What is the management of traumatic pulmonary contusions?

Management of Traumatic Pulmonary Contusions

Traumatic pulmonary contusions require supportive care focused on adequate tissue perfusion during initial resuscitation followed by judicious fluid management, aggressive pain control, and selective mechanical ventilation based on respiratory failure criteria rather than radiographic findings alone. 1

Initial Resuscitation and Airway Management

Fluid Management Strategy

• Ensure adequate tissue perfusion without restriction during the initial resuscitation phase, particularly in patients with concomitant flail chest 1
• Once resuscitation is complete, avoid unnecessary fluid administration to prevent deterioration of pulmonary function 1
• The historical concern about fluid overload in pulmonary contusion should not limit initial resuscitation in hypovolemic shock 2, 3

Airway and Ventilation Decisions

• Perform endotracheal intubation for airway obstruction, altered consciousness (GCS ≤8), hypoventilation, or hypoxaemia 4
• Maintain normoventilation (PaCO2 5.0-5.5 kPa or 38-41 mmHg) and avoid routine hyperventilation, even in head injury 4
• Hyperventilation may be used briefly as a temporizing rescue measure only if signs of imminent cerebral herniation develop (pupillary changes, sudden ICP rise, bradycardia with hypertension) 4
• Avoid hypoxaemia (Grade 1A recommendation) 4
• Avoid hyperoxaemia except in imminent exsanguination 4

Mechanical Ventilation Strategy

Indications for Intubation

• Use selective intubation based on clinical criteria: severe hypoxia (pO2/FiO2 <300), respiratory distress, inability to maintain airway, or deteriorating gas exchange 2, 3
• The presence of pulmonary contusion on CT scan alone has limited clinical significance and should not drive intubation decisions 5

Ventilator Settings

• Apply lung-protective ventilation with tidal volumes <6 mL/kg predicted body weight and moderate PEEP to prevent additional lung injury 1, 6
• Maintain plateau pressure ≤30 cmH2O as an absolute ceiling, reducing tidal volume further if necessary 6
• Accept permissive hypercapnia with pH >7.20 rather than using injurious ventilation parameters 6
• Pressure-controlled ventilation (PCV) is an effective alternative to volume-controlled ventilation when pulmonary compliance deteriorates, reducing peak inspiratory pressures while maintaining oxygenation 7

Pain Management

Aggressive pain control is essential to reduce the risk of respiratory failure by enabling effective cough, deep breathing, and pulmonary toilet 1, 8

• Prescribe adequate oral and intramuscular analgesia 1
• Consider regional anesthesia techniques (epidural, paravertebral blocks) for severe chest wall pain, particularly with rib fractures

Supportive Care Measures

• Implement vigorous pulmonary toilet: chest physiotherapy, incentive spirometry, frequent suctioning, and early mobilization 8, 2
• Provide supplemental oxygen therapy as needed to maintain adequate saturation 5
• Consider diuretics judiciously once resuscitation is complete to avoid fluid overload 5
• Monitor for pneumonia development (incidence 5-50% in severe contusions) 8

Management of Associated Rib Fractures

Surgical Stabilization Considerations

• Surgical stabilization of rib fractures (SSRF) is most beneficial in patients with anterolateral flail chest and respiratory failure WITHOUT severe pulmonary contusion 4, 1
• In severe pulmonary contusion (Blunt Pulmonary Contusion score ≥7), SSRF does not demonstrate clear reduction in mechanical ventilation duration or ICU stay 4, 1
• Recent evidence suggests early SSRF (within 48-72 hours) may benefit patients with minor to moderate pulmonary contusion, showing shorter hospital stays and lower morbidity 4, 1
• The decision requires multidisciplinary evaluation considering contusion severity, fracture pattern, and respiratory status 4

Pleural Space Management

• Most patients with pulmonary lacerations can be managed with closed thoracostomy drainage alone 1
• Perform thoracocentesis or tube thoracostomy for significant pneumothorax or hemothorax 5, 2

Diagnostic Approach

Imaging Considerations

• In facilities without CT availability, suspect pulmonary contusion in patients with multiple rib fractures, tachypnea, shock, and paradoxical chest wall movement 1
• CT scan is more sensitive than chest radiograph (89% of contusions diagnosed by CT) but CT-only findings without clinical respiratory compromise have limited significance 5
• The extent of contusion on admission chest radiograph does not predict mortality or need for intubation 3

Prognostic Factors and Monitoring

High-Risk Features Requiring Intensive Monitoring

• Injury Severity Score ≥25 3
• Initial Glasgow Coma Scale ≤7 3
• Transfusion requirement >3 units 3
• pO2/FiO2 ratio <300 3
• Concomitant flail chest (increases likelihood of mechanical ventilation but not mortality) 3

Expected Outcomes

• Mortality from isolated pulmonary contusion is low (1.4%) when managed appropriately 2
• Respiratory insufficiency develops in approximately 25% of all pulmonary contusions but only 8% of isolated contusions 5
• Most patients requiring mechanical ventilation need it for less than 3 days 2

Critical Pitfalls to Avoid

• Do not routinely hyperventilate: PaCO2 <27 mmHg causes cerebral vasoconstriction, impaired venous return, and cardiovascular collapse 9
• Do not use high tidal volumes (>6 mL/kg): even short-term ventilation with 12 mL/kg promotes pulmonary inflammation and coagulopathy 9, 6
• Do not restrict fluids during active hemorrhagic shock: mortality correlates with shock and inadequate resuscitation, not fluid administration 3
• Do not base intubation decisions solely on radiographic findings: clinical respiratory status determines need for mechanical ventilation 5, 2
• Do not delay SSRF beyond 72 hours if indicated: early stabilization (within 48-72 hours) optimizes outcomes when appropriate 4