Talk:Pulmonary contusion

GA Review

This review is transcluded from Talk:Pulmonary contusion/GA1. The edit link for this section can be used to add comments to the review.

I am currently reviewing this "Pulmonary contusion" as a "Good Article" candidate. Axl (talk) 12:24, 10 June 2008 (UTC)

This sentence is from 1.1 "Associated injuries", paragraph 2: "Pulmonary lacerations, in which lung tissue is torn or cut, may also result from blunt and penetrating forces in the same injury that causes a pulmonary contusion and may be associated with the latter injury." It is too long and should be simplified, perhaps split into two sentences. Axl (talk) 17:09, 10 June 2008 (UTC)

Done. delldot talk 06:27, 11 June 2008 (UTC)

In "Causes", paragraph 2: "However, except with shotgun wounds, pulmonary contusions that accompany gun and knife wounds are not usually severe enough to have a major effect on outcome, and penetrating trauma causes less widespread lung damage than does blunt trauma." So do shotgun wounds produce more serious pulmonary contusion? If so, this deserves a separate sentence. Axl (talk) 17:20, 10 June 2008 (UTC)

Sentence added, how is it? delldot talk 06:59, 11 June 2008 (UTC)

That's good. Axl (talk) 07:18, 11 June 2008 (UTC)

From the "Mechanism" section: "After the shock wave passes, the gas in the lung may expand beyond its original volume and may tear alveoli; this is the implosion effect." Gas in the lung expanding beyond its original volume? This really doesn't sound like "implosion". Can someone clarify and expand on this mechanism please? Axl (talk) 17:31, 10 June 2008 (UTC)

I'm having trouble finding anything about the origin of the name. The implosion effect is mentioned in dozens of sources, but always with the same sentence about the gas expanding after the pressure wave has passed. My instinct is that the term comes from the initial compression of the gas that leads to the overexpansion, but I haven't seen this confirmed anywhere (though I did find the word "rebound" in a source and added that to the article). Ideally I'd just look at the original studies the reports are citing for who coined the term--hopefully they'd have an explanation--but I don't have access for before the mid '90's for most journals. I can keep working on this, but I'm not sure how much luck I'm going to have. Any suggestions? delldot talk 12:04, 11 June 2008 (UTC)

Okay, I'll search around in the library. Axl (talk) 12:25, 11 June 2008 (UTC)

Thanks much, good luck. This is cited in Cohn, it might be the origin of the term: Huller T, Bazini Y. Blast injuries of the chest and abdomen. Arch Surg. 1970 PMID 5409672 delldot talk 12:40, 11 June 2008 (UTC)

Got it! Is what I added enough? delldot talk 01:52, 12 June 2008 (UTC)

Excellent! Now I understand it. Axl (talk) 07:13, 12 June 2008 (UTC)

From "Pathophysiology": "Lung water increases over the first 72 hours after injury." What is "lung water"? Perhaps this means "pulmonary edema"? Axl (talk) 17:41, 10 June 2008 (UTC)

An excess accumulation of lung water leads to pulmonary edema. As I understand it, they are not synonymous, because there's a normal lung water content in a healthy person;[1][2] however you only ever hear about it in the context of edema and it looks like they're informally treated as synonymous. How is this tweak? delldot talk 07:18, 11 June 2008 (UTC)

"Lung water" is slightly loose terminology. Your first reference seems to equate "lung water" with "extravascular lung water". In any case, I've added another sentence about pulmonary edema. Axl (talk) 12:40, 11 June 2008 (UTC)

From "Pathophysiology", subsection "Consolidation": "When alveoli consolidate as a result of bleeding into them, it causes the pressure within the capillaries of the lungs to rise; this increased pressure can get so high that blood and serum leak from the capillaries and lead to intrapulmonary shunting." Is this really true? I would have expected the initial injury to cause a transient rise in pressure leading to capillary damage and haemorrhage into the alveoli. This impedes gas transfer locally, at the site of capillary damage. Reduced oxygenation of blood then leads to (arterial) vasoconstriction at the site of lung/capillary damage. Thus I expect that the "consolidated" lung leads to shunt which then leads to vasoconstriction and raised pulmonary arterial pressure. Unfortunately I don't have direct access to the quoted reference. Axl (talk) 17:57, 10 June 2008 (UTC)

Your mechanism sounds reasonable, but I haven't found a source that says all of that exactly yet; I'll keep looking though. Here's what the source I used (PMID 8895709) says: "...the extravasation of blood into the alveolar space and subsequent consolidation lead to an increased intravascular pressure. When the pulmonary capillary pressure exceeds the pressure at which the vessels can retain blood and serum (7 mm Hg), an intrapulmonary shunt develops." Do you think I accurately represented the source with the sentence you quoted? I can keep looking for more detail on pathophysiology. delldot talk 09:06, 11 June 2008 (UTC)

In that case I can't fault your interpretation of the reference. However I am not convinced that the second sentence is correct: "When the pulmonary capillary pressure exceeds the pressure at which the vessels can retain blood and serum (7 mm Hg), an intrapulmonary shunt develops." I would expect shunt to develop before the capillary pressure rises that high. Again, I'll search the textbooks. Axl (talk) 12:48, 11 June 2008 (UTC)

Hm, it's true that I don't think I've seen that anywhere else. How about if I make it more general until we find more info? Thanks much for doing all this extra work to improve the article, you're really going above and beyond the call of reviewer duty! delldot talk 13:10, 11 June 2008 (UTC)

From "Consolidation": "Findings from animal studies indicate that even when only one side of the chest is injured, inflammation may spread to the other lung and lead to respiratory failure in both lungs." Is this ARDS? Axl (talk) 18:03, 10 June 2008 (UTC)

The source just calls it a "significant inflammatory response". It doesn't cite sources for that sentence, but does for the one before it. PMID 10963530 makes no mention of inflammation, PMID 11493780 is about inflammation spreading to the uninjured lung but makes no mention of ARDS. I'm not sure this inflammation has all the features of ARDS, and from the second study it looks like the time courses may be different (beginning within a couple hours in that study, whereas ARDS develops over a day or two). So I'd hesitate to call that ARDS, but on the other hand, we do know that ARDS develops after pulmonary contusion, it's discussed in complications. Should I take out the inflammation mention and limit the discussion to the complications section? delldot talk 14:07, 11 June 2008 (UTC)

