pulmonary contusion

1. PULMONARY
CONTUSION
TIM JAGA

2. PENDAHULUAN
• Pulmonary contusion is the most common
pulmonary parenchymal injury in blunt
chest trauma. Of all contusions, 70% occur
secondary to motor vehicle crashes with
other causes including falls from a
significant height and penetrating thoracic
injury, although the latter does not produce
the widespread extent of injury compared
with blunt trauma.
• Overall, mortality resulting strictly from the
contusion is difficult to identify in that it is
rare to sustain such an isolated injury. In
multitrauma patients, mortality in
association with pulmonary contusion is
35%.
Edward A. Ullman, Lawrence P. Donley, William J. Brady. Pulmonary trauma Emergency department evaluation and management. Emerg Med Clin N Am 21 (2003) 291–313.

3. PATHOPHYSIOLOGY:
• Lung contusion develops as a result of damage to the
compressed lung tissue caused by an external force.
• The inertial effect leads to a similar axonal damage. The
lighter alveolar tissue is injured as a result of the shearing
force of hilar structures. This is a consequence of the fact
that tissues of different density decelerate and accelerate
differently.
• Spalling: a tear develops in the lung tissue where the
pressure wave encounters different bordering
surfaces, such as e.g the alveolar wall
• Implosion: it occurs upon sudden increase in airway
pressure. Shock waves compress the gas within
tissues containing air bubbles, thereafter, the gas
expands to manifold its original volume causing micro
explosions within the aerated tissue
inertial
effect
spalling effect
implosion
effect
Szilárd Rendeki, Tamás F. Molnár. Pulmonary contusion (review article). J Thorac Dis 2019;11(Suppl 2):S141-S151.

4. THE MURRAY LUNG INJURY SCORE
(LIS) IS USED FOR THE ASSESSMENT
OF THE SEVERITY OF ALI (ACUTE
LUNG INJURY)
K Atabai, M A Matthay. The pulmonary physician in critical care c 5: Acute lung injury and the acute respiratory distress syndrome: definitions and epidemiology. Article in Thorax · June 2002.

5. TREATMENT
• Oxygen delivery
• Intravenous fluid replacement
• Adequate pain management
• Surgical stabilization in flail chest
• Steroid
Szilárd Rendeki, Tamás F. Molnár. Pulmonary contusion (review article). J Thorac Dis 2019;11(Suppl 2):S141-S151.

6. OXYGEN DELIVERY
• The goal of oxygen administration and the use of positive pressure ventilation is to achieve
adequate oxygenation of the blood.
• Ventilatory support: Patients with pulmonary contusion, respiratory failure or abnormalities
in blood gases (pO2 <60 mmHg and pCO2> 60 mmHg) require some type of ventilatory
support.
Szilárd Rendeki, Tamás F. Molnár. Pulmonary contusion (review article). J Thorac Dis 2019;11(Suppl 2):S141-S151.

7. INTRAVENOUS FLUID REPLACEMENT
• Fluid overload, on the other hand, should be avoided as hypervolemia increases pulmonary
oedema and consequently aggravates gas exchange. Regarding the recommended volume
for fluid resuscitation, the literature suggests the monitoring of pulmonary artery pressure,
the normal range of which is 25–30/9–10 mmHg.
Szilárd Rendeki, Tamás F. Molnár. Pulmonary contusion (review article). J Thorac Dis 2019;11(Suppl 2):S141-S151.

8. ADEQUATE PAIN MANAGEMENT
• In Moon et al. the epidural analgesia group had a significant reduction of pain with
coughing compared with patients receiving systemic opioids via patient-controlled
anesthesia. Pain control in the epidural group was also significantly less on Day 3.
• Data on pain were available in only one observational study included in this
recommendation. Median pain scores were statistically lower compared with intermittent
systemic morphine in Wu et al.
• Ingalls et al. performed an eloquent prospective, randomized controlled trial of lidocaine 5% patch
versus placebo for patients with rib fractures. The study was well powered, and the lidocaine patch
failed to show sparing of narcotics versus the placebo group.
Bruce Simon, MD, James Ebert, MD, Faran Bokhari, MD, et al. Management of pulmonary contusion and flail chest: An Eastern Association for the Surgery of Trauma practice management guideline. J
Trauma Acute Care Surg. Volume 73, Number 5, Supplement 4

9. SURGICAL STABILIZATION
IN FLAIL CHEST
Patrick T. Delaplain MD, Sebastian D. Schubl MD FACS, Fredric M. Pieracci, MD MPH FACS, et al. CHEST WALL INJURY SOCIETY GUIDELINE FOR SSRF INDICATIONS, CONTRAINDICATIONS
AND TIMING. www.cwisociety.org

10. STEROID
• The use of steroids for the treatment of PC (Pulmonary Contusion) has rarely been
addressed in the literature. Franz et al. administered methylprednisolone 30 minutes after
creation of experimental PC in dogs. The weight ratio of contused to normal lung was
significantly decreased in treated animals, and the volume of injury was less on post
mortem. Since the animals were killed, the effect of steroids on recovery and survival could
not be assessed. In a small retrospective human study.
• Svennevig et al. concluded that the mortality in severe chest injury was reduced through
the use of steroids. This study, however, involved neither randomization nor constant
criteria for administration of steroids. Since the cause of deaths were not specified, it was
difficult to assess the complications and risk versus benefit of steroid use.
Szilárd Rendeki, Tamás F. Molnár. Pulmonary contusion (review article). J Thorac Dis 2019;11(Suppl 2):S141-S151.