Rosen & Barkin's 5-Minute Emergency Medicine Consult (586 page)

• Adequate pain control is key for optimal outcome.
  
• Steroids have no proven benefit.
  
• Prophylactic antibiotics are not indicated.
  

Increased pliability of the chest wall increases the frequency of pulmonary contusions.

• Suboptimal cardiopulmonary reserve in combination with large-volume fluid resuscitation increases the likelihood of worsening of pulmonary contusions in the elderly.
  
• Pulmonary contusion has been identified as a marker for bad outcomes in elderly patients with isolated blunt chest trauma.
  

FOLLOW-UP

Patients with pulmonary contusion must be admitted to the hospital for observation in anticipation of delayed-onset respiratory compromise.

• Patients with minimal chest trauma
  
• No evidence of respiratory distress or hypoxemia:
  
  • Normal respiratory rate
    
  • Reassuring pulse oximetry
    
  • Negative chest radiograph
    
• Strict return criteria should be discussed with the patient prior to discharge:
  
  • Shortness of breath
    
  • Hemoptysis
    
  • Inadequate pain control or increased pain
    
  • Cough
    

• Avoid underestimating the severity of pulmonary injury based on initial chest x-ray.
  
• Failure to recognize this injury in the ED can lead to unexpected deterioration.
  
• Comorbid conditions such as chronic lung disease and renal failure increase the likelihood of requiring mechanical ventilation.
  
• Careful monitoring and reassessment is key.
  

• Cohn SM, DuBose JJ. Pulmonary contusion: An update on recent advances in clinical management.
  World J Surg.
  2010;34:1959–1970.
  
• de Mova MA, Manolakaki D, Chang Y, et al. Blunt pulmonary contusion: Admission computed tomography scan predicts mechanical ventilation.
  J Trauma.
  2011;71:1543–1547.
  
• Hamrick MC, Duhn RD, Ochsner MG. Critical evaluation of pulmonary contusion in the early post-traumatic period: Risk of assisted ventilation.
  Am Surg
  . 2009;75(11):1054–1058.
  
• Kiraly L, Schreiber M. Management of the crushed chest.
  Crit Care Med.
  2010;38(Suppl):S469–S477.
  
• Lotfipour S, Kaku SK, Vaca FE, et al. Factors associated with complications in older adults with isolated blunt chest trauma.
  West J Emerg Med
  . 2009;10:79–84.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Dyspnea
  
• Chest Trauma, Blunt
  
• Flail Chest
  
• Trauma, Multiple
  

The author gratefully acknowledges Nicholas C. Mosely for his work on the previous edition of this chapter.

CODES

• 861.21 Contusion of lung without mention of open wound into thorax
  
• 861.31 Contusion of lung with open wound into thorax
  

BASICS

Imbalance in Starling forces causes an accumulation of alveolar fluid secondary to leakage from pulmonary capillaries into the interstitium and alveoli of the lungs.

• Cardiogenic:
  
  • Abnormality in cardiac function leading to inadequate tissue perfusion
    
  • Acute decompensated cardiac failure: Acute fluid overload in the setting of chronic HF
    
  • Acute vascular failure: Decreased contractility and increased vascular resistance
    
• Noncardiogenic:
  
  • Increased alveolar–capillary membrane permeability, and accumulation of fluid in the alveoli without a cardiac etiology
    
  • Acute lung injury: Lower severity
    
  • Acute respiratory distress syndrome (ARDS): PaO
    ₂
    /FiO
    ₂
    ratio of ≤200 mm Hg
    
• New York Heart Association classification:
  
  • Class I: Not limited in normal physical activity by symptoms
    
  • Class II: Ordinary physical activity results in fatigue, dyspnea, or other symptoms
    
  • Class III: Marked limitation in normal activity
    
  • Class IV: Symptoms at rest or with any activity
    
• Epidemiology:
  
  • 5.8 million patients in US
    
  • Increases with increasing age and affects 10% of population >75 yr.
    
  • 30–40% of patients with HF are hospitalized every year.
    
  • 11% 1 mo mortality after AHF admission
    

• Cardiogenic etiologies:
  
  • Contractile dysfunction:
    
    • Ischemic heart disease
      
    • Idiopathic cardiomyopathy
      
    • Myocarditis
      
  • Systolic pressure overload:
    
    • Aortic stenosis
      
    • Systemic hypertension
      
  • Systolic volume overload:
    
    • Aortic regurgitation
      
    • Mitral regurgitation
      
  • Restricted diastolic filling:
    
    • Mitral stenosis
      
    • Left atrial myxoma
      
    • Hypertrophic cardiomyopathy
      
  • High-output states:
    
    • Hyperthyroidism
      
    • Anemia
      
    • Arteriovenous fistula
      
    • Wet beriberi
      
  • Congenital heart disease
    
  • Endocarditis
    
  • Rheumatic heart disease
    
• Noncardiogenic etiologies:
  
  • Sepsis
    
  • Acute pulmonary infection, aspiration
    
  • Inhalation injuries
    
  • Aspiration
    
  • Near drowning
    
  • Disseminated intravascular coagulation
    
  • Pancreatitis
    
  • Pulmonary contusion
    
  • Severe (nonthoracic) trauma
    
  • Cardiopulmonary bypass
    
  • Uremia
    
  • High-altitude pulmonary edema
    
  • Neurogenic pulmonary edema
    
  • Narcotic overdose
    
  • Salicylate overdose
    
  • Pulmonary embolism
    
  • Fat embolism
    
  • Transfusion-related acute lung injury
    

DIAGNOSIS

• Risk factors:
  
  • Prior CHF diagnosis
    
  • History of coronary artery disease or myocardial infarction
    
  • Diabetes
    
  • Severe systemic illness
    
• Symptoms:
  
  • Dyspnea on exertion progressing to dyspnea at rest
    
  • Orthopnea
    
  • Peripheral edema
    
  • Paroxysmal nocturnal dyspnea
    
  • Acute weight gain
    
  • Weakness/fatigue
    
  • Cough
    

• Vital signs
  
  • May be hypertensive or hypotensive
    
  • Tachypnea
    
  • Low oxygen saturation
    
• General
  
  • Diaphoresis
    
  • Cold, ashen, or cyanotic skin
    
• Respiratory:
  
  • Rales
    
  • Wheezes
    
  • Accessory muscle use
    
• Cardiovascular
  
  • Tachycardia
    
  • Jugular venous distention
    
  • Increased P2, S3, S4
    
  • Hepatojugular reflex
    
• Extremities
  
  • Peripheral edema
    
• Noncardiogenic
  
  • Similar pulmonary but rarely peripheral signs