12/9/23, 4:15 PULMONARY CONTUSION AND FLAIL CHEST | Clinical Gate

PULMONARY CONTUSION AND FLAIL

CHEST
CHAPTER 36 PULMONARY CONTUSION AND FLAIL CHEST

Carl J. Hauser, David H. Livingston

Pulmonary contusion and flail chest are the two most common anatomic complications of major
blunt chest trauma. Each will directly alter pulmonary physiology in a specific and unique fashion,
and thus contribute to pulmonary dysfunction and failure after trauma. Pulmonary contusion was
probably first described by Morgagni in the 18th century, but Laurent’s description in the Lancet in
18831 appears to be the first to recognize the possibility that plasticity of the chest wall, most
notably in the young, can allow injury to the underlying lungs without disruption of the bony thorax.
Conversely, flail chest is predominantly a disease of the elderly, with most patients being in the
sixth decade of life and beyond and older patients having the worst outcomes.2–4 Pulmonary
contusion and flail chest commonly coexist but their degree of association changes and they may
exist entirely separately under specific circumstances in specific patient groups. Yet because of
their close association, their effects on pulmonary pathophysiology are often confused. Such
confusion can lead to misapplication of studies aimed at one entity or the other and eventually to
inappropriate treatment.

INCIDENCE
Pulmonary hemorrhage and contusion were noted to be common at autopsy of patients dying
from battlefield and blast injuries during World War I.5,6 Similar findings were noted in World War
II,7,8 and the term “pulmonary concussion” appears to have been coined by Hadfield describing
civilian injuries from bomb blasts sustained during the Battle of Britain.9 Reports in the 1960s first
noted that pulmonary contusions occurred frequently after civilian motor vehicular trauma and
were seen in up to 10% of thoracic injuries.10

Currently, the incidence of “pulmonary contusion” varies markedly depending on how aggressively
it is sought and diagnosed. In some large series, about 15% of major blunt injuries11 are found to
have a pulmonary contusion. Using closer computed tomography (CT) evaluation, up to 25% of
patients with chest trauma may be noted to have some form of contusion.12 Yet a 10-year registry
review of approximately 20,000 blunt trauma patients seen at the New Jersey State Trauma
Center in Newark performed in preparation for this review showed that only 2.6% of all patients
arriving at our Level I trauma center were diagnosed as having a pulmonary contusion.

So the “denominator” patient population examined will clearly affect the disease incidence
reported in administrative databases, as will the tendency to identify and report less severe
injuries. Yet our experience over the last several years indeed shows that the diagnosis of
pulmonary contusion is increasing alongside our increased use of CT diagnosis for chest trauma
(Figure 1).

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Figure 1 Subclinical “computed tomography–only” pulmonary contusion.

The extent to which these previously subclinical injuries will turn out to predispose patients to
complications remains to be seen, but these considerations suggest that future scaling systems
for thoracic trauma will need to take into account the fact that modern imaging may find
contusions that are either physiologically insignificant or that may “prime” the lung for secondary
injury rather than lead to immediate dysfunction.

The relative frequency of flail chest as compared with pulmonary contusion will also vary
depending upon the denominator population. Pediatric reviews find that the majority of major
thoracic trauma presents with pulmonary contusions whereas flail chest is very rare, even where
multiple fractures exist.13,14 In contrast, in a large contemporary descriptive series examining
adult blunt chest trauma, flail chest was diagnosed in about half of all patients with significant
pulmonary contusions.11 Moreover, the diagnosis of flail chest is often missed or delayed in sicker
patients that require mechanical ventilation.4 This results from the synchronous expansion of the
lungs and “splinting” of the chest wall by positive intrathoracic pressure. Thus, it is clear that the
proportions change and flail chest becomes increasingly common with advancing age and
brittleness of the thoracic cage. Consequently, the frail elderly frequently sustain a flail chest with
relatively minor chest trauma and little or no pulmonary contusion. Similarly, flail chest has been
reported in newborns with osteogenesis imperfecta.15

Physical Mechanisms of Injury

The overwhelming majority of significant blunt chest trauma in civilian life occurs as a result of
motor vehicle crashes and motor vehicle versus pedestrian injuries. Falls are another common
cause of pulmonary contusion and flail chest. Thoracic compression injuries are not as common
as vehicular trauma and falls, and although they may produce similar syndromes, the slower
speed of impact makes contusion less likely than flail chest. Rather, these patients may manifest
traumatic asphyxia. In military practice, blast injuries from high explosives can occur both in air
and underwater. These produce specific and recognizable diffuse contusion patterns resulting
from the concentration of energy at interfaces between denser tissues and tissues that contain
gas, like the lung and bowel. Although these injuries have been rare in civilian life for the last 60
years, the advent of international terrorism as a mode of political action within the last 10 years
has led to a resurgence of such injuries in civilian life—first in the Middle East, and now in the
West.16