How about "Findings from animal studies indicate that even when only one side of the chest is injured, inflammation may also affect the other lung."? Axl (talk) 17:16, 11 June 2008 (UTC)

Done. delldot talk 18:14, 11 June 2008 (UTC)

From "Pathophysiology", subsection "Ventilation/perfusion mismatch": "Since contused lungs become stiff and lose compliance, more pressure may be needed when ventilating the patient to fill the lungs with the same volume of air." This is true, but is irrelevant to ventilation/perfusion mismatch. Axl (talk) 18:06, 10 June 2008 (UTC)

Good catch. This is actually covered already under treatment, so I just removed this unnecessary sentence. delldot talk 07:22, 11 June 2008 (UTC)

From "Prognosis and Complications": "It is less common for ARDS to develop as a result of pulmonary contusion in children than in adults." And from "Epidemiology": "Pulmonary contusion is equally serious in children and adults." I presume that the development of ARDS is more likely to lead to death? Does the lower incidence of ARDS in children reflect the young compliant chest wall that allows contusion with a weaker (i.e. lower energy) trauma? If this is the case, why is contusion equally serious in children and adults? Both of those sentences have the same reference, but again I don't access to it. Axl (talk) 18:57, 10 June 2008 (UTC)

I found a contradiction of the ARDS fact in another source. I've made some changes, what do you think? To try to answer the question, it might be that the second sentence is comparing pulmonary contusion alone without taking into account its complications, but i"m not sure. delldot talk 08:37, 11 June 2008 (UTC)

You've alluded to some other potential factors that may be different between child and adult injuries. This could account for the similar mortality. I have adjusted the sentence. Axl (talk) 12:57, 11 June 2008 (UTC)

GA pass

I am delighted to pass "Pulmonary contusion" as a Good Article. It is accurate, well-written and well-referenced. Particular congratulations to delldot. For future improvement, the flow of the prose could be adjusted a little. Some sentences remain a little long and could be split. Also, a CT image of pulmonary contusion (not pneumothorax) would be ideal. Axl (talk) 07:21, 12 June 2008 (UTC)

Axl, thank you so much for the very thorough review and for putting in so much effort to improving the article and making sure it's up to par. The project needs more people with your dedication to quality. I'll definitely keep working, thanks for the great suggestions. delldot talk 08:10, 12 June 2008 (UTC)

Update: I've been working on the copyediting bit by bit. In other news, CT image found! Woohoo! Do you think three chest X-ray images are too many? If so, can you think of any ideas for replacing the generic one under diagnosis? delldot talk 18:13, 27 June 2008 (UTC)

Children

I have added a reference to a case series (Nakayama: "Chest injuries in childhood") where 105 children were admitted to hospital due to chest trauma. Of these, 56 children (53%) had pulmonary contusion. Of the 105 children, seven died, i.e. 6.7%. None of the dead patients were explicitly noted to have contusion, although it is likely that most did have contusion. Even if all seven had contusion, the death rate among children with contusion would reach 12.5%. This is still below the rates indicated by Gavelli ("Traumatic injuries: imaging of thoracic injuries") and Miller ("Blunt traumatic lung injuries"). The key reference is Allen & Cox: "Pulmonary contusion in children: Diagnosis and management", Southern Medical Journal 1998. Unfortunately my hospital library stopped receiving Southern Medical Journal from 1993. Can anyone (delldot?) explicitly quote this reference for me, indicating the mortality rates for children and adults? Thanks. Axl (talk) 19:12, 12 June 2008 (UTC)

Allen and Cox (1998) says: "Mortality isolated to PC is difficult to define because of coexistent injuries but is generally accepted to be between 10% and 20%." and "...despite different overall injury severity and associated injuries, children did not have a more favorable outcome than adults. Need for intubation and incidence of pneumonia, ARDS, and death did not differ significantly between groups." Unfortunately I don't know if there have been studies that actually compare the mortality rates between children and adults, I don't know if we're going to find hard numbers like that. delldot talk 19:33, 12 June 2008 (UTC)

Hmm. I've just found a related article by the same authors: "Pulmonary contusion: are children different?", J Am Coll Surg. 1997 Sep;185(3):229-33. delldot, have a look if you can. Interestingly, children had far fewer co-existent thoracic injuries than adults. This would fit with the "compliance" theory. However the number of extra-thoracic injuries was equal in both groups. Unfortunately I don't see an explicit statement of the number of patients with pulmonary contusion alone. Of note, "In the absence of extrathoracic injury, death from isolated pulmonary contusion is uncommon, occurring in four adults (1.9%) and no children." With such low numbers of deaths, no statistical inference can be made. However it appears that pulmonary contusion itself is an incidental finding, not related to mortality at all (at least in children). Axl (talk) 20:00, 12 June 2008 (UTC)

Good find. Yeah, lots of sources discuss the difficulty of estimating morbidity and mortality because it's so hard to find the injury alone. Probably when it does occur in isolation, people weren't injured that badly. But it does compound and complicate other injuries. I think I've found sources that discuss how people with PC and flail chest did much worse than those with either alone, I can try to find more info like that if you think it's a good idea.

On an unrelated note, it's my understanding that we shouldn't be using primary studies if it's avoidable, what's your take on that? WP:PSTS includes "published experimental results by the person(s) actually involved in the research" as primary, and I've had people tell me to cut use of primary sources before, e.g. Ebulides's and Colin's comments at Wikipedia:Peer review/Concussion/archive1. But I'm not sure how strictly we're supposed to be avoiding them. delldot talk 14:40, 13 June 2008 (UTC)

Well, that is the official Wikipedia guideline at Wikipedia:WikiProject Medicine/Reliable sources, although they are called sources rather than studies. Ironically in my own reading, if I see something in a secondary source (usually a textbook) that seems unusual or doesn't fit with my background knowledge, I look for the primary source, and I seek other similar primary sources. In Wikipedia, I suppose that if no secondary source provides the required information, it is better to look at primary sources rather than completely ignore that information. Axl (talk) 17:51, 13 June 2008 (UTC)

That sounds reasonable. In some cases if something hasn't been in any secondary sources it might be too detailed, but I can see how we might need to use primary sources sometimes here, since the topic isn't written about that much. delldot talk 18:55, 13 June 2008 (UTC)

Review by Colin

Lead

I'm reviewing this version.

