hest Trauma

Pulmonary Contusion
Pulmonary contusion is an injury to lung parenchyma, leading to
oedema and blood collecting in alveolar spaces and loss of
normal lung structure & function. This blunt lung injury develops
over the course of 24 hours, leading to poor gas exchange,
increased pulmonary vascular resistance and decreased lung
compliance. There is also a significant inflammatory reaction to
blood components in the lung, and !"#!$ of patients %ith
significant pulmonary contusions %ill develop bilateral &cute
'espiratory (istress )yndrome *&'()+.
Pulmonary contusions occur in approximately 2!$ of blunt
trauma patients %ith an ,njury )everity )core over -, and it is
the most common chest injury in children. The reported mortality
ranges from -! to 2$, and 4!"#!$ of patients %ill re.uire
mechanical ventilation. The complications of pulmonary
contusion are &'(), as mentioned, and respiratory failure,
atelectasis and pneumonia.
(iagnosis
Pulmonary contusions are rarely diagnosed on physical
examination. The mechanism of injury may suggest blunt chest
trauma, and there may be obvious signs of chest %all trauma
such as bruising, rib fractures or flail chest. These suggest the
presence of an underlying pulmonary contusion. Crac/les may be
heard on auscultation but are rarely heard in the emergency room
and are non"specific.
)evere bilateral pulmonary contusions may present %ith hypoxia
" but more usually hypoxia develops as the pulmonary contusions
blossom or as a result of subse.uent &'().
Chest 0"ray
1ost significant pulmonary contusions are diagnosed on plain
chest 0"ray. 2o%ever the chest 0"ray %ill often under"estimate
the si3e of the contusion and tends to lag behind the clinical
picture. 4ften the true extent of injury is not apparent on plain
films until 24"45 hours follo%ing injury.
C26)T T'&71&
,8,T,&9
6:&97&T,48
P86714T24'&0
T68),48 P86714
4P68 P86714
2&614T24'&0
C48T7),48
',; <'&CT7'6 =
<9&,9
&4'T,C ,8>7'?
C26)T ('&,8)
P79148&'?
C48T7),48
P',1&'? )7':6?
&,'@&?
;'6&T2,8A
C,'C79&T,48
(,)&;,9,T?
60P4)7'6
&(>78CT)
C0'
)6C48(&'?
)7':6?
9 pulmonary contusion
9 pneumothorax
Pulmonary Contusion
&dmission C0'
Pulmonary Contusion
24 2ours
Computed Tomography
Computed tomography *CT+ is very sensitive for identification of
pulmonary contusion, and may allo% differentiation from areas
of atelectasis or aspiration. CT also allo%s for B"dimensional
assessment and calculation of the si3e of contusions. 2o%ever,
most contusions that are visible only on a CT scan are not
clinically relevant, in that they are not large enough to impair gas
exchange and do not %orsen outcome. 8evertheless, CT %ill
accurately reflect the extent of lung injury %hen pulmonary
contusion is present.

lung contusion at
thoracotomy
1anagement
1anagment of pulmonary contusion is supportive %hile the
pulmonary contusion resolves. 1ost contusions %ill re.uire no
specific therapy. 2o%ever large contusions may affect gas
exchange and result in hypoxaemia. &s the physiological impact
of the ocntusions tends to develop over 24"45 hours, close
monitoring is re.uired and supplemental oxygen should be
administered.
1any of these patients %ill also have a significant chest %all
injury, pain from %hich %ill affect their ability to ventilate and to
clear secretions. 1anagement of a blunt chest injury therefore
includes ade.uate and appropriate analgesia. Tracheal intubation
and mechanical ventilation may be necessary if there is difficulty
in oxygenation or ventilation. 7sually ventilatory support can be
discontinued once the pulmonary contusion has resolved,
irrespective of the chest %all injury.
The classic management of pulmonary contusion includes fluid
restriction. 1uch of the data to support this comes from animal
models of isolated pulmonary contusion. 2o%ever, %hile relative
fluid excess and pulmonary oedema %ill augment any respiratory
insufficience, the conse.uences of the opposite " hypovolaemia
are more severe and long"lasting. Prolonged episode of
hypoperfusion in trauma patients %ill result in inflammatory
activation and acute lung injury, and may result in &'() and
multiple organ failure. 2ence the goal for management of
patients %ith pulmonary contusion should be euvolaemia.
Complications
Pulmonary contusions %ill usually resolve in B to days,
provided no secondary insult occurs. The main complications of
pulmonary contusion are &'() and pneumonia. &pproximately
!$ of patients %ith pulmonary contusion develop &'(), and
5!$ of patients %ith pulmonary contusions involving over 2!$
of lung volume. (irect lung trauma, alveolar hypoxia and blood
in the alveolar spaces are all major activators of the inflammatory
path%ays that result in acute lung injury.
Pneumonia is also a common complication of pulmonary
contusion, blood in the alveolar spaces providing an excellent
culture medium for bacteria. Clearance of secretions is decreased
%ith pulmonary contusion, and this is augmented by any chest
%all injury and mechanical ventilation. Aood tracheal toilet and
pulmonary care is essential to minimise the incidence of
pneumonia in this susceptible group.