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3 Einteilung

Man unterscheidet die Kalottenfraktur, die Schdelbasisfraktur und die Gesichtsschdelfraktur.


Eine zeitliche Einteilung in der Rechtsmedizin bietet die Puppe-Regel.

3.1 Gesichtsschdelfraktur
Zu den Gesichtsschdelfrakturen gehren:

Nasenbeinfrakturen

Mittelgesichtsfrakturen

Jochbogenfrakturen

Mandibulafrakturen

Blow-out-Fraktur

3.2 Schdelbasisfraktur
Bei den Schdelbasisfrakturen unterscheidet man die frontobasalen Frakturen mit Beziehung zu
den Nasennebenhhlen, frontolaterale Frakturen mit Einbeziehung der Orbita sowie die
laterobasalen Frakturen mit Einbeziehung der Felsenbeine.

3.3 Kalottenfraktur
Unter der Kalottenfraktur versteht man einen Knochenbruch im Bereich der Schdelkalotte.

S00Verletzungen des Kopfes


S09
Inkl.: Verletzungen: Auge
Verletzungen: behaarte Kopfhaut
Verletzungen: Gaumen
Verletzungen: Gesicht [jeder Teil]
Verletzungen: Kiefer
Verletzungen: Kiefergelenkregion
Verletzungen: Mundhhle
Verletzungen: Ohr
Verletzungen: Periokularregion

Verletzungen: Zahn
Verletzungen: Zahnfleisch
Verletzungen: Zunge
Exkl. Auswirkungen eines Fremdkrpers auf das uere Auge (T15.-)
:
Auswirkungen eines Fremdkrpers in: Kehlkopf (T17.3)
Auswirkungen eines Fremdkrpers in: Mund (T18.0)
Auswirkungen eines Fremdkrpers in: Nase (T17.0-T17.1)
Auswirkungen eines Fremdkrpers in: Ohr (T16)
Auswirkungen eines Fremdkrpers in: Rachen (T17.2)
Erfrierungen (T33-T35)
Insektenbiss oder -stich, giftig (T63.4)
Verbrennungen und Vertzungen (T20-T32)
S02.- Fraktur des Schdels und der Gesichtsschdelknochen
Info.: Benutze eine zustzliche Schlsselnummer aus S01.84-S01.89 zusammen mit S02,
um den Schweregrad des Weichteilschadens bei einer Fraktur zu verschlsseln.
Dies gilt nicht, wenn die Fraktur mit einer intrakraniellen Verletzung einhergeht. In
diesem Fall ist S01.83 zu verwenden.
Ein Bewusstseinsverlust bei einer Schdelfraktur ist mit einer zustzlichen
Schlsselnummer aus S06.7 zu verschlsseln.
S02.0 Schdeldachfraktur
Inkl.: Os frontale
Os parietale
Os temporale, Pars squamosa
S02.1 Schdelbasisfraktur
Inkl.: Orbitadach
Os occipitale

Pulmonary contusion
From Wikipedia, the free encyclopedia

Pulmonary contusion

A CT scan showing a pulmonary contusion (red


arrow) accompanied by a rib fracture (blue
arrow)
Classification and external resources
ICD-10

S27.3

ICD-9

861.21, 861.31

A pulmonary contusion (or lung contusion) is a contusion (bruise) of the lung, caused by chest
trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue.
The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels
(hypoxia). Unlike pulmonary laceration, another type of lung injury, pulmonary contusion does
not involve a cut or tear of the lung tissue.
A pulmonary contusion is usually caused directly by blunt trauma but can also result from
explosion injuries or a shock wave associated with penetrating trauma. With the use of
explosives during World Wars I and II, pulmonary contusion resulting from blasts gained
recognition. In the 1960s its occurrence in civilians began to receive wider recognition, in which
cases it is usually caused by traffic accidents. The use of seat belts and airbags reduces the risk to
vehicle occupants.
Diagnosis is made by studying the cause of the injury, physical examination and chest
radiography. Typical signs and symptoms include direct effects of the physical trauma, such as
chest pain and coughing up blood, as well as signs that the body is not receiving enough oxygen,
such as cyanosis. The contusion frequently heals on its own with supportive care. Often nothing
more than supplemental oxygen and close monitoring is needed; however, intensive care may be
required. For example, if breathing is severely compromised, mechanical ventilation may be
necessary. Fluid replacement may be required to ensure adequate blood volume, but fluids are
given carefully since fluid overload can worsen pulmonary edema, which may be lethal.
The severity ranges from mild to deadlysmall contusions may have little or no impact on the
patient's healthyet pulmonary contusion is the most common type of potentially lethal chest

trauma. It occurs in 3075% of severe chest injuries. With an estimated mortality rate of 14
40%, pulmonary contusion plays a key role in determining whether an individual will die or
suffer serious ill effects as the result of trauma. Pulmonary contusion is usually accompanied by
other injuries. Although associated injuries are often the cause of death, pulmonary contusion is
thought to cause death directly in a quarter to half of cases. Children are at especially high risk
for the injury because the relative flexibility of their bones prevents the chest wall from
absorbing force from an impact, causing it to be transmitted instead to the lung. Pulmonary
contusion is associated with complications including pneumonia and acute respiratory distress
syndrome, and it can cause long-term respiratory disability.
Contents

