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Pulmonary Contusion

Contusion of Lung

Pulmonary contusion is a traumatic state of the lung parenchyma that is caused by an acute chest injury, without any laceration of the parenchymal tissue itself. Associated injuries to the chest region may co-exist. It is a life-threatening condition, which can lead to acute respiratory distress syndrome and death.


Presentation

The destruction of the alveolocapillary membrane and the accumulation of fluid and blood within the alveolar space lead to the impairment of gas exchange, low levels of O2 measured from arterial blood, cyanosis, and low SpO2 [11]. These pathophysiological changes are responsible for the patients' labored breathing and chest pain. Individuals who have sustained pulmonary contusions also exhibit chest bruises, cough and hemoptysis. Usually, not all the symptoms are present; depending on the complications or absence thereof, any combination of the aforementioned symptoms is possible.

In cases of severe pulmonary contusions, the clinical picture may be further complicated by dizziness, excessive sweating, cyanotic lips/nail beds or disorientation. Tachycardia and tachypnea are signs of a severer contusion [12].

Cough
  • Abstract Pneumonia is diagnosed and treated with symptoms of fever, cough, expectoration and chest X ray showing evidence of consolidation. When a pattern of opacification does not fit into segmental or lobar pattern, reevaluation is essential.[ncbi.nlm.nih.gov]
  • You may even have coughed up blood after the injury. Your doctor may advise you to cough and take deep breaths, even though your chest hurts. Breathing deeply and coughing can help keep the air passages in your lungs open and free of mucus.[myhealth.alberta.ca]
  • Wheezing and coughing are other signs. Coughing up blood or bloody sputum is present in up to half of cases. Cardiac output (the volume of blood pumped by the heart) may be reduced, and hypotension (low blood pressure) is frequently present.[en.wikipedia.org]
  • Breathe deeply and cough: This helps to open the air passages and bring up sputum from your lungs. You can breathe deeply and cough on your own, or with the help of an incentive spirometer.[drugs.com]
  • Other Supportive care: • Pain control • Pulmonary toilet – suctioning, deep breathing, coughing • Chest physiotherapy – breathing exercises, percussion • Optimal positioning – placing the good lung in a dependent position 14.[slideshare.net]
Hemoptysis
  • He complained of upper back pain and had an episode of hemoptysis after the dive.[ncbi.nlm.nih.gov]
  • Immediate hemoptysis following trauma has also been rarely documented as an indicator of a possible pulmonary contusion. We describe the case of a diver who suffered a pulmonary contusion with immediate hemoptysis after his chest impacted the water.[dx.doi.org]
  • Abstract We present an unusual case in which a pediatric patient sustained iatrogenic pulmonary contusion resulting in severe hemoptysis.[ncbi.nlm.nih.gov]
  • Clinical signs and symptoms, such as dyspnea, hemoptysis, and chest wall pain, should increase the suspicion for possible pulmonary contusion.[pulmonarychronicles.com]
  • External thoracic wall contusion, fracture of the bony thorax, tachypnea, hemoptysis, and abnormal breath sounds were frequently absent on presentation.[ncbi.nlm.nih.gov]
Rales
  • His chest was clear to auscultation with no rhonchi, rales, or wheezes. There was no dullness to percussion of his chest. His chest wall showed no gross deformity and no flail segments in the ribs.[journals.lww.com]
  • They may have pulmonary edema ("rales" or "crackles") as well as lower extremity edema depending upon the extent of the contusion.[forums.studentdoctor.net]
  • In addition to ECG changes, other findings include dyspnoea, pericardial friction rub, pulmonary rales and an elevated central venous pressure.[doi.org]
Painful Cough
  • Patients may present with a variety of symptoms, including dyspnea, chest pain, cough, andhemoptysis. Physical examination may reveal tachypnea, hypoxia, cyanosis, anddecreased breath sounds.[doi.org]
  • Obvious effects of the physical trauma on the skin where the lungs are located Chest pain Coughing up blood or bloody sputum Cyanosis (the body not getting enough oxygen). The bruise usually heals on its own when properly cared for.[nobodyproblems.com]
Pleuritic Pain
  • Pleuritic pain may not develop for hours. If the pneumothorax is large, hyperresonance to percussion may be present. Respiratory distress, shock, unilateral absence of breath sounds, and hyperresonance to percussion indicate tension pneumothorax.[madsci.com]
Upper Back Pain
  • He complained of upper back pain and had an episode of hemoptysis after the dive.[ncbi.nlm.nih.gov]
Quadriplegia
  • Exclusion criteria include Glasgow Coma Scale (GCS) score of less than 9T before extubation, successful use of noninvasive positive-pressure ventilation after extubation, quadriplegia, and preextubation FIO2 of greater than 0.5.[ncbi.nlm.nih.gov]

Workup

Severe thoracic traumas should always raise suspicion of a concomitant pulmonary contusion, especially when the patient exhibits difficulty in breathing or signs of a more crucial condition, such as cyanosis, tachycardia or tachypnea. Observing the chest will allow the physician to detect bruising. Generally, pulmonary contusions are diagnosed with a combination of tests including arterial blood gases (ABG), chest X-ray and a Computerized Tomography (CT) scan.

