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| | '''For patient information, click [[Pulmonary laceration (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}} |
| | {{Pulmonary laceration}} |
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| {{EH}}
| | ==[[Pulmonary laceration overview|Overview]]== |
| | | ==[[Pulmonary laceration classification|Classification]]== |
| ==Overview==
| | ==[[Pulmonary laceration pathophysiology |Pathophysiology]]== |
| A '''pulmonary laceration''' is a chest injury in which [[lung]] tissue is torn or cut.<ref name="Karmy02">
| | ==[[Pulmonary laceration causes|Causes]]== |
| {{
| | ==[[Pulmonary laceration differential diagnosis|Differentiating Pulmonary Laceration from other Diseases]]== |
| cite book |chapter=Pulmonary contusion | author=Sattler S, Maier RV |editor=Karmy-Jones R, Nathens A, Stern EJ |title=Thoracic Trauma and Critical Care |publisher=Springer |location=Berlin |year=2002 |pages=161-163|isbn=1-4020-7215-5 |oclc= |doi= |accessdate=2008-05-05 |url=http://books.google.com/books?id=zSge9BxBCd0C&pg=PA235&dq=%22pulmonary+contusion%22&lr=&sig=uGqtmdp1-4Rg6zbN2W3gTE_aszU#PPA235,M1
| | ==[[Pulmonary laceration epidemiology and demographics|Epidemiology and Demographics]]== |
| }}
| | ==[[Pulmonary laceration natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| </ref> An injury that is potentially more serious than [[pulmonary contusion]], pulmonary [[laceration]] involves disruption of the architecture of the lung.<ref name="Collins07">
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| cite book |author = Collins J, Stern EJ |title= Chest Radiology: The Essentials | isbn=0781763142 | publisher = Lippincott Williams & Wilkins |year= 2007 | url=http://books.google.com/books?id=LCeOBrXIY1sC&pg=PA120&dq=pulmonary+contusion&lr=&client=firefox-a&sig=qv_leqFHepNlE9nWnC8rmzQede8 |accessdate=2008-04-26 |page=120
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| </ref> Pulmonary laceration is commonly caused by [[penetrating trauma]] but may also result from forces involved in [[blunt trauma]] such as [[shear stress]]. A cavity filled with blood, air, or both can form.<ref name="Collins07"/> The injury is diagnosed when collections of air or fluid are found on a [[CT scan]] of the chest. Surgery may be required to stitch the laceration, to drain blood, or even to remove injured parts of the lung. The injury commonly heals quickly with few problems if it is given proper treatment; however it may be associated with scarring of the lung or other complications.
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| ==Causes==
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| Pulmonary laceration is a common result of [[penetrating trauma]] but may also be caused by [[blunt trauma]]; [[rib fracture|broken ribs]] may perforate the lung, or the tissue may be torn due to [[Shear stress |shearing force]]s<ref name="Matthay05"> | |
| {{
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| cite book |author=| chapter=Thoracic trauma, surgery, and perioperative management |editor=Matthay RA, George RB, Light RJ, Matthay MA |title=Chest Medicine: Essentials of Pulmonary and Critical Care Medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2005 |pages=580 |isbn=0-7817-5273-6 |oclc= |doi= |accessdate= 2008-04-21 |url= http://books.google.com/books?id=ZzlX2zJMbdgC&pg=RA1-PA587&dq=%22pulmonary+contusion%22&lr=&sig=n6DLtwZBenAAwCpYUaKSczmeU6c#PRA1-PA578,M1
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| </ref> that result from different rates of acceleration or deceleration of different tissues of the lung.<ref name="Hollister95"/> Pulmonary laceration may result from blunt and penetrating forces that occur in the same injury and may be associated with pulmonary contusion.<ref name="ullman03">
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| {{
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| cite journal |author=Ullman EA, Donley LP, Brady WJ |title=Pulmonary trauma emergency department evaluation and management |journal=Emergency Medicine Clinics of North America |volume=21 |issue=2 |pages=291–313 |year=2003 |pmid=12793615 |doi=10.1016/S0733-8627(03)00016-6 |url=
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| </ref><ref name="mlr07">
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| {{
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| cite journal |author=Miller DL, Mansour KA |title=Blunt traumatic lung injuries |journal=Thoracic Surgery Clinics |volume=17 |issue=1 |pages=57–61 |year=2007 |pmid=17650697 |doi= 10.1016/j.thorsurg.2007.03.017
