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ISSN- 2394-5125 VOL 7, ISSUE 18, 2020 INCIDENCE OF MORBIDITY AND MORTALITY IN THORACIC TRAUMA PATIENTS IN INTENSIVE CARE UNIT IN MINIA UNIVERSITY HOSPITAL

Mohammed M. Ali1, Nagy S. Ali1, Khaled A. Abdo1, YS. Mubarak2

1Anesthesiology and intensive care Department1 , Minia university hospital, Minia University, Egypt 2Cardiothoracic surgeryDepartment, Minia university hospital, Minia University, Egypt

Corresponding Author Mohammed M. Ali

Received: 16 March 2020 Revised and Accepted: 16 June 2020

Abstract: Thoracic trauma is a serious condition affecting morbidity and mortality especially in old patients with different comorbidities especially if contusion is present which usually need . The higher APACHE II score, ISS or TTSS scores the higher the mortality and vice-versa. Keywords: Chest trauma, fracture ribs, lunge contusion, mechanical ventilation, morbidity, mortality.

I- Introduction Chest has a negative impact on the economy of the families in the developing world, in poly-trauma patients; is an important component that increases morbidity and mortality. (1) Thoracic trauma is responsible for approximately 25% of trauma deaths, Blunt chest wall trauma accounts for over 10% of all trauma patients presenting to emergency departments worldwide, in the civilian population, blunt chest trauma largely exceeds . (2)

II- Methodology: After obtaining approval from our hospital – El-Minia university hospital – ethics committee , in a period of 24 months from first of July, 2018, to the last of June, 2020, a total of 50 adult trauma patients ,aged of 18 to 65 years of either sex presented with blunt or penetrating chest trauma were approached and enrolled in this prospective, descriptive study. Patients admitted to ICU not due to chest trauma, died within 24 hours after admission or discharged-or died- in the emergency room also were excluded. Information obtained included the patients’ demographics, diagnosis, etiology and mechanisms of trauma, trauma severity scores ( (ISS), injury class (e.g., blunt versus penetrating), Emergency Room vital signs (e.g., blood pressure, Glasgow Coma Scale Score (GCS), preexisting clinical diagnoses, and discharge status (mortality, discharge destination), any complications, interventions, outcomes and length of stay in the ICU, All patients were followed until discharge from ICU. All patients were assigned an ISS on admission, GCS on admission and discharge, trauma severity score (TTSS) on admission and APACHE II score at the time of admission and/or within 24 hours after admission. On admission, patient characteristics such as age, sex, acute physiology and chronic health evaluation (APACHE II) score and GCS were recorded, Routine electrocardiogram (ECG), noninvasive blood pressure monitoring as well as central venous pressure (CVP) and urine output were monitored, Patients were mechanically ventilated if they met the criteria of mechanical ventilation and weaned upon improvement according to protocols, Routine laboratory investigations were performed including Complete blood count (CBC), liver function tests, renal function tests, arterial blood gases, coagulation profiles, infection markers and measurement of serum electrolytes. Parameters assessed were Demographic data Including age and sex, Clinical assessment, Routine ICU monitoring including, continues ECG monitoring, rate (beat / minuet), mean arterial blood pressure (mmHg) and oxygen saturation all were measured on admission and continuously. In mechanically ventilated patients, the arterial blood gases (ABG) and fluid charts for input and output were recorded. The time of arrival to the ICU. The following ICU trauma scores were used: A-Acute physiology and chronic health evaluation (APACHE II) score: It is a disease severity classification system. It was done to the patients within 24 hours from admission to predict the prognosis of the patients. APACHE II scoring system is the most common system used in assessment of critically ill patients in ICU. It generates a point score ranging from 0 to 71 based on 12 physiologic variables, age and underlying health. (3). Table (1) 4514

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B-Glasgow coma scale score (GCS): Is the most widely used clinical measurement, GCS is based on eye response, verbal response, and motor response. GCS was recorded on admission, and on discharge. (4). Table (2) C-Injury severity score (ISS): Severity of trauma is related not just to the severity of individual , but also to the combined effects of multiple injuries which are graded by the Injury Severity Score (ISS), which is an empirical system based on the AIS grades for the three worst body regions and gives a score between 0 and 75 for total body injury; 16 or more indicates , ISS was done on admission. (5). Table (3) D-Thorax trauma severity score (TTSS): Thorax trauma severity score (TTSS) combines patient-related parameters with the anatomical and physiological parameters and it can be easily calculated in the emergency room and was done on admission. Table (4)

