What is the management of pulmonary contusions?

Management of Pulmonary Contusions

Pulmonary contusions require multimodal, symptom-based management focused on adequate initial resuscitation followed by judicious fluid restriction, aggressive pain control, and lung-protective ventilation strategies to prevent respiratory failure and associated complications. 1

Initial Resuscitation and Fluid Management

• Ensure adequate tissue perfusion without limitation during initial resuscitation, particularly in patients with concomitant flail chest, as fluid restriction during the acute phase can worsen outcomes 1, 2
• Once resuscitation is complete and hemodynamic stability achieved, avoid unnecessary fluid administration to prevent deterioration of pulmonary function 1, 2
• Resuscitate to maintain signs of adequate tissue perfusion rather than following rigid fluid restriction protocols 2
• Diuretics may be used only in hemodynamically stable patients with documented fluid overload or known congestive heart failure 2

Pain Control Strategy

Aggressive pain control is essential to reduce the likelihood of respiratory failure by enabling effective cough and chest physiotherapy 1, 2

• Epidural analgesia is the preferred mode of pain delivery in severe flail chest injury 2
• Paravertebral analgesia may be equivalent to epidural and appropriate when epidural is contraindicated 2
• Prescribe adequate oral and intramuscular analgesia for patients not requiring epidural placement 1

Respiratory Support Algorithm

Non-Invasive Ventilation

• Consider mask CPAP or BiPAP as first-line respiratory support in alert patients with marginal respiratory status and adequate compliance 2
• Avoid obligatory mechanical ventilation in the absence of true respiratory failure 2

Mechanical Ventilation Indications

Intubate based on standard clinical criteria including:

• Respiratory rate >24 breaths/min with progressive hypoxemia 3
• Inability to maintain adequate oxygenation despite non-invasive support 3, 4
• Altered mental status preventing airway protection 5

Ventilator Management

• Apply lung-protective ventilation with tidal volumes <6 mL/kg predicted body weight and moderate PEEP to prevent additional lung injury 1, 6
• Provide PEEP or CPAP in all mechanically ventilated patients 2
• Maintain normoventilation (PaCO2 5.0-5.5 kPa) and avoid routine hyperventilation, as PaCO2 <27 mmHg causes cerebral vasoconstriction and cardiovascular collapse 6
• Brief intentional hyperventilation may be used only as temporary rescue therapy if signs of imminent cerebral herniation develop 1
• Consider high-frequency oscillatory ventilation for patients failing conventional modes 2
• Independent lung ventilation may be considered in severe unilateral contusion when shunt cannot be otherwise corrected 2
• Separate patients from mechanical ventilation at the earliest possible time 2

Diagnosis and Severity Assessment

• CT chest is the gold standard for initial diagnosis, as conventional chest X-ray may underestimate injury extent 7
• The extent of pulmonary contusion correlates directly with incidence and severity of complications 7, 4
• Chest X-ray remains useful for short-term follow-up monitoring 7
• In emergency settings without CT availability, suspect pulmonary contusion in patients with multiple rib fractures, tachypnea, shock, and paradoxical chest wall movement 1
• Moderate to severe contusions (AIS ≥3 or BPC18 ≥3) are associated with longer mechanical ventilation duration, ICU stays, and hospital length of stay 4

Clinical Course Expectations

• Hypoxemia typically worsens until day 4-5 after intubation before improvement begins 3
• Severe contusions demonstrate significantly worse early hypoxemia on days 1-2 compared to mild-moderate contusions 3
• Most patients with mild-moderate contusions require mechanical ventilation for approximately 7 days, while severe contusions average 10 days 3
• Pneumonia incidence is high (51%) but can be minimized with aggressive pulmonary toilet 5

Management of Associated Injuries

Flail Chest

• Surgical stabilization of rib fractures (SSRF) is most beneficial in anterolateral flail chest with respiratory failure WITHOUT severe pulmonary contusion 1
• In the presence of severe concomitant pulmonary contusion, SSRF does not reduce mechanical ventilation duration or ICU stay 1
• Surgical fixation may be considered in severe flail chest failing ventilator weaning or when thoracotomy is required for other indications 2

Pulmonary Lacerations

• Most patients with lung lacerations can be managed with closed thoracic drainage alone 1, 8
• For patients with progressive hemothorax and no improvement in dyspnea after drainage, thoracotomy may be needed to identify and suture hemorrhage or air leak sites 8
• In severe cases where repair is impossible, consider lobectomy or segmentectomy, with pneumonectomy as last resort (mortality >50%) 8

Adjunctive Therapies

• Apply aggressive chest physiotherapy to minimize respiratory failure risk 2
• Implement self-activating multidisciplinary protocols for chest wall injuries where feasible, as these may improve outcomes 2
• Steroids should NOT be used in pulmonary contusion therapy 2
• Begin mechanical thromboprophylaxis immediately in all patients without absolute contraindications 6
• Start LMWH-based pharmacologic thromboprophylaxis within 48-72 hours once hemostasis is secured 6
• Initiate early enteral feeding within 72 hours when hemodynamically stable and not requiring vasopressor support 6

Critical Pitfalls to Avoid

• Do not excessively restrict fluids during initial resuscitation, as this worsens outcomes 1, 2
• Avoid routine hyperventilation even in traumatic brain injury patients 1, 6
• Do not use high tidal volumes (>6 mL/kg), as even short-term ventilation with 12 mL/kg promotes pulmonary inflammation and coagulopathy 6
• Do not perform obligatory intubation in the absence of respiratory failure 2