IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med April-June 2004 Vol 8 Issue 2

Original Article

Outcome in patients with blunt chest trauma and pul-

monary contusions
T. Vignesh, A. S. ArunKumar, V. Kamat
Abstract

Abstract: Severe pulmonary contusions occur in blunt chest trauma, especially with high velocity injuries.
Pulmonary contusions following trauma may result in significant hypoxemia and decreased compliance
which may progress over several days. Extensive contusions may result in respiratory difficulty or progress
to adult respiratory distress syndrome, which increases mortality. We decided to review the cases of
polytrauma with associated pulmonary contusions to determine the factors which influence outcome.
Materials and Methods: A retrospective chart review of all cases of trauma with pulmonary contusions on
X-ray or CT scan. The cases were examined for age, type of injuries, admission APACHE II, SAPS II and
SOFA scores, PaO /FiO ratio, presence or absence of rib fractures, average positive fluid balance, aver-
2 2
age sedation dose, pulmonary haemorrhage, ventilator days, ICU days and hospital outcome. Results:
There were 18 cases of pulmonary contusions. All had associated injuries. 6 patients died, 4 in the ICU and
2 patients died 1 week after transfer to a high dependency unit, one due to sepsis and the other due to
massive haemothorax. There was a significant difference in PaO /FiO ratio at admission and throughout
2 2
the ICU course, fluid balance and sedation dose, but not in ventilator days and ICU days between survivors
and nonsurvivors. The incidence, frequency and amount of pulmonary haemorrhage were higher in the
nonsurvivors. Conclusions: Close attention to improving gas exchange, and early management of
hemoptysis might improve outcome in pulmonary contusions

Key Words: Chest trauma, pulmonary contusion, fluid balance, hemoptysis, rib fractures.

Introduction In young people, the compliant chest wall usually re-

Pulmonary contusion following chest trauma results in
pulmonary bleeding and microscopic disruption of alveoli.
Pulmonary contusion is reported to be present in 30%
to 75% of patients with significant blunt chest trauma,
most often from automobile accidents with rapid decel-
eration.1 Pulmonary contusion can also be caused by
high- velocity missile wounds and the passage of a shock
wave through the tissue.
From:
Department of Anesthesiology and Critical Care, Sri Ramachandra Medical
College and Research Institute, Chennai, India.
Correspondence:
Dr. V. Kamat
Department of Anesthesiology & Critical Care,
Sri Ramachandra Medical College & Research Institute (Deemed University),
Chennai, India. E-mail: vjkamat@hotmail.com
turns to normal without fracturing the ribs. With increas-
ing age, rib fractures are more common. Patients may
initially have minimal respiratory compromise due to the
injury only to develop progressive respiratory dysfunc-
tion and adult respiratory distress syndrome2 (ARDS)
over several days. Alternatively they may present in res-
piratory difficulty and rapidly progress to ARDS.
Pulmonary contusions must be suspected in blunt
trauma to the chest with rib fractures and hemoptysis.
Hypoxemia is caused by ventilation-perfusion mis-
matching, resulting from collapsed or edema-flooded
alveoli. Early diagnosis and treatment are important and

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Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 IJCCM October-December 2003 Vol 7 Issue 4

the traditional management of pulmonary contusion has

MS Dose
mg /day
included a degree of fluid restriction. Animal models of

30
25
40

45
50

40

45
25
14

25

25
35

25
50
0

0
isolated pulmonary contusion showed that large volumes
of fluid or administration of colloids may worsen lung
injury due to extensive flooding of the alveoli. However,

PO2 / FiO2
Ratio

213
209
335
166
133
140

252

279

222
180
192

232

171

359
211
203

281
this has not been substantiated in clinical studies.3

98
We decided to review the cases of pulmonary contu-

Output (ml)
sion admitted in our multidisciplinary intensive care unit

Hourly
Urine

111
202
135
185

188

111
125

180

111
120
121

102
173
163
60

92
34

73
to analyse the factors which may have contributed to
poor outcome.

Materials and Methods

Bleed
ET

+
+
+
+

+
+

+
+
+

-
-

-
-

-
-

-
A retrospective chart review was done on all patients
with blunt chest trauma, admitted between Feb 2002 and

Right Leg Crush Injury,

Left Leg Amputation

Oct 2004. Institutional review board approval was sought

# Cervical Vertebra,
# Clavicle Humerus

Jejunal Perforation
Degloving Injury
Splenic Rupture
Diaphragm Tear
Liver Contusion
# Pelvis Femur
Assoc. Injury

Splenic injury
and we were informed that it was not required, since

Splenic Tear
Head Injury
Head Injury

# Humerus

# Humerus
# Scapula
Liver Tear

Liver Tear
# Femur
this was an observational study. Records were reviewed
for demographics, need for mechanical ventilation, fluid
requirements, and hospital course.