All blunt injuries result from the physical transfer of energy to the patient, but because of the
rigidity of the bony thorax, all pulmonary contusions and most flail chest injuries are high-energy
injuries, with the primary exception being occasional chest wall injuries in the frail elderly. Thus,
they are seen primarily in motor vehicular trauma, perhaps most classically where unrestrained
drivers strike the steering column. Pedestrian trauma and falls from a distance are frequent
causes. Interpersonal violence leading to blows with blunt objects or kicking are occasional
causes of pulmonary contusion. Flail chest however, is rare in our experience, first because
assaults are most common in young adults and second because biomechanically they are unlikely
Current Therapy
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that rib fractures in infants and small children occur most commonly as a result of child abuse,
and that any rib fracture in a child is a marker for severe trauma.17

The transfer of energy typically leads directly to hemorrhage into the lung. Pulmonary lacerations
are uncommon but can occur (Figure 2) and in our experience are seen with increasing frequency
when routine CT imaging is used. On rare occasions, tangential gunshot injuries will cause
contusions of the underlying pulmonary parenchyma without actually entering and lacerating the
lung. These injuries are usually very limited in their extent and cause little or no physiologic
effects. Another potential mechanism of pulmonary dysfunction after trauma is the activation of
pulmonary vascular endothelium by percussive cellular deformation per se. This phenomenon is
much better documented in cerebrovascular endothelial beds,18,19 but it is likely to exist in the
pulmonary bed as well (see Figure 2).

Figure 2 The admitting chest CT of 14-year-old patient in high-speed crash. Contusion with
pulmonary laceration is evident. There was no significant pneumothorax or hemothorax. No rib
fractures were found, but the transverse processes of T4–T7 on the right were fractured (arrow).
In our experience, costovertebral joint separations like this are not uncommon on CT, and are the
biomechanical equivalents of posterior rib fractures. CT, Computed tomography.

Mechanisms of Physiologic Injury

Studies done toward the end of World War I suggested that blast injury predominantly resulted in
pulmonary hemorrhage,5 and it was felt that pulmonary failure reflected the effects of blood filling
the air spaces. Whereas this effect undoubtedly contributes to the increased pulmonary shunting
(Qs/Qt) seen after injury, many other pathophysiologic processes are at work. There is now little
doubt that the majority of pulmonary dysfunction seen after chest trauma results from secondary
injury processes rather than direct injury to the lung. It is most convenient to divide the various
pathophysiologic influences on pulmonary function into those that result in increased Qs/Qt and
hypoxemia, and those that alter the work of breathing and can lead to ventilatory failure. Either
can result from chest wall or parenchymal pathology. It is important to note that associated
intrapleural collections of air and blood may also impact mechanical chest wall function and
pulmonary aeration as well as systemic hemodynamic performance, although these
considerations are outside the scope of this review.

Shunting and Hypoxemia

Systemic shock and ischemia/reperfusion (I/R) are well-known activators of immune system
attacks on the lung, causing shunting and hypoxia. This is perhaps most clearly evident in lung
transplantation,20 but is also seen in systemic I/R21 as well as intestinal I/R.22 All will activate the
innate immune system and cause systemic inflammatory response syndrome (SIRS), which
contributes to acute lung injury (ALI) and pulmonary dysfunction after chest trauma. Inadequately
treated pain resulting from chest wall injury and splinting is a common cause of splinting and
hypoventilation. The resultant atelectasis is a common cause of increased Qs/Qt and hypoxemia
after trauma. The use of mechanical ventilation, although necessary, can result in ventilator-
induced lung injury (VILI) through a number of mechanisms.23 Immunologic injury can be induced
by leukocytes in the presence activating cytokines, resulting in increased lung water and
decreased diffusion capacity of the lung (DL). Thus, secondary immune attack on the “primed”
lung can be initiated by pneumonia, shock, injudicious ventilation strategies, or the release of
cytokines into the circulation, as may happen in long-bone fixation.24,25

Increased Work of Breathing and Ventilatory Failure

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Ventilatory failure, hypercarbia, and respiratory acidosis after injury are most commonly the result
of increased work of breathing. Such increases in work of breathing seen are typically
multifactorial. Chest wall injuries can lead to decreased compliance of the chest wall as well as
deficits in neuromuscular chest wall function. The pain and splinting associated with chest wall
injuries will also lead to decreased tidal volume. Because decreased tidal volume per se results in
relatively increased anatomic dead space (Vd/Vt), patients with chest injuries need to increase
minute ventilation simply to achieve normal alveolar ventilation. This can be difficult or impossible
to achieve in the presence of musculoskeletal chest wall dysfunction.

In the presence of a flail chest, CO2 retention has commonly been attributed to the pendelluft
phenomenon, where to-and-fro flow of gas has been postulated to exist between the two
hemithoraces in the presence of a unilateral flail segment. This concept is intuitively appealing,
and the re-breathing of airway gas does create a pathologic dead space. Yet direct application of
this concept to clinical chest injury is probably simplistic. In practice, elevated shunt fractions and
hypoxemia are more common in flail chest and in trauma in general than is hypercarbia.
Moreover, pendelluft occurs in acute lung injury even without chest wall instability. This results
from the heterogeneous viscoelastic properties of the injured lung itself, which leads to gas
movements between lung segments of differing compliance.26 Clearly though, flail segments do
make ventilation both painful and increasingly inefficient.

