Emerg Med Clin N Am 21 (2003) 291313

Pulmonary trauma Emergency department evaluation and management

Edward A. Ullman, MDa, Lawrence P. Donley, MDb, William J. Brady, MDb,*
Department of Emergency Medicine, Beth Israel-Deaconess Medical Center, Harvard Medical School, Boston, MA 02155, USA b Department of Emergency Medicine, University of Virginia Health System, University of Virginia School of Medicine, Charlottesville, VA 22908-0699, USA
a

Injury to the respiratory system is frequent among victims of signicant trauma. Such injury presents across a spectrum of severity. Isolated rib fractures can result in signicant pain yet cause minimal morbidity or mortality. Alternatively, pulmonary injury may impair cardiorespiratory function, resulting in signicant danger to life. Complex rib fractures (eg, pneumothorax, ail chest, hemothorax, pulmonary contusion or laceration, and tracheobronchial disruptions) are signicant injuries with substantial associated morbidity and mortality. This article focuses on the pathophysiology, recognition, and emergency department (ED) management of these life-threatening pulmonic injuries.

Pneumothorax The pleural cavity is a potential space that is created between the opposing surfaces of the visceral and parietal pleura. The surface of the lungs is enveloped by the visceral pleura, whereas the parietal pleura is adherent to the chest wall, diaphragm, and mediastinum. The two pleural surfaces are contiguous and maintain a resting negative pressure relative to the atmosphere. There is a small amount of serous uid within that allows

* Corresponding author. Department of Emergency Medicine, PO Box 800699, University of Virginia Health System, Charlottesville, VA 22908-0699. E-mail address: wb4z@virginia.edu (W.J. Brady). 0733-8627/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S0733-8627(03)00016-6

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for smooth movement between the pleurae [1]. The maintenance of this negative intrapleural pressure is important in active pulmonary expansion and passive chest wall relaxation during normal respiratory physiology [2]. A pneumothorax is the abnormal accumulation of air within the pleural space. Pneumothoraces have been described in one in ve patients surviving major trauma [3]. The pneumothorax can lead to potential life-threatening alterations in respiratory and cardiovascular physiology. The presence of air within the pleural cavity acts as a space-occupying lesion, leading to lung atelectasis, pulmonary collapse, and disturbances in ventilation and cardiac hemodynamics [2]. In blunt trauma, air can be introduced into the pleural space by two mechanisms: (1) alveolar rupture from crush injury or force applied against a closed glottis that increases intrathoracic pressure or (2) parenchymal injury from rapid deceleration or a laceration from a rib fracture. Traumatic pneumothoraces can be divided into open and closed injuries. In a closed, or noncommunicating pneumothorax, an injury has occurred in which extra-alveolar air is present in the pleural space. The air is contained and does not communicate outside of the chest wall. In blunt trauma, a closed pneumothorax frequently accompanies rib fractures. In penetrating trauma, thoracic stab wounds or gunshot wounds may produce a noncommunicating pneumothorax if the pleura is violated but the entrance tract does not communicate freely outside the chest wall. In contrast, an open pneumothorax is present when air within the pleural space is accompanied by loss of integrity of the chest wall and freely communicates with the atmosphere. The presence of an open pneumothorax can be life-threatening because it impedes normal ventilation in the unaected lung. If the diameter of the open chest wall defect is greater than the diameter of the trachea, air follows the path of least resistance and preferentially ows from the atmosphere into the pleural space on contraction of the diaphragm [4]. The open defect in the thoracic wall can cause a paradoxical decrease in pulmonary parenchymal volume on inspiration with a simultaneous increase on exhalation, as air is expelled from the pleural space. With large defects, a sucking chest wound may be appreciated, in which air may be heard rushing in and out of the pleural space with respirations. The clinician should be suspicious of a pneumothorax in any patient who has sustained thoracic trauma. Although it can be an isolated injury in blunt trauma, a pneumothorax frequently accompanies injuries to other structures within the chest and abdominal cavities [5,6]. Rib fractures are a common blunt injury leading to a pneumothorax. Even in the absence of an associated fracture or other injury, blunt force applied to the chest can cause an increase of intrathoracic pressure and rupture alveoli, resulting in a closed pneumothorax. The hallmarks of a pneumothorax on pulmonary examination are decreased breath sounds and hyperresonance to percussion over the aected