1 Classification

2 Signs and symptoms

3 Causes

4 Mechanism

5 Pathophysiology

5.1 Bleeding and edema

5.2 Consolidation and collapse

5.3 Ventilation/perfusion mismatch

6 Diagnosis
o

6.1 X-ray

6.2 Computed tomography

6.3 Ultrasound

7 Prevention

8 Treatment
o

8.1 Ventilation

8.2 Fluid therapy

8.3 Supportive care

9 Prognosis
o

9.1 Complications

9.2 Associated injuries

10 Epidemiology

11 History

12 References

13 External links

Classification

The alveoli

Pulmonary contusion and laceration are injuries to the lung tissue. Pulmonary laceration, in
which lung tissue is torn or cut, differs from pulmonary contusion in that the former involves
disruption of the macroscopic architecture of the lung,[1] while the latter does not.[2] When
lacerations fill with blood, the result is pulmonary hematoma, a collection of blood within the
lung tissue.[3] Contusion involves hemorrhage in the alveoli (tiny air-filled sacs responsible for
absorbing oxygen), but a hematoma is a discrete clot of blood not interspersed with lung tissue.[4]
A collapsed lung can result when the pleural cavity (the space outside the lung) accumulates
blood (hemothorax) or air (pneumothorax) or both (hemopneumothorax). These conditions do
not inherently involve damage to the lung tissue itself, but they may be associated with it.
Injuries to the chest wall are also distinct from but may be associated with lung injuries. Chest
wall injuries include rib fractures and flail chest, in which multiple ribs are broken so that a
segment of the ribcage is detached from the rest of the chest wall and moves independently.
Signs and symptoms

Presentation may be subtle; people with mild contusion may have no symptoms at all.[5]
However, pulmonary contusion is frequently associated with signs (objective indications) and

symptoms (subjective states), including those indicative of the lung injury itself and of
accompanying injuries. Because gas exchange is impaired, signs of low blood oxygen saturation,
such as low concentrations of oxygen in arterial blood gas and cyanosis (bluish color of the skin
and mucous membranes) are commonly associated.[6] Dyspnea (painful breathing or difficulty
breathing) is commonly seen,[6] and tolerance for exercise may be lowered.[7] Rapid breathing and
a rapid heart rate are other signs.[8][9] With more severe contusions, breath sounds heard through a
stethoscope may be decreased, or rales (an abnormal crackling sound in the chest accompanying
breathing) may be present.[6][10] People with severe contusions may have bronchorrhea (the
production of watery sputum).[11] Wheezing and coughing are other signs.[12] Coughing up blood
or bloody sputum is present in up to half of cases.[12] Cardiac output (the volume of blood
pumped by the heart) may be reduced,[11] and hypotension (low blood pressure) is frequently
present.[6] The area of the chest wall near the contusion may be tender[13] or painful due to
associated chest wall injury.
Signs and symptoms take time to develop, and as many as half of cases are asymptomatic at the
initial presentation.[5] The more severe the injury, the more quickly symptoms become apparent.
In severe cases, symptoms may occur as quickly as three or four hours after the trauma.[11]
Hypoxemia (low oxygen concentration in the arterial blood) typically becomes progressively
worse over 2448 hours after injury.[14] In general, pulmonary contusion tends to worsen slowly
over a few days,[4] but it may also cause rapid deterioration or death if untreated.[6]
Causes

Motor vehicle accidents are the most common cause of pulmonary contusion.

