What are the symptoms and treatment options for pulmonary contusion?

Symptoms and Treatment of Pulmonary Contusion

Pulmonary contusion requires prompt respiratory support with supplemental oxygen, effective pain control, and careful fluid management to maintain adequate oxygenation while preventing complications. 1

Clinical Presentation

Symptoms

• Chest pain
• Dyspnea (shortness of breath)
• Tachypnea (rapid breathing)
• Hypoxemia (low blood oxygen)
• Hemoptysis (coughing up blood) in severe cases

Physical Findings

• Decreased breath sounds over affected areas
• Tachycardia
• Cyanosis in severe cases
• Bruising on chest wall (may be absent in up to 50% of cases)

Diagnostic Findings

• Infiltrates on chest radiography (may develop hours after injury)
• CT scan shows patchy or confluent areas of consolidation (more sensitive than X-ray) 2
• Arterial blood gas abnormalities (hypoxemia, possibly hypercarbia)

Treatment Algorithm

Immediate Management

1. Airway Management:

   • Maintain patent airway
   • Administer supplemental oxygen to maintain SpO2 > 94% 1
   • Consider early intubation for:
     • Severe hypoxemia refractory to supplemental oxygen
     • Progressive respiratory failure
     • GCS < 8 with associated head trauma
     • Respiratory rate > 35 breaths/minute

2. Pain Control:

   • Implement effective analgesia to facilitate breathing and coughing 1
   • Options include:
     • Intercostal nerve blocks
     • Epidural analgesia for multiple rib fractures
     • Intravenous opioids with careful respiratory monitoring

3. Fluid Management:

   • Avoid overhydration once the patient is adequately resuscitated 1
   • Target euvolemia to prevent worsening pulmonary edema
   • Monitor urine output and vital signs to guide fluid administration

Respiratory Support

1. For Mild-Moderate Contusion:

   • Supplemental oxygen via nasal cannula or face mask
   • Incentive spirometry every 1-2 hours while awake
   • Early mobilization if no contraindications
   • Chest physiotherapy

2. For Severe Contusion:

   • Mechanical ventilation with lung-protective strategies 3
   • Consider pressure-controlled ventilation (PCV) for poorly compliant lungs
   • Maintain PEEP to prevent atelectasis 1
   • Target tidal volumes of 6-8 mL/kg ideal body weight
   • Avoid routine hyperventilation, even with associated head trauma 1

Monitoring and Complication Management

1. Continuous Monitoring:

   • Most critical period is first 24-48 hours (highest risk for deterioration) 1
   • Monitor for:
     • Worsening hypoxemia
     • Increasing work of breathing
     • Development of pneumothorax or hemothorax
     • Signs of infection

2. Complication Management:

   • Perform chest tube drainage for pneumothorax or hemothorax 1
   • Monitor for development of ARDS (independent risk factor for poor prognosis) 4
   • Implement VAP prevention bundle for intubated patients
   • Consider surgical stabilization for associated flail chest within 48-72 hours of injury 5

Prognostic Factors

Poor prognostic indicators include:

• GCS score < 5.5
• ISS score > 20.5
• Development of ARDS
• Shock on admission
• Need for blood transfusion within 24 hours 4

Special Considerations

• Elderly patients may deteriorate more rapidly and have higher mortality rates
• Patients with pre-existing pulmonary disease require more aggressive management
• Pulmonary contusion typically resolves within 7 days if complications are prevented 6
• Hypoxemia typically worsens until day 4-5 after injury before improving 7

Remember that pulmonary contusion can be present even without visible external chest wall injuries, and symptoms may develop or worsen hours after the initial trauma. Early recognition and appropriate respiratory support are essential to prevent complications and improve outcomes.