant/antiplatelet treatment, delay from trauma to hospital admission. From the CT-scan results, we accurately extracted thoracic lesion assessment: the number of fractured ribs, presence of flail chest, unilateral or bilateral fractured ribs damage, lung parenchyma involvement including lung contusion, hemo-pneumothorax, the side of the injury; and other injuries (abdominal, brain, spinal trauma, orthopedic, pelvic fracture, skin decay, face trauma). Different global severity scores were collected by the same investigator within the first 24 hours : simplified acute physiological score II (8) (SAPS II) and sequential organ failure assessment (9) (SOFA) score. Specifically, for chest trauma, we used the injury severity score (10) (ISS) with the thoracic abbreviated injury score (11) (AIS) and the thoracic trauma severity score (12)(TTS). We also included the clinical data at the ED admission and at 48 hours of ICU admission: respiratory rate (RR) over 20, gas exchange values (pH, PaCO2, PaO2), PaO2/FIO2 ratio, oxygen support (oxygen flow  4L/min or > 4L/min, HFO, NIV and MIV). For evaluation of pain intensity, we used the numerical rating scale (NRS) at ICU admission. The type of multimodal analgesia and the presence of a morphine patientcontrolled analgesia (PCA) or a loco-regional analgesia (paravertebral block, serratus block and epidural catheter) were recorded. Then, we assessed the patients evolving towards early ARF, and delay between ICU admission and respiratory distress. Respiratory complications included the occurrence of pneumonia and/or an acute respiratory distress syndrome (ARDS) requiring prone position or extracorporeal assistance. The NIV duration, MIV duration, ICU stay lengths, hospital length of stay and the mortality during hospital stay were also reported.

Table des matières

ABSTRACT
INTRODUCTION
METHODS
Study design and patients
Data collection
Ethics and Statistical analysis
RESULTS
DISCUSSION
CONCLUSION
TABLES
FIGURES
ABBREVIATIONS
ANNEXES
REFERENCES

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