Pulmonary contusion is the most common injury found in blunt chest trauma,[15] occurring in 25
35% of cases.[16] It is usually caused by the rapid deceleration that results when the moving chest
strikes a fixed object.[12] About 70% of cases result from motor vehicle collisions,[17] most often
when the chest strikes the inside of the car.[6] Falls,[17] assaults,[18] and sports injuries are other
causes.[19] Pulmonary contusion can also be caused by explosions; the organs most vulnerable to
blast injuries are those that contain gas, such as the lungs.[20] Blast lung is severe pulmonary
contusion, bleeding, or edema with damage to alveoli and blood vessels, or a combination of
these.[21] This is the primary cause of death among people who initially survive an explosion.[22]

Unlike other mechanisms of injury in which pulmonary contusion is often found alongside other
injuries, explosions can cause pulmonary contusion without damage to the chest wall.[15]
In addition to blunt trauma, penetrating trauma can cause pulmonary contusion.[23] Contusion
resulting from penetration by a rapidly moving projectile usually surrounds the path along which
the projectile traveled through the tissue.[24] The pressure wave forces tissue out of the way,
creating a temporary cavity; the tissue readily moves back into place, but it is damaged.
Pulmonary contusions that accompany gun and knife wounds are not usually severe enough to
have a major effect on outcome;[25] penetrating trauma causes less widespread lung damage than
does blunt trauma.[17] An exception is shotgun wounds, which can seriously damage large areas
of lung tissue through a blast injury mechanism.[25]
Mechanism

The physical processes behind pulmonary contusion are poorly understood. However, it is
known that lung tissue can be crushed when the chest wall bends inward on impact.[26] Three
other possible mechanisms have been suggested: the inertial effect, the spalling effect, and the
implosion effect.

In the inertial effect, the lighter alveolar tissue is sheared from the heavier
hilar structures, an effect similar to diffuse axonal injury in head injury.[5] It
results from the fact that different tissues have different densities, and
therefore different rates of acceleration or deceleration. [10]

In the spalling effect, lung tissue bursts or is sheared where a shock wave
meets the lung tissue, at interfaces between gas and liquid. [20] The alveolar
walls form such a gas-liquid interface with the air in the alveoli. [5][27] The
spalling effect occurs in areas with large differences in density; particles of
the denser tissue are spalled (thrown) into the less dense particles. [28]

The implosion effect occurs when a pressure wave passes through a tissue
containing bubbles of gas: the bubbles first implode, then rebound and
expand beyond their original volume.[29] The air bubbles cause many tiny
explosions, resulting in tissue damage;[29] the overexpansion of gas bubbles
stretches and tears alveoli.[30][31] This effect is thought to occur
microscopically when the pressure in the airways increases sharply. [26]

Contusion usually occurs on the lung directly under the site of impact, but, as with traumatic
brain injury, a contrecoup contusion may occur at the site opposite the impact as well.[24] A blow
to the front of the chest may cause contusion on the back of the lungs because a shock wave
travels through the chest and hits the curved back of the chest wall; this reflects the energy onto
the back of the lungs, concentrating it. (A similar mechanism may occur at the front of the lungs
when the back is struck.)[31]

The amount of energy transferred to the lung is determined in a large part by the compliance
(flexibility) of the chest wall.[24] Children's chests are more flexible because their ribs are more
elastic and there is less ossification of their intercostal cartilage.[13] Therefore, their chest walls
bend, absorbing less of the force and transmitting more of it to the underlying organs.[13][32] An
adult's more bony chest wall absorbs more of the force itself rather than transmitting it.[32] Thus
children commonly get pulmonary contusions without fractures overlying them, while elderly
people are more likely to suffer fractures than contusions.[14][24] One study found that pulmonary
contusions were accompanied by fractures 62% of the time in children and 80% of the time in
adults.[31]
Pathophysiology

Normally, oxygen and carbon dioxide diffuse across the capillary and alveolar
membranes and the interstitial space (top). Fluid impairs this diffusion, resulting in
less oxygenated blood (bottom).

Pulmonary contusion results in bleeding and fluid leakage into lung tissue, which can become
stiffened and lose its normal elasticity. The water content of the lung increases over the first
72 hours after injury, potentially leading to frank pulmonary edema in more serious cases.[20] As a
result of these and other pathological processes, pulmonary contusion progresses over time and
can cause hypoxia (insufficient oxygen).
Bleeding and edema

In contusions, torn capillaries leak fluid into the tissues around them.[33] The membrane between
alveoli and capillaries is torn; damage to this capillaryalveolar membrane and small blood
vessels causes blood and fluids to leak into the alveoli and the interstitial space (the space
surrounding cells) of the lung.[11] With more severe trauma, there is a greater amount of edema,
bleeding, and tearing of the alveoli.[17] Pulmonary contusion is characterized by
microhemorrhages (tiny bleeds) that occur when the alveoli are traumatically separated from
airway structures and blood vessels.[24] Blood initially collects in the interstitial space, and then
edema occurs by an hour or two after injury.[30] An area of bleeding in the contused lung is
commonly surrounded by an area of edema.[24] In normal gas exchange, carbon dioxide diffuses
across the endothelium of the capillaries, the interstitial space, and across the alveolar
epithelium; oxygen diffuses in the other direction. Fluid accumulation interferes with gas
exchange,[34] and can cause the alveoli to fill with proteins and collapse due to edema and
bleeding.[24] The larger the area of the injury, the more severe respiratory compromise will be.[17]
Consolidation and collapse

