Pulmonary Contusion
mortality rate of 14-40%. It is usually accompanied
 
            Also known as a lung contusion, a bruise of
the lung caused by chest trauma, with resulting
blood and other fluids accumulating in lung tissue
and leading to possible inadequate oxygen levels
(hypoxia). In the above image, see the rib fracture
(blue arrow) with pulmonary contusion (red arrow)
alongside.
            It is typically gotten in blunt trauma, though it
can also result from explosion injuries or a shock
wave linked to penetrating trauma. It is not often
linked to traffic accidents.
            Diagnosis is made by studying cause of injury,
physical examination and chest radiography. See
chest pain and coughing up blood (direct effects) and
other signs of not receiving oxygen, like cyanosis.
Contusion will typically heal on its own, requiring
nothing more than supplemental oxygen and close
monitoring, but intensive care may be required if
breathing is severely compromised, and fluid
replacement may be necessary to maintain blood
volume while avoiding fluid overload.
            Pulmonary contusion is the most common
type of potentially lethal chest trauma, occurring in
30-75% of severe chest injuries, with estimated
by other injuries. Children are at high risk due to the
flexibility of their bones. Linked to pneumonia and
ARDS.
Classification
            Compare vs. other lung injuries, like a
pulmonary laceration which affects macroscopic
architecture. When lacerations fill with blood, this is
a pulmonary hematoma, a discrete clot of blood not
interspersed with lung tissue (vs. hemorrhage in the
alveoli). Can see a collapsed lung if the pleural cavity
accumulates blood or air (hemothorax,
pneumothorax, hemopneumothorax), which do not
necessarily involve damage to the lung tissue itself.
Injuries to the chest wall are distinct. Can see rib
fractures and flail chest associated as well.
Signs and Symptoms
            Can be subtle. Look for signs of low blood
oxygen saturation, dyspnea, tachycardia and rapid
breathing. With more severe sounds, breath sounds
can be decreased or rales. People with severe
contusions can have bronchorrea (watery sputum)
or bloody sputum. Cardiac output may be reduced,
and hypotension can be seen.
            As many as 50% will be asymptomatic initially,
with symptoms developing in 3-4 hours. It can get
worse and lead to death in days.
Causes
            70% of cases are from car collisions, linked to
rapid deceleration from when the moving chest
strikes a fixed object – see also falls, assaults, and
sports injuries. The organs most vulnerable to blast
injuries are those filled with gas – blast lung is
severe pulmonary contusion, bleeding, or edema,
and is the primary cause of death among those who
initially survive an explosion. Explosions can cause
contusion without damage to the chest wall.
            Penetrating trauma can also cause pulmonary
contusion, surrounding the path along which the
projectile moved away from the pressure wave.
Typically, not severe enough (not widespread) to
affect outcome, with the exception of shotgun
wounds.
Mechanism
            In the inertial effect, the lighter alveolar tissue
is sheared from heavier hilar structures, like diffuse
axonal injury.
            In the spalling effect, lung tissue bursts or is
sheared when shock wave meets lung tissue, at
interfaces between gas and liquid (alveolar walls).
Occurs in areas with large differences in density.
            Implosion effect is when pressure wave
passes through bubbles of gas – bubbles implode,
then rebound and expand beyond initial volume,
resulting in tiny explosions and tissue damage.
            As in TBI, a contrecoup contusion can occur at
sites opposite to impact. A shock wave can travel
through the chest and hit the curved back of the
chest wall, reflecting energy onto the back of the
lungs, concentrating it. Energy transferred relies on
flexibility of chest wall – children have more flexible
bones and don’t get as much of the force here,
without fractures more frequently.
Pathophysiology
            Pulmonary contusion results in bleeding and
fluid leakage into lung tissue, which can become
stiffened and lose normal elasticity. Water content
of the lung increases over the first 72 hours, leading
to possible pulmonary edema and hypoxia.
            In contusions, torn capillaries leak fluid into
the tissues around them, with the membrane
between alveoli and capillaries being torn, with
damage to the capillary-alveolar membrane and
small blood vessels causing blood and fluid to leak
into the interstitial space. Pulmonary contusions
have microhemorrhages when alveoli are
traumatically separated, with areas of bleeding
surrounded by edema. This causes alveoli to fill with
proteins and collapse.
            Pulmonary contusion can cause parts of the
lung to consolidate due to being filled with blood –
there is also decrease in surfactant, even in
surrounding tissue, leading to this. Inflammation can
also lead to this, with excess mucus produced and
leading to collapse. Inflammation can affect the
other lung to the degree of ARDS.