• Alveoli are described as "microscopic air-filled sacs". But the article alveoli says they range in size from 0.05 to 0.1mm, which is certainly visible (human hair). How about "tiny".
  • Done. delldot talk 23:02, 2 July 2008 (UTC)
• "interstitial space" needs a lay alternative or definition because I've no idea what it is.
  • Is this enough, or should I elaborate more? delldot talk 23:02, 2 July 2008 (UTC)
• "Pulmonary contusion may interfere with gas exchange in the lungs and can therefore result in hypoxia". Your source says "Pulmonory contusion causes aveolar edema and impairs gas exchange. The primary sign of pulmonary contusion is hypoxia." Let's be more definite and drop the "may" and "can". I wonder if we can get away with "This" rather than repeating "Pulmonary contusion": "This interferes with gas exchange in the lungs, leading to inadequate oxygen levels (hypoxia)."
  • Done. delldot talk 23:02, 2 July 2008 (UTC)
• "may be caused by blunt or penetrating trauma" has me confused. Surely a penetrating trauma would cause a laceration, which is explicitly excluded earlier on? Surely bruising is generally a blunt injury? If penetrating trauma can lead to such bruising, is it as common a cause? At the moment, you've placed blunt and penetrating side-by-side in terms of cause. Ah, I see the 4th source "Thoracic Trauma and Critical Care" says "Both penetrating and blunt injuries to the chest result in pulmonary contusion. Significant blunt trauma to the chest is associated with pulmonary contusion in 75% of cases...Penetrating injuries to the chest almost always create some degree of associated contusion in addition to the laceration of the lung parenchyma." So it looks like contusion can (and usually does) accompany a laceration but is more commonly caused by a blunt, non-penetrating, injury. If I've got this correct, can you try to make this clearer in the lead?
  • That's exactly right. Penetrating injury by a high-velocity object causes a shock wave that temporarily pushes tissues out of the way, resulting in contusion. Do you think this expansion is enough, or should it be clarified more? delldot talk 23:02, 2 July 2008 (UTC)

More to follow. Colin°^Talk 22:31, 2 July 2008 (UTC)

Thanks so much Colin, this is really a great help! delldot talk 23:02, 2 July 2008 (UTC)

Delldot, you're really rocking out on this article. I love it! Antelan^talk 18:45, 3 July 2008 (UTC)

Awww, thank you Antelan! Your help with the X-ray section was much appreciated. :D delldot talk 20:58, 3 July 2008 (UTC)

Reviewing this version,

• Happy with improvements above. However, the "are usually caused ... can also cause them." sentence seems to end clumsily but I can't think of better way to make it flow just now.
  • "but can also result from"? Maybe still not perfect. delldot talk 02:43, 4 July 2008 (UTC)
• "heals on its own with supportive care". Can you indicate how much care? I don't know if "supportive" means an oxygen mask in a hospital bed, or a packet of paracetamol at home.
  • Elaborated. delldot talk 02:43, 4 July 2008 (UTC)
• "The severity can range from mild to deadly." makes me wonder about how often it is deadly and how often mild, etc. Your source says "PC is the most common potentially lethal chest injury" (which sounds like good dramatic language for a lead) but I can't find anything on that page about it being mild (though I guess it is quite possible to have a small bruise on your lung and not even seek medical attention).
  • Expanded, and added estimated mortality rate to the lead. delldot talk 02:43, 4 July 2008 (UTC)
• "Pulmonary contusions" Why plural here? Can one typically have multiple contusions?
  • Yes, but there wasn't any rhyme or reason to the switch to plural here. delldot talk 02:43, 4 July 2008 (UTC)
• I'd like to move "The most common serious injury to occur in association with thoracic trauma" to the end of the sentence: ", making it the most serious..." as I think that reads better, but you've got two sources there and I don't know whether they need to move too.
  • I ended up moving a lot of the statistics out of the lead, so this got entirely reworded. Do you think I went too far? Good advice about rearranging the sentence, done. delldot talk 02:43, 4 July 2008 (UTC)
• The "injury severity score" sentence is also backwards IMO but since it is a jargon rating known only to physicians, I think we can drop that from the lead altogether.
  • Good call, moved to Epidemiology. delldot talk 02:43, 4 July 2008 (UTC)
• I'll start reading the rest of the article tomorrow (deliberately didn't read it so that I could judge if the lead made sense). The only other thing I'll add for now is that you check the lead is an adequate summary of the article. Colin°^Talk 22:02, 3 July 2008 (UTC)
  • I think it is; there's something from each section in there, anyway. Thanks again Colin, you're very thorough, as usual. delldot talk 02:43, 4 July 2008 (UTC)

Signs and symptoms

I'm reviewing this version.

