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Basics ⬇

Author(s): DouglasComeau, DO, CAQSM, FAAFP and Angelene M.Elliott, DO

Description

  • Blunt trauma to the chest causing disruption of alveolar capillary interface, resulting in collection of blood, edema, and protein in the interstitium and alveoli
  • Clinical diagnosis is suggested by hemoptysis or progressive respiratory distress and confirmed by imaging.
  • Synonym(s): bruised lung

Epidemiology

  • In contact sports, chest wall contusions occur frequently and are managed by athletic trainers without being reported.
  • There are only seven sport-reported cases of pulmonary contusion in the literature since 1997 (2,3,4,5,6).
  • In all comers to an emergency department (ED) during the 1990s (7):
    • 26% of rib fractures are associated with pulmonary contusion.
    • 32% are associated with hemothorax/pneumothorax.

Etiology and Pathophysiology

Blunt trauma to the chest causing disruption of alveolar capillary interface, resulting in collection of blood, edema, and protein in the interstitium and alveoli which can lead to bronchospasm, increase in production and decrease of clearance of mucus, and decrease in production of surfactant, resulting in possible pulmonary dysfunction like ventilation/perfusion mismatch, increase in intrapulmonary shunt, increase in lung fluid, and loss of lung compliance. This results in damaged lung that is unable to exchange gas effectively in respiration.

Risk-Factors

  • Collision/contact sports
  • Sports with high speeds or where the athlete is airborne:
    • Cycling, equestrian, winter sports, auto and motorcycle racing, extreme sports, and so forth

General Prevention

Use protective equipment and padding appropriate for the activity, such as seat restraints in motor sports to prevent ejection:

  • Padding may diffuse force on impact.
  • Padding after the injury can decrease pain of subsequent impacts.

Commonly Associated Conditions

  • Chest wall contusion
  • Rib fracture
  • If high-velocity trauma, intra-abdominal organ injury may occur.

Diagnosis ⬆ ⬇

Diagnosis is suspected when an athlete sustains a blunt trauma to the chest and has respiratory difficulty:

  • Hemoptysis after an injury is highly suggestive of a pulmonary contusion.

History

  • Blunt nonpenetrating trauma
  • Chest wall contusion is often the initial diagnosis.
  • Hemoptysis may be present, but its absence does not rule out a contusion.
  • Pain in the shoulder or scapular angle suggests abdominal or diaphragmatic injury.
  • If fever is present, consider infectious differential.
  • Consider pulmonary parenchymal contusion when dyspnea is progressive over hours or days or if hemoptysis occurs.
  • Nasal or facial trauma supports consideration of epistaxis as the etiology of bleeding possibly instead of pulmonary injury in the absence of obvious chest trauma.
  • High-energy/velocity injuries should increase suspicion for associated injuries.

Physical Exam

  • High-velocity/energy injuries should prompt full trauma evaluation:
    • Both primary and secondary surveys should be performed in these cases.
  • Dyspnea or tachypnea must be present for diagnosis, unless hemoptysis occurs.
  • Palpable and pleuritic chest wall pain are present due to the impact force required to produce a pulmonary contusion.
  • Arm or trunk movement may worsen chest pain.
  • Dyspnea may persist after rest.
  • Chest wall region is tender.
  • Ecchymosis usually will not be present initially, but crepitus or more severe point tenderness often is present when ribs are fractured.
  • Auscultation is generally normal:
    • Consider hemopneumothorax if abnormal lung sounds are present.
  • Inspect and record naso-oropharyngeal findings, as hemoptysis may be reported later:
    • Note any evidence of bleeding in the nose or mouth.
    • Evaluate nose and posterior pharynx for sites of bleeding, as nasal trauma or bites of cheeks or tongue are more common than pulmonary contusion as the source of blood in suspected hemoptysis.
  • Clear cervical (C)-spine and other abdominal injuries in the presence of significant blunt trauma to the chest.
  • Record serial vital signs/exams if athlete is unable to return to play to observe for deterioration:
    • Pulse oximetry <91% suggests contusion with arteriovenous (AV) shunting.
  • Abdominal examination for tenderness or guarding is critical:
    • Penetrating injury occurring anteriorly at rib interspace 5 or below may penetrate the abdomen
  • Observe the chest closely for paradoxical movement of a segment of ribs indicative of flail chest.

