Management of Pulmonary Contusion
Pulmonary contusion management centers on aggressive pain control, judicious fluid administration after initial resuscitation, lung-protective ventilation when needed, and selective rather than routine intubation based on clinical criteria.
Initial Resuscitation and Fluid Management
- Ensure adequate tissue perfusion without restriction during initial resuscitation, particularly in patients with concomitant flail chest 1
- Once resuscitation is complete, strictly avoid unnecessary fluid administration to prevent deterioration of pulmonary function 1
- Mortality is not correlated with presence of shock or amount of intravenous fluid administration, but excessive fluids worsen outcomes 2
- Avoidance of fluid overload is a critical component of successful management 3
Pain Control
- Aggressive pain control is essential to reduce the likelihood of respiratory failure 1
- Prescribe adequate oral and intramuscular analgesia for pain management 1
- Effective analgesia enables vigorous pulmonary toilet and prevents atelectasis 3
Respiratory Support Strategy
Selective Intubation Approach
- Use selective intubation based on standard clinical criteria rather than routine mechanical ventilation for all patients 3
- Intubate patients presenting with severe hypoxia (PaO2/FiO2 ratio <300) 2
- Consider intubation for patients with injury severity score ≥25, Glasgow Coma Scale ≤7, or requiring >3 units blood transfusion 2
- Approximately 75% of pulmonary contusion patients can be successfully managed without intubation 3
Mechanical Ventilation Parameters
- Apply lung-protective ventilation with low tidal volumes and moderate PEEP to prevent additional lung injury 1
- Expect moderate hypoxemia that typically worsens until day 4-5 after intubation 4
- Severe pulmonary contusion demonstrates significantly worse early hypoxia on days 1-2 compared to mild-moderate contusion 4
- Most patients requiring mechanical ventilation need it for less than 3 days 3
Non-Invasive Ventilation
- Consider non-invasive ventilation (BiPAP) if patient comorbidities and compliance allow 5
- However, discontinue BiPAP during episodes of massive bleeding 1
Diagnostic Approach
- Computed tomography of the chest is recommended for initial diagnosis as it accurately defines extent of injury 5
- The extent of pulmonary contusion on CT correlates with incidence and severity of complications 5
- Conventional chest X-ray may initially underestimate the injury but is useful for short-term follow-up 5
- In emergency settings without CT availability, suspect pulmonary contusion in patients with multiple rib fractures, rapid breathing, shock, and paradoxical chest wall movement 1
- The extent of contusion on admission chest radiograph is not predictive of mortality or need for intubation 2
Management of Associated Injuries
Concomitant Flail Chest
- Surgical stabilization of rib fractures (SSRF) is most beneficial in patients with anterolateral flail chest and respiratory failure WITHOUT severe pulmonary contusion 6, 1
- In presence of severe pulmonary contusion (Blunt Pulmonary Contusion score >7), SSRF does not demonstrate shorter mechanical ventilation time or ICU stay 6, 1
- Recent evidence suggests early SSRF (within 48-72 hours) may benefit patients with minor to major pulmonary contusion, showing shorter hospital stays and lower morbidity 6
- Patients with flail chest are more likely to require mechanical ventilation but do not have increased mortality 2
Lung Lacerations
- Most patients with lung lacerations can be managed with closed thoracic drainage 1, 7
- For patients with no improvement in dyspnea and progressive hemothorax after drainage, thoracotomy may be needed to identify and suture hemorrhage or air leak sites 7
- In severe cases where repair is impossible, consider lobectomy or segmentectomy, with pneumonectomy as last resort (mortality exceeds 50%) 7
Advanced Therapies
- ECMO therapy may be considered as ultima ratio in patients with severe lung injury and deteriorating condition 5
- ECMO should only be performed at specialized hospitals, requiring early consideration of patient transfer 5
Monitoring and Follow-up
- Use invasive cardiopulmonary monitoring for severe cases 8
- Monitor oxygenation index, which better characterizes hypoxemia severity than PaO2/FiO2 ratio alone 4
- Severe pulmonary contusion shows durable elevations in oxygenation index despite confounders like transfusion and fluid administration 4
- Median duration of mechanical ventilation is 7 days for mild-moderate contusion versus 10 days for severe contusion 4
Common Pitfalls to Avoid
- Do not routinely hyperventilate patients, even with concomitant head trauma 1
- Brief intentional hyperventilation may be used only as temporary rescue therapy if signs of imminent cerebral herniation develop 1
- Do not assume chest X-ray adequately defines injury extent—CT is superior 5
- Do not routinely intubate all patients with pulmonary contusion—96.6% of non-intubated patients have successful outcomes 3
- Recognize that pulmonary contusion demonstrates dynamic progression, making early extent assessment difficult 5