Pulmonary Contusion

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History:

  • Symptoms include SOB and chest pain.

    • Remember this may manifest as back pain depending on mechanism.

    • Look for in high impact injuries to chest (MVC, fall, pedestrian struck, trampled by livestock, etc)

    • MOA being compression-decompression.

Exam:

  • Flail chest or crackles (however unlikely unable to auscultate in ED).

  • Observe for crepitus for possible pneumothorax.

  • Seatbelt sign.

Diagnosis:

  • CXR or CT chest

  • Extent of injury not apparent on CXR for 24-48 hours

  • Areas of lung opacification within 6 hours diagnostic of pulmonary contusion.

  • There are NEXUS chest guidelines (yes, chest!) for patients>14 to omit any imaging in chest trauma (see appendix below) - 98.8% sensitive.

  • Look for homogenous focal or diffuse opacity that may cross typical anatomical landmarks (i.e. lobes).

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Treatment:

  • Primarily supportive. Watch for delayed presentation!

  • Consider Bipap; pain control with intercostal block or epidural inpatient. Avoid unnecessary fluids.

  • Up to 40-60% will require mechanical ventilation. Also may be necessary to sedate for pain control.

  • Place good lung in dependent position to improve V/Q mismatch 50% go on to develop ARDS (blood in alveoli activates inflammatory cascade).

  • If not improving - ECMO (V-V) is a possibility.

Bottom line:

  • Monitor patients suspicious for pulmonary contusion - if they have signs of CXR there is a good chance they may need more invasive support (e.g. intubation).

  • Have low suspicion for concurrent injuries including mediastinal and vascular injuries, diaphragmatic rupture, and cardiac contusion.

  • Be aware of patient fluid status and try not to overload patient.

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Keywords:  Pulmonary Contusion NEXUS Chest Radiography Chest Trauma

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