Table (1) Table (2)

Table (3)

Table (4) 3-Injury cause, type and mechanism Whether injury is caused by road traffic accidents, fall from height, gunshots, striking by heavy objects or assault from others, the type of injury either intentional or non-intentional and the mechanism; blunt or penetrating injury, 4-Numbers of units of blood transfused 5-Admission hypotension: Presence of hypotension on admission after trauma is an indicator of severs trauma and/or massive blood loss (6). 6-The need and duration of mechanical ventilation: The time spent on mechanical ventilation by the patients who required it. 7-Pre-existing co-morbidities: It included, hypertension, diabetes mellitus, cerebrovascular accident, liver disease, pulmonary disease, chronic kidney disease, alcoholism, and a current smoking history were reported. 8-The length of stay in ICU: Defined as the number of days from the start of the therapy to the discharge of the patient from the ICU (7). 9-Side effects or complications related to any procedures or medications. 10-PaO2/FiO2 ratio: Done, on admission and serially.

III - Laboratory work: -Routine investigations: These include: A) Investigations done on admission and then daily until discharge: - Complete blood count (CBC). 4515

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- Blood urea and serum creatinine (mg/dl). - Arterial blood gases - Serum blood glucose (mg/dl). - Serum electrolytes (mEq/l) B) Investigations done on admission and then when required: - Liver function tests (AST, ALT and albumin). - Coagulation profile

IV - Radiological assessment: - Brain CT scan was done for diagnosis and for follow up to exclude new lesion or expanding , it is done on admission and after 48 hours or postoperative or with deteriorating GCS. - Plain chest X-ray daily and if new onset hypoxia or tachypnea. - Chest CT was done when needed to diagnose lung contusions or any insult couldn't be assessed by plain chest x-ray. - Abdominal sonar to exclude associated trauma on admission and for follow up of surgical abdomen. - Plain X-ray on the bony skeleton and cervical spine In the form of plan chest x-ray, chest ultrasonography and chest CT scan

V- Morbidities: Morbidity is defined as any departure, subjective or objective, from a state of physiological or psychological well-being, In practice Morbidity refers to the diseases and illness, injuries, and disabilities in a population whether or not leads to death (8). Morbidities are classified by body systems

VI-Mortality: Defined as, the number of patients who died during the period of ICU stay (9). Each case of morbidity or mortality were marked as iatrogenic or non-iatrogenic

Results: First for descriptive statistics for age, sex, cause of trauma, mode of trauma, APACHE II score, ISS, TTSS, injury, presence of fracture ribs or lung contusion, blood transfusion and number of units transfused, mechanical ventilation and its duration, admission hypotension, insertion, tracheostomy tube required, comorbidities in the form of HTN, DM, Liver disease, source of admission, length of stay at ICU, cause of discharge. All data shown in tables, from table (5) to table (11).

Descriptive statistics

N=50 Range (18-65) Age Mean ± SD 39.4±16.8 Male 37(74%) Sex Female 13(26%) MCA 29(58%) FFH 11(22%) Cause of trauma HHO 3(6%) Stab chest 7(14%) Blunt 43(86%) Mode of trauma Penetrating 7(14%) Table (5)

Descriptive statistics

N=50 Median 10 APACHE II IQR (7-12) Median 15 ISS IQR (9-25) Median 7 TTSS IQR (4-11) Table (6)

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Descriptive statistics

N=50

No 16(32%) Fracture ribs One 2(4%) Two 32(64%) No 30(60%) Lung contusion Yes 20(40%) Table (7)

Descriptive statistics

N=50 No 23(46%) Blood transfusion Yes 27(54%) Median 4 Units of blood IQR (2-4) No 33(66%) MV Yes 17(34%) Median 7 Duration of MV IQR (4-17) Table (8)

Descriptive statistics

N=50 No 36(72%) Admission hypotension Yes 14(28%) Unilateral 31(62%) Chest tube Bilateral 19(38%) No 47(94%) Tracheostomy Yes 3(6%) Table (9)

Descriptive statistics

N=50 No 37(74%) Comorbidity Yes 13(26%) No 39(78%) HTN Yes 11(22%) No 46(92%) DM Yes 4(8%) No 45(90%) Liver disease Yes 5(10%) Table (10) Descriptive statistics

N=50 ER 40(80%) Source of admission OR 10(20%) Median 5 LOS at ICU IQR (4-10) <7 29(58%) ICU stay ≥7 21(42%) Improvement 42(84%) Cause of discharge Death 8(16%) Table (11)

For age there was a significant statistical difference regarding to improvement or death as shown in table (10), we found that the older the patient the higher the mortality rate.

