Management of pulmonary contusion and flail chest

An eastern association for the surgery of trauma practice management guideline

Bruce Simon, James Ebert, Faran Bokhari, Jeannette Capella, Timothy Emhoff, Thomas Hayward, Aurelio Rodriguez, Lou Smith

Research output: Contribution to journalArticle

90 Citations (Scopus)

Abstract

BACKGROUND: Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. METHODS: A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. RESULTS: Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. CONCLUSION: Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

Original languageEnglish
JournalJournal of Trauma and Acute Care Surgery
Volume73
Issue number5 SUPPL.4
DOIs
StatePublished - Nov 2012

Fingerprint

Flail Chest
Contusions
Practice Management
Practice Guidelines
Lung
Wounds and Injuries
Analgesia
Thoracic Injuries
Continuous Positive Airway Pressure
Guidelines
Mechanical Ventilators
Artificial Respiration
Respiratory Insufficiency
Committee Membership
High-Frequency Ventilation
Epidural Analgesia
Positive-Pressure Respiration
Thoracic Wall
Thoracotomy
Clinical Protocols

Keywords

  • chest trauma
  • flail chest
  • Guideline
  • pain control
  • pulmonary contusion

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

Management of pulmonary contusion and flail chest : An eastern association for the surgery of trauma practice management guideline. / Simon, Bruce; Ebert, James; Bokhari, Faran; Capella, Jeannette; Emhoff, Timothy; Hayward, Thomas; Rodriguez, Aurelio; Smith, Lou.

In: Journal of Trauma and Acute Care Surgery, Vol. 73, No. 5 SUPPL.4, 11.2012.

Research output: Contribution to journalArticle

Simon, Bruce ; Ebert, James ; Bokhari, Faran ; Capella, Jeannette ; Emhoff, Timothy ; Hayward, Thomas ; Rodriguez, Aurelio ; Smith, Lou. / Management of pulmonary contusion and flail chest : An eastern association for the surgery of trauma practice management guideline. In: Journal of Trauma and Acute Care Surgery. 2012 ; Vol. 73, No. 5 SUPPL.4.
@article{52218e183f0c4f3aaa0adbec1c71aeac,
title = "Management of pulmonary contusion and flail chest: An eastern association for the surgery of trauma practice management guideline",
abstract = "BACKGROUND: Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. METHODS: A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. RESULTS: Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. CONCLUSION: Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.",
keywords = "chest trauma, flail chest, Guideline, pain control, pulmonary contusion",
author = "Bruce Simon and James Ebert and Faran Bokhari and Jeannette Capella and Timothy Emhoff and Thomas Hayward and Aurelio Rodriguez and Lou Smith",
year = "2012",
month = "11",
doi = "10.1097/TA.0b013e31827019fd",
language = "English",
volume = "73",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",
number = "5 SUPPL.4",

}

TY - JOUR

T1 - Management of pulmonary contusion and flail chest

T2 - An eastern association for the surgery of trauma practice management guideline

AU - Simon, Bruce

AU - Ebert, James

AU - Bokhari, Faran

AU - Capella, Jeannette

AU - Emhoff, Timothy

AU - Hayward, Thomas

AU - Rodriguez, Aurelio

AU - Smith, Lou

PY - 2012/11

Y1 - 2012/11

N2 - BACKGROUND: Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. METHODS: A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. RESULTS: Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. CONCLUSION: Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

AB - BACKGROUND: Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. METHODS: A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. RESULTS: Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. CONCLUSION: Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

KW - chest trauma

KW - flail chest

KW - Guideline

KW - pain control

KW - pulmonary contusion

UR - http://www.scopus.com/inward/record.url?scp=84869793048&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84869793048&partnerID=8YFLogxK

U2 - 10.1097/TA.0b013e31827019fd

DO - 10.1097/TA.0b013e31827019fd

M3 - Article

VL - 73

JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

IS - 5 SUPPL.4

ER -