Pediatric emergency medicine trisk 3706 3706

When pulmonary contusion is suspected, CXR is the imaging modality of choice
( Fig. 115.4 ). However, the contusion itself may not be visible on CXR for 4 to 6
hours after the injury, and even then, false-negative rates of up to 33% have been
reported.
Although more sensitive than CXR in detecting pulmonary contusion, a chest
CT scan is usually unnecessary unless a significant injury to the vasculature is
suspected, as management will depend on the clinical condition of the patient and
not the radiographic size of the contusion.
Treatment of pulmonary contusion is supportive. If required, supplemental
oxygen should be administered. If the patient cannot maintain oxygenation
despite passive supplemental oxygen delivery, endotracheal intubation and
mechanical ventilation with positive pressure is the treatment of choice. Fluid
restriction is helpful to avoid exacerbation of pulmonary edema, though must be
balanced against the fluid needs arising from concurrent injuries to other organ
systems and shock in the severely injured child. Patients may require high
inflation pressures to maintain adequate oxygenation, which combined with
injury to the lung leads to high risk of barotrauma and pneumothorax.

Disposition
Due to risk of progression of symptoms and need for increasing respiratory
support, all patients with pulmonary contusion should be admitted for
observation. Given the low sensitivity of CXR for pulmonary contusion, children
with significant chest pain or shortness of breath or an unexplained oxygen
requirement after blunt chest trauma should also be admitted even if chest
imaging is normal. Admission to an intensive care unit is appropriate for patients
with concerning vital signs, a significant oxygen requirement, respiratory distress,
or who otherwise appear to be at high risk of progressing to require mechanical
ventilation.

BLUNT CARDIAC INJURIES
CLINICAL PEARLS AND PITFALLS