Pulmonary contusion can cause parts of the lung to consolidate, alveoli to collapse, and
atelectasis (partial or total lung collapse) to occur.[35] Consolidation occurs when the parts of the
lung that are normally filled with air fill with material from the pathological condition, such as
blood.[36] Over a period of hours after the injury, the alveoli in the injured area thicken and may
become consolidated.[24] A decrease in the amount of surfactant produced also contributes to the
collapse and consolidation of alveoli;[16] inactivation of surfactant increases their surface tension.
[31]
Reduced production of surfactant can also occur in surrounding tissue that was not originally
injured.[26]
Inflammation of the lungs, which can result when components of blood enter the tissue due to
contusion, can also cause parts of the lung to collapse. Macrophages, neutrophils, and other
inflammatory cells and blood components can enter the lung tissue and release factors that lead
to inflammation, increasing the likelihood of respiratory failure.[37] In response to inflammation,
excess mucus is produced, potentially plugging parts of the lung and leading to their collapse.[24]

Even when only one side of the chest is injured, inflammation may also affect the other lung.[37]
Uninjured lung tissue may develop edema, thickening of the septa of the alveoli, and other
changes.[38] If this inflammation is severe enough, it can lead to dysfunction of the lungs like that
seen in acute respiratory distress syndrome.[39]
Ventilation/perfusion mismatch

Normally, the ratio of ventilation to perfusion is about one-to-one; the volume of air entering the
alveoli (ventilation) is about equal to that of blood in the capillaries around them (perfusion).[40]
This ratio is reduced in pulmonary contusion; fluid-filled alveoli cannot fill with air, oxygen does
not fully saturate the hemoglobin, and the blood leaves the lung without being fully oxygenated.
[41]
Insufficient inflation of the lungs, which can result from inadequate mechanical ventilation or
an associated injury such as flail chest, can also contribute to the ventilation/perfusion mismatch.
[31]
As the mismatch between ventilation and perfusion grows, blood oxygen saturation is
reduced.[41] Pulmonary hypoxic vasoconstriction, in which blood vessels near the hypoxic alveoli
constrict (narrow their diameter) in response to the lowered oxygen levels, can occur in
pulmonary contusion.[27] The vascular resistance increases in the contused part of the lung,
leading to a decrease in the amount of blood that flows into it,[38] directing blood to betterventilated areas.[27] Although reducing blood flow to the unventilated alveoli is a way to
compensate for the fact that blood passing unventilated alveoli is not oxygenated,[27] the
oxygenation of the blood remains lower than normal.[40] If it is severe enough, the hypoxemia
resulting from fluid in the alveoli cannot be corrected just by giving supplemental oxygen; this
problem is the cause of a large portion of the fatalities that result from trauma.[41]
Diagnosis

To diagnose pulmonary contusion, health professionals use clues from a physical examination,
information about the event that caused the injury, and radiography.[17] Laboratory findings may
also be used; for example, arterial blood gasses may show insufficient oxygen and excessive
carbon dioxide even in someone receiving supplemental oxygen.[35] However, blood gas levels
may show no abnormality early in the course of pulmonary contusion.[23]
X-ray

A chest X-ray showing right sided (seen on the left of the picture) pulmonary
contusion associated with rib fractures and subcutaneous emphysema

Chest X-ray is the most common method used for diagnosis,[37] and may be used to confirm a
diagnosis already made using clinical signs.[20] Consolidated areas appear white on an X-ray film.
[42]
Contusion is not typically restricted by the anatomical boundaries of the lobes or segments of
the lung.[27][43][44] The X-ray appearance of pulmonary contusion is similar to that of aspiration,[32]
and the presence of hemothorax or pneumothorax may obscure the contusion on a radiograph.[25]
Signs of contusion that progress after 48 hours post-injury are likely to be actually due to
aspiration, pneumonia, or ARDS.[10]
Although chest radiography is an important part of the diagnosis, it is often not sensitive enough
to detect the condition early after the injury.[35] In a third of cases, pulmonary contusion is not
visible on the first chest radiograph performed.[7] It takes an average of six hours for the
characteristic white regions to show up on a chest X-ray, and the contusion may not become
apparent for 48 hours.[7][27][43] When a pulmonary contusion is apparent in an X-ray, it suggests
that the trauma to the chest was severe and that a CT scan might reveal other injuries that were
missed with X-ray.[2]
Computed tomography

