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
Cardiac/Vascular
- Cardiac injury
  - Blunt cardiac injury
    - Cardiac contusion
    - Commotio cordis
  - Penetrating cardiac injury
  - Cardiac tamponade
- Traumatic aortic transection
Musculoskeletal
Other

Pulmonary Edema Types

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
- Sympathetic crashing acute pulmonary edema (SCAPE)
- Immersion pulmonary edema
- Hantavirus pulmonary syndrome
- Missed dialysis in kidney failure

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

Disposition

See Also

Rib Fracture
Traumatic Pneumothorax

References

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