Controversies in the management of pulmonary contusion.

Most polytraumatized patients with lung contusion also have injury to the chest wall. Both are serious but the lung contusion is most important in contributing to respiratory failure. A small and localized injury to the lung leads to generalized edema in surrounding lung and even in the opposite lung. The permeability of capillaries is affected and there is an outpouring of the fluid through a leaking pulmonary membrane. Diagnosis is easy when the condition is straightforward and severe, but may be complicated in a confused or unconscious patient with or without head, abdominal and orthopedic injuries producing shock. Pulmonary aspiration and pneumonia may cloud the issue. Aggressive chest physiotherapy combined with the reduction of pain by local intercostal blockade or epidural anesthesia may obviate the need for mechanical ventilation.