pulmonary contusion

Q: 38 years old male is admitted to ICU after Motor Vehicle Accident (MVA) with pulmonary contusion due to rapid inflation of airbag. Patient is admitted to ICU. Patient is now on High Flow Nasal Cannula (HFNC) saturating about 90 percent on pulse OX. Patient seems comfortable while at rest but requires higher oxygenation while ambulating. There is no hypercarbia while ambulating. CXR shows subjective mild deterioration in 24 hours. The patient should have been intubated earlier in the course now and managed with low tidal volumes.

A) True

B) False

Answer: B

In pulmonary contusion, the most important thing is to follow the clinical deterioration. If hypoxemia can be managed with non-invasive oxygenation, there is no need for mechanical ventilation. In pulmonary contusion, the patient should be "intubated only when necessary". Intubation and sedation with invasive mechanical ventilation do not either heal lungs fast or stabilize the chest wall. Although hypercapnia is an important marker of worsening gas exchange, clinical judgment supersedes the numbers. Intubation may bring longer lengths of stay and other complications.

If the patient gets intubated, a lung-protective strategy is preferred, and early extubation should always be the priority.

#pulmonary

#trauma

References:

1. Simon B, Ebert J, Bokhari F, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73:S351.

2. Shackford SR, Virgilio RW, Peters RM. Early extubation versus prophylactic ventilation in the high risk patient: a comparison of postoperative management in the prevention of respiratory complications. Anesth Analg 1981; 60:76.

3. Cohn SM, Dubose JJ. Pulmonary contusion: an update on recent advances in clinical management. World J Surg. 2010 Aug;34(8):1959-70. doi: 10.1007/s00268-010-0599-9. PMID: 20407767.