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lung [7]. With extravasation of air from the pleural space to the soft tissue, subcutaneous emphysema may be present. The patient can present in extremis with hypotension, tachycardia, cyanosis, and tachypnea or can appear relatively uninjured with normal vital signs and without distress. The most common physical complaints are chest pain and dyspnea, a result of the chest trauma and physiologic consequences of the pneumothorax itself. In the stable patient in whom the diagnosis is considered, the chest radiograph is the preferred initial study. If possible, an upright chest radiograph better delineates small pneumothoraces because air tends to accumulate at the apex of the lung [4]. In most trauma cases, the patient must remain supine because of the potential for spine trauma so the portable anteroposterior chest lm with the patient supine frequently is used. Figs. 1 and 2 are radiographic examples of pneumothoraces. If an upright lm does not show a pneumothorax and one remains clinically suspicious, an expiratory chest radiograph may prove benecial. The expiratory lm

Fig. 1. Pneumothorax. (A) Chest radiograph shows a left-sided pneumothorax. Note the sharp line (arrows) that identies the pneumothorax; this line is the interface of the periphery of the collapsed lung and pleural air collection. (B) A close-up image depicts the line (arrows) that is the interface of the periphery of the collapsed lung and pleural air collection. Numerous lines are seen on the chest radiograph. These lines may represent features external to the patients body, such as skin folds, clothing, sheets, monitoring cables, or intravenous lines; alternatively, these lines may represent bony, vascular, or organ structures within the thorax. These lines also may represent pneumothorax. In general, a line resulting from a pneumothorax does not extend beyond the hemithorax, is usually linear with gradual changes in direction, and is sharply dened compared with the other causes of such lines noted on the chest radiograph.

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Fig. 2. Pneumothorax. A right-sided pneumothorax (arrows) is seen in this patient after a motor vehicle crash with right-sided impact in a T-bone collision. A hepatic injury also was noted on evaluation. Note the clearly dened line that does not extend beyond the hemithorax, is sharply dened, and is gradual in its path (ie, no sudden changes in its path).

decreases the parenchymal volume and may make a small pneumothorax radiographically evident. The chest lm most often easily shows the pneumothorax. A precise line is noted that identies the pneumothorax; this line is the interface of the periphery of the collapsed lung and pleural air collection. Numerous lines are seen on the chest radiograph. These lines may represent features external to the patients body, such as skin folds, clothing, sheets, monitoring cables, or intravenous lines; alternatively, these lines may represent bony, vascular, or organ structures within the thorax. These lines also may represent pneumothorax. In general, a line resulting from a pneumothorax does not extend beyond the hemithorax, is linear with gradual changes in direction, and is sharply dened. The preferred method of treatment of the traumatic pneumothorax is tube thoracostomy [8]. In this procedure, a large-caliber chest tube is placed in the fth intercostal space in the midaxillary line. In the absence of uid within the pleural space, the tube can be directed anteriorly toward the apex with the patient in the supine position. With a concomitant hemothorax, the tube should be positioned posteriorly to allow adequate drainage of blood in

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the pleural space. Ideally a large-caliber chest tube (32F to 40F) should be used in the traumatic pneumothorax to facilitate adequate drainage of any uid and prevent collapse of the tube lumen [9]. The chest tube is connected to a constant source of vacuum, typically 20 cm H2O, allowing the evacuation of air within the pleural space and restoring negative intrapleural pressure. Ultimately, re-expansion of the lung is accomplished. In an asymptomatic patient without associated injuries, some investigators have advocated the use of a small (20F to 22F) tube to resolve the pneumothorax [10]. Although not typically employed in the patient who has sustained multitrauma, Laronga and colleagues [11] described the use of a pigtail catheter to resolve small pneumothoraces. In the placement of the thoracostomy tube, an open wound is created; it is important to ensure adequate closure of the wound with a secure chest tube. Distally the chest tube has multiple holes from which air and uid are evacuated from the pleural space. It is necessary to ensure that the most proximal side-port on the thoracostomy tube is advanced within the thoracic cavity. Failure to do so allows free communication of the pleural space with the atmosphere, creating an open pneumothorax. The proper placement of the chest tube should be conrmed radiographically. In addition to adequate lung expansion, one should visualize the radiopaque line delineating the proximal side-port and ensure its placement within the chest cavity. The treatment of open pneumothoraces diers in that the chest wall defect must be closed. In the initial management, the open defect should be covered with a clean occlusive dressing. This occlusive dressing application eectively creates a closed pneumothorax, allowing restoration of ventilation in the contralateral lung. To prevent a tension pneumothorax from developing after the application of an occlusive dressing, the occlusive dressing should be secured only on three sides, creating a one-way valve in which air can exit the pleural space only on exhalation [4]. Denitive care includes placement of a thoracostomy tube and repair of the open thoracic defects. In the hemodynamically unstable patient who has sustained blunt or penetrating trauma to the chest, a potentially life-saving technique is needle decompression of the pneumothorax. In this maneuver, a large-gauge intravenous catheter with attached needle is placed in the second intercostal space in the midclavicular line of the aected hemothorax. Although not a denitive therapy, the bore of the needle creates a communication of the pleural space with the atmosphere and can relieve physiologic derangements caused by a large amount of air in the pleural space. In the presence of a tension pneumothorax, a rush of air can be appreciated as positive intrapleural pressure is evacuated through the inserted needle. This technique is termed needle decompression and is only a temporizing measure until a more denitive tube thoracostomy is placed; in most instances, this treatment should occur within 10 to 30 minutes.

