Morning Report: Management of Pulmonary Contusions

Case #1: Middle-aged patient on Coumadin rollover MVC:

PulmContusion1

Case #2: Young patient jump off bridge:

PulmContusion2

Pulmonary contusions were first described during WWI, when the battlefield dead were noted to be without signs of trauma but postmortem exams revealed lung hemorrhage. Pulmonary contusions are caused by direct bruising of the lung parenchyma followed by alveolar edema and hemorrhage. It is most commonly seen after MVC’s with rapid deceleration, high velocity missile wounds, and blast injuries. If sufficient hemorrhage to the lung has occurred, the injury will be apparent on CXR. The treatment is supportive. Here were a few points I learned from these two cases:

  • There are no pathognomonic features for pulmonary contusion on CXR. The same increased density of tissue and alveolar consolidation can occur with pneumonia, aspiration, or pulmonary infarction. It is the context of trauma that defines the appearance as contusion.
  • The natural history of pulmonary contusions is that it tends to worsen over the first 24-48 hours before it improves over the next 7 days. Therefore, keep a close eye on these folks in the trauma bay, especially when the pulmonary contusion is already visible on your initial CXR. Respiratory distress and hypoxia are indications for intubation.

The first patient died, and the second patient was discharged after a prolonged course in the TICU on ECMO.

 

References:

Broder, J. (2011). Chapter 6: Imaging Chest Trauma. Diagnostic Imaging for the Emergency Physician. 
Simon, B, et al. (2012). Management of Pulmonary Contusions and Flail Chest EAST Guidelines.

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