Differential Diagnosis

  • Pulmonary emboli
  • Traumatic pneumothorax or hemothorax
  • Diaphragmatic, splenic, or hepatic injury
  • Pulmonary laceration or hematoma
  • Spontaneous pneumothorax
  • Rib fracture or contusion
  • Naso-oropharyngeal trauma
  • Tracheobronchial mucosal avulsion
  • Epistaxis

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

  • Decreasing pulse oximetry (<91%) suggests pulmonary contusion with AV shunting:
    • Consider pneumothorax with low pulse oximetry as well.
  • Posterior, anterior, and lateral CXR:
    • May not be required for chest pain in absence of dyspnea or hemoptysis
    • Rib films do not contribute to management in absence of pulmonary symptoms or clinical flail fracture.
    • Clinically significant hemopneumothorax and pneumothorax can generally be ruled out with negative radiographs; however, additional imaging should be considered based on the mechanism of injury and clinical findings, as normal radiographs do not definitively exclude underlying lung injury.
  • Posterior, anterior, and lateral CXR reveals peripheral infiltrate in area of trauma when significant contusion occurs:
    • Generally seen within 6 hr but may take up to 48 hr for radiographic changes
    • The infiltrate may not correlate to lobular architecture.
    • Enlargement in x-ray in first 24 hr is generally a poor prognostic finding.
  • CT and other imaging will be guided by the clinical picture:
    • CT might be useful to determine the need for mechanical ventilation and likelihood of pneumonia or acute respiratory distress syndrome (ARDS).
    • Ventilation/perfusion scan may show matched ventilation/perfusion defect, unlike pulmonary embolus, which shows ventilation/perfusion mismatch.
  • Chest ultrasound (US) may be comparable to CT for pulmonary contusion.
  • Follow-up imaging guided by clinical symptoms and severity of injury:
    • Isolated contusion in the athlete generally does not require repeat radiographs.
    • Consider if symptoms are not resolving over 5 to 7 days or worsen.

Diagnostic Procedures/Other

If hemoptysis is recurrent over >48 hr, bronchoscopy may be considered, depending on clinical status (8):

  • Hemoptysis should generally clear within 1 wk.

Treatment ⬆ ⬇

  • Prehospital:
    • Primary on-field concerns:
      • Multiple cites of trauma in motor sports or high-velocity sports (downhill skiing) should be stabilized and transported immediately by emergency services to a designated trauma center:
        • Primary concerns with severe trauma are airway, breathing, and circulation.
        • Evaluate for C-spine injury; immobilize as indicated.
        • Expose by removing equipment as needed.
        • Report any increase in dyspnea; may need support, oxygen, and ventilation
    • Mild to moderate injuries may be observed on site and reevaluated frequently for signs of decompensation.
    • Transport for worsening symptoms:
      • Dyspnea and tachypnea are the most important signs of deterioration.
  • ED treatment:
    • In cases of multiple trauma due to motor vehicle accident or high-velocity impact, general trauma protocols should be followed.
    • In contact sports, trauma with isolated pulmonary contusion may be treated with observation and minimal support as needed:
      • Pain medication
      • Oxygen
    • Penetrating injuries and flail chest are associated with a much higher risk of complications, including the need for mechanical support.

Medication

  • Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as first line for mild to moderate pain:
    • Consider avoiding NSAIDs in patients with hemoptysis.
  • Narcotic pain medications may be needed in more severe cases:

Additional Therapies

  • Isolated pulmonary contusion in stable patients does not require additional treatment:
    • Rest from strenuous exercise as needed to allow pulmonary healing
  • Additional supportive and treatment measures will be dictated by the severity of injuries:
    • Pulmonary toilet
    • Chest tube may be required emergently if hemopneumothorax is present.
  • Light exercise or walking promotes deep breathing and retards atelectasis.
  • When asymptomatic, begin stepwise return to play as tolerated by symptoms.
  • Rib taping and other attempts at immobilization are generally not effective and should be used with caution, as they could possibly increase the risk of atelectasis and pneumonia.

Admission, Inpatient, and Nursing Considerations

  • Admission criteria:
    • Traumatic injuries requiring stabilization and support
    • Patient with respiratory difficulty and oxygen saturations <90%
    • Patients with uncontrolled pain
  • Special considerations:
    • Rib fractures can be associated with severe blunt trauma, but these cases generally involve high-energy mechanism.
    • Flail chest is a rare but serious complication requiring hospitalization to observe for pulmonary deterioration and need for intubation with respiratory support.
    • Pulmonary laceration:
      • Transfer of energy from the chest wall; shear forces often are generated that can tear the lung.
      • Most lacerations heal without complications, but elastic recoil of the lung may extend the laceration to form a pulmonary pseudocyst, which may result in infection, abscess, hemoptysis, air leak, adult respiratory distress syndrome, and death.
      • One case report in soccer player
    • Airway avulsion or rupture:
      • Most common site is within 2.5 cm of the carina between tracheal rings.
      • Findings include subcutaneous (SC) emphysema and hemoptysis.
    • Isolated pneumothorax is uncommon with blunt trauma due to dense fibroconnective tissue surrounding carina and mainstem bronchi.
  • Discharge criteria
    • Stable patients can be discharged home with observation and instructions to return for worsening symptoms:
      • Pain controlled
      • No significant dyspnea
      • Stable oxygen saturation on room air:
        • No consensus but generally >90% for an otherwise healthy individual

