Management of Lung Contusion
Lung contusion management centers on aggressive pain control, judicious fluid management after initial resuscitation, and lung-protective mechanical ventilation when respiratory failure develops. 1
Initial Assessment and Resuscitation
Fluid Management Strategy
- Ensure adequate tissue perfusion without limitation 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
- This two-phase approach recognizes that while initial perfusion is critical, excess fluids worsen gas exchange in injured lung tissue 1
Pain Control
- Aggressive pain control is essential to reduce the risk of respiratory failure 1
- Adequate oral and intramuscular analgesia should be prescribed for pain management 1
- Effective analgesia prevents splinting, improves pulmonary toilet, and reduces atelectasis 1
Diagnostic Approach
- In emergency settings without CT availability, suspect lung contusion in patients with multiple rib fractures, rapid breathing, shock, and paradoxical chest wall movement 1
- CT scanning is highly sensitive for diagnosing pulmonary contusion and should be obtained when available 2
Mechanical Ventilation Strategy
Indications for Intubation
- Oxygen saturation <95% on room air despite supplemental oxygen 3
- Respiratory distress with increased work of breathing 4
- Refractory hypoxemia (PaO2 <60 mmHg despite high-flow oxygen) 4
- Respiratory rate >35 breaths/minute 4
Ventilator Management
- Apply lung-protective ventilation with low tidal volumes (<6 mL/kg predicted body weight) and moderate PEEP to prevent additional lung injury 1, 5
- Pressure-controlled ventilation (PCV) is an effective alternative when lung compliance deteriorates on volume-controlled ventilation (VCV) 6
- When converting from VCV to PCV, expect significant reductions in peak inspiratory pressure (from 49 to 31 cm H2O) and improved oxygenation 6
- Maintain normoventilation (PaCO2 5.0-5.5 kPa) and avoid routine hyperventilation, even in patients with traumatic brain injury 1, 5
- Brief intentional hyperventilation may be used only as temporary rescue therapy for signs of imminent cerebral herniation 1
Critical Ventilation Pitfalls
- Never use high tidal volumes (>6 mL/kg), as even short-term ventilation with 12 mL/kg promotes pulmonary inflammation and coagulation abnormalities 5
- Avoid hyperventilation (PaCO2 <27 mmHg), which causes neuronal injury, cerebral vasoconstriction, and cardiovascular collapse 5
Management of Associated Injuries
Rib Fracture Stabilization
- Surgical stabilization of rib fractures (SSRF) is most beneficial in patients with anterolateral flail chest and respiratory failure WITHOUT severe pulmonary contusion 1
- In patients with severe pulmonary contusion (Blunt Pulmonary Contusion score >7), SSRF does not reduce mechanical ventilation time or ICU length of stay 1
- Early SSRF (within 48-72 hours) may benefit patients with minor to major pulmonary contusion, showing shorter hospital stays and lower morbidity 1
Pulmonary Lacerations
- Most patients with pulmonary lacerations can be managed with closed thoracostomy drainage alone 1
Expected Clinical Course
Oxygenation Patterns
- Expect moderate hypoxemia that worsens until day 4-5 after intubation 7
- Severe pulmonary contusion demonstrates significantly worse early hypoxia on days 1-2 compared to mild-moderate contusion 7
- Median duration of mechanical ventilation is 7 days for mild-moderate contusion versus 10 days for severe contusion 7
Complications
- Adult respiratory distress syndrome occurs in 5-20% of cases 8
- Pneumonia develops in 5-50% of cases 8
- Overall mortality ranges from 5-10% 8