Measuring arterial blood gases will give useful insight into the levels of O2, CO2 and bicarbonates in the arterial blood [13]. The patient's status can be evaluated and pulmonary dysfunction will manifest with a disturbance of these values.

A chest radiograph is able to depict the contusion in its full extent after 24 to 48 hours after the injury [14]. The majority of extensive contusions are visible through an X-ray but cannot substitute the vitality of the clinical diagnosis, since they do not illustrate the injury from the beginning.

Lastly, a CT scan may be conducted to diagnose contusions regardless of their extent, as this test is extremely sensitive for their depiction. It also allows for the differentiation between a pulmonary contusion and other lung conditions, such as atelectatic regions or aspiration. The correct size of any injury can be measured via Computer Tomography [15]; however, not all contusions diagnosed with a CT scan require treatment, as they may cause no symptomatology if they are limited in extent.

Pulmonary Infiltrate
  • This results in pulmonary contusion, characterized by development of pulmonary infiltrates with hemorrhage into the lung tissue 4.[slideshare.net]
Decreased Lung Compliance
  • This blunt lung injury develops over the course of 24 hours, leading to poor gas exchange, increased pulmonary vascular resistance and decreased lung compliance.[prep4usmle.com]
  • Large hemorrhages from contusions may lead to ventilation/perfusion mismatch, pulmonary edema, and decreased lung compliance. 6 , 7 Table: Characteristics of Pulmonary Contusion in Football Players Case Age Type of Collision Initial Symptoms CXR Findings[pulmonarychronicles.com]
  • These factors contribute to the ventilation/perfusion mismatch, pulmonary shunting, and decreased lung compliance. The primary goal in the management of pulmonary contusions is the maintenance of adequate oxygenation.[ahcmedia.com]
Decreased Functional Residual Capacity
  • Pulmonary contusion causes long-term respiratory dysfunction with decreased functional residual capacity. J Trauma . 1991;31:1203–8; discussion 1208–10. PubMed CrossRef Google Scholar Kishikawa M, Minami T, Shimazu T, et al.[link.springer.com]
  • Prognosis • Most resolve 5 to 7 days after injury • Signs detectable by radiography are usually gone within 10 days after injury • Lung fibrosis with decreased functional residual capacity can occur up to 6 years after injury • Contusion can also permanently[slideshare.net]
  • As late as four years post-injury, decreased functional residual capacity has been found in most pulmonary contusion patients studied. During the six months after pulmonary contusion, up to 90% of people suffer difficulty breathing.[en.wikipedia.org]
  • functional residual capacity has been found in most pulmonary contusion patients studied. [ 42 ] During the six months after pulmonary contusion, up to 90% of people suffer difficulty breathing. [ 26 ] [ 42 ] In some cases, dyspnea persists for an indefinite[en.academic.ru]

Treatment

The extent to which the lung is damaged further dictates the therapeutic regime in cases of pulmonary contusions. Measures are generally directed towards the relief of pain, oxygenation and removal of blood and fluid that has accumulated in the pulmonary cavities. 

Painkillers may be necessary depending on the severity of the symptoms. Medication may be administered intravenously or epidurally. Additionally to relieving the patient of their painful sensations, painkillers also encourage better ventilator chest movements. Furthermore, nasal cannulas or masks are used to supply oxygen, should the patient be in a deoxygenized state [16].

In severer traumatizations, the quantity of fluids that have built up in the alveoli fail to be absorbed by the organism itself; in these cases, they require suctioning or chest tubes in order to be removed. Suctioning may be performed through the oral cavity, nose or endotracheally. Chest tubes, on the other hand, are directly placed within the thorax via an incision.

Lastly, there may also be a need for noninvasive positive-pressure ventilation, such as CPAP or BiPAP, in cases where oxygenation cannot be achieved otherwise, or the patient exhibits atelectasis [17]. Mechanical ventilation via endotracheal tube is also an option.