• The opening sentence (listing typical S&S) should either include all the typical ones or else you should admit there are too many to list in once sentence and try a different approach. Can we divide them in two: those symptoms due to the contusion directly, and those due to other injuries (I'm assuming the tenderness and coughing up blood is due to accompanying injuries, for example)? Also, would it help to restrict "symptom" for the obvious patient-aware stuff and "sign" for the subtle doctor-discovered stuff (e.g., breath sounds, heart output, blood pressure) -- I'm no expert here. There's also the distinction between severe and milder contusions that might help you group S&S. I'm not sure of the best way to group, order or structure the paragraph, but currently it seems a bit random.
  • Rearranged. Currently it's grouped by s/s of contusion proper and associated injuries. It goes O2 sats, respiratory distress, cardiac signs, signs of associated injuries. I added parentheticals for signs and symptoms, not sure if that was what you were looking for there though. I think grouping mild and severe would be repetitive because it's sort of a continuum (e.g. mild respiratory distress -> severe)
• There's a bit of repetition with the "signs of low blood oxygen saturation" at the start and cyanosis at the end.
  • Eliminated delldot talk 18:48, 8 July 2008 (UTC)
• The second paragraph seems to deal with the speed at which symptoms occur. I think the "People with mild contusions may have no symptoms at all" could be moved to near the start of the first paragraph (though keep the other bit of the sentence here).
  • Done delldot talk 18:48, 8 July 2008 (UTC)
• There's a bit of repetition in this second paragraph (or almost repetition).
  • Is it gone? delldot talk 18:48, 8 July 2008 (UTC)
• "However, deterioration may also be rapid." -- it isn't clear whether this refers to just hypoxemia (in which case, join it to the previous sentence) or person's general health (in which case, it is linked to the "tend to worsen slowly" clause).
  • The source says patients "can become critically ill rapidly", so not hypoxemia alone. So I rearranged and reworded this. delldot talk 18:48, 8 July 2008 (UTC)
• The "but pulmonary contusion tends to worsen slowly over a few days" describes the progression of the injury and doesn't necessarily contradict the clause before it -- so why the "but"?
  • Just to contrast the severe with the usual case. It's now "In general..." delldot talk 18:48, 8 July 2008 (UTC)
• How about a restructure of the paragraph along the lines of (paraphrase) "Half asymptomatic at presentation; therefore suspected if patient history makes it likely; if serious then symptoms appear within a few hours; otherwise gets worse over a day or two"
  • Another great suggestion. Done delldot talk 18:48, 8 July 2008 (UTC)
• The "Chest Radiology Companion" citation mentions page 80, which isn't available via Google books and the link is to page 176. Is this right?
  • Weird, p. 80 is available to me and that's what the link takes me to. delldot talk 18:48, 8 July 2008 (UTC)
• You say "its presence can be used to gauge the severity of an injury" and cite the above source but the page I can read doesn't say this. Is that info on page 80? Although this is an interesting fact, it probably isn't the one you should lead with. The second and third sentences could be merged and form a new first sentence.
  • The info is on p. 80: "it takes a significant amount of energy absorption to bruise the lung; a pulmonary contusion is a marker of injury severity." I couldn't figure out where else to integrate the first sentence, so I put it at the end of the second sentence (since it's linked to the idea of requiring a lot of force to cause). I can take it out if necessary. delldot talk 18:48, 8 July 2008 (UTC)
• "hemothorax, pneumothorax, and flail chest" all three need lay explanations.
  • Done delldot talk 18:48, 8 July 2008 (UTC)
• "A 2000 study found that the most common accompanying injuries were hemothorax and pneumothorax." No need to mention the study. If you are confident of the facts, just state them. Why don't we drop the "such as rib fracture, hemothorax, pneumothorax, and flail chest" bit (which just gets repeated over the rest of the paragraph) and move this up to become something like "About three-quarters of cases are accompanied by other chest injuries; the most common of these are hemothorax and pneumothorax...".
  • Great suggestion! Done, but kept "as many as" wording. delldot talk 18:48, 8 July 2008 (UTC)
• "these are thought to develop in between 4 and 11% of pulmonary contusions" makes it sound like a theory rather than the results of clinical study/experience.
  • Changed to 'reported to'. delldot talk 18:48, 8 July 2008 (UTC)
• "shunting of blood" doesn't mean anything to me.
  • Changed to 'intrapulmonary shunting', the wording the source uses. delldot talk 18:48, 8 July 2008 (UTC)

Colin°^Talk 13:09, 8 July 2008 (UTC)

Thanks again Colin, all of this is very helpful. I appreciate you taking so much time to help with this. delldot talk 18:48, 8 July 2008 (UTC)

casliber's 2c worth...

• OK - I am not thriled with the first 3 sentences of the lead and am busy scratching my head trying to think of a rewording. Just seems to mentally flow jerkily.

sentence 2 should be at end of para 1 - finsh describing what it is before starting on what it isn't.

• Done delldot talk 05:00, 7 July 2008 (UTC)

Contusion causes an accumulation of... --> 'Fluid and blood then accumulate...' (mixing up subjects)

• With the rewording, it's a little different from what you suggested, but is this OK? delldot talk 05:00, 7 July 2008 (UTC)

• Looks better, I am still ruminating. Cheers, Casliber (talk · contribs) 05:35, 7 July 2008 (UTC)

Para 1 is what it is, para 2 is causes, and para 3 treatment (?) - in which case this sentence Pulmonary contusion rarely occurs in isolation; it is usually accompanied by other injuries - should go in para 2.

• Is this placement OK? delldot talk 05:00, 7 July 2008 (UTC)

• Better.

This sentece - Fluid overload caused by excessive fluid resuscitation can worsen this pulmonary edema, contributing to a worse outcome. - might be also beter in para 2 as it is about causes.

• Couldn't figure out where to put it in para 2, but reworded fit it in para 3 in discussion of treatment. delldot talk 14:24, 7 July 2008 (UTC)

• There should be something on epidemiology/prevalence/incidence in lead.
  • Added It is estimated to occur in 30–75% of severe chest injuries. delldot talk 14:24, 7 July 2008 (UTC)

• Signs and symptoms typical of pulmonary contusion include.. - 'Typical signs and symptoms include'
  • Done delldot talk 14:24, 7 July 2008 (UTC)

• it is assumed that pulmonary contusion may have occurred.. - ' pulmonary contusion is assumed to have occurred...'
  • Changed to is suspected to avoid implication of certainty. delldot talk 14:24, 7 July 2008 (UTC)

• There are two Blast Lungs close together in Causes - try to remove or reword one.
  • Changed to this--is that OK? delldot talk 14:24, 7 July 2008 (UTC)

• The implosion effect is proposed to occur.. - proposed looks funny in passive. Try 'The implosion effect is thought to occur'
  • Done delldot talk 14:24, 7 July 2008 (UTC)

Something has come up. I will read from Pathophysiology later, and find some other stuff. Cheers, Casliber (talk · contribs) 08:39, 7 July 2008 (UTC)

Thanks so much Casliber, great suggestions. I hope I've addressed everything OK. delldot talk 14:24, 7 July 2008 (UTC)

I gave it a bit of a copyedit myself. The only thing I can think of more is maybe more prominence to watching for infection afterwards. There might also be a bit more repetition which can be trimmed - have a look for repeated words and phrases.