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Occult pneumothorax With the increased application of abdominal computed tomography (CT) in trauma evaluation, pneumothoraces that are absent on the initial chest radiograph are being detected on abdominal scansthe so-called occult pneumothorax [12]. Occult pneumothoraces are dened as injuries that are noted on the CT scan yet are not detected on chest radiograph (Figs. 3 and 4) Wolfman and coworkers [13] prospectively sought to identify further the characteristics of occult pneumothorax to determine ones that ultimately would require tube thoracostomy. In patients who had a small pneumothorax (dened as pneumothorax  1 cm and present in four contiguous CT cuts), only 2 patients of 16 underwent tube thoracostomy. There is a growing body of evidence that patients with an occult pneumothorax who do not require positive-pressure ventilation can be observed as an inpatient [1215]. The evidence is less clear regarding patients requiring positive-pressure ventilation. Certain clinicians believe that all patients with pneumothoraces requiring any operative procedure or mechanical ventilation should undergo tube thoracostomy, given the concern for worsening of the patients clinical state. Alternatively, others advocate aggressive monitoring for deterioration of cardiorespiratory status, only then necessitating chest tube placement.

Fig. 3. Occult pneumothorax. Abdominal computed tomography scan with pneumothorax (arrows).

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Fig. 4. Occult pneumothorax. Abdominal computed tomography scan with pneumothorax (arrows).

Tension pneumothorax When an external chest wall or an intrapleural injury creates a one-way valve eect causing small amounts of air to collect continually within the pleural space, a tension pneumothorax can develop. Tension pneumothorax can result in profound respiratory and hemodynamic instability. This trapped air causes a mass eect on the mediastinal structures, causing a shift toward the unaected side and increasing intrathoracic pressures, resulting in a reduction in venous return [16]. A tension pneumothorax may develop at any time after an injury and should be considered immediately for any trauma patient presenting in extremis or in any patient who acutely decompensates after sustaining trauma. The diagnosis of a tension pneumothorax always should be a clinical diagnosis. It is not recommended to await conrmation of pneumothorax under tension by chest radiograph; management should proceed accordingly [17]. If one obtains a chest radiograph in such a circumstance, the radiograph reveals a shift of the tracheal to the unaected side in addition to the pneumothorax (Fig. 5). Often the development of a tension pneumothorax has a rapid progression to marked cardiorespiratory decompensation followed by death. A patient may present tachypneic, tachycardic, and cyanotic with elevated

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Fig. 5. Tension pneumothorax. (A) A left-sided pneumothorax under tension is shown; note the shift of the trachea to the right toward the unaffected side. The actual pneumothorax in this projection is difcult to visualize. Simultaneously a right-sided pulmonary contusion is seen. (B) The same chest radiograph with arrows showing the tracheal shift (large arrows) and the penumothorax (small arrows).