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No significant difference as regards to sex, cause of trauma or mode of trauma table (12). As table (13) shows, the higher APACHE II score, ISS or TTSS scores the higher the mortality and vice-versa. Lung contusion was found significantly affecting mortality rates among the studied patients. Table (14) Also, mortality rate was higher among patients needed mechanical ventilation. Table (15) Comorbidities as HTN, DM and Liver disease also significantly increase the mortality rate as shown in table (16) Improved Died P value N=42 N=8 Median 34.5 65 Age <0.001* IQR (21.5-46.3) (49.3-65) Male 31(73.8%) 6(75%) Sex 0.994 Female 11(26.2%) 2(25%) MCA 25(59.5%) 4(50%) FFH 8(19%) 3(37.5%) Cause of trauma 0.307 HHO 2(4.8%) 1(12.5%) Stab chest 7(16.7%) 0(0%) Blunt 35(83.3%) 8(100%) Mode of trauma 0.580 Penetrating 7(16.7%) 0(0%) Table (12)

Improved Died P value N=42 N=8 Median 9 14 APACHE II <0.001* IQR (6.8-10) (11.3-21) Median 13 27 ISS 0.028* IQR (9-25) (14.8-44.3) Median 6.5 12.5 TTSS 0.014* IQR (4-10.3) (11-17.5) Table (13)

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Improved Died P value N=42 N=8

No 15(35.7%) 1(12.5%) Fracture ribs One 2(4.8%) 0(0%) 0.466 Two 25(59.5%) 7(87.5%) No 29(69%) 1(12.5%) Lung contusion 0.005* Yes 13(31%) 7(87.5%) Table (14)

Improved Died P value N=42 N=8 No 20(47.6%) 3(37.5%) Blood transfusion 0.711 Yes 22(52.4%) 5(62.5%) Median 3.5 4 Units of blood 0.251 IQR (1.8-4) (3-5.5) No 33(78.6%) 0(0%) MV <0.001* Yes 9(21.4%) 8(100%) Median 10 6 Duration of MV 0.439 IQR (3-34.5) (4-7.8) Table (15)

Improved Died P value N=42 N=8 No 36(85.7%) 1(12.5%) Comorbidity <0.001* Yes 6(14.3%) 7(87.5%) No 37(88.1%) 2(25%) HTN 0.001* Yes 5(11.9%) 6(75%) No 41(97.6%) 5(62.5%) DM 0.011* Yes 1(2.4%) 3(37.5%) No 41(97.6%) 4(50%) Liver disease 0.001* Yes 1(2.4%) 4(50%) Table (16)

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III- Discussion: Chest trauma either blunt or penetrating is considered as one of the most important causes of morbidity and mortality especially in developing countries. This also found in the study of O'Connor JV et al 2010, as they found that thoracic trauma directly accounts for approximately 25% of trauma related mortality and is a contributing factor in another 25%. (12) In our study we found that some of the demographic data of our patients in the form of age affecting mortality rate significantly Patients suffer from chronic diseases such as HTN, DM or Liver disease found to have higher mortality as expected. Since comorbidities dose increase with age, it may be difficult to judge their effect on prognosis separately. However, age of 65 years or above has been described as a major predictor of mortality. (9) Different scores we used for evaluation of our patients showed acceptable validity in prediction of prognosis of our traumatized patients. J.-Y. Fagon, et al 1996 found that APACHE II scoring system is considered to show good correlation with the risk of mortality and hospital-acquired infections.(4) ISS was significantly higher in those who died. The high ISS in Hefny AF et al 2013 study indicates severe injury of admitted patients.(3) Zahran et al. The Cardiothoracic Surgeon (2020) 28:3 found that low TTSS values were associated with a good prognosis, and the high TTSS values were associated with higher morbidity and mortality.(17) Lung contusion is the most important factor affecting prognosis as our results showed that mortality is significantly higher among patients with lung contusion. Previous reports on the impact and outcome of pulmonary laceration following blunt chest trauma are scarce. Two Japanese studies of 13 and 42 cases report mortality rates as high as 44% following pulmonary lacerations. (10, 11) Patients needed mechanical ventilation found to have higher mortality rates either due to the severity of injury or the complications of mechanical ventilation itself. In Lentsck MH,et al 2020 study, mechanical ventilation, regardless of the justification for its use, increased the probability of death fivefold.(7)

