Pulmonary contusion: Difference between revisions

Latest revision as of 13:29, 10 April 2021

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
Cardiac/Vascular
- Cardiac injury
- Traumatic aortic transection
Musculoskeletal
Other

Pulmonary Edema Types

Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema^[1]

Cardiogenic pulmonary edema
Noncardiogenic pulmonary edema
- Negative pressure pulmonary edema
  - Upper airway obstruction
  - Reexpansion pulmonary edema
  - Strangulation
- Neurogenic causes
- 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

CXR showing right-sided pulmonary contusion, associated with rib fractures and subcutaneous emphysema.

Chest CT showing a pulmonary contusion (red arrow) accompanied by rib fracture (blue arrow).

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

Disposition

References

↑ Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.

Authors:

[1] Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.

[1]

@@ Line 1: / Line 1: @@
 ==Background==
+*Direct injury to lung resulting in hemorrhage and edema in absence of lung laceration
+*Flail chest almost always associated with contusion
-*direct damage to lung causing alveolar hemor & edema & mucus/debris accumulation
+==Clinical Features==
+*[[Dyspnea]]
+*Tachypnea
+*[[Chest pain]]
+*Coarse breath sounds
+*[[Hypoxia]]
+*Widened A-a gradient
-==Diagnosis==
+==Differential Diagnosis==
+{{Thoracic trauma DDX}}
-*pts= sob, tachy, cyanosis, low bp, rales, hypoxia, wide a-A
+{{Pulmonary edema types}}
-*cxr= patchy irregular infiltrates, always see by 4-6 hr, always worse than 1st xr shows!
+==Evaluation==
+[[File:Pulmonary contusion.jpg |thumb|[[CXR]] showing right-sided pulmonary contusion, associated with [[rib fractures]] and [[subcutaneous emphysema]].]]
+[[File:Pulmonary contusion CT arrow.jpg|thumb|Chest CT showing a pulmonary contusion (red arrow) accompanied by [[rib fracture]] (blue arrow).]]
+*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
-*CXR does NOT give clues to physiologic effects of contusion (ie, Rx pt & sx NOT CXR, even small contusion can be bad, watch pt sats & abg!!)
+==Management==
+*Ensure adequate ventilation
+**[[Analgesia]]
+**Ventilatory Assistance
+***Patients with >25% of lung involvement frequently require ventilatory assistance
+***[[NIPPV|NIV]] may be tried
+***[[Intubate]] if NIV fails
+****Low tidal volume, high PEEP
+*Avoid unnecessary fluid administration
-*flail chest= 2 or more rib fx @ 2 or more points, problem w/ this is the underlying contusion almost 100% hve!
+==Disposition==
-==Treatment==
-*Rx= peep b/c response to O2 is poor, intubate prn & low TV & high PEEP vent setting has become standard practice!
-*if possible intubate each side b/c peep can blow out lung + may need diff settings for ea lung.
-*steroids improve cxr but NOT outcome, abx iff aspiration o/w no chng in outcome
 ==See Also==
+*[[Rib Fracture]]
+*[[Traumatic Pneumothorax]]
+==References==
+<references/>
-(Burbulys 2004/Trauma Reports 4/04 /A-Digest 7/04) -by Lampe
+[[Category:Pulmonary]]
 [[Category:Trauma]]