Data on survivors and nonsurvivors were analysed and

Colloid
Given

Yea

Yes
Yes

Yes

Yes

Yes
Yes

No

No
No
No

No
No
No
No

No

No
No
the following variables were measured: age, the APACHE
II, SAPS II and SOFA scores; the PaO2/FiO2 ratios on
day 1, 3, 5, 8, 10, and 15; the mean positive fluid bal-
Days
ICU

63
16
16
14
19

10

4
7

6
5

5
6
9
3
8

4
ance per day; the use of colloids, presence of rib frac-
tures, associated injuries, the number of days on seda-
Days
Vent.

tion; the mean daily sedation dose; the ventilator days

46
14
14
19

10

0
6

5
4

4
5
9
3
8

0
and ICU days. Post mortem examination was done on
all patients who died.
Score
SOFA

10

3
2

3
5
5

4
1

3
9
6
5

3
3

Statistical analysis was by chi square test.

II Score

A – Alive, D – Dead, MS – Morphine Sulphate, Vent – Ventilator Days

SAPS

23
34

17
34
24

29

26
17

27

12
26
65
44
39

36

17

22
36

Results
There were 18 patients with lung contusions, all data
are shown in Table 1.
APACHE
II Score

12
14
15
23
20
10

12

11

3
6
8

2
5

4
6

Six patients died and the rest survived.

Seda-

Days
tion

34

Four patients died in the ICU with refractory hypoxia.

0
0
6
5

3
3

3
3
0
2
7

3
9

Two patients had severe head injuries as well. Of the

Balance

two patients who died in the HDU, one patient died of

+1845
+1140

+1699
Fluid

+803
+267
+208
+370
+657

+257

+530
+920

+407

+573
+458
+325
+768

+505

+560
/Day
Table 1: Patient data

massive hemothorax (postmortem revealed a lung lac-

eration and continued bleeding), and the other patient
come
Out-

died of sepsis.
D
D

D
D
D

A
A

A
A

A
A

A
A
A

A
Patient

Demographic data revealed that the age of the patients

ranged from 19-75 years.
17.
10.
11.

12.

15.
13.

16.

18.
14.
2.
1.

3.
4.
5.
6.
7.
8.
9.

74
 IJCCM October-December 2003 Vol 7 Issue 4
There were only two females in the entire group.
The mechanisms of injury were:
Head-on collision with heavy vehicles at high velocity
Hit and run accidents (pedestrian struck by vehicle)
Fall from height or blunt injury to the chest due to fall of
heavy machinery on the chest.
Associated injuries included multiple rib fractures in all
except two survivors; long bone fractures, abdominal
injuries including splenic rupture, liver lacerations, pel-
vic fractures and head injury. Two nonsurvivors had ma-
jor head injuries.
The mean age of non survivors was higher than survi-
vors, (mean age 46.33 in nonsurvivors compared to 36.6
in survivors P < 0.05).
There were two patients older than 65 years.
Postmortem on the nonsurvivors revealed hemothorax
in all six patients; severe pulmonary contusions in four
patients and lung lacerations in two patients along with
associated injuries. Two patients had intracerebral bleeds.
The admission PaO2/FiO2 ratio as well as the mean
PaO2/FiO2 ratio throughout the ICU stay was lower in
nonsurvivors. (Figures 1 and 2)
In some patients the admission chest Xray was nor-
mal, and worsened during the subsequent days (Figure
3-5). Others had infiltrates on the admission X-ray. All
nonsurvivors were classified as having ARDS and were
severely hypoxic at the time of death.
PO2/FiO2 ratio
PO2/FiO2 ratio
Figure 1: PaO2/ FiO2 of nonsurvivors
Indian J Crit Care Med April-June 2004 Vol 8 Issue 2
Nonsurvivors were more severely injured with higher
admission mean APACHE II (14 vs 7 P = 0.03) and SAPS
II (40 vs 26 P = 0.007) scores. However, the mean SOFA
scores were not significantly different (nonsurvivors 5.83
and survivors 3.83).
Nonsurvivors had lower mean PaO2/FiO2 ratio through-
out the ICU stay than survivors, (158 vs 245 P<0.05)
indicating worse lung injury.
There was a increased incidence of hemoptysis, posi-
tive fluid balance, increased morphine requirement and
higher APACHE II and SAPS II scores in nonsurvivors.
These values were statistically significant. There was no
difference in crystalloid or colloid use, ventilator days or
ICU days between survivors and nonsurvivors.
Discussion
Blunt trauma to the chest in high velocity accidents
causes rib fractures and contusion of the underlying lung.
Contusions are usually suspected in the presence of rib
fractures and hemoptysis. Intra-alveolar hemorrhage can
progress to ALI/ARDS which can increase mortality due
to severe hypoxia.
Pulmonary contusion can generate worsening gas ex-
change, which may persist in spite of adequate
ventilatory management. Despite advances in pulmonary
care and ICU management, pulmonary contusion con-
tributes to higher mortality and morbidity for patients with
other severe injuries.1
Our results showed that the mean age of survivors
(36.6 years) was statistically lower than of nonsurvivors
(46.6 years). This is not surprising as it is well known
that the elderly patient does not tolerate major chest
trauma.4
Figure 2: PaO2/ FiO2 of survivors
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Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 IJCCM October-December 2003 Vol 7 Issue 4

