Pulmonary contusion - Wikipedia https://en.wikipedia.

org/wiki/Pulmonary_contusion

From Wikipedia, the free encyclopedia

A pulmonary contusion (or lung contusion) is a

contusion (bruise) of the lung, caused by chest trauma. Pulmonary contusion
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 A CT scan showing a pulmonary contusion (red
recognition. In the 1960s its occurrence in civilians arrow) accompanied by a rib fracture (blue arrow)
began to receive wider recognition, in which cases it is Classification and external resources
usually caused by traffic accidents. The use of seat belts
and airbags reduces the risk to vehicle occupants. Specialty emergency medicine
ICD-10 S27.3 (http://apps.who.int
Diagnosis is made by studying the cause of the injury, /classifications/icd10/browse/2016/en#
physical examination and chest radiography. Typical /S27.3)
signs and symptoms include direct effects of the physical
trauma, such as chest pain and coughing up blood, as ICD-9-CM 861.21 (http://www.icd9data.com
well as signs that the body is not receiving enough /getICD9Code.ashx?icd9=861.21),
oxygen, such as cyanosis. The contusion frequently heals 861.31 (http://www.icd9data.com
on its own with supportive care. Often nothing more than /getICD9Code.ashx?icd9=861.31)
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 deadly: small contusions may have little or no impact on the patient's
health, yet pulmonary contusion is the most common type of potentially lethal chest trauma. It occurs in
30–75% 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.

1 Classification

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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
6.1 X-ray
6.2 Computed tomography
6.3 Ultrasound
7 Prevention
8 Treatment
8.1 Ventilation
8.2 Fluid therapy
8.3 Supportive care
9 Prognosis
9.1 Complications
9.2 Associated injuries
10 Epidemiology
11 History
12 References
13 External links

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 The alveoli
(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.

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

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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 24–48 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]

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 Motor vehicle accidents are the most
these.[21] This is the primary cause of death among people who common cause of pulmonary
initially survive an explosion.[22] Unlike other mechanisms of injury contusion.
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]

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.

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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]

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 capillary–alveolar 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

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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
Normally, oxygen and carbon dioxide
syndrome.[39]
diffuse across the capillary and
alveolar membranes and the
Ventilation/perfusion mismatch interstitial space (top). Fluid impairs
this diffusion, resulting in less
Normally, the ratio of ventilation to perfusion is about one-to-one;
oxygenated blood (bottom).
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 better-ventilated
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]

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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

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
A chest X-ray showing right sided
ARDS.[10]
(seen on the left of the picture)
Although chest radiography is an important part of the diagnosis, it pulmonary contusion associated with
is often not sensitive enough to detect the condition early after the rib fractures and subcutaneous
injury.[35] In a third of cases, pulmonary contusion is not visible on emphysema
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

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 24–48 hours
after trauma as bleeding and edema into lung tissues progress.[46] CT
scanning also helps determine the size of a contusion, which is A chest CT scan revealing pulmonary
useful in determining whether a patient needs mechanical contusions, pneumothorax, and
ventilation; a larger volume of contused lung on CT scan is pseudocysts
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]

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Ultrasound

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]

An ultrasound image showing early

Prevention of pulmonary contusion is similar to that of other chest pulmonary contusion, at this moment
trauma. Airbags in combination with seat belts can protect vehicle not visible on radiography. Interstitial
occupants by preventing the chest from striking the interior of the
syndromes are expressed with the
vehicle during a collision, and by distributing forces involved in the
vertical white lines, the "B-lines".[48]
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]

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

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

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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 Mechanical ventilation may be
required if pulmonary contusion
occur,[7] but most significant contusions do require intubation, and it
causes inadequate oxygenation.
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]

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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]

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 injury—when 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 This CT scan, taken 22 days after
capacity for as long as six years after the injury.[38] As late as four pulmonary contusion with major
years post-injury, decreased functional residual capacity has been chest trauma, shows that the
found in most pulmonary contusion patients studied.[43] During the contusion has completely
six months after pulmonary contusion, up to 90% of people suffer resolved.[64]
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

Pulmonary contusion can result in respiratory failure—about half of such cases occur within a few hours of
the initial trauma.[43] Other severe complications, including infections and acute respiratory distress

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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

A chest X-ray showing acute 20% of people with pulmonary contusion.[13] Contused lungs are
respiratory distress syndrome 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

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 Severe pulmonary contusion with
the scapula are associated with pulmonary contusion. [27] The pneumothorax and hemothorax
contusion is frequently found underlying fracture sites.[35] When following severe chest trauma[68]
accompanied by a fracture, it is usually concentrated into a specific
location—the 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 4–11% of pulmonary contusions.[6]

Pulmonary contusion is found in 30–75% of severe cases of chest injury, making it the most common

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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 14–40%, 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]

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]

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

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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 Giovanni Battista Morgagni, credited
described.[20] Before the 1960s, it was believed that the respiratory with having first described lung
insufficiency seen in flail chest was due to "paradoxical motion" of trauma without chest wall trauma
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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