I also dislike see also sections but that is my opinion. Either something is important enough to be linked in the text or it isn't. I have seen a few exceptions but find most can go. Cheers, Casliber (talk · contribs) 21:26, 7 July 2008 (UTC)

• Thanks again Casliber, great work. The See also section is gone, I've been working on the repetition and I'll keep an eye out for it. I'll work on expanding the infection bit. delldot talk 16:51, 8 July 2008 (UTC)

References

I'm examining the references. Delldot, can you expand on reference 51 ("Moore031", Livingston and Hauser) please? Axl (talk) 17:14, 8 July 2008 (UTC)

This is from the same chapter as Moore03, but a different page number: Livingston DH, Hauser CJ (2003). "Trauma to the chest wall and lung". In Moore EE, Feliciano DV, Mattox KL (ed.). Trauma. Fifth Edition. McGraw-Hill Professional. p. 515. ISBN 0071370692. Retrieved 2008-06-30.{{cite book}}: CS1 maint: multiple names: editors list (link)

I wasn't sure how to do this. Should I create a separate "references" and "notes" section? (Seems kind of weird to have one thing in references and everything else in notes). Cite the whole citation twice, just with different page numbers? Use the same citation, listing all the page numbers used? Any suggestions would be appreciated. delldot talk 21:22, 8 July 2008 (UTC)

Your current format looks much better. If you use a single large book for several references, each of which is from a different part of the book, you can use a "Bibliography" section. Have a look here. Using a Bibliography, you place the main book details in the Bibliography, while the page numbers of the specific references are in "References". Axl (talk) 07:21, 9 July 2008 (UTC)

I think that's the only case where I've used two separate pages from the same chapter. I kind of hate to create a separate section just for that book. In cases where I've used two chapters from the same book (different authors), I've done the full citation for both. (And that's how I have it for that case now, though it can easily be changed if that's best). [[user:delldot on a public span style="color:#990066;">delldot on a public computer]] talk 19:02, 9 July 2008 (UTC)

FAC

How far off do you reckon this article is from going for FA status? It seems a good length to me, well written, well referenced and with plenty of images. Is there anything major you're lacking that FAC wouldn't point out? — CycloneNimrod  ^Talk? 22:53, 8 July 2008 (UTC)

Two experts looked at it and said that it looked ok, but I'd like to find an expert to give it a more thorough review. That's the main thing I want to do before FAC. One of the experts recommended expanding on the pulmonary shunting, so I'm gonna do that when I get time. Colin may be able to do some further reviewing when he has time (in which case it'll probably need a lot of work, judging by how much he found in just the lead and s/s sections). Casliber mentioned some repetitiveness, so I'll work on that, and maybe we can find someone to give it a copy edit. So there's a fair amount to do, plus I've got a lot going on in my life at the moment. It may be a few weeks before I have the time I'd need to dedicate to an FAC. I can keep you updated. Please let me nominate it or check with me before nominating it to make sure I have time.

I'd be most interested to hear what others think about this question! Thanks for the interest and help! delldot talk 23:06, 8 July 2008 (UTC)

It shouldn't take too much. I changed or highlighted specific things I saw, but I have the sneaking suspicion that I could find some more. So another lot of fresh-pair-of-eyes copyediting would do the trick nicely. Also, this is not my area of expertise and there may be a minor thing missing comprehensiveness-wise. Cheers, Casliber (talk · contribs) 05:50, 9 July 2008 (UTC)

Fair enough. I'll see if I can copy edit the whole thing throughout today, i'm a bit busy this morning though. — CycloneNimrod  ^Talk? 06:41, 9 July 2008 (UTC)

Rad, thanks much Cyclone! It'd be great if we could get a Wikipedian familiar with lungs to look at it, does anyone know of such a person? Maybe I should open another peer review and mention it at WT:MED. delldot talk 14:57, 9 July 2008 (UTC)

*cough* Axl (talk) 17:26, 9 July 2008 (UTC)

Quick comments by Eubulides

I was asked to look at Pulmonary contusion #Epidemiology and am afraid I haven't yet found time to do it justice with a real review. It's on my list of things to do but not at the top yet. Here are a few preliminary comments about the article, though:

• The article needs a Classification section as per WP:MEDMOS #Diseases/disorders/syndromes. Such a section would distinguish pulmonary contusion from "nearby" conditions such as tension pneumothorax, collapsed lung, flail chest, ARDS, etc. To experts this stuff is obvious, but most Wikipedia readers are clueless about this sort of thing.
  • Is this more or less what you were looking for? I can keep working on it. delldot talk 16:59, 11 July 2008 (UTC)
    • Yes, thanks, that's helpful. It distinguishes pulmonary contusions from other kinds of pulmonary problems. Do you think it would also be helpful to briefly distinguish pulmonary contusions from other kinds of contusions, e.g., chest wall contusion? Eubulides (talk) 22:01, 11 July 2008 (UTC)
      • There's the sentence "Pulmonary contusion is an injury to the lung tissue", I could add "as opposed to other tissues" or something, but I doubt it would add anything useful. delldot talk 21:53, 12 July 2008 (UTC)

• Isn't Pulmonary contusion #Associated injuries about comorbid conditions, which are typically under Epidemiology? (Just asking....)
  • Dunno, but moved. delldot talk 16:59, 11 July 2008 (UTC)
    • Ah, more work for me to review carefully now. I should have remained silent. :-) Eubulides (talk) 22:01, 11 July 2008 (UTC)

• How about a Prevention section? Something brief like "Stay away from bombs, don't play football, don't get into auto accidents"? OK, so I'm kidding a bit, but still, prevention is a real topic, and a brief discussion of protective measures would be appropriate.
  • I'm afraid most info would be about general chest trauma, there isn't much on PC alone. But I could do a section starting with "Prevention of pulmonary contusion is similar to that of general chest trauma" or some such and discuss these general measures. I could also move the discussion of ventilator-induced lung injury from the ventilation subsection of treatment, where it currently is, though it might be best to keep all the ventilation stuff together. delldot talk 16:59, 11 July 2008 (UTC)
    • Keeping the ventilator stuff together sounds reasonable. You could cross-reference to it, I suppose. I'm just looking for a brief section here. At least I hope it'd be brief; you never know what you'll find until you look for it. Eubulides (talk) 22:01, 11 July 2008 (UTC)

• Should Complications be a subsection of Prognosis?
  • Done delldot talk 16:59, 11 July 2008 (UTC)