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| </ref> As with contusions, pulmonary lacerations usually occur near solid structures in the chest such as [[rib]]s.<ref name="Collins07"/> Pulmonary laceration is suspected when rib fractures are present.<ref name="Hopkins08"/>
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| ==Classification==
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| In 1988, a group led by R.B. Wagner divided pulmonary lacerations into four types based on the manner in which the person was injured and indications found on a [[CT scan]].<ref name="Wright02">
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| cite book |author=Wright F |title=Radiology of the Chest and Related Conditions: Together with an Extensive Illustrative Collection of Radiographs |publisher=Taylor and Francis |location=London |year=2002 |pages= 11.3 |isbn=0-415-28141-5 |oclc= |doi= |accessdate=2008-05-05 |url= http://books.google.com/books?id=Bif0zpmEWtAC&pg=PT361&vq=pulmonary+laceration&dq=pulmonary+laceration&lr=&client=firefox-a&source=gbs_search_s&sig=FBa0p1KOmaptfpLh4nHB1lg2T1U#PRA1-PT266,M1
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| </ref> In type 1 lacerations, which occur in the mid lung area, the air-filled lung bursts as a result of sudden compression of the chest.<ref name="Wright02"/> Also called compression-rupture lacerations, type 1 are the most common type and usually occur in a central location of the lung.<ref name="Karmy02"/> They tend to be large, ranging in size from 2–8 cm.<ref name="Thoongsuwan05">
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| {{
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| cite journal |author=Thoongsuwan N, Kanne JP, Stern EJ |title=Spectrum of blunt chest injuries |journal=Journal of Thoracic Imaging |volume=20 |issue=2 |pages=89–97 |year=2005 |month=May |pmid=15818207 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0883-5993&volume=20&issue=2&spage=89
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| </ref> The shearing stress in type 2 results when the lower chest is suddenly compressed and the lower lung is suddenly moved across the [[vertebra]]l bodies.<ref name="Wright02"/><ref name="Thoongsuwan05"/> Type 2, also called compression-shear,<ref name="Karmy02"/> tends to occur near the spine and have an elongated shape.<ref name="Thoongsuwan05"/> Type 2 lacerations usually occur in younger people with more flexible chests.<ref name="Hollister95">
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| {{
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| cite journal |author=Hollister M, Stern EJ, Steinberg KP |title=Type 2 pulmonary laceration: A marker of blunt high-energy injury to the lung |journal=American Journal of Roentgenology |volume=165 |issue=5 |pages=1126 |year=1995 |month=November |pmid=7572488 |doi= |url=http://www.ajronline.org/cgi/pmidlookup?view=long&pmid=7572488
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| }}<!--primary-->
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| </ref> Type 3, which are caused by punctures from fractured ribs, occur in the area near the chest wall underlying the broken rib.<ref name="Wright02"/> Also called rib penetration lacerations, type 3 lacerations tend to be small<ref name="Karmy02"/> and accompanied by pneumothorax.<ref name="Wright02"/> Commonly, more than one type 3 laceration will occur.<ref name="Thoongsuwan05"/> Type 4, also called adhesion tears,<ref name="Karmy02"/> occur in cases where a pleuropulmonary adhesion had formed prior to the injury, in which the chest wall is suddenly fractured or pushed inwards.<ref name="Thoongsuwan05"/> They occur in the [[pleura|subpleural]] area and result from shearing forces at sites of transpleural adhesion.<ref name="Hollister95"/>
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| ==Pathophysiology== | |
| [[Image:Pneumothorax CT.jpg|thumb|left|200px|A CT scan of a pneumothorax, a chest injury that may accompany pulmonary laceration]] | |
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| A pulmonary laceration can cause air to leak out of the lacerated lung<ref name="Moore03">
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| {{
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| cite book ||chapter=Trauma to the chest wall and lung|author = Livingston DH, Hauser CJ |title=Trauma. Fifth Edition |editor=Moore EE, Feliciano DV, Mattox KL |year= 2003 |publisher= McGraw-Hill Professional | isbn= 0071370692 |url= http://books.google.com/books?id=VgizxQg-8QQC&dq=pulmonary+contusion&client=firefox-a&source=gbs_summary_s&cad=0 | accessdate=2008-04-26 |pages=532
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| </ref> and into the [[pleural cavity |pleural space]], if the laceration goes through to it.<ref name="mlr07"/> Pulmonary laceration invariably results in [[pneumothorax]] (due to torn [[airway]]s), [[hemothorax]] (due to torn [[blood vessel]]s), or a [[hemopneumothorax]] (with both blood and air in the chest cavity).<ref name="Gwinnutt03">
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| {{
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| cite book |author=Kishen R, Lomas G |chapter=Thoracic trauma |editor=Gwinnutt CL, Driscoll P |title=Trauma Resuscitation: The Team Approach |publisher=Informa Healthcare |location= |year=2003 |isbn=1-85996-009-X |oclc= |doi= |accessdate=2008-05-03 |pages=64 |url= http://books.google.com/books?id=bzm12Y1RhBAC&pg=PA64&dq=pulmonary+laceration&lr=&client=firefox-a&sig=siPnk1jd_rKlmRZgPGQAWSW0UrQ
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| </ref> Unlike hemothoraces that occur due to pulmonary contusion, those due to lung laceration may be large and long lasting.<ref name="Gavelli02"/> However, the lungs do not usually bleed very much because the blood vessels involved are small and the pressure within them is low.<ref name="Matthay05"/> Therefore, pneumothorax is usually more of a problem than hemothorax.<ref name="mlr07"/> A pneumothorax may form or be turned into a [[tension pneumothorax]] by [[mechanical ventilation]], which may force air out of the tear in the lung.<ref name="Gavelli02"/>
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| The laceration may also close up by itself, which can cause it to trap blood and potentially form a [[cyst]] or [[hematoma]].<ref name="mlr07"/> Because the lung is elastic, the tear forms a round cyst called a ''traumatic air cyst'' that may be filled with air, blood, or both and that usually shrinks over a period of weeks or months.<ref name="Helms07">
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| {{
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| cite book |author=Helms CA, Brant WE |title=Fundamentals of Diagnostic Radiology |publisher=Lippincott, Williams & Wilkins |location=Philadelphia |year=2007 |pages=557 |isbn=0-7817-6135-2 |oclc= |doi= |accessdate=2008-04-29 |url=http://books.google.com/books?id=Sossht2t5XwC&pg=PA557&dq=pulmonary+laceration&client=firefox-a&sig=qhs0_eVneANRDtc8W8opdYhvLRg#PPA557,M1
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| </ref> Lacerations that are filled with air are called [[pneumatocele]]s, and those that are filled with blood are called '''pulmonary hematomas'''.<ref name="White99"/> In some cases, both pneumatoceles and hematomas exist in the same injured lung.<ref name="Gavelli02"/> A pneumatocele can become enlarged, for example when the patient is mechanically ventilated or has [[acute respiratory distress syndrome]], in which case it may not go away for months.<ref name="Gavelli02"/> Pulmonary hematomas take longer to heal than simple pneumatoceles and commonly leave the lungs scarred.<ref name="White99">
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| {{
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| cite book |author=White C, Stern EJ |title=Chest Radiology Companion |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=1999 |pages=80, 176 |isbn=0-397-51732-7 |oclc= |doi= |accessdate=2008-04-30 |url=http://books.google.com/books?id=keNyAl8AArUC&pg=PA176&dq=pulmonary+laceration&lr=&client=firefox-a&sig=wvrEbz3w48sBnRaXtSxF9E6DwzM#PPA80,M1
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| </ref>
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| Over time, the walls of lung lacerations tend to grow thicker due to edema and bleeding at the edges.<ref name="Karmy02"/>
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| ==Diagnosis== | | ==Diagnosis== |
| [[Image:Pulmonary contusion.jpg|left|thumb|210px|A chest X-ray of a right sided pulmonary contusion associated with [[flail chest]] and [[subcutaneous emphysema]]. Contusion may mask pulmonary laceration on chest X-ray. ]] | | [[Pulmonary laceration history and symptoms|History and Symptoms]] | [[Pulmonary laceration physical examination|Physical Examination]] | [[Pulmonary laceration laboratory findings|Laboratory Findings]] | [[Pulmonary laceration chest x ray|Chest X Ray]] | [[Pulmonary laceration CT|CT]] | [[Pulmonary laceration other diagnostic studies|Other Diagnostic Studies]] |