IV- Conclusion: Thoracic trauma is a serious condition that affecting morbidity and mortality especially in old patients with different comorbidities especially if lung contusion is present which usually needs mechanical ventilation. APACHE II score, Injury severity score and Thorax trauma severity score are good predictors for morbidity and mortality in thoracic trauma patients.

V- Recommendations: Further studies should be done to clarify whether the mechanical ventilation itself is a predictor of mortality or the severity of the injury itself which requires mechanical ventilation as a management. Other scores could be investigated in thoracic trauma such as Wagner score, chest (AIS), Lung Injury Scale, score (PCS), or RibScore.

VI- References:

[1] Baker M, Armstrong J, Reilly JJ et al, Epidemiology, Biostatistics, and Preventive Medicine (2nd edition) 19, 10, 983-990, 2000. [2] Cosgriff N, Moore EE, Sauaia A, et al, Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009, 66:41–48. [3] Hefny AF, Idris K, Eid HO, Abu-Zidan FM. Factors affecting mortality of critical care trauma patients. African Health Sciences. 2013 Sep;13(3):731-735. DOI: 10.4314/ahs.v13i3.30. [4] J.-Y. Fagon, J. Chastre, A. Vuagnat, J.-L. Trouillet, A. Novara, and C. Gibert, “Nosocomial pneumonia and mortality among patients in intensive care units,” Journal of theAmerican Medical Association, vol. 275, no. 11, pp. 866–869, 1996. 4520

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[5] Kashuk JL, Moore EE, Sawyer M, et al, Pos-tinjury coagulopathy management: goal directed via POC thrombelastography. Ann Surg 2010, 251:604–614. [6] Langfitt TW ., Measuring the outcome from head injuries. J Neurosurg 2015;48:673–678 [7] Lentsck MH, Oliveira RR, Corona LP, Mathias TAF. Risk factors for death of trauma patients admitted to an Intensive Care Unit. Rev. Latino-Am. Enfermagem. 2020;28:e3236. [8] Lewis FR: Thoracic trauma. Surg clin North Am 1982;62:97-104 [9] Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S: Chest injury due to [10] . Eur J Cardiothorac Surg 2003, 23(3):374–378. [11] Matsumoto K, Noguchi T, Ishikawa R, Mikami H, Mukai H, Fujisawa T: The surgical treatment of lung lacerations and major bronchial disruptions caused by blunt thoracic trauma. Surg Today 1998, 28(2):162–166. [12] Nishiumi N, Inokuchi S, Oiwa K, Masuda R, Iwazaki M, Inoue H: Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma. Ann Thorac Surg 2010, 89(1):232–238. [13] O'Connor JV, Adamski J. The diagnosis and treatment of non-cardiac thoracic trauma. J R Army Med Corps. 2010;156(1):5–14. [14] Pressley CM, et al. Predicting outcome of patient chest wall injury. Am Js 2012;204(6):910-3 discussion 913-4 [15] Teasdale G and Jennett B. Assessment of coma and impaired consciousness: A practical scale. Lancet 2001;2:81–84. [16] Ward MM, Factors predictive of acute renal failure in . Arch Intern Med 2008, 148:1553– 1557. [17] West JG, Trunkey DD and Lim RC. Systems of trauma care: A study of two counties. Arch Surg 2008;114:445–460. [18] Zahran, Mohamed & Elwahab, Amr & Nasr, Mohamed & Heniedy, Mohamed. (2020). Evaluation of the predictive value of thorax trauma severity score (TTSS) in thoracic-traumatized patients. 28. 7. 10.1186/s43057-020-0015-7.

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