Hope this helps. Eubulides (talk) 21:15, 10 July 2008 (UTC)

Thanks much Eubulides! I'll get to work on these points. delldot talk 05:16, 11 July 2008 (UTC)

Since you mention prevention, I wonder if seat belts and air-bags have been shown to prevent pulmonary contusion? Axl (talk) 12:55, 11 July 2008 (UTC)

Not that I know of. Airbags have been reported to cause pulmonary contusion in rare cases; see Caudle et al. 2007, PMID 18072996, which (summarizing previous work) says "Serious but rare pulmonary (i.e., pulmonary contusion, hemothorax and pneumothorax), ophthalmologic, neurologic or cardiovascular injuries have been reported for adults who were out of position relative to the airbag at the moment of deployment." Eubulides (talk) 22:01, 11 July 2008 (UTC)

I forgot this area - public health measures directly related to reducing (or it looks like inadvertentl causing) this injury should be included. Cheers, Casliber (talk · contribs) 22:14, 11 July 2008 (UTC)

Done! Er, well, probably not done, but the section is there now. delldot talk 23:47, 13 July 2008 (UTC)

URLs to books.google.com

The article has several URLs that point to within books.google.com. I am not a fan of this sort of citation.

• It won't work for many readers. Google Books will put you on a leash and won't let you read too many books; this can be a problem if you're in a college dorm, say, and your IP address is shared among many book readers; I often observe this problem myself.
• The URLs themselves give Google (and presumably, others) information about which Wikipedia editor added the URL, and they give Google (and presumably, others) information about exactly which Wikipedia links are being clicked on.
• There are arguably some copyright concerns with Wikipedia linking into copyrighted works like that. At some point it stops becoming fair uses. I don't know where that point is and I suspect nobody does, but I'd rather not worry about it.
• I have fewer concerns for books that are freely readable ("full view", in Google terminology). I think we can work around the URL problems if we're careful. But for "limited preview" there is a problem.

I don't know of any Wikipedia policy or guidelines on this matter, but for the reasons above I suggest removing all URLs to books.google.com, unless the citations are to full-view books (which I doubt). This won't affect the list of sources (they remain the same), just the URLs. Eubulides (talk) 22:12, 11 July 2008 (UTC)

Good points, links removed by Cyclonenim (thanks Cyclonenim!) delldot talk 21:53, 12 July 2008 (UTC)

No worries ;) Stole the easy job! — CycloneNimrod  ^Talk? 22:12, 12 July 2008 (UTC)

I lack access to sources, alas

Alas, I lack access to most of the sources in the Epidemiology section, including all the important ones (what can I say? medical journals are expensive!), so I'm afraid I can't do a proper review of it. From my limited porthole it appears that the section is quite good given the lack of reviews specifically on the epidemiology of the condition. Good work! Eubulides (talk) 22:28, 11 July 2008 (UTC)

OK, thanks much for your time and your helpful comments! I won't take it to FAC before I've dealt with the prevention thing. Do you have any other advice before going to FAC? delldot talk 21:53, 12 July 2008 (UTC)

Reviews

Axl

The chest x-ray at the top right isn't of good quality, although this may be partly due to the transfer to jpg. The left lung field appears almost completely black, more suggestive of a left-sided pneumothorax. Right-sided rib fractures are visible, so flail chest is unsurprising, but would be confirmed on inspection of the chest, not on x-ray. At least the subcutaneous emphysema is unambiguous. Axl (talk) 17:58, 14 July 2008 (UTC)

Switched with the CT image, but should the X-ray be removed entirely? I currently have it in Diagnosis. I can look for a better one. Is the issue that you don't think there's really a pulmonary contusion, or just that the image isn't of good quality (e.g. it's grainy)? delldot talk 20:10, 14 July 2008 (UTC)

I'm sure that there is contusion, but there are also other more obvious injuries. Also, the quality is mediocre. The CT is a better image. Axl (talk) 19:37, 15 July 2008 (UTC)

Is it bad enough that it should be removed entirely, or could it stay in the diagnosis section? I can keep looking for another X-ray image. delldot talk 01:45, 16 July 2008 (UTC)

Leave it in the "Diagnosis" section. Although a better x-ray would be preferable. Axl (talk) 09:15, 16 July 2008 (UTC)

From the lead, paragraph 3: "With an estimated mortality rate of 14–40%, pulmonary contusion plays a key role in determining whether an individual will die or suffer serious ill effects as the result of injury." Curiously this contradicts the work by Allen & Cox, who appeared to find pulmonary contusion an incidental feature of more serious injuries. Axl (talk) 18:03, 14 July 2008 (UTC)

Yes, the mortality rate is hard to tell because it so rarely occurs in isolation. But most sources I've seen have said that the injury does carry significant morbidity and mortality itself, and it definitely increases the mortality when combined with other injuries, e.g. flail chest. There's more info with references in the epidemiology section. delldot talk 20:10, 14 July 2008 (UTC)

Added a sentence to the lead clarifying PC's role in mortality. delldot talk 03:23, 15 July 2008 (UTC)

Okay. Thanks for confirming the point. I find it somewhat surprising, but if that is what the references say, that's fine by me. Axl (talk) 19:42, 15 July 2008 (UTC)

From "Classification": "Although they may occur at the same time, injuries to the chest wall are distinct entities; these include rib fractures and flail chest, in which multiple ribs are broken so that a segment of the ribcage is detached from the rest of the chest wall and moves independently." It's not clear that rib fractures are distinct from flail chest. However flail chest actually requires rib fractures. Axl (talk) 18:10, 14 July 2008 (UTC)

Good catch, reworded so the meaning's clear. delldot talk 20:10, 14 July 2008 (UTC)

From "Signs and symptoms", paragraph 2: "Signs and symptoms may take time to develop and as many as half of cases are asymptomatic at the initial presentation." This implies that only a fraction of these remain asymptomatic? Axl (talk) 18:32, 14 July 2008 (UTC)

Yes, symptoms often develop over time. I can elaborate on this if necessary. delldot talk 20:10, 14 July 2008 (UTC)

Also from "Signs and symptoms", paragraph 2: "Therefore, pulmonary contusion is suspected whenever someone suffers an injury involving force sufficient to cause it." Is this specifically a chest injury? How much force is sufficient? Axl (talk) 18:34, 14 July 2008 (UTC)

