The levels of recommendation (1-3) and classes of evidence (I-III) are defined at the end of the "Major Recommendations" field.
Level 1
- There is no support for Level I recommendations regarding pulmonary contusion/flail chest (PC-FC).
Level 2
- Trauma patients with PC-FC should not be excessively fluid restricted, but rather should be resuscitated as necessary with isotonic crystalloid or colloid solution to maintain signs of adequate tissue perfusion. Once adequately resuscitated, unnecessary fluid administration should be meticulously avoided. A pulmonary artery catheter may be useful to avoid fluid overload.
- Obligatory mechanical ventilation should be avoided.
- The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure and ensuing ventilatory support. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. (see EAST Practice Management Guideline (PMG) "Pain Management in Blunt Thoracic Trauma")
- Patients with PC-FC 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/continuous positive airway pressures (PEEP/CPAP) should be included in the ventilatory regimen.
- Steroids should not be used in the therapy of pulmonary contusion.
Level 3
- A trial of mask continuous positive airway pressure (CPAP) should be considered in alert, compliant patients with marginal respiratory status.
- Independent lung ventilation may be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected due to mal-distribution of ventilation or when crossover bleeding is problematic.
- Diuretics may be used in the setting of hydrostatic fluid overload as evidenced by elevated pulmonary capillary wedge pressures in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.
- Surgical fixation may be considered in severe unilateral flail chest or in patients requiring mechanical ventilation when thoracotomy is otherwise required.
Definitions:
Rating Scheme for Strength of Recommendations
Level 1
The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data, however, strong Class II evidence may form the basis for a Level I recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low quality or contradictory Class I data may not be able to support a Level I recommendation.
Level 2
The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.
Level 3
The recommendation is supported by available data but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.
Rating Scheme for Strength of Evidence
Class I
Prospective randomized controlled trials
Class II
Clinical studies in which data was collected prospectively and retrospective analyses that were based on clearly reliable data. Types of studies so classified include observational studies, cohort studies, prevalence studies and case control studies.
Class III
Studies based on retrospectively collected data. Evidence used in this class includes clinical series and database or registry review.