A chest CT scan revealing pulmonary contusions, pneumothorax, and pseudocysts

Computed tomography (CT scanning) is a more sensitive test for pulmonary contusion,[6][33] and
it can identify abdominal, chest, or other injuries that accompany the contusion.[38] In one study,
chest X-ray detected pulmonary contusions in 16.3% of people with serious blunt trauma, while
CT detected them in 31.2% of the same people.[45] Unlike X-ray, CT scanning can detect the
contusion almost immediately after the injury.[43] However, in both X-ray and CT a contusion
may become more visible over the first 2448 hours after trauma as bleeding and edema into
lung tissues progress.[46] CT scanning also helps determine the size of a contusion, which is
useful in determining whether a patient needs mechanical ventilation; a larger volume of
contused lung on CT scan is associated with an increased likelihood that ventilation will be
needed.[43] CT scans also help differentiate between contusion and pulmonary hematoma, which

may be difficult to tell apart otherwise.[47] However, pulmonary contusions that are visible on CT
but not chest X-ray are usually not severe enough to affect outcome or treatment.[37]
Ultrasound

An ultrasound image showing early pulmonary contusion, at this moment not visible
on radiography. Interstitial syndromes are expressed with the vertical white lines,
the "B-lines".[48]

Pulmonary ultrasound, performed at the bedside or on the accident scene, is being explored as a
diagnosis for pulmonary contusion. Its use is still not widespread, being limited to facilities
which are comfortable with its use for other applications, like pneumothorax, airway
management, and hemothorax. Accuracy has been found to be comparable to CT scanning.[49]
Prevention

Prevention of pulmonary contusion is similar to that of other chest trauma. Airbags in


combination with seat belts can protect vehicle occupants by preventing the chest from striking
the interior of the vehicle during a collision, and by distributing forces involved in the crash
more evenly across the body.[6] However, in rare cases, an airbag causes pulmonary contusion in
a person who is not properly positioned when it deploys.[50] Child restraints such as carseats
protect children in vehicle collisions from pulmonary contusion.[51] Equipment exists for use in
some sports to prevent chest and lung injury; for example, in softball the catcher is equipped
with a chest protector.[52] Athletes who do not wear such equipment, such as basketball players,
can be trained to protect their chests from impacts.[52] Protective garments can also prevent
pulmonary contusion in explosions.[53] Although traditional body armor made from rigid plates or
other heavy materials protects from projectiles generated by a blast, it does not protect against
pulmonary contusion, because it does not prevent the blast's shock wave from being transferred
to the lung.[53] Special body armor has been designed for military personnel at high risk for blast
injuries; these garments can prevent a shock wave from being propagated across the chest wall to
the lung, and thus protect wearers from blast lung injuries.[53] These garments alternate layers of
materials with high and low acoustic impedance (the product of a material's density and a wave's
velocity through it) in order to "decouple" the blast wave, preventing its propagation into the
tissues.[53]

Treatment

No treatment is known to speed the healing of a pulmonary contusion; the main care is
supportive.[39] Attempts are made to discover injuries accompanying the contusion,[20] to prevent
additional injury, and to provide supportive care while waiting for the contusion to heal.[39]
Monitoring, including keeping track of fluid balance, respiratory function, and oxygen saturation
using pulse oximetry is also required as the patient's condition may progressively worsen.[54]
Monitoring for complications such as pneumonia and acute respiratory distress syndrome is of
critical importance.[55] Treatment aims to prevent respiratory failure and to ensure adequate blood
oxygenation.[16][23] Supplemental oxygen can be given and it may be warmed and humidified.[41]
When the contusion does not respond to other treatments, extracorporeal membranous
oxygenation may be used, pumping blood from the body into a machine that oxygenates it and
removes carbon dioxide prior to pumping it back in.[56]
Ventilation

Mechanical ventilation may be required if pulmonary contusion causes inadequate


oxygenation.

Positive pressure ventilation, in which air is forced into the lungs, is needed when oxygenation is
significantly impaired. Noninvasive positive pressure ventilation including continuous positive
airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), may be used to improve
oxygenation and treat atelectasis: air is blown into the airways at a prescribed pressure via a face
mask.[39] Noninvasive ventilation has advantages over invasive methods because it does not carry
the risk of infection that intubation does, and it allows normal coughing, swallowing, and speech.
[39]
However, the technique may cause complications; it may force air into the stomach or cause
aspiration of stomach contents, especially when level of consciousness is decreased.[4]
People with signs of inadequate respiration or oxygenation may need to be intubated[7] and
mechanically ventilated.[12] Mechanical ventilation aims to reduce pulmonary edema and increase