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| Pulmonary laceration may not be visible using [[chest X-ray]] because an associated [[pulmonary contusion]] or [[hemorrhage]] may mask it.<ref name="Gavelli02"/><ref name="Karmy02"/><ref name="Hopkins08"/> [[CT scan]]ning is more sensitive and better at detecting pulmonary laceration than [[X-ray]]s are,<ref name="Karmy02"/><ref name="Matthay05"/><ref name="Costantino06"> | |
| {{
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| cite journal |author=Costantino M, Gosselin MV, Primack SL |title=The ABC's of thoracic trauma imaging |journal=Seminars in Roentgenology |volume=41 |issue=3 |pages=209–225 |year=2006 |month=July |pmid=16849051 |doi=10.1053/j.ro.2006.05.005 |url=
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| </ref> and often reveals multiple lacerations in cases where chest X-ray showed only a contusion.<ref name="Gavelli02"/> Before CT scanning was widely available, pulmonary laceration was considered unusual because it was not common to find with [[X-ray]] alone.<ref name="Gavelli02"/> On a CT scan, pulmonary lacerations show up in a contused area of the lung,<ref name="Hopkins08">
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| {{
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| cite book |author=Hopkins RL, Peden C, Ghandi S |chapter=Trauma radiology |title=Radiology for Anaesthesia and Intensive Care |publisher=Cambridge University Press |location=Cambridge, UK |year=2008 |pages=135 |isbn=0-521-69485-X |oclc= |doi= |accessdate= |url=http://books.google.com/books?id=9UDvpaw8d6YC&pg=PA133&dq=pulmonary+laceration&lr=&client=firefox-a&sig=DGLYopNn5ICNDT7nad_RdWxdrQg#PPA135,M1
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| </ref> typically appearing as cavities filled with air or fluid<ref name="Strife02">
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| {{
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| cite book |author=Donnelly LF |chapter=CT of Acute pulmonary infection/trauma |editor=Strife JL, Lucaya J |title=Pediatric Chest Imaging: Chest Imaging in Infants and Children |publisher=Springer |location=Berlin |year=2002 |pages= 123 |isbn=3-540-43557-3 |oclc= |doi= |accessdate= 2008-05-01 |url=http://books.google.com/books?id=o5FLRDJsOFgC&pg=PA124&dq=pulmonary+laceration&lr=&client=firefox-a&sig=2nK66fOXCjEiEMc3N7I8O83DcJE
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| </ref> that usually have an elliptical or ovoid shape.<ref name="Gavelli02"/> The roundness of the cavity is due to the elasticity of the lung.<ref name="Karmy02"/>
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| Hematomas appear on chest radiographs as smooth masses that are round or ovoid in shape.<ref name="Karmy02"/> Like lacerations, hematomas may initially be hidden on X-ray by lung contusions, but they become more apparent as the contusion begins to heal.<ref name="Karmy02"/> Pneumatoceles have a similar shape to that of hematomas but have thin, smooth walls.<ref name="Schnyder00">
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| {{
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| cite book |author=Schnyder P, Wintermark M |title=Radiology of Blunt Trauma of the Chest |publisher=Springer |location=Berlin |year=2000 |pages=62 |isbn=3-540-66217-0 |oclc= |doi= |accessdate= 2008-05-06 |url = http://books.google.com/books?id=Q4haCU0cX14C&pg=PA62&lpg=PA62&dq=pulmonary+laceration+type&source=web&ots=HUWMAZ1iXh&sig=-o9MQ09BCVfIrsoo2_xLbXm41VE&hl=en
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| </ref> Lacerations filled with both blood and air display a distinctive "[[air-fluid level]]" on upright chest X-rays.<ref name="Schnyder00"/>
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| Pulmonary laceration is usually accompanied by [[hemoptysis]] (coughing up blood or of blood-stained sputum).<ref name="Gavelli02"> | |
| {{
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| cite journal |author=Gavelli G, Canini R, Bertaccini P, Battista G, Bnà C, Fattori R |title=Traumatic injuries: imaging of thoracic injuries |journal=European Radiology |volume=12 |issue=6 |pages=1273–1294 |year=2002 |month=June |pmid=12042932 |doi=10.1007/s00330-002-1439-6 |url=
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| </ref>