            V/Q will become mismatched, as oxygen does
not fully saturate the hemoglobin. There can also be
insufficient inflation (inadequate mechanical, or flail
chest), reducing blood oxygen saturation. Pulmonary
hypoxic vasoconstriction in response to the lowered
oxygen levels can occur, with vascular resistance
increasing here to direct to better ventilated areas as
a compensation mechanism. If it is severe enough,
hypoxemia from fluid cannot be corrected with
supplemental O2, leading to death.
Diagnosis
            Use physical exam, information, and
radiography. Blood gases may not be immediately
abnormal early in the course.
            Chest x-ray is the most common method
used, seeing consolidated areas not restricted to
boundaries of the lobes, similar to aspiration, and
presence of hemothorax or pneumothorax can
distort it. Signs of contusion that progress 48+ hours
post-injury are more likely to be aspiration,
pneumonia, or ARDS. Note that this is often not
sensitive to pick up on first one, taking six hours to
manifest – you want to follow up with a CT scan.
            CT is more sensitive and is able to identify
abdominal, chest, or other injuries, and can detect
almost immediately and determine size. Can help
differentiate from a pulmonary hematoma. Note
that if you can see it on CT but not CXR, it is probably
not severe enough to affect outcome or treatment.
            Ultrasound is still being explored.
Prevention
            Use of airbags, carseats, equipment in sports.
Special body armor which blocks a shock wave rom
being propagated along the chest by alternating
layers with high and low acoustic impedence to
“decouple” the blast wave help with this.
Treatment
            No treatment speeds healing – provide
supportive therapy, and discover accompanying
injuries and monitor fluid balance and pulse
oximetry. Monitor for pneumonia and ARDS
development, aiming to prevent respiratory failure.
When contusion does not respond to other
treatments, can give extracorporeal membranous
oxygenation, pumping blood from the body to an
oxygenation machine.
            Ventilation (in positive pressure form) is
needed if oxygenation is significantly impaired –
CPAP or BIPAP. Non-invasive has advantages (less
infection, allows normal coughing, swallowing and
speech) and disadvantages (can force air to stomach
or cause stomach content aspiration). People with
inadequate respiration here may need to be
intubated and mechanically ventilated. Pulmonary
contusion or ARDS can cause lungs to lose
compliance, so higher pressures may be needed –
PEEP can prevent edema and keep alveoli from
collapsing.
            Fluid therapy is controversial – avoid
hypovolemic shock at this time, and possibly place a
catheter in the pulmonary artery to avoid edema.
Diuretics can be used if some fluid overload does
occur – prefer furosemide which relaxes smooth
muscle in the veins of the lung.
            Supportive care involves use of pulmonary
toilet, use of suction, deep breathing, coughing, and
other methods. Chest physical therapy can help.
Place with uninjured lung lower to improve
oxygenation. Pain control can also facilitate
elimination of secretions to make coughing less
painful and stop inadequate breathing and
atelectasis – give analgesics or possible nerve
blockade (anesthetics into chest wall).
Prognosis
            Usually resolves itself without permanent
complications in five to seven days, with signs
detectable by radiography gone within ten days.
Possible risk of fibrosis with dyspnea, low blood
oxygenation, and reduced FRC for up to six years
after the injury. During the six months after the
contusion, up to 90% will have difficulty breathing.
Can also reduce compliance of lungs.
Complications
            Can result in respiratory failure, with about
half of such cases within a few hours of the initial
trauma, with risk of infections and ARDS as well.
Elderly people and those with other organ disease
are more likely to have longer hospital stays.
            Pneumonia can develop in up to 20% of
people – contused lungs cannot remove bacteria as
well as uninjured lungs, and intubation and
mechanical ventilation can carry bugs from nose or
mouth into airways. Intubation also blocks coughing,
which could clear secretions, and secretions pool
near the tube’s cuff – want to remove as early as
possible without removing so early it has to be put
back in. Those who are at risk of pulmonary
aspiration are especially likely.
Associated Injuries
            A large amount of force is required to cause a
pulmonary contusion. Up to 75% will have other
chest injuries like hemothorax or pneumothorax, or
flail chest with significant pulmonary contusion, with
contusion often being the main cause of respiratory
failure in those with flail chest. Sternal fracture and
scapula fractures are also often associated.
Lacerations can be linked as well.
Differential Diagnosis
1. Acute respiratory distress syndrome
1. Common complication of trauma,
usually manifests 24-48 hours after
trauma with bilateral, patchy alveolar
infiltrates on CXR as opposed to the
patchy, irregular, but localized infiltrate
seen here
2. Pneumonia
1. Complication of PC, but with fever
and cough several days after trauma,
restricted anatomically
2. Cardiac contusion
1. Usually asymptomatic, can have
hypotension, sinus tachycardia
2. Hemothorax
1. Pleural effusion with hypotension
possible
2. Pneumothorax
1. Blunt force trauma which presents
with tachypnea, decreased or absent
breath sounds
2. Will see an area without lung
markings
Pulmonary Laceration
            Typically due to penetrating trauma, a
disruption in the architecture of the lung, forming a
cavity filled with blood, air, or both. Diagnosed when
collections of air or fluid are found on a CT scan.