Prognosis

The existence of simultaneous thoracic injuries and the degree to which the pulmonary contusion has affected the lungs both cause the rate of mortality to fluctuate between 14 and 40% [9]. In cases where the patient has solely sustained a pulmonary contusion and exhibits no subsequent complications, the contusion is expected to resolve within 3-14 days [10]. 

Etiology

Pulmonary contusions are caused by chest traumatic injuries, inflicted via various mechanisms. Some of them are the following:

  • Impact traumatizations which cause the chest wall to flex inward.
  • Assaults.
  • Falls from considerable heights.
  • Rapid deceleration, where the thorax is forced to stop violently on an anchored object [3].
  • Blunt traumas to the area of the chest [4].
  • Various types of sports injuries.

Epidemiology

Around 20% of the patients who sustain a blunt chest injury also exhibit pulmonary contusions [5], which are the type of chest trauma most frequently observed in children. Mortality rates fluctuate between 20-25%, with half of the patients being also in need of assisted ventilation. Most of the patients exhibit concurrent chest injuries, including hemothorax, pneumothorax, and flail chest amongst others [6]. 

Sex distribution
Age distribution

Pathophysiology

Pulmonary contusions are all induced by chest traumas of various kinds, as described above. In general, fundamental pulmonary structures are disturbed, leading to the loss of its full functionality: the balance between ventilation and perfusion is distorted, shunts are formed, inflammation and edema are exhibited and alveolocapillary membrane becomes increasingly penetrable [7].

The basic pathophysiologic mechanism behind a pulmonary contusion begins with the initial trauma. Despite the absence of any visible laceration, the force exerted on the thorax results in the destruction of the alveolocapillary membrane and adjacent blood vessels. As a result, water and blood fill the alveoli and subsequently, an edema is caused in case of severe damage. Normal pulmonary elasticity is impaired and the exchange of gases is rendered abnormal, due to the amount of fluid and blood that take up the alveolar space and leads to their destruction [8]. This leads to the clinical manifestations of labored breathing, as well as to reduced O2 and increased CO2 in the peripheral blood.

Simultaneous thoracic injuries , such as hemo- or pneumothorax cause additional strain on the lungs, since the tissue that has not sustained any damage is compressed and therefore dysfunctional. A potentially life-threatening condition connected to chest injuries is tension pneumothorax: air is released from lung tissue into the peural space and tension gradually builds up in the damaged parenchymal region. Continually increasing pressure exerts compresive forces towards the antipodal hemithorax and in some cases, venous return to the right atrium can be impaired , due to compression of the superior vena cava. This can lead to a circulatory compromise.

Prevention

Protection of the thoracic area in all cases where a forceful traumatization is possible is the optimal means of preventing a pulmonary contusion. Specific cases to which protective measures are available, include seat belts and airbags when driving and specially designed armors used by military recruits. In the first case, airbags and seatbelts prevent the impact from a car crash from affecting only a particular region of the chest, thus contributing to less damage sustain in each location. In the latter case, military armors are made of materials with different acoustic impedance, which protects the thorax from a blast shock wave [18].

Summary

Pulmonary contusion, otherwise referred to as lung contusion or LC, is an injury to the lung's parenchymal tissue, caused by any type of severe chest traumatization, including penetrating traumas, impact traumas or other blunt traumas. The pulmonary parenchyma exhibits no lacerations itself, but alveolar capillaries sustain a significant force-induced trauma. This leads to the increase of blood and water encased within the capillaries, so ventilation is impaired. The severity of functional impairment varies, depending on the force exerted during the chest injury. Various mechanisms account for the functional loss, including the accumulation of fluid, shunts and an imbalance between lung perfusion and ventilatory ability amongst others [1].

Patients typically experience shortness of breath and decreased circulating oxygen, which can be detected in the blood gases. Treatment is supportive and addresses the potential hypovolemia and ventilatory dysfunction. Depending on the general status of each patient and the co-existence of other injuries, intensive care may be mandatory in order to maintain a stable status and ensure that gas exchange is going to be conducted properly.

A lethal complication of lung contusion is the acute respiratory distress syndrome (ARDS) syndrome, which can prove fatal. Patients receive mechanical ventilation of various types, with the more common one being positive-end expiratory pressure devices (PEEP). Biphasic positive airway pressure ventilation, abbreviated as BiPAP, is an extremely useful tool in cases of simultaneous severe thoracic traumas, since it reduces the need of sedatives to minimize thoracic stress [2].

