Pulmonary contusion

Background

• Direct injury to lung resulting in hemorrhage and edema in absence of lung laceration
• Flail chest almost always associated with contusion

Clinical Features

• Dyspnea
• Tachypnea
• Chest pain
• Coarse breath sounds
• Hypoxia
• Widened A-a gradient

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Pulmonary Edema Types

Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema

• Cardiogenic pulmonary edema
• Noncardiogenic pulmonary edema
  • Negative pressure pulmonary edema
    • Upper airway obstruction
    • Reexpansion pulmonary edema
    • Strangulation
  • Neurogenic causes
    • Seizure
    • Head trauma
    • Subarachnoid hemorrhage
    • Electrocution
  • Iatrogenic fluid overload
    • Multiple blood transfusions
    • IV fluid
    • Inhalation injury
    • Pulmonary contusion
    • Aspiration pneumonia and pneumonitis
  • Other
    • High altitude pulmonary edema
    • Hypertensive emergency
    • ARDS
    • Flash pulmonary edema
    • Immersion pulmonary edema
    • Hantavirus pulmonary syndrome
    • Missed dialysis in kidney failure
    • Naloxone reversal

Evaluation

• Areas of lung opacification on chest imaging within 6hr of blunt trauma is diagnostic
• CXR
  • Patchy irregular infiltrates
• CT
  • Ground-glass opacities in mild-moderate contusions, widespread consolidation if severe
  • May pick up 70% of contusions not seen on CXR
  • Contusion >20% of lung volume associated with 80% risk of developing ARDS

Management

• Ensure adequate ventilation
  • Analgesia
  • Ventilatory Assistance
    • Patients with >25% of lung involvement frequently require ventilatory assistance
    • NIV may be tried
    • Intubate if NIV fails
      • Low tidal volume, high PEEP
• Avoid unnecessary fluid administration

See Also

• Rib Fracture
• Traumatic Pneumothorax