oxygenation.[27] Ventilation can reopen collapsed alveoli, but it is harmful for them to be
repeatedly opened, and positive pressure ventilation can also damage the lung by overinflating it.
[57]
Intubation is normally reserved for when respiratory problems occur,[7] but most significant
contusions do require intubation, and it may be done early in anticipation of this need.[4] People
with pulmonary contusion who are especially likely to need ventilation include those with prior
severe lung disease or kidney problems; the elderly; those with a lowered level of consciousness;
those with low blood oxygen or high carbon dioxide levels; and those who will undergo
operations with anesthesia.[41] Larger contusions have been correlated with a need for ventilation
for longer periods of time.[15]
Pulmonary contusion or its complications such as acute respiratory distress syndrome may cause
lungs to lose compliance (stiffen), so higher pressures may be needed to give normal amounts of
air[4] and oxygenate the blood adequately.[33] Positive end-expiratory pressure (PEEP), which
delivers air at a given pressure at the end of the expiratory cycle, can reduce edema and keep
alveoli from collapsing.[13] PEEP is considered necessary with mechanical ventilation; however,
if the pressure is too great it can expand the size of the contusion[17] and injure the lung.[39] When
the compliance of the injured lung differs significantly from that of the uninjured one, the lungs
can be ventilated independently with two ventilators in order to deliver air at different pressures;
this helps avoid injury from overinflation while providing adequate ventilation.[58]
Fluid therapy

The administration of fluid therapy in individuals with pulmonary contusion is controversial.[41]


Excessive fluid in the circulatory system (hypervolemia) can worsen hypoxia because it can
cause fluid leakage from injured capillaries (pulmonary edema), which are more permeable than
normal.[31][43] However, low blood volume (hypovolemia) resulting from insufficient fluid has an
even worse impact, potentially causing hypovolemic shock; for people who have lost large
amounts of blood, fluid resuscitation is necessary.[41] A lot of the evidence supporting the idea
that fluids should be withheld from people with pulmonary contusion came from animal studies,
not clinical trials with humans; human studies have had conflicting findings on whether fluid
resuscitation worsens the condition.[20] Current recommendations suggest giving enough fluid to
ensure sufficient blood flow but not giving any more fluid than necessary.[15] For people who do
require large amounts of intravenous fluid, a catheter may be placed in the pulmonary artery to
measure the pressure within it.[6] Measuring pulmonary artery pressure allows the clinician to
give enough fluids to prevent shock without exacerbating edema.[59] Diuretics, drugs that increase
urine output to reduce excessive fluid in the system, can be used when fluid overload does occur,
as long as there is not a significant risk of shock.[15] Furosemide, a diuretic used in the treatment
of pulmonary contusion, also relaxes the smooth muscle in the veins of the lungs, thereby
decreasing pulmonary venous resistance and reducing the pressure in the pulmonary capillaries.
[43]

Supportive care

Retaining secretions in the airways can worsen hypoxia[60] and lead to infections.[4] Thus, an
important part of treatment is pulmonary toilet, the use of suction, deep breathing, coughing, and
other methods to remove material such as mucus and blood from the airways.[7] Chest physical
therapy makes use of techniques such as breathing exercises, stimulation of coughing,
suctioning, percussion, movement, vibration, and drainage to rid the lungs of secretions, increase
oxygenation, and expand collapsed parts of the lungs.[61] People with pulmonary contusion,
especially those who do not respond well to other treatments, may be positioned with the
uninjured lung lower than the injured one to improve oxygenation.[43] Inadequate pulmonary
toilet can result in pneumonia.[40] People who do develop infections are given antibiotics.[17] No
studies have yet shown a benefit of using antibiotics as a preventative measure before infection
occurs, although some doctors do recommend prophylactic antibiotic use even without scientific
evidence of its benefit.[13] However, this can cause the development of antibiotic resistant strains
of bacteria, so giving antibiotics without a clear need is normally discouraged.[20] For people who
are at especially high risk of developing infections, the sputum can be cultured to test for the
presence of infection-causing bacteria; when they are present, antibiotics are used.[27]
Pain control is another means to facilitate the elimination of secretions. A chest wall injury can
make coughing painful, increasing the likelihood that secretions will accumulate in the airways.
[62]
Chest injuries also contribute to hypoventilation (inadequate breathing) because the chest wall
movement involved in breathing adequately is painful.[62][63] Insufficient expansion of the chest
may lead to atelectasis, further reducing oxygenation of the blood.[35] Analgesics (pain
medications) can be given to reduce pain.[12] Injection of anesthetics into nerves in the chest wall,
called nerve blockade, is another approach to pain management; this does not depress respiration
the way some pain medications can.[31]
Prognosis

This CT scan, taken 22 days after pulmonary contusion with major chest trauma,
shows that the contusion has completely resolved. [64]

Pulmonary contusion usually resolves itself[23] without causing permanent complications;[1]


however it may also have long-term ill effects on respiratory function.[38][65] Most contusions
resolve in five to seven days after the injury.[1] Signs detectable by radiography are usually gone
within 10 days after the injurywhen they are not, other conditions, such as pneumonia, are the
likely cause.[27] Chronic lung disease correlates with the size of the contusion and can interfere
with an individual's ability to return to work.[24] Fibrosis of the lungs can occur, resulting in
dyspnea (shortness of breath), low blood oxygenation, and reduced functional residual capacity
for as long as six years after the injury.[38] As late as four years post-injury, decreased functional
residual capacity has been found in most pulmonary contusion patients studied.[43] During the six
months after pulmonary contusion, up to 90% of people suffer difficulty breathing.[27][43] In some
cases, dyspnea persists for an indefinite period.[7] Contusion can also permanently reduce the
compliance of the lungs.[66]
Complications

A chest X-ray showing acute respiratory distress syndrome

Pulmonary contusion can result in respiratory failureabout half of such cases occur within a
few hours of the initial trauma.[43] Other severe complications, including infections and acute
respiratory distress syndrome (ARDS) occur in up to half of cases.[31] Elderly people and those
who have heart, lung, or kidney disease prior to the injury are more likely to stay longer in
hospital and have complications from the injury. Complications occur in 55% of people with
heart or lung disease and 13% of those without.[37] Of people with pulmonary contusion alone,
17% develop ARDS, while 78% of people with at least two additional injuries develop the
condition.[6] A larger contusion is associated with an increased risk. In one study, 82% of people
with 20% or more of the lung volume affected developed ARDS, while only 22% of people with
less than 20% did so.[7]
Pneumonia, another potential complication, develops in as many as 20% of people with
pulmonary contusion.[13] Contused lungs are less able to remove bacteria than uninjured lungs,
predisposing them to infection.[67] Intubation and mechanical ventilation further increase the risk
of developing pneumonia; the tube is passed through the nose or mouth into the airways,

potentially tracking bacteria from the mouth or sinuses into them.[39] Also, intubation prevents
coughing, which would clear bacteria-laden secretions from the airways, and secretions pool near
the tube's cuff and allow bacteria to grow.[39] The sooner the endotracheal tube is removed, the
lower the risk of pneumonia, but if it is removed too early and has to be put back in, the risk of
pneumonia rises.[39] People who are at risk for pulmonary aspiration (e.g. those with lowered
level of consciousness due to head injuries) are especially likely to get pneumonia.[39] As with
ARDS, the chances of developing pneumonia increase with the size of the contusion.[7] Children
and adults have been found to have similar rates of complication with pneumonia and ARDS.[31]
Associated injuries

Severe pulmonary contusion with pneumothorax and hemothorax following severe


chest trauma[68]

A large amount of force is required to cause pulmonary contusion; a person injured with such
force is likely to have other types of injuries as well.[23] In fact, pulmonary contusion can be used
to gauge the severity of trauma.[25] Up to three quarters of cases are accompanied by other chest
injuries,[39] the most common of these being hemothorax and pneumothorax.[37] Flail chest is
usually associated with significant pulmonary contusion,[15] and the contusion, rather than the
chest wall injury, is often the main cause of respiratory failure in people with these injuries.[69]
Other indications of thoracic trauma may be associated, including fracture of the sternum and
bruising of the chest wall.[63] Over half of fractures of the scapula are associated with pulmonary
contusion.[27] The contusion is frequently found underlying fracture sites.[35] When accompanied
by a fracture, it is usually concentrated into a specific locationthe contusion is more diffuse
when there is no fracture.[31][43] Pulmonary lacerations may result from the same blunt or
penetrating forces that cause contusion.[6] Lacerations can result in pulmonary hematomas; these
are reported to develop in 411% of pulmonary contusions.[6]
Epidemiology

Pulmonary contusion is found in 3075% of severe cases of chest injury, making it the most
common serious injury to occur in association with thoracic trauma.[6] Of people who have

multiple injuries with an injury severity score of over 15, pulmonary contusion occurs in about
17%.[20] It is difficult to determine the death rate (mortality) because pulmonary contusion rarely
occurs by itself.[17] Usually, deaths of people with pulmonary contusion result from other injuries,
commonly traumatic brain injury.[24] It is controversial whether pulmonary contusion with flail
chest is a major factor in mortality on its own or whether it merely contributes to mortality in
people with multiple injuries.[70] The estimated mortality rate of pulmonary contusion ranges
from 1440%, depending on the severity of the contusion itself and on associated injuries.[11]
When the contusions are small, they do not normally increase the chance of death or poor
outcome for people with blunt chest trauma; however, these chances increase with the size of the
contusion.[37] One study found that 35% of people with multiple significant injuries including
pulmonary contusion die.[17] In another study, 11% of people with pulmonary contusion alone
died, while the number rose to 22% in those with additional injuries.[6] Pulmonary contusion is
thought to be the direct cause of death in a quarter to a half of people with multiple injuries
(polytrauma) who die.[71] An accompanying flail chest increases the morbidity and mortality to
more than twice that of pulmonary contusion alone.[43]

A right-sided pulmonary contusion post blunt chest trauma with increased opacity
just below the horizontal fissure

Pulmonary contusion is the most common cause of death among vehicle occupants involved in
accidents,[72] and it is thought to contribute significantly in about a quarter of deaths resulting
from vehicle collisions.[25] As vehicle use has increased, so has the number of auto accidents, and
with it the number of chest injuries.[39] However an increase in the number of airbags installed in
modern cars may be decreasing the incidence of pulmonary contusion.[6] Use of child restraint
systems has brought the approximate incidence of pulmonary contusion in children in vehicle
accidents from 22% to 10%.[51]
Differences in the bodies of children and adults lead to different manifestations of pulmonary
contusion and associated injuries; for example, children have less body mass, so the same force
is more likely to lead to trauma in multiple body systems.[31] Since their chest walls are more

flexible, children are more vulnerable to pulmonary contusion than adults are,[23] and thus suffer
from the injury more commonly.[30] Pulmonary contusion has been found in 53% of children with
chest injuries requiring hospitalization.[73] Children in forceful impacts suffer twice as many
pulmonary contusions as adults with similar injury mechanisms, yet have proportionately fewer
rib fractures.[13] The rates of certain types of injury mechanisms differ between children and
adults; for example, children are more often hit by cars as pedestrians.[31] Some differences in
children's physiology might be advantageous (for example they are less likely to have other
medical conditions), and thus they have been predicted to have a better outcome.[74] However,
despite these differences, children with pulmonary contusion have similar mortality rates to
adults.[31]
History

Giovanni Battista Morgagni, credited with having first described lung trauma without
chest wall trauma

In 1761, the Italian anatomist Giovanni Battista Morgagni was first to describe a lung injury that
was not accompanied by injury to the chest wall overlying it.[20] Nonetheless, it was the French
military surgeon Guillaume Dupuytren who is thought to have coined the term pulmonary
contusion in the 19th century.[71] It still was not until the early 20th century that pulmonary
contusion and its clinical significance began to receive wide recognition.[70] With the use of
explosives during World War I came many casualties with no external signs of chest injury but
with significant bleeding in the lungs.[70] Studies of World War I injuries by D.R. Hooker showed
that pulmonary contusion was an important part of the concussive injury that results from
explosions.[70]
Pulmonary contusion received further attention during World War II, when the bombings of
Britain caused blast injuries and associated respiratory problems in both soldiers and civilians.[20]

Also during this time, studies with animals placed at varying distances from a blast showed that
protective gear could prevent lung injuries.[65] These findings suggested that an impact to the
outside of the chest wall was responsible for the internal lesions.[65] In 1945, studies identified a
phenomenon termed "wet lung", in which the lungs accumulated fluid and were simultaneously
less able to remove it.[20][75] They attributed the respiratory failure often seen in blunt chest trauma
in part to excessive fluid resuscitation, and the question of whether and how much to administer
fluids has remained controversial ever since.[20]
During the Vietnam War, combat again provided the opportunity for study of pulmonary
contusion; research during this conflict played an important role in the development of the
modern understanding of its treatment.[20] The condition also began to be more widely recognized
in a non-combat context in the 1960s, and symptoms and typical findings with imaging
techniques such as X-ray were described.[20] Before the 1960s, it was believed that the respiratory
insufficiency seen in flail chest was due to "paradoxical motion" of the flail segment of the chest
wall (the flail segment moves in the opposite direction as the chest wall during respiration), so
treatment was aimed at managing the chest wall injury, not the pulmonary contusion.[56] For
example, positive pressure ventilation was used to stabilize the flail segment from within the
chest.[15][39] It was first proposed in 1965 that this respiratory insufficiency is most often due to
injury of the lung rather than to the chest wall,[20] and a group led by J.K. Trinkle confirmed this
hypothesis in 1975.[38] Hence the modern treatment prioritizes the management of pulmonary
contusion.[70] Animal studies performed in the late 1960s and 1970s shed light on the
pathophysiological processes involved in pulmonary contusion.[65] Studies in the 1990s revealed
a link between pulmonary contusion and persistent respiratory difficulty for years after the injury
in people in whom the injury coexisted with flail chest.[15] In the next decade studies
demonstrated that function in contused lungs improves for years after the injury.[15]
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External links

Chest Trauma - pulmonary contusion, trauma.org


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Chest trauma, excluding fractures (S20S29, 860862)


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Trauma

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