P27 – TAP versus VAP: Early Diagnosis of Pneumonia in Trauma Patients

Author(s):
Nicole Hooft, Christine Lovato, Pam Goslar, Kristina Kahzeni, Tom Gillespie, Scott Petersen, St. Joseph

Background: Pneumonia is a major cause of morbidity and mortality in ventilated trauma patients. It is difficult to determine the true etiology of pneumonia during the first 24-72 hours in ventilated trauma patients as these patients can present with a variety of diagnoses such as aspiration in the field, systemic inflammatory response syndrome (SIRS), pulmonary contusion, and true ventilator associated pneumonia (VAP). Trauma associated pneumonia(TAP) is a term that has been coined in an attempt to make the point clear that traditional definitions of VAP in ventilated trauma patients should not be applied.

Hypothesis: The aim of this study is to assess the true etiology of TAP using the mini-bronchoalveolar lavage (mini-BAL) to detect early aspiration in emergently intubated trauma patients.

Methods: Patients who were emergently intubated either in the field or trauma bay were prospectively assessed on a daily basis for clinical signs of pneumonia, and if suspected underwent a mini-BAL. Cultures were defined as positive when they showed bacterial growth >1 x 10^4 colony-forming unit (cfu)/ml. Positive cultures on mini-BAL at <48 hours were defined as an aspiration pneumonia and after 48 hours were defined as VAP.

Results: Forty patients were identified that were intubated at the scene or after evaluation in the trauma center. Median GCS was 9, mean age was 38.6, 64% of patients were male, 60% loss of consciousness and 60% had illegal substances on board or blood alcohol level over 80. Twenty-five patients (62.5%) met clinical indications to receive a mini-BAL during their hospital stay, 17 (68%) of these being in the first 48 hours from injury. Of these patients 47.1% had culture proven pneumonia. Of the 15 patients who were never cultured 80% were extubated within 24 hours, one patient died and one patient never met clinical indication for culture prior to 48 hours.

Conclusions: In trauma patients requiring emergent intubation 47% with clinical suspicion of pneumonia have culture proven aspiration prior to 48 hours. Organisms isolated in these patients are consistent with bacteria from a patient derived source. Early diagnosis based on mini-BAL culture facilitates identification of these patients early, which allows for early antibiotic coverage and evaluation of sensitivities. Early diagnosis of TAP versus VAP may help in clarification of quality indicator standards for pneumonia in ventilated trauma patients.