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Pulmonary Contusion After Sports Injury

Most pulmonary contusions occur after diffuse, high energy blunt trauma like a fall or car crash. Occasionally, pulmonary injury can occur after a much more focal injury like an impact during sports. This may occur due to direct impact from another player, or from a rapidly moving object like a ball or puck. Today, I’ll focus on the latter, impact from a fast-moving object.

Typically, the athlete will complain of pain at the area of impact and some degree of breathing impairment. This is usually due to musculoskeletal pain, rib fracture or involuntary splinting. It is possible to develop pneumothorax or hemothorax, especially if a rib is fractured. At some point, hemoptysis may be present. This is pathognomonic for the presence of a pulmonary contusion.

Any athlete with more than mild to moderate pain, or any physical exam findings other than tenderness, should be more fully evaluated. Here are some important tips:

  • The only imaging required is a two view conventional chest xray. This will identify significant pneumothorax, hemothorax or contusions that require additional management.
  • Chest CT is not indicated. It does not change management.
  • Use your typical algorithms for managing hemothorax and pneumothorax
  • A pneumatocele visible on the xray indicates a small pulmonary laceration. A followup xray or two may be needed to ensure that it does not expand or cause a pneumothorax. Thoracic surgery involvement is not usually indicated
  • Hemoptysis is normal, and may present immediately or several days later. The patient should be reassured in advance so they don’t call you frantically in the middle of the night.

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    Hare Traction – Putting It On, Taking It Off

    Femoral traction devices have been around for a long time. One reader has asked about the timing of removal of these devices after they arrive at the hospital. I learned a number of things while reviewing the literature to answer this question.

    Most importantly, there is really only one indication for applying a traction splint to the femur: an isolated, relatively mid-shaft femur fracture. Unfortunately, there are lots of contraindications. They consist of other injuries or fractures that could sustain further damage from traction. Specifically, these include:

    • Pelvic or hip fracture
    • Hip dislocation
    • Knee injury
    • Tib/fib, ankle or foot fracture

    I did find one interesting study from 1999 that looked at how useful these splints really were. Of 4,513 EMS runs, only 16 had mid-thigh trauma and 5 of these appeared to have a femur fracture. Splint application was attempted in 3, and only 2 were successful. This was the experience in only one city (Evanston, IL) for one year. However, it mirrors what I see coming into our trauma center.

    Unfortunately, when it comes to removal, there are very few guidelines out there. My advice is to have your orthopedic surgeon evaluate as soon as imaging is complete. They can help decide whether converting to some type of definitive traction is necessary, or whether it can be changed to a more conventional splint. In any case, the objective is to minimize the total amount of time in the traction splint to avoid any further injury to other structures.

    Reference: Prehospital midthigh rauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med, 19:137-140, 2001.

      (Source: https://www.youtube.com/)
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      Managing Chest Tube Air Leaks

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      There are a lot of opinions and not so much literature on how to manage chest tube air leaks. Here is some practical advice on how to deal with this occasional problem.

      Most air leaks are an alveolar-pleural fistula, representing a connection between a very small airspace and the pleura. This should not be confused with a bronchopleural fistula, which involves larger airways and is much more challenging to manage.

      First, identify what kind of leak it is. Remember, dry seal chest tube systems will not show an air leak unless it has a fluid chamber that can be filled with water (see related post below).

      • Expiratory – occurs during normal expiration only
      • Forced expiratory – occurs only with coughing
      • Inspiratory – occurs during inspiration in ventilated patients
      • Continuous

      Inspiratory leaks are rare and should be managed conservatively with maneuvers to minimize airway pressures. Continuous air leaks can be monitored, but may indicate a bronchopleural fistula.

      Expiratory and forced expiratory types account for about 98% of all air leaks. Small air leaks should be managed with water seal, not with increased suction. The main concept is to reduce air flow through the fistula so it can heal. A prospective study has shown that this technique stops small to moderate size leaks sooner than leaving on suction.

      Larger air leaks will probably not seal on their own and are probably not safe to place on water seal. They will likely require pleurodesis, either chemical or mechanical via a VATS procedure. Blood and fibrin patches have also been tried.

      Any air leak that extends hospital stay should be evaluated for appropriateness of discharge with a Heimlich valve or VATS pleurodesis.

      References:

      • A prospective algorithm for the management of air leaks after pulmonary resection. Ann Thoracic Surg 66:1726-1731, 1998.
      • Prospective randomized trial compares suction versus water seal for air leaks. Ann Thoracic Surg 71:1613-1617, 2001.

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      Field Concussion Testing For Athletes

      Public awareness of concussions, particular those from sports, is on the rise. It’s difficult enough for trauma professionals to diagnose some of the milder forms of head injury. Expecting lay people to do this is just not realistic.

      Most people have heard of ImPACT testing for head injury. This involves determining a player’s baseline ability to remember a series of words. It tests memory, attention span and reaction time. A baseline study is required, and the test takes about 20 minutes to administer using a computer.

      The King-Devick test is a numerical processing tool that can be administered using an iPad or a deck of cards. A baseline value is required as well, and the test takes about 2 minutes to administer. See the video for details.

      Both tests have been validated by a number of scientific studies, and both are only available for purchase. Several hospitals, trauma centers, and schools have purchased the programs and will administer them for free. 

      Check out these valuable programs and consider providing them at your own local sporting events.

      Links:

      Related post: TBI screening with the Short Blessed Test

      (Source: http://impacttest.com/)
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      New Developments On Distracted Driving

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      The Governors Highway Safety Association released a study that sifted through 350 scientific papers dealing with distracted driving. They summarized their analysis in a nice report that can be downloaded here.

      There are 4 types of distraction:

      • Visual – looking at something other than the road
      • Auditory – listening to something not related to driving
      • Manual – manipulating something other than the steering wheel
      • Cognitive – thinking about something other than driving

      Smart phones provide all four modalities! About two thirds of drivers report using a cell phone while driving, and 7-10% were observed to be using one at any given time. About 12% of drivers admit to texting while driving, and about 1% of drivers are texting at any given time. At least one driver is reported to be distracted in 15-30% of car crashes. 

      The following items were gleaned from the papers reviewed:

      • Cell phone use increases crash risk, but the exact amount is not known
      • Hands-free cell phone use has not been shown to be safer
      • Texting increases crash risk, but the exact amount is not known
      • Hand-held phone bans reduce use somewhat
      • Texting bans have not shown any significant effect, although high visibility enforcement campaigns offer some hope

      Syracuse NY and Hartford CT enacted high visibility campaigns (“Phone in one hand, ticket in the other”) in late 2010 and spring 2011. They found that cell phone use dropped by half, and texting dropped 72% in Hartford and 32% in Syracuse. These results do not agree with the GHSA findings, most likely because of the intensity of the efforts in these two cities. 

      Bottom line: We all know that texting while driving is bad and cell phone discussions while on the road are not very good either. There may be some utility to enacting bans on these activities. However, given the other responsibilities of our police departments, enforcement will always be a lower priority. Engineering solutions like roadway rumble strips can help divert attention back to driving, and crash investigations should aggressively examine any contributions to driver distraction. Ultimately, we’re going to have to treat this problem like we do for driving while intoxicated, with stiff penalties and driving restrictions. Unfortunately, I don’t think we’ve got the fortitude to do it anytime soon.

      Download: GHSA Report on Distracted Driving

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