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Trauma ICU Case discussion

Trauma ICU Case discussion. Pulmonary Contusion Intern 林文瑛. Basic information. Name: 王 OO 22 year-old man H/W:168cm/ 61kg Healthy before. Brief history. 95/12/04: motorcycle accident  Initial loss of conscious and left chest pain 署立台北 hospital

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Trauma ICU Case discussion

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  1. Trauma ICU Case discussion Pulmonary Contusion Intern 林文瑛

  2. Basic information • Name: 王OO • 22 year-old man • H/W:168cm/ 61kg • Healthy before

  3. Brief history • 95/12/04: motorcycle accident Initial loss of conscious and left chest pain • 署立台北hospital Left lung contusion and left scapular fracture SDH was suspected.

  4. 95/12/05 transfer to NTUH • Vital sign:TPR:37/110/25 • BP:124/76 mmHg • SpO2:96% • CT: • L’t lung contusion with hemothroax. • L’t scapular fracture. • L’t 2nd rib fracture. • L’t perirenal fluid accumulation. • L’t kidney and psoas muscle swelling.

  5. Treatment course Chest tube ↓

  6. 95/12/06 post-chest tube 95/12/09 post-BiPAP 95/12/05 am 1:49 95/12/06am 3:56

  7. Pulmonary contusion • Who? Blunt chest trauma, and occur in 17% to 75% of patients Am Surg 1996;62(11):895–900. • How? Chest wall is compressed against the lung parenchyma at the time of injury. • What?  Injury alveoli walls and pulmonary vessels allows blood to leak into the alveolar and interstitial spaces

  8. Pulmonary contusion ….Where? • Typically, contusions are located adjacent to the osseous structures of the thoracic cage. • An accompanying fracture often is absent • Especially in the pediatric population in which there is greater musculoskeletal elasticity

  9. Image finding • Chest radiograph and CT Mild Ill-defined, patchy, ground- glass density regions of opacification Severe Widespread areas of consolidation • Geographic or nonsegmental in location • Air bronchograms can be seen Radiol Clin N Am 44 (2006) 213–224

  10. Pulmonary contusion ….Image • CT > radiographs : more sensitive • Radiographs : 6 hours after injury. J Trauma 1997;43:405–11.

  11. Pulmonary contusion ….Image • On radiography and CT, contusions may blossom in the first 24 to 48 hours after injury as hemorrhage and edema accumulate in the parenchyma • Clearance of contusions on radiographs typically is seen within 2 to 3 days, but complete resolution of severe contusion may take up to 14 days Radiol Clin N Am 44 (2006) 213–224

  12. Pulmonary contusion ….ARDS • Persistence of airspace disease beyond this period suggests the development of pneumonia, aspiration, or adult respiratory distress syndrome (ARDS) • In that study, patients who had • >20% : 82% developed ARDS • < 20%: only 22% J Trauma 2001;51:223–30.

  13. Pulmonary contusion ….therapy • Adequate pain relief Chest wall pain may cause patients to adopt a rapid, shallow breathing pattern, • Further worsen atelectasis • Supplemental oxygen • Tracheobronchial toilet Mason: Murray & Nadel's Textbook of Respiratory Medicine, 4th ed.

  14. Pulmonary Atelectasis • What? ↓ Lung compliance. Impairment of oxygenation. ↑ Pulmonary vascular resistance. Development of lung injury. Anesthesiology 2005; 102:838–54

  15. Pulmonary Atelectasis….etiology • Compression of lung tissue • Absorption of alveolar air • Impairment of surfactant function. Anesthesiology 2005; 102:838–54 Mason: Murray & Nadel's Textbook of Respiratory Medicine, 4th ed.

  16. Mechanical Ventilation….PC • Supplemental oxygen to treat the hypoxia • Prophylactic intubation without signs of impending respiratory failure is not indicated. Crit Care Clin 20 (2004) 71– 81

  17. Mechanical Ventilation….flail chest • Continuous prolonged mechanical ventilation not recommended • Noninvasive ventilation: High-flow continuous positive airway pressure (CPAP) are accompanied by less chest wall distortion during inspiration. Mason: Murray & Nadel's Textbook of Respiratory Medicine, 4th ed.

  18. Mechanical Ventilation….atelectasis • Intermittent positive-pressure breathing • Deep-breathing exercises • Incentive spirometry • Chest physiotherapy. Phys Ther 1994; 74:3–10

  19. Pulmonary contusion ….Controversy • Fluid? Crystalloids and blood products to obtain euvolemia • Corticosteroids? Experimental model in severe contusion • Antibiotics? Treatment of specific organisms

  20. Take home massages • Pulmonary contusion: hemorrhage into substance worsens over 1 to 2 Ds and then generally resolves over 7 Ds. • Edema increases during 3 Ds. hypoxemia and hypercarbia. • Therapy: Adequate pain relief, Supplemental oxygen, Tracheobronchial toilet.

  21. THANKS FOR YOUR ATTENTION

  22. The actual underlying mechanisms are ……….complex Bursting effects :At the gas–liquid interface of the alveolus, Inertial effects: Differential rates of acceleration between the low-density alveoli and heavier hilar structures Implosion effects :That are due to overexpansion of gas bubbles after passage of a pressure wave Physiol Rev 1956;36:336–54.

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