Yikes, I'm glad you brought this up, because the source is actually specific to pediatrics, so doesn't apply generally (children are particularly likely to have PC without other signs like chest wall injuries). That sentence didn't really fit there anyway, so I'm removing it. delldot talk 20:27, 14 July 2008 (UTC)

I found a general reference that says it should be suspected whenever there's "major chest wall injury" but I don't know if it should go back in or not. delldot talk 21:25, 14 July 2008 (UTC)

Probably better off without the sentence. I suspect that it's a circular argument: What is a major chest injury? A chest injury that is sufficient to cause pulmonary contusion. Axl (talk) 20:02, 15 July 2008 (UTC)

In "Pathophysiology", the diagram of the fluid-filled alveolus could use some arrows to indicate blood flow through the capillaries, and a label for the alveolus. Axl (talk) 18:48, 14 July 2008 (UTC)

Done, let me know if you can think of further improvements. delldot talk 21:25, 14 July 2008 (UTC)

From "Pathophysiology", "Consolidation and collapse": "When alveoli consolidate as a result of bleeding into them, it causes the pressure within the capillaries of the lungs to rise; this increased pressure can rise so high that blood and serum leak from the capillaries." We discussed this point during the GA review. Is it really the high pressure in the capillaries that causes leakage? The mechanism is suggestive of ARDS. In the reference, is the capillary pressure actually measured? Perhaps a surrogate: PCWP is measured? Axl (talk) 18:54, 14 July 2008 (UTC)

Of course the first (and I assume main) cause of leakage is the damage to the capillary-alveolar membrane, but I can see how leakage would occur by this mechanism too. The part I quoted in the GA review is all Allen (1996) has to say on the matter; the source they cited for the info (PMID 5541483) used a dog lung preparation and measured pressures in pulmonary artery and vein. They weren't studying pulmonary contusion, but concluded that fluid overload could possibly lead to lung edema. Since I haven't seen this anywhere else, and it's from an old paper citing an even older one, I think it might be best to remove this sentence. As added bonuses, this reduces the lengthy pathophysiology section and allows a smoother transition into the inflammation paragraph by ending on discussion of the uninjured lung being affected. delldot talk 01:02, 15 July 2008 (UTC)

From "Pathophysiology", "Ventilation/perfusion mismatch": "This shunts blood away from the hypoxic alveoli and to better-ventilated areas." This is an inaccurate use of the term "shunt". "Shunt" actually refers to blood passing from the systemic venous side to the systemic arterial side without being oxygenated in the lungs. Alveolar filling is one cause of shunt. Pulmonary hypoxic vasoconstriction tends to mitigate the impact of shunt, although also causing pulmonary hypertension. Axl (talk) 19:07, 14 July 2008 (UTC)

Yes, I think a lot of the confusion results from the fact that a lot of sources do call the hypoxic vasoconstriction "shunting" as well, so you see crazy stuff like 'this shunting compensates for the shunt'. Reworded to "directs". delldot talk 01:02, 15 July 2008 (UTC)

From "Treatment": "In most cases, the injury does not require surgical intervention." So in some cases, pulmonary contusion requires surgery? Axl (talk) 19:27, 14 July 2008 (UTC)

• The first ref says "most [chest] injuries and particularly lung contusions can be treated nonoperatively or only with intercostal tubes"--I guess I interpreted this to mean "surgery's usually not necessary for contusions", but it could mean it's never used for contusions. Miller (PMID 17650697) says "If a pulmonary hematoma or pulmonary contusion is identified at the time of thoracotomy, the surgeon should resist the temptation to resect the involved lung. Despite the gross appearance, there is rarely an indication for resection of an injured lung, unless there is associated significant injury to the airway or pulmonary vessels." None of the sources exactly say it's never used, but surgery is never listed as part of treatment in anything I've found, so I'll take this sentence out. delldot talk 03:23, 15 July 2008 (UTC)

That makes sense. Pulmonary contusion is not treated with intercostal tube drainage. Pneumothorax/haemothorax is treated with intercostal tube drainage. Uncomplicated pulmonary contusion requires only supportive treatment. Axl (talk) 20:16, 15 July 2008 (UTC)

Thanks a ton Axl, this is all good stuff. I'll get to the last three tonight. delldot talk 21:30, 14 July 2008 (UTC)

I think I've addressed everything here, but I'm certainly open to making more changes as needed. Thanks again Axl. delldot talk 03:23, 15 July 2008 (UTC)

From "Prognosis": "During the six months after pulmonary contusion, up to 90% of people suffer with difficulty breathing, which may persist for an indefinite period." This is a stark difference from the opening sentence of the section: "Pulmonary contusion usually resolves by itself and, in most cases, it resolves in 5-7 days after the injury without permanent complications." Axl (talk) 06:45, 15 July 2008 (UTC)

Good catch, it was bad to combine those facts into one sentence because it creates a false implication that it can last indefinitely in the 90%. The source says "Some patients experience dyspnea indefinitely". I've reorganized this section, hopefully that fixes it. delldot talk 14:23, 15 July 2008 (UTC)

From "Complications": "Also, the tube inhibits coughing...." It's not the tube that inhibits coughing, it's the anaesthetic (technically muscle relaxant) that's given as part of mechanical ventilation. The person is paralyzed, hence unable to cough. Axl (talk) 06:58, 15 July 2008 (UTC)

Thanks for pointing this out, reworded. delldot talk 14:23, 15 July 2008 (UTC)

More good stuff Axl, thanks again! delldot talk 14:23, 15 July 2008 (UTC)

Okay, delldot, that's my review finished. Thanks for addressing my comments. The accuracy and comprehensiveness of the text is as good as we can achieve from the top quality references provided. My only concern is about achieving "brilliant prose". I suspect that some of the FAC reviewers may comment on this. I'll certainly try to help out when you submit this to FAC. Axl (talk) 14:03, 16 July 2008 (UTC)

Thanks Axl, you are so awesome. delldot talk 15:03, 16 July 2008 (UTC)

TimVickers

• Comments on the lead
• Citations in the lead isn't standard, it is supposed to simply summarise the rest of the article.
  •  Done Axl (talk) 07:56, 20 July 2008 (UTC)
• Lead is a bit over-balanced on treatment, doesn't mention history or prevention.
  • Partially done. I added a sentence mentioning the use of seatbelts and airbags. I didn't add info about history, partly due to size constraints. This would require another paragraph. Medical featured articles "Schizophrenia" and "Lung cancer" don't mention history in their lead sections. "Tourette syndrome" includes a single sentence in a separate paragraph. Axl (talk) 08:19, 20 July 2008 (UTC)
    • Added a sentence on history. delldot talk 14:07, 20 July 2008 (UTC)
• The English isn't as simple as it could be, examples:
  • "injurious event" - how the injury occurred
    •  Done Axl (talk) 07:39, 20 July 2008 (UTC)
  • "This excess of fluids interferes" - The excess fluids interfere
    •  Done Axl (talk) 08:32, 20 July 2008 (UTC)
  • "most often is due to motor vehicle accidents" - usually caused by car accidents
    •  Done Although there is a debate at "Talk:Car accident" regarding the appropriate title/description. I have changed it to "Car accident", in line with Wikipedia's article name. Axl (talk) 08:32, 20 July 2008 (UTC)
      • I think the source used "traffic accidents" or another term not specific to cars, so it might not be accurate to say that cars still account for the majority (as opposed to e.g. trucks). It's a reasonable guess that cars account for the majority of these and since traffic accidents are so far and away the main cause, accidents involving cars would still account for the majority. But I would change it to "traffic" or "vehicle" or another vague term to remain loyal to the source if no one objects. delldot talk 13:54, 20 July 2008 (UTC)
        • Actually I went ahead with "traffic", change back if it's a problem. delldot talk 14:07, 20 July 2008 (UTC)
  • "Pulmonary contusion rarely occurs in isolation; it is usually accompanied by other injuries" - Pulmonary contusion is usually accompanied by other injuries
    •  Done Axl (talk) 08:42, 20 July 2008 (UTC)
  • "no impact on the patient's outcome" - no impact on health
    •  Done Axl (talk) 08:42, 20 July 2008 (UTC)
      • How about long-term health? delldot talk 13:54, 20 July 2008 (UTC)
  • "It is estimated to occur" - just say It occurs if the source is reliable, but if you doubt the accuracy of the source name the author and attribute the estimate
    • Done, this is loyal to the source anyway. delldot talk 13:54, 20 July 2008 (UTC)
  • "can worsen pulmonary edema, contributing to a worse outcome." - can worsen pulmonary edema, which may be lethal.
    • Done. delldot talk 13:54, 20 July 2008 (UTC)

Thanks so much Tim, this is all good advice! delldot talk 13:54, 20 July 2008 (UTC)

And thanks much to Axl for addressing most of these, nice work! delldot talk 14:07, 20 July 2008 (UTC)

As a general tip I go through (Ctrl+F) my FACs to find all instances of "can", "may" and think about if I can delete them with no loss in accuracy. This helps you find weak pieces of writing. Tim Vickers (talk) 16:38, 20 July 2008 (UTC)

Great suggestion, I found a bunch of "may"s and "can"s that I removed (most had to stay for accuracy, though). delldot talk 17:11, 20 July 2008 (UTC)

Frequency in blunt chest trauma

We say Pulmonary contusion, which occurs in 25–35% of all blunt chest trauma. Grainger & Allison say "Pulmonary contusion occurs in up to 75% of cases of blunt chest trauma", and they cite this work for that figure: "Stark P: The radiology of thoracic trauma, Boston, Andover Medical, 1993." I'm in no position to evaluate who is correct or which figure we should go by, but I thought I'd point this out. Cheers, Antelan 23:29, 16 July 2008 (UTC)

I think it's a matter of how severe an injury has to be in order to be qualified as "chest trauma", that's why you get widely different statistics. I think I've also seen '30-75% of chest trauma' or similar. Really what we need is some objective measurement of how severe the chest trauma is, but as Axl points out above, it's going to be kind of circular--how severe is severe? Severe enough to cause injuries to the organs? I'll look through my sources to make sure we're using the most oft-cited figure. delldot talk 23:56, 16 July 2008 (UTC)

Certainly true - this is going to be a circular exercise. Your figure is already cited; might as well go with it. 25-35% is still within the limits of "up to 75%" so in that regard, the sources don't disagree. =) Antelan 00:10, 17 July 2008 (UTC)

Sounds good. Oh yeah, the 30-75% figure is cited in the article--it's for "severe" chest trauma, so maybe that's where Grainger & Allison came up with the up to 75 figure. :) delldot talk 02:11, 17 July 2008 (UTC)

No interwikis?

Is the American classification incompatible with any foreign system to the point where the subject is unlinkable? NVO (talk) 04:02, 28 November 2008 (UTC)

As far as I know, the article doesn't exist in other languages. In fact, it didn't exist here until April. delldot ∇. 04:07, 28 November 2008 (UTC)

Congratulations!

On making the front page! A big well done to all who worked on the article, especially Delldot! —Cyclonenim (talk · contribs · email) 07:38, 28 November 2008 (UTC)

Thanks much Cyclone! :D It was a big, er, surprise to log on and see it on the front page! delldot ∇. 21:54, 28 November 2008 (UTC)

National Guidance Clearinghouse

The "external links" section contained a link to a page that has clearly expired, because it now redirects to the main page. When searching the repository, I came across doi:10.1097/TA.0b013e31827019fd which looks useful and might be integrated into the article. I see Delldot edits occasionally... JFW | T@lk 06:59, 15 January 2014 (UTC)

Thanks JFW, I will read it and see what I can do! delldot ∇. 21:02, 15 January 2014 (UTC)

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FAR?

I saw in an old edit to WT:MED mention of this article needing FAR probably just because it was promoted so long ago. I'd be down to work on updating it although 2020 has been insane and I don't know where I'll find the time. I'm not sure if someone's going to bring it to FAR or whether they were just saying it probably needs looked at. But I'd be excited to collaborate if anyone has the time. delldot ∇. 01:20, 15 December 2020 (UTC)

"Excited to collaborate"? Hmm. FAR implies that someone thinks it doesn't meets FA standards any more. In any case, I can help with improvements. Axl ¤ [Talk] 02:03, 15 December 2020 (UTC)