Last, in any major trauma with secondary acute lung injury the same immune attack on the
pulmonary parenchyma that leads to ALI-ARDS and hypoxemia will also lead to “stiff lungs” and
increased work of breathing. Such decreases in pulmonary compliance may persist even after the
chest wall has resumed normal configuration and biomechanics. A final, extra-pulmonary cause of
decreased pulmonary compliance that should always be sought in acute situations is abdominal
compartmental hypertension.

Inflammatory Lung Injury

Deteriorating pulmonary function after chest trauma is commonly related to systemic inflammation
after injury. Acute lung injury (ALI) and adult respiratory distress syndrome (ARDS) are terms
widely used to reflect the increasing severity of secondary lung injury after trauma. Such injury is
widely believed to result from polymorphonuclear neutrophil (PMN)–endothelial cell (EC)
interactions that injure pulmonary capillary endothelial membranes, causing interstitial and
alveolar edema, and resulting in diminished compliance and gas diffusion. ALI/ARDS are usually
defined as a diagnosis of exclusion where hypoxemia exists in the absence of other discrete
causes of pulmonary failure such as pneumonia or congestive heart failure. In fact, ALI/ARDS
probably exists in all major chest trauma to some extent. Although management of ALI/ARDS is to
date supportive, an understanding of the pathogenesis is important because the lung should be
understood to be “primed” for secondary insults after chest trauma and at risk for marked
deterioration in the event of secondary insults like shock and sepsis. There is increased risk of
pneumonia after chest trauma, and pneumonia, of course, can act both as a primary cause of
pulmonary dysfunction and as a trigger for “second-hit” organ failure. A special problem is that
chest trauma is often accompanied by long-bone fractures and patients with chest injuries are
clearly at special risk for pulmonary deterioration after fracture fixation.27 Fractures are reservoirs
for inflammatory mediators in the early post-injury period which can be mobilized to the
bloodstream by operation and potentially contribute to ALI/ARDS.24,26,28,29 Prospective studies
will be needed to determine whether orthopedic management of these patients should be tailored
to the protection of lung function.

Extravascular Lung Water

Before the routine clinical use of pulmonary artery (PA) catheters, it was widely believed that fluid
overload and subsequent increases in extravascular lung water were the primary cause of
pulmonary dysfunction after trauma. In contrast, modern concepts emphasize that hypovolemia,
hypoperfusion, and reperfusion can lead to inflammatory organ injury. Also, impaired right-to-left
blood flow leads to preferential perfusion of the dependent (West Zone III) lung segments that are
poorly ventilated, thus also increasing shunt. Chest injury may be associated with myocardial
dysfunction as well, but this is typically right ventricular in nature, and resolves quickly.30 Shock
and resuscitation do in fact lead to some expansion of extravascular water, but pulmonary
lymphatics protect the lung from interstitial overload remarkably well.31 We therefore stress
maintaining euvolemia and circulatory adequacy in patients with chest injuries. In patients with
underlying cardiac, renal, or hepatic disease, however, extravascular lung-water accumulation
may be a significant issue. These patients may require inotropes, diuretics, or oncotic support.

DIAGNOSIS Current Therapy of Trauma and Surgical Critical Care

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Physical Examination
The diagnosis of flail chest is best made by visual inspection or palpation of asymmetric chest wall
movement in the spontaneously breathing patient. Palpation is often the more sensitive test. It is
rapid and informative but is often overlooked. Mobile segments of chest wall and sternum can
often be palpated even when not visible on inspection. Clinical flail chest is associated with worse
outcomes and greater need for intubation than pulmonary contusion alone.32 Spontaneously
breathing patients are often best examined by placing both hands on the two hemithoraces and
palpating the symmetry of chest wall motion. Crepitance is also a common finding and point
tenderness over the costochondral junctions may point to dislocations or cartilaginous fractures
that are not visible on radiographs. Auscultation of the chest is usually suboptimal in trauma, and
will play little role in the diagnosis of pulmonary contusion and flail chest except to diminish
concern for lesions (such as pneumothoraces) that may deteriorate acutely.

Chest X-Rays
Chest x-ray (CXR) and computed tomography (CT) of the chest play key roles in the diagnosis of
chest trauma. The initial anteroposterior/supine chest x-rays that are typically done in seriously
injured patients may show pulmonary contusion or suggest flail chest (Figure 3).

Figure 3 Chest x-ray done after empirically chest tube placement in a patient with subcutaneous
emphysema and arterial desaturation. Note the left lower-lobe pulmonary contusion, the
apparently ideal placement of the chest tube (arrows) and the absence of a visible residual
pneumothorax. Fractures of the left ribs four, five, and six were visible laterally.

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MAXILLOFACIAL GASTRIC THE EXTREMITY

INJURIES INJURIES DIAGNOSIS REPLANTATION:

PREHOSPITAL INJURY
CARE OF SEVERITY

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