jugular venous distention and evidence of air hunger. Because of the mass eect on mediastinal structures, tracheal deviation toward the unaected side, absent breath sounds, and hyperresonance to percussion may be evident [18]. Patients can present in shock with physiology similar to that of cardiac tamponade because atrial diastolic lling is compromised by the increased intrapleural pressure. As such, when one clinically suspects a tension pneumothorax, potentially life-saving therapeutic interventions should take place before any further investigations. The crucial maneuvers to treat and relieve a tension pneumothorax must take place as soon as the clinical diagnosis is suspected. The tension is relieved on insertion of a large-bore needle in the second intercostal space of the anterior midclavicular line. This needle eectively creates a communication between the atmosphere and the pleural space and decompresses the mass eect on the mediastinal structures. A rush of air is appreciated as air from the increased intrapleural space quickly ows down a pressure gradient to the atmosphere. With prompt relief of the mass eect, ventilation is restored, and hemodynamics can improve rapidly as diastolic lling pressures and cardiac output increase. After needle decompression of a tension pneumothorax, denitive therapy includes insertion of a thoracostomy tube. Similar to simple pneumothoraces, a large-bore chest tube should be inserted in the fth intercostal space directed posteriorly toward the apex. The thoracostomy tube should be connected to a constant source of vacuum, typically 20 cm H2O in a closed system.

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Rib fractures Rib fractures are the most common type of chest injury [19]. Although the incidence is unknown, studies show most rib fractures are secondary to motor vehicle accidents [1921]. In patients admitted to trauma services, rib fractures rarely are isolated. Related pulmonary contusion, pneumothorax, hemothorax, lung lacerations, and vascular injuries and related abdominal injuries frequently are found. Although rib fractures rarely are fatal, the physician must be aware of signicant pain and the potential for reductions in pulmonary function. The diagnosis of rib fractures often can be made at the physical examination. Patients often note pain and have restricted respiratory mechanics. Frequently, point tenderness and chest wall deformity are noted. The fourth through ninth ribs are most prone to fracture. The usual mechanism is an anteroposterior impact causing mid rib and lateral rib fractures. Cadaver studies show that the thorax can tolerate a 20% volume compression before rib fractures occur [22]. More recent data show that patients with air bags and shoulder belts require a much larger force to incur rib fractures versus patients with only seat belts [23]. This discrepancy is likely due to the dispersion of force in the lap belt scenario versus the front-loaded impact in patients with shoulder belts. Approximately 50% of rib fractures are noted on initial chest radiograph [21]. In patients in whom rib fractures are a concern, the chest radiograph is valuable for detection of concomitant intrathoracic injury [20]. The use of specic rib lms rarely adds clinical or therapeutic benet, and such a radiographic approach is not recommended. It is important to maintain a high level of suspicion for multiple injuries in patients with rib fractures. Shweiki and colleagues [24] found a relation between site of rib fracture and abdominal injury. Patients with right-sided rib fractures had an odds ratio of 2.87 for hepatic injury, whereas patients with left-sided rib fractures had an odds ratio of 3.98 for splenic injury. Elderly patients with multiple rib fractures have an increased incidence of pneumonia and overall increased mortality [25]. In a study of 277 elderly patients compared with a younger cohort of patients with similar Injury Severity Scores and numbers of rib fractures, the patients older than 65 developed pneumonia at rates of 31% versus 14% in the patients younger than 65 [25]. In patients with isolated rib fractures, pain management is crucial. Patients with pain often splint and hypoventilate, predisposing them to pneumonia. A prior history of altered lung function, such as chronic obstructive pulmonary disease or asthma, has not been shown to increase pulmonary complications secondary to rib fractures [19]. Outpatient management of isolated rib fractures with oral pain medications is adequate. In patients with multiple rib fractures, oral analgesia may not be sufcient. If outpatient management fails, several methods exist for analgesia. Direct intercostal nerve blockade can provide 6 hours of pain relief. A mixture of 2% lidocaine with bupivacaine is injected at the inferior border of the rib in

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question. The use of epidural catheter pain relief in isolated rib trauma has shown efcacy. There is no consensus as to which is better, the traditional intercostal blocks and more invasive procedures such as epidural blockade [26,27]. Although it is thought that fractures of the rst and second ribs indicate a high likelihood of great vessel injury, solid evidence to support this belief is lacking. Poole [1] reviewed the literature, reporting a 3% incidence of aortic injury in patients with rst or second rib fractures. However, there was no comparison between aortic injury in those with and without rib fractures. Other investigators conclude, however, that there is no conclusive evidence predicting aortic injury in blunt trauma patients with or without rst or second rib fractures [28,29].