Ongoing Care ⬆ ⬇

Return to play (2,3)[C]:

  • Simple chest wall contusions:
    • Same day
    • Athlete must be nondyspneic, able to perform usual movements as required for the sport, and able to tolerate pain without narcotics or local anesthetic.
    • On return to play, rib pads, flak jacket, or equestrian chest protector may decrease discomfort and reinjury during contact.
    • Remove from activity for recurrent dyspnea; consider CXR.
  • Pulmonary contusions:
    • Field-side diagnosis with hemoptysis or persistent pain precludes return to that contest.
    • Athlete may return to full activity at 1 wk if they tolerate progressive training without dyspnea, hemoptysis, or limited performance after the last episode.
    • After strenuous exercise is tolerated for 48 hr and athlete is able to perform at a level appropriate for contact sports, return to play in contact sports may be allowed.

Follow-up Recommendations

  • Report any deterioration in performance or dyspnea.
  • Pulmonary consultation for bronchoscopy if hemoptysis persists

Prognosis

  • Most isolated pulmonary contusions will resolve without complication.
  • Chest wall pain usually persists for 6 wk but generally will not interfere with function.
  • Isolated pulmonary contusion in young, healthy patients is not associated with mortality.

Complications

  • Posttraumatic empyema
  • ARDS (strong association if Thoracic Trauma Severity score at admission >13) (9)[C]
  • Pneumonia
  • Factors associated with a poor outcome in severe pulmonary contusion (multiple traumas/motor vehicle accident):
    • Poor outcome = death, prolonged hospitalization >7 days, severe complications (pneumonia, empyema, atelectasis requiring bronchoscopy or bronchopleural fistula):
      • Pulmonary contusion on admission CXR
      • Three or more rib fractures
      • Chest tube insertion
      • Hypoxia on admission (PO2 <70 torr)

Additional Reading ⬆ ⬇

Dubinsky I, Low A. Non-life-threatening blunt chest trauma: appropriate investigation and treatment. Am J Emerg Med. 1997;15(3):240–243.

References ⬆ ⬇

  1. Cohn SM, Dubose JJ. Pulmonary contusion: an update on recent advances in clinical management. World J Surg. 2010;34(8):1959–1970.
  2. Lively MW, Stone D. Pulmonary contusion in football players. Clin J Sport Med. 2006;16(2):177–178.
  3. Meese MA, Sebastianelli WJ. Pulmonary contusion secondary to blunt trauma in a collegiate football player. Clin J Sport Med. 1997;7(4):309–310.
  4. Gillespie H, Sisson R, DiFiori JP. Pulmonary contusion in a football player. Curr Sports Med Rep. 2013;12(2):57–58.
  5. Milne LW. Thoracic trauma in polo: two cases and a review of the literature. J Emerg Med. 2011;40(4):410–414.
  6. Lively M. Pulmonary contusion in a collegiate diver: a case report. J Med Case Rep. 2011;5:362.
  7. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975–979.
  8. Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management. Am Fam Physician. 2005;72(7):1253–1260.
  9. Daurat A, Millet I, Roustan J, et al. Thoracic trauma severity score on admission allows to determine the risk of delayed ARDS in trauma patients with pulmonary contusion. Injury. 2016;47(1):47–153.

Clinical Pearls ⬆

  • Blunt thoracic trauma with high-energy mechanism should always prompt a thorough evaluation, as pulmonary contusions and rib fractures are commonly associated with significant internal injuries:
    • This is in contrast to most sports-related injuries, which are usually lower energy and are generally associated with good outcomes.
  • Significant morbidity in clinically stable patients has not been reported. One episode of hemoptysis in an asymptomatic athlete will likely not recur and imaging is not required. Pulmonary dysfunction associated with a contusion may take 24 to 48 hr to develop as fluid accumulates in the air spaces. Serial reevaluations daily may be needed to detect worsening tachypnea and tachycardia. Get emergency follow-up evaluation if delayed deterioration occurs rapidly.
  • Future ability to play is only as limited by chest wall pain. Return to peak conditioning depends on ability to reach maximum exertion effort. Involuntary guarding of pleuritic pain during healing may delay recovery to peak form for up to 6 wk.