Parenchymal Trauma

Pulmonary contusions and intrabronchial hemorrhage are common. A restrictive breathing pattern may be noted in patients with mild and moderate parenchymal injury. Patients with severe parenchymal injury often have a parenchymal pattern, seen as respiratory distress with labored inspiration and expiration, with or without hemoptysis.

- Auscult the chest for decreased lung sounds, which suggest either fluid (blood) or air in the pleural space, or pulmonary contusions. A patchy distribution of altered lung sounds may be noted, which helps differentiate parenchymal injury from pleural space trauma.
- A negative thoracocentesis suggests the presence of pulmonary contusions in patients with these clinical signs. Note that radiographic signs (mixed interstitial-alveolar pattern) may lag 12-24 hours, and the stress of the process is usually not warranted.
- Hemoptysis, especially of arterialized (bright red) blood suggests significant large pulmonary vessel trauma that typically carries a very guarded prognosis.
- Most MWDs with pulmonary contusions do not require mechanical ventilation. Management of pulmonary contusions involves minimizing stress, providing oxygen supplementation, cautious intravenous fluid administration to prevent progression of contusions and/or development of pulmonary edema, and possible addition of colloids to the fluid therapy plan to decrease the amount of lung water that may accumulate during shock resuscitation. Diuretics and steroids are not indicated in treatment of pulmonary contusions, and may increase patient morbidity and mortality.
- Severe, life-threatening major pulmonary vessel hemorrhage may require resuscitative thoracotomy. Refer to the discussion of Resuscitative Thoracotomy in this CPG for guidance and technique.