Flail chest Flail chest may occur when more than three ribs are fractured in more than two areas. This type of injury can lead to chest wall instability and subsequent paradoxical chest wall motion. Four major injury factors aect respiratory mechanics in the ail chest scenario: pulmonary contusion, airway obstruction, pneumothorax or hemothorax, and pain. The extent of pulmonary contusion has the greatest eect on pulmonary mechanics in the patient with a ail chest [19]. Most of these injuries occur secondary to motor vehicle crashes. Other causes include falls, crush injuries, and direct impact secondary to altercations; rarely, ail chest has been noted in patients with severe osteoporosis and minimal trauma [30]. The elderly are more prone to ail segments because of decreased central muscle mass, osteoporosis, and decreased chest compliance [31]. Albaugh and coworkers [32] showed that elderly patients with ail segments had a higher mortality compared with younger patients despite similar injuries. A ail segment rarely is seen in isolation because the force required often generates multisystem involvement [33]. The diagnosis of ail chest is clinical and radiographic. Patients present with chest pain, dypsnea, and abnormal chest wall mechanics. The paradoxical motion can be seen; forced expiration or coughing may be required, however, to accent the deformity. The incidences of concomitant contusion and pneumothorax are 50% and 77% [34]. Chest radiography can indicate the presence of multiple rib fractures (Fig. 6), pulmonary contusion, and pneumothorax. Patients with pulmonary contusions are more likely to require endotracheal intubation with positive-pressure ventilation, have longer intensive care unit stays, have increased risk of pneumonia, and have higher mortality [34,35]. Treatment is based on close observation of pulmonary function. Before 1960, patients with ail segments underwent external xation. In the subsequent 2 decades, all patients were intubated to provide internal

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Fig. 6. Flail chest. Multiple rib fractures are seen on this chest radiograph of a patient who fell from a signicant height, landing on his left chest. Anterior fractures (arrows) and lateral fractures (arrowheads) are seen.

stabilization. In 1975, Trinkle and associates [36] showed that selective intubation of patients with ail segment decreased morbidity and mortality. In patients who are selectively monitored, aggressive analgesia is crucial for adequate pulmonary function. In more recent studies, epidural analgesia provided superior pain relief versus patient-controlled analgesia [26]. Hypotension is a known complication of epidural pain management; this treatment should be used in hemodynamically stable patients. Patients with ail segments are more likely to require endotracheal intubation compared with patients with simple rib fractures [32]. Multiple studies cite the following criteria for intubation: shock, closed head injury, requirement for surgery, respiratory failure or distress, and airway obstruction [20,37,38]. Although limited, there is evidence for internal xation of isolated ail segments [39]. In patients with pulmonary contusion and ail segments, there is limited benet in operative repair [40]. The high rate of associated pulmonary morbidity, including pneumonia, atelectasis, and hemorrhagereported as high as 50%limits the overall effectiveness of open stabilization [41].

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Hemothorax Hemothorax occurs when blood collects and ultimately is trapped within the pleural space. The potentially large volume of this space allows for a considerable collection of blood (2 L per hemothorax), eventually leading to hypotension and shock. The source of the hemorrhage can be from the lung itself, surrounding chest wall, adjacent great vessels, or the relatively distant intra-abdominal tissue. Penetrating trauma, particularly gunshot wounds, has a predisposition to hemothorax. If one compares traumatic causes, overall mortality is greater in blunt (40%) versus penetrating (20%) injuries [42]. Although the physical examination may suggest hemothorax, the diagnosis is made most often by chest radiograph (Fig. 7). A minimum of 200 to 300 mL of blood is needed for blunting of the costophrenic angle as seen on the chest radiograph. In the supine patient, blood layers posteriorly, creating a diffuse radiodensity that can range from minimal density to complete opacication. Lateral chest lms may differentiate a pulmonary contusion from hemorrhage. Treatment is based on evacuation of blood and constant evaluation for continued hemorrhage. Patients are at risk for shock, collapse of the aected lung, and preload compromise secondary to vena caval impingement [43]. A large thoracostomy tube, 36F or 38F, should be placed posteriorly for proper drainage. A repeat chest lm is needed for evaluation of proper placement of the tube and adequate drainage of the pleural blood collection. In the patient with greater than 1500 mL of blood at tube placement or at a rate of drainage of 200 mL/h for 3 hours, the clinician should obtain surgical consultation for consideration of thoracotomy [32]. Other indications for thoracotomy are weight based using an initial blood loss of 20 mL/kg or 7 mL/kg for 3 hours. The incidence of thoracotomy for hemothorax is 5% to 15% [44]. It is important to evacuate all blood to reduce the opportunity for empyema and to allow for complete pulmonary parenchymal expansion [45,46]. There has been an increase in the use of thoracoscopy for the evacuation of residual hemothorax given the low postoperative complication rate and earlier discharge from the hospital [47,48]. In patients with continued bleeding from a thoracic wound that does not require thoracotomy, thoracoscopic evaluation can provide an alternative to prolonged chest tube placement [49]. Pulmonary contusion Pulmonary contusion is the most common pulmonary parenchymal injury in blunt chest trauma. Of all contusions, 70% occur secondary to motor vehicle crashes [50] with other causes including falls from a signicant height and penetrating thoracic injury, although the latter does not produce the widespread extent of injury compared with blunt trauma. Of patients