Surgery an be required to stitch laceration, drain
blood, or remove injured parts. Typically heals
quickly if treated properly, but can be linked to
scarring of lung or other issues.
            Typically, the result of violent compression,
and often caused by ribs or spine.
Classification
            Type I: mid-lung area, the result of sudden
compression of the chest, typically central and range
in size from 2-8c.m.
            Type II: lower chest is suddenly compressed
and lower lung moves across the vertebral bodies,
near the spine and with an elongated shape, seen in
younger people
            Type III: from a broken rib, in the area of the
chest underneath the rib, small and accompanied by
pneumothorax (typically occur more than one at a
time)
            Type IV: also known as adhesion tears, where
a pleuropulmonary adhesion has formed prior
Pathophysiology
            A laceration can cause air to leak out into the
pleural space – invariably results in leakage of either
air or fluid. Hemothoraces can occur due to
contusion as well, but those from lung laceration are
large and long lasting – though note that lungs do
not usually bleed much, as the blood vessels are
small and pressure is low, with pneumothorax being
a larger issue.
            Laceration can close by itself, causing it to
trap blood and forming a cyst or hematoma, called a
“traumatic air cyst” filled with air, blood, or both,
shrinking over weeks to months. Lacerations filled
with air are pneumatoceles, and those that fill with
blood are pulmonary hematomas, which can exist in
the same injured lung. Pulmonary hematomas take
longer to heal than simple pneumatoceles, and
commonly leave the lungs scarred.
Diagnosis
            Often difficult to see on CXR due to contusion
or hemorrhage masking it – CT scanning is better at
detecting it. Appear as cavities filled with air or fluid,
with round or ovoid shape. Hematomas can be
initially hidden, but appear as smooth masses that
are round or ovoid in shape. Lacerations can be filled
with air or blood, with possible air-fluid level.
            Hemoptysis is often seen here. Thoracoscopy
can be used in diagnosis. Unlike pulmonary nodules,
a laceration will decrease in size over time on
radiographs.
Treatment
            Treat with supplemental oxygen, ventilation,
and drainage of fluids from the chest cavity. Can use
a thoracostomy tube to remove blood and air from
the chest cavity. 5% of cases will require surgery,
thoracotomy, especially if the lung fails to re-expand,
if pneumothorax, bleeding, or coughing up blood
persist. Surgical treatment can include suturing,
stapling, oversewing, or wedging out the laceration.
Occasional, a lobectomy or pneumonectomy (entire
lung) is done.
Prognosis
            Full recovery is common with proper
treatment, healing quickly afte ra chest tube is
inserted. Lacerations filled with air commonly heal in
one to three weeks. Lungs may be scarred after.
Small lacerations can heal on their own is fluid is
removed from the space.
Complications
            Uncommon, but there is risk of infection,
abscess, and bronchopleural fistula if there is
communication between laceration, bronchiole, and
the pleura, causing air to leak into the pleural space
despite placement of a chest tube. One
complication, air embolism, can be fatal.
Rib Fractures
Break in the rib bone, with pain worse when
breathing in. Can lead to flail chest. Potential
common complications are pneumothorax,
pulmonary contusion, and pneumonia. Typically
from motor vehicle collision or crush injury, though
in some cases severe coughing or metastatic cancer
can also result in broken ribs.
Pain control is the most important part of
treatment – use paracetamol, NSAIDs, or
opioids, ensuring that people can take full
breaths. Flail chest calls for surgery.
Causes
Can occur with or without direct trauma
in recreational activity. Cardiopulmonary
resuscitation (CPR) has also been known to
cause thoracic injury, including but not limited
to rib and sternum fractures. They can also be
a consequence of cancer or rheumatoid
arthritis. Can be due to falls in the elderly.
Diagnosis
Key signs are:
1. Pain on inhalation
2. Swelling in chest area
3. Bruise in chest area
4. Dyspnea
5. Coughing up blood (damaged lung)
More likely in adults, as children have
more flexible ribs – a broken rib in a child
would indicate a significant amount of force,
hence why it is a key sign of child abuse, and
would also indicate likely pulmonary
contusion.
Broken ribs can be imaged with CXR or CT
scanning.
Treatment
No specific treatment. In simple fractures,
pain can lead to reduced movement and cough
suppression, precipitating infection.