Patient Information

A pulmonary contusion includes the accumulation of water and blood in the lung due to a chest injury, which does not, however, involve any tear of the lung's tissue.

A person may sustain a pulmonary contusion when there is a chest trauma. Typically, that may involve a car accident, an explosion, fall from a considerable height, sports-related injuries or injuries due to heavy machinery used in the workplace.

Lacerations may be seen on the skin of the chest, but in the case of pulmonary contusion, the lung itself is not punctured. Symptoms include difficulty in breathing, coughing up blood, rapid breathing and chest pain. Because the patient cannot breathe properly in order to supply their body and tissues with oxygen, in severe cases, low levels of oxygen in the blood may lead to cyanosis, where the skin starts to turn blue. Low blood pressure and wheezing sound when breathing can also be observed.

A physician will suspect the existence of a pulmonary contusion when the patient reports a chest injury and the symptoms mentioned above also exist to a certain extent. A chest X-ray can help to illustrate the contusion but may need to be repeated, since the injury is not expected to be obvious in the first two days. A CT scan can reveal pulmonary contusions of any kind, at any point of time after the chest injury. Arterial blood gases and pulse oximetry can help a physician evaluate the oxygen on your blood and , therefore, how severe the contusion is.

Regarding treatment schemes, painkillers are given to people with pulmonary contusions in order to ease the pain and encourage normal breathing. Fluids are replaced and oxygen is also administered, depending on how severe the trauma is. The blood and water that has accumulated in the lung may be suctioned and mechanical ventilation may be necessary in severe cases. Surgical repairment is reserved for patients whose bleeding cannot be stopped otherwise.

References

Article

  1. Oppenheimer L, Craven KD, Forkert L, et al. Pathophysiology of pulmonary contusion in dogs. J Appl Physiol 1979; 47(4):718-28.
  2. Borges JB, Okamoto VN, Matos GF, et al. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med 2006; 174(3):268-78.
  3. Yamamoto L, Schroeder C, Morley D, et al. Thoracic trauma: The deadly dozen. Crit Care Nurs Q 2005; 28(1):22-40.
  4. Moloney JT, Fowler SJ, Chang W. Anesthetic management of thoracic trauma. Curr Opin Anaesthesiol 2008; 21(1):41-6.
  5. Brun-Buisson C, Minelli C, Bertolini G, et al. Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study. Intensive Care Med 2004; 30(1):51-61.
  6. Allen GS, Cox CS Jr, Moore FA, et al. Pulmonary contusion: are children different? J Am Coll Surg. 1997; 185(3):229.
  7. Cohn SM, Zieg PM. Experimental pulmonary contusion: review of the literature and description of a new porcine model. J Trauma 1996;4 1(3):565-71.
  8. Sattler S, Maier RV. Pulmonary contusion. In Karmy-Jones R, Nathens A, Stern EJ. Thoracic Trauma and Critical Care. Berlin: Springer. 2002;159-160 and 235-243.
  9. Gavelli G, Canini R, Bertaccini P, et al. Traumatic injuries: Imaging of thoracic injuries. Eur Radiol 2002;12(6):1273-94.
  10. Wanek S, Mayberry JC. Blunt thoracic trauma: Flail chest, pulmonary contusion, and blast injury. Crit Care Clin 2004; 20(1):71-81.
  11. Miller DL, Mansour KA. Blunt traumatic lung injuries. Thorac Surg Clin 2007; 17(1):57-61, vi.
  12. Mick NW, Peters JR, Egan D, Nadel ES. Chest trauma. Blueprints Emergency Medicine. 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2006; 76.
  13. Keough V, Pudelek B. Blunt chest trauma: Review of selected pulmonary injuries focusing on pulmonary contusion. AACN Clin Issues 2001; 12(2):270-81.
  14. Klein Y, Cohn SM, Proctor KG. Lung contusion: Pathophysiology and management. Current Opinion in Anaesthesiology 2002; 15(1):65-68.
  15. Wiot JF. The radiologic manifestations of blunt chest trauma. JAMA 1975; 231(5):500-3.
  16. Pettiford BL, Luketich JD, Landreneau RJ. The management of flail chest. Thorac Surg Clin 2007; 17(1):25-33.
  17. Sutyak JP, Wohltmann CD, Larson J. Pulmonary contusions and critical care management in thoracic trauma. Thorac Surg Clin 2007; 17(1):11-23, v.
  18. Cooper GJ. Protection of the lung from blast overpressure by thoracic stress wave decouplers. J Trauma 1996; 40(3 Suppl):S105-10. 

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Last updated: 2018-06-22 04:46