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Fig. 7. Hemothorax. (A) Right-sided hemothorax with blood accumulation primarily in the right costophrenic angle and right base (black arrows) and minimal tracking upward of the blood in the pleural space (white arrows). This radiograph was taken with the patient in a semiupright position. (B) Close-up of radiograph. (C) In contrast to A, this chest radiograph was obtained in the supine position. As such, the blood is tracking posteriorly and upward (arrows).

with multiple injuries secondary to blunt trauma in the Yale trauma registry, 17% had pulmonary contusion [51]. Overall, mortality resulting strictly from the contusion is difcult to identify in that it is rare to sustain such an isolated injury. In multitrauma patients, mortality in association with pulmonary contusion is 35% [52]. The associated pathophysiology is unclear. There are three proposed mechanisms of pulmonary contusion: (1) the implosion eect, which results from expansion of air secondary to a pressure wave, leading to alveolar tearing; (2) the inertia eect, which occurs when lighter alveoli are stripped from heavier bronchial structures; and (3) the spalling eect, which is shearing at the gas-liquid interface. The damage leads to subsequent ventilation-perfusion inequalities and decreased lung compliance

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[20,5052]. With minor pulmonary injury, relatively smaller areas of hemorrhage and edema are noted. With increased trauma, a marked increase in edema, hemorrhage, and alveolar rupture is shown [53]. Diagnosis is based on knowledge of the mechanism, the physical examination, and the chest radiograph. Patients who sustain chest wall trauma should be evaluated for developing pulmonary contusion; the presence of respiratory compromise manifested by dyspnea, tachypnea, and hypoxia should heighten the clinicians concern. The chest lm is the mainstay of diagnosis of pulmonary contusion (Fig. 8). Presentation varies within a spectrum of patchy inltrates to frank consolidation. The presence of rib fractures should raise the suspicion of pulmonary contusion. Chest lms do not have high sensitivity in the acute setting (ie, early in the presentation). In a study by Hoff and colleagues [53], only 64% of patients diagnosed with pulmonary contusion had a positive initial chest lm. The radiographic ndings are often seen within 6 hours of injury [38]. It has been shown that 11% of patients with pulmonary contusion have a delayed radiographic presentation of the injury [52]. Chest CT has shown promise in earlier and more detailed detection of pulmonary contusion [54]. It is unclear, however, if the use of the chest CT scan alters clinical decision making. Omert and colleagues [54] showed that a patient with a pulmonary contusion diagnosed by chest CT scan only rarely required aggressive pulmonary intervention. It also has been shown that the initial size of the contusion does not correlate with mortality, although larger injuries have increasingly deleterious effects on respiratory function [52,55,56]. Radiographic ndings of pulmonary contusions usually resolve within 10 days. In patients who present to the ED with a recent pulmonary contusion and evidence of progressive worsening of pulmonary function, the clinician should have a high index of suspicion for pneumonia [50]. Patients with pulmonary contusion require aggressive cardiorespiratory monitoring, supplemental oxygen, and careful observation. Early aggressive pulmonary toilet is crucial in reducing the need for mechanical ventilation because there is no benet in prophylactic intubation [36]. In patients who are managed with endotracheal intubation with mechanical ventilatory support, the use of positive end-expiratory pressure during mechanical ventilation is crucial. Judicious use of positive end-expiratory pressure is warranted, however, because excessive pressure can lead to increased contusion size [50]. Rapid or large-volume crystalloid infusions, which frequently are given during trauma resuscitation, may produce increased areas of edema and inammatory inltrate in contused areas owing to increased capillary permeability in the injury zone [57]. In patients with known contusion and hypotension, early administration of colloid may limit total lung involvement [50]. Antibiotics should be given only if there is evidence of pneumonia. No studies show benet in prophylactic antibiotic administration, including patients who are managed with mechanical ventilation despite their