Accordingly, pain control to maintain
adequate ventilation is the main goal of all rib
fracture management, as otherwise you can
see hypoventilation with atelectasis and
pneumonia. For extensive fractures managed
as inpatient, epidural infusion is preferred –
intercostal nerve blocks can be used, but carry
risk of iatrogenic pneumothorax. Patients with
less extensive rib fractures can be managed
with NSAIDs and, occasionally, opioids, with
disadvantage here outweighed by benefits of
adequate pain control.
Flail chest can require assisted
ventilation. A first rib fracture is a high-energy
injury, and investigation of damage to
underlying viscera or spinal damage should
require further investigation. Common
treatment options are:
1. Judet and/or Sanchez plates/struts,
metal plates with strips, bends around ribs and
is secured with sutures
2. Synthes matrix rib fixation system
(precontoured metal plates, intramedullary
splint)
3. Anterior locking plates
4. U-plates
Sternal Fractures
Sternal fractures, as pictured above as a
comminuted (multiple fragments) fracture, occurs in
5-8% of those who experience blunt chest trauma,
commonly in car accidents or possibly CPR or as a
pathologic fracture. Its primary significance is
indicating possibly more serious internal injuries to
the heart or lungs.
Causes
Vehicle collisions are the usual cause of sternal
fracture, in about 3% of auto accidents, particularly
without wearing the lap seatbelt. It can also occur
when the chest suddenly flexes in the absence of an
impact.
Associated Injuries
As a clinician, if you see a sternal fracture,
suspect multiple severe injuries if this is seen, with
myocardial and pulmonary contusions likely, other
blood vessel damage, myocardial rupture, head and
abdominal injuries, flail chest, and vertebral
fractures. Sternal fractures can accompany rib
fractures, and can cause bronchial tears in some
cases. Mortality rate is 25-45% - though in isolation,
they are good.
Signs and Symptoms
Crepitus can result (broken bone ends rubbing
one another), pain, tenderness, bruising, and
swelling. Fractures can visibly move when the person
breaths, or can be bent or deformed, forming a
“step” at the junction of the broken bone ends.
Upper and middle parts of the heart are most likely
to fracture, typically below the sternal angle.
Assessment and Treatment
X-rays are taken in people with chest trauma
and sternal fracture symptoms, and these can be
followed with CT scanning. X-rays from the front
may miss the injury and should be taken from the
side as well. Treat associated injuries – fractures
alone do not need to be hospitalized. Always check
EKG. Fractures that are very out of place can be
operated on to fix them.
Cardiac Tamponade
See hypotension that does not respond to IV fluid
bolus, tachycardia, and elevated JVP that occurs
after blunt thoracic trauma – it occurs acutely here,
due to a bleed into a stiff pericardium, with only
100-200mL of blood needed to cause a sudden rise,
compromising venous return (elevated JVP) and
cardiac output (tachycardia and hypotension). The
CXR can appear normal in these patients, without a
change in cardiac silhouette size due to the small
amount of pericardial fluid.
Treat with pericardiocentesis or surgical
pericardotomy to remove the small fluid.
In contrast, a chronic process like malignancy or
renal failure causes slow accumulation of pericardial
fluid that gradually increases the intrapericardial
pressure and allows the pericardial elasticity to
change slowly – resulting in a possible accumulation
of 1-2L of fluid before reaching a critical point,
showing classic findings of an enlarged cardiac
silhouette.
Differential
Aortic rupture usually leads to death –
survival to the ED means the injury is just
distal to left subclavian and contained as
hematoma. This usually causes hypertension
(visceral afferent reflexes, psuedocoarctation)
and not JVD.
Myocardial Contusion (Blunt Cardiac
Injury)
Can also result from blunt trauma, commonly
seen with tachycardia and rib fractures. Cannot be
solely identified on imaging.
Can also see valvular failures, often in the right
heart because it is on the anterior surface. Seen with
rib fractures, pneumothorax, and heart valve
injuries. Consider all other chest injuries when you
suspect this. Signs and symptoms vary, but an
electrocardiogram should be done to determine
irregularities with cardiac function. The presentation
of an abnormal heart rhythm after a contusion can
be delayed for 72+ hours.
Myocardial contusion can result in left
ventricular dysfunction, with elevated intracardiac
filling pressure reflected in an elevated pulmonary
capillary wedge pressure.
Management
Echocardiography and cardiac consultation
should be obtained in any patient with blunt thoracic
trauma accompanied by complex arrhythmia,
cardiac dysfunction, new diastolic murmur, or signs
of heart failure.
Screening with serial ECGs, cardiac monitoring,
and observation for 4-6 hours is satisfactory in a
stable patient for whom there is concern about BCI.
Cardiac biomarkers aren’t needed unless the patient
is 60+.