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| [[Tracheobronchial]] injury can be ruled out using [[bronchoscopy]].<ref name="Sartorelli04"/> [[Thoracoscopy]] may be used in both diagnosis and treatment of pulmonary laceration.<ref name="mlr07"/> | |
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| ==Treatment== | | ==Treatment== |
| As with other chest injuries such as pulmonary contusion, hemothorax, and pneumothorax, pulmonary laceration can often be treated with just supplemental oxygen, ventilation, and drainage of fluids from the chest cavity.<ref name="Hara04">
| | [[Pulmonary laceration medical therapy|Medical Therapy]] | [[Pulmonary laceration surgery|Surgery]] | [[Pulmonary laceration cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Pulmonary laceration future or investigational therapies|Future or Investigational Therapies]] |
| {{
| | ==Case Studies== |
| cite journal |author=Hara H, Yoshimura H |title=Traumatic lung injury |language=Japanese |journal=Kyobu Geka |volume=57 |issue=8 |pages=762–769 |year=2004 |month=July |pmid=15362557 |doi= |url=
| | [[Pulmonary laceration case study one|Case #1]] |
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| </ref>
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| A [[chest tube|thoracostomy tube]] can be used to remove blood and air from the chest cavity.<ref name="Sartorelli04">
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| {{
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| cite journal |author=Sartorelli KH, Vane DW |title=The diagnosis and management of children with blunt injury of the chest |journal=Seminars in Pediatric Surgery |volume=13 |issue=2 |pages=98–105 |year=2004 |month=May |pmid=15362279 |doi=doi:10.1053/j.sempedsurg.2004.01.005 |url=
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| </ref> About five percent of cases require surgery, called thoracotomy.<ref name="Gwinnutt03"/> Thoracotomy is especially likely to be needed if a lung fails to re-expand; if pneumothorax, bleeding, or coughing up blood persist; or in order to remove clotted blood from a hemothorax.<ref name="Gwinnutt03"/> Surgical treatment includes suturing,<ref name="Gwinnutt03"/> stapling, oversewing, and wedging out of the laceration.<ref name="mlr07"/> Occasionally, surgeons must perform a [[lobectomy]], in which a lobe of the lung is removed, or a [[pneumonectomy]], in which an entire lung is removed.<ref name="Gwinnutt03"/>
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| ==Prognosis and complications== | |
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| Full recovery is common with proper treatment.<ref name="Hara04"/> Pulmonary laceration usually heals quickly after a chest tube is inserted and is usually not associated with major long-term problems.<ref name="mlr07"/> Pulmonary lacerations usually heal within three to five weeks,<ref name="Gavelli02"/> and lacerations filled with air will commonly heal within one to three weeks but on occasion take longer.<ref name="Karmy02"/> However, the injury often takes weeks or months to heal, and the lung may be [[scar]]red.<ref name="Collins07"/> Small pulmonary lacerations frequently heal by themselves if material is removed from the [[pleura]]l space, but surgery may be required for larger lacerations that do not heal properly or that bleed.<ref name="Sartorelli04"/>
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| One complication, [[air embolism]], in which air enters the bloodstream, is potentially fatal, especially when it occurs on the left side of the heart.<ref name="Matthay05"/> Air can enter the circulatory system through a damaged [[vein]] in the injured chest and can travel to any organ; it is especially deadly in the heart or brain.<ref name="Matthay05"/> [[Positive pressure ventilation]] can cause pulmonary embolism by forcing air out of injured lungs and into blood vessels.<ref name="Matthay05"/>
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| ==References==
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| {{reflist|2}}
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| {{Injuries, other than fractures, dislocations, sprains and strains}} | | {{Injuries, other than fractures, dislocations, sprains and strains}} |
| {{SIB}}
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[Category:Chest trauma]] | | [[Category:Chest trauma]] |
| [[Category:Pulmonology]] | | [[Category:Pulmonology]] |
| | [[Category:Disease]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |