Should we follow ATLS® guidelines for the management of traumatic pulmonary contusion: the role of non-invasive ventilatory support

Objective: To assess the management of patients with blunt traumatic pulmonary contusion admitted to our hospital. To identify the role of early blood gas analysis, non-invasive ventilation and to assess the validity of the current Advanced Trauma Life Support® manual statement that "Patients with significant hypoxia, i.e. PaO₂<65 mmHg or 8.6 kPa on room air, SaO₂<90%, should be intubated and ventilated within the first hour after injury". Setting: A 24 bed Intensive Care Unit in a major Trauma Centre situated in South Western Sydney, Australia. Methods: Retrospective review of adults with blunt traumatic pulmonary contusion identified from the trauma registry. Results: A total of 75 patients with an age range of 16-81 years were identified over a 2-year period. Arterial blood gas measurement was available for 32 patients during the immediate resuscitative period (<1 h from admission). All patients received supplemental oxygen and a PaO₂/FiO₂ ratio was calculated. Seven patients had significant pulmonary contusion, indicated by an initial PaO₂/FiO₂ ratio of <300, and were treated successfully with non-invasive ventilatory support. A further five patients without arterial blood gas (ABG) analysis on admission but with PaO₂/FiO₂ ratio of <300 in the ICU were also managed with non-invasive ventilatory support. Multi-modal analgesia was commonly used. Conclusions: All major trauma patients admitted to our hospital received supplemental oxygen. Interpretation of ABG breathing room air was not used as an indicator for intubation. Most decisions to intubate early were based on clinical need. Patients with significant pulmonary contusion required intubation for reasons other than respiratory failure. Patients with significant pulmonary contusion were managed safely with non-invasive ventilatory support. Further investigation will determine the role of non-invasive ventilatory support in the management of these patients.