There was a significant difference in the mean daily

positive fluid balance between nonsurvivors and survi-
vors (1075 ml vs 488 ml P = 0.007). However, the in-
crease in fluid balance was not due to increase in fluid
intake (average fluid infused per hour was the same in
nonsurvivors (162.5 ml) and survivors (159.75 ml P >
0.05) but was probably related to worse hemodynamics
and lower urine output (mean hourly urine output of 80
ml/hour in nonsurvivors vs 128 ml/hour in survivors).
Whether the positive fluid balance and consequent in-
crease in extravascular lung water worsened the lung
injury and hypoxemia and contributed to mortality is un-
clear.
Figure 3: Chest X-ray of patient 1 (on admission)

Nonsurvivors needed more sedation (mean daily mor-

phine dose 38.3 mg vs 22.9 mg ) than survivors. In addi-
tion to the pain of rib fractures and associated injuries,
the increased need for sedation could have been due to
the hypoxia of severe lung injury necessitating more
sedation for ventilatory management, as well as the
higher incidence of head trauma in nonsurvivors.

The incidence of significant hemoptysis was higher in

nonsurvivors (66% vs 33%). This could have been an-
other factor contributing to mortality.

It has been suggested that significant hemoptysis

should be controlled with single lung ventilation. It has
been reported that lung isolation procedures may be
required in 33% of patients with airway bleeding.5

Emergency thoracotomy and control of bleeding is

another option.
Figure 3: Chest X-ray of patient 1 (day 3)

Would our mortality have been lower if we had under-

taken these measures?

The ultimate outcome after major trauma is multifacto-

rial and any single intervention such as lung resection
has not been known to reduce mortality. Thoracotomy
following blunt injury resulted in three times the mortal-
ity seen in patients with penetrating injury and most likely
reflects the multisystem involvement in blunt force inju-
ries.6

All our nonsurvivors were severely hypoxic. All patients

were ventilated with pressure control mode of ventilation
Figure 5: X-ray of patient 3 (on admission) with the following strategies to improve oxygenation:

76
IJCCM October-December 2003 Vol 7 Issue 4
Inverse ratio ventilation, PEEP and recruitment strate-
gies and prone positioning were used whenever feasi-
ble. Patients with pelvic fractures, head injuries or un-
stable fractures were not turned prone.
When the above measures fail, two strategies have
shown improvement in oxygenation in patients with lung
contusions and refractory hypoxia. These include indi-
vidual lung ventilation with a double lumen tube7 and
high frequency jet ventilation.8
Canella et al7 hypothesized that in unilateral lung con-
tusion, each lung would have a different compliance and
equal tidal volumes would result in vastly different air-
way pressures; overdistending one lung and
underventilating the other. Separating the lungs and ven-
tilating each lung at different tidal volumes to set the
plateau pressures < 26 cm H2O to prevent barotrauma
would lead to better gas exchange. 12 patients with chest
trauma and unilateral lung contusions were ventilated in
this manner with vast improvements in both PaO2 and
PaCO2.
High frequency jet ventilation also dramatically in-
creased the PaO2 in life-threatening hypoxia following
bilateral lung contusions.8
Unfortunately we did not undertake any of these meas-
ures due to nonavailability of high frequency jet ventila-
tion, and poor visualization of the airway due to bleed-
ing, limiting the insertion of double lumen tubes.
Vidhani et al9 reported good outcome in patients with
pulmonary contusions with noninvasive ventilation. They
questioned the validity of strictly following ATLS guide-
lines which mandate invasive ventilatory support for all
trauma patients with hypoxia. This needs to be explored
further.
Indian J Crit Care Med April-June 2004 Vol 8 Issue 2
Our study has several limitations. Being a retrospective
chart review, we could not standardize several interven-
tions such as prone positioning, alveolar recruitment, etc.
However, the main inference from the study is that blunt
trauma and pulmonary contusions can have a consider-
able mortality especially in the face of severe hypoxemia,
and measures to limit hypoxia should be undertaken
early. Early institution of one lung ventilation in the event
of bleeding and hypoxia should be a consideration.
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