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Fig. 8. Pulmonary contusion. (A) Right upper eld pulmonary contusion in a blunt trauma patient. Note the opacity (white, large arrow) and the adjacent lateral rib fractures (small, black arrows). (B) Signicant right-sided pulmonary contusion noted by the opacity (arrow). (C) Chest radiograph performed 12 days later that shows near-complete resolution of the contusion.

increased risk for pulmonary infection [50,51]. Prophylactic use of steroids has shown equivocal results; it is unclear whether the use of steroids would increase the incidence of pneumonia [23]. As such, the administration of steroids currently is not recommended. Patients with blunt or penetrating chest trauma also may experience pulmonary laceration. Blunt injuries, secondary to the shear force mechanisms, and penetrating injuries produce laceration of the lung tissue. In the blunt trauma patient, this injury almost always occurs with coexistent rib fracture and pulmonary contusion. The radiographic appearance (Fig. 9) has a large spectrum ranging from patchy inltrates to frank consolidation. In the acute setting, contusion can mimic the clinical presentation of hemothorax [58]. The diagnosis is conrmed by chest CT scan. Management ranges from close observation to thoracotomy depending on the mechanism, degree of injury, and associated problems.

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Fig. 9. Pulmonary laceration. Right-sided opacity in a blunt trauma patient. This patient was involved in a high-speed motor vehicle crash. Subsequent chest computed tomography scan revealed signicant parenchymal injury with lung laceration.

Post-traumatic pulmonary pseudocyst The spectrum of pulmonary parenchymal injuries ranges from pulmonary contusion to post-traumatic pseudocysts (PTPs). PTPs are a rare manifestation, occurring only in 3% of all lung parenchymal traumas [5961]. They have been reported in children and young adults primarily secondary to blunt trauma [58,61,62]. PTPs caused by penetrating trauma are secondary to intraparenchymal lesions [59]. The pathophysiology of blunt trauma causing PTP is less clear. Concussive forces can create shearing stresses that overcome the elastic properties of the lung. Compressive forces can rupture alveoli. In animal models, the combined forces seem to determine the extent of parenchymal injury [61]; this is likely to occur in a situation in which bronchial pressure cannot escape because of a closed glottis. Air initially enters the nonepithelialized cavity with subsequent bleeding into the cavity creating an air-uid level.

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The clinical symptoms of PTP are nonspecic and consist of chest pain, cough, and hemoptysis [16,62]. Most PTPs present within 12 hours to 14 days after trauma [61,62]. Respiratory failure caused by PTP alone is rare in young adults. The clinician should have a high index of suspicion for signicant pulmonary pathology in patients with respiratory complications. Adults are more likely to have associated pulmonary contusion and respiratory difculty [61]. Diagnosis is made by chest radiograph. The lesion appears as a rounded area with or without an air-uid level. Often the lesion is midthorax adjacent to mediastinal structures or pulmonary contusions, if present [60]. PTP has been mistaken for diaphragmatic herniation. CT scan has allowed for increased early and precise detection of PTP [62]. Management is primarily supportive because most PTPs resolve spontaneously. Infected pseudocycts are rare and usually require surgical drainage because antibiotic therapy is rarely eective [61]. Patients with complex lesions may require surgical thoracotomy and possible lobectomy.

Tracheobronchial injuries Traumatic rupture of the bronchus is a rare but potentially lethal injury in blunt pulmonary trauma. This injury is unusual; in Bertelsen and Howitzs study [63], approximately 3% of 1128 patients at autopsy had evidence of tracheobronchial injury, with most (81%) having died before ED presentation. Clinical presentations are nonspecic, yet always feature prominent respiratory distress; associated injuries, involving the respiratory system and extending beyond the lungs, include pneumothorax, hemothorax, rib fracture, pulmonary contusion, and numerous other multisystem injuries [18,6468]. Only 45% of tracheobronchial injuries were identied by physical examination, showing the underlying difculty in a prompt diagnosis [69]. The chest radiograph (Fig. 10), although nonspecic for rupture, may show pneumothorax and pneumomediastinum. Often in the ED, the patient is noted to have a persistent air leak on endotracheal intubation or continued pneumothorax despite adequate placement of the tube thoracostomy. Chest CT scan may show the actual site of injury; conversely, it may show only a continued collapse of the lung with chest tube placement in the hemothorax (Fig. 11). Bronchoscopy continues to be the gold standard for diagnosis and should be done in the operating room to allow for immediate surgical repair [66,67]. There are three proposed mechanisms for tracheobronchial injuries [64]. First, on thoracic compression, the lungs are pulled creating carinal traction. Rupture occurs when the elasticity is compromised. Second, with a closed glottis, the intrabronchial pressure is increased greatly, particularly in the larger bronchi [64,67]. Third, rapid deceleration creates high shearing forces on the xed carina. Most injuries are secondary to high-speed motor vehicle

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Fig. 10. Tracheobronchial injury. Right main stem bronchial injury in a blunt trauma patient. The lung has collapsed on the hilar area and lies dependent on in the chest. Continued collapse despite the presence of a chest tube is a strong clinical suggestion of tracheobronchial injury. This appearance of the lung is termed the fallen lung sign.

accidents because these can generate the necessary kinetic energy. Other causes include crush injuries and falls [65]. Of all ruptures, 47% occur in the right bronchus [65]. Usually the injury occurs within 2.5 cm of the carina. Although rare, reported cases describe bilateral bronchial injuries. Because physical ndings and chest radiographs often are nonspecic, the diagnosis frequently is missed [67]. Delay in surgical repair can lead to bronchial stenosis and subsequent atelectasis, pneumonia, mediastinitis, and increased mortality. Penetrating injuries to the bronchus are seen rarely in the ED because they carry a high mortality owing to their involvement of the great vessels. Charity Hospital in New Orleans reported only 22 cases in a 20-year period [70]. In patients who survived to the ED, the size of the bronchial wound, associated injuries, and blood loss determine survival [43]. With respect to the involvement of the airway, most penetrating injuries occur in the cervical trachea; 18% of injuries occur at the carina or distally [71]. The diagnosis of penetrating tracheobronchial injuries, similar to cases of blunt trauma, is made by bronchoscopy. Management involves thoracotomy in the unstable patient. It is recommended that a right-sided thoracotomy be performed initially because this avoids the aorta, while exposing most of the bronchial tissue. In the case of left-sided distal injury, the thoracotomy can be extended [72].

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Fig. 11. Tracheobronchial injury. Chest computed tomography scan of the patient in Fig. 10 shows the persistent pneumothorax despite the presence of the tube thoracostomy.

Penetrating injuries Initial management of pulmonary trauma requires aggressive monitoring of the ABCs of airway, breathing, and circulation. Prompt recognition of life-threatening complications (ie, tension pneumothorax, ail chest, open pneumothorax, and massive hemothorax) should be diagnosed and treated by advanced trauma life support protocol during the primary assessment [42]. Lethal injuries can be evaluated using only the patients clinical presentation [73]. Patients who do not require immediate transport to the operating room for stabilization often have pulmonary injuries; a chest radiograph for the evaluation of pneumothorax, hemothorax, pulmonary contusion, and fractured ribs is required [74]. Patients with a pneumothorax should receive a tube thoracostomy. Penetrating injuries bordered by the nipple anteriorly, the scapula posteriorly, the scapula superiorly, and the xyphoid inferiorly likely require operative exploration. With the evolution of observation units in ED, ultrasound performed at the bedside can aide in the diagnosis of cardiac tamponade [75]. In patients with thoracic trauma not requiring immediate intervention, serial chest radiographs are used to evaluate delayed presentations of pneumothorax and hemothorax. Approximately 10% to 12% of patients with initially negative chest lms develop pneumothorax in penetrating trauma [76]. Initial studies showed that a 6-hour observation period was appropriate for a negative evaluation of thoracic stab wounds in patients

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with initial normal chest radiographs [77]. A 3-hour observation for asymptomatic chest wounds in stable patients has proved successful [78,79]. In these studies, no patient developed a pneumothorax on the 6-hour chest radiograph, and none were readmitted secondary to complications. Summary Pulmonary trauma is a signicant cause of morbidity and mortality in the United States. It is imperative for the emergency physician to identify promptly patients who require immediate therapy. In patients who have limited injuries, literature shows that often conservative management provides improved outcome. As the exposure to automobiles and rearms continues to increase in the setting of improved prehospital management, the emergency physician will encounter an increasing amount of pulmonary trauma. This rise in respiratory injuries will require a more aggressive approach of patients with minimal morbidity and mortality. A systematic approach to respiratory injuries is crucial to improving patient outcomes. References
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