Contemporary management strategies of blunt tracheobronchial injuries

Abstract

Background: Tracheobronchial injuries are rare but feasibly life-threatening conditions. A prompt diagnosis and early management can be lifesaving. Due to the unspecific symptoms and indirect radiological signs the diagnosis often delays.Objectives: We present a short series of patients suffering from tracheobronchial airway laceration. All the three patients had blunt thoracic or neck trauma and showed early signs of tracheobronchial injury. In the first case a 44-year-old woman was crushed by a bus. Subcutaneous emphysema, pneumothorax on chest computed tomography and hypoxaemia despite of chest tube suggested the presence of an airway injury. During operation a 4-cm-long tear of the trachea and a complete transection of the right main bronchus were found. In the second case a 12-year-old girl was crossed by a truck trailer. Early signs were respiratory failure, extended subcutaneous emphysema, blood clot in the larynx, pneumothorax on both sides. Chest CT showed pneumomediastinum. During the operation a longitudinal laceration was found separating the two main bronchi at the bifurcation. In the third case a 9-year-old boy was injured in a car accident, when the seat-belt crossed his neck. Spreading subcutaneous emphysema, pneumomediastinum and an overinflated endotracheal tube's cuff were found on CT. A completely transected trachea between the first and second tracheal rings was found. All three patients required fast intubation and bronchoscopic examination to confirm the diagnosis, and to identify the site of lacerations. All the patients underwent primary reconstruction and recovered successfully. Conclusions:In case of suspected tracheobronchial injury, a high index of suspicion is required for early diagnosis. Most commonly respiratory distress, subcutaneous emphysema and pneumothorax are found on physical examination. Prompt intubation below the site of the injury and early laryngo-or bronchoscopic examination have priority, as we did in our cases. A primary anastomosis is required with minimal resection during urgent operation. A better outcome is to be expected when extubation is done early after surgery. We offer ordinal steps that should be taken to lead to a prompt management and good long-term outcome based on the literature and our experiences.

Paediatric Longitudinal Tracheal Laceration From Blunt Force Trauma: A Case Report

“…TBI in the paediatric population is caused by blunt trauma in 94% of cases [ 1 ]. Our patient sustained the laceration following a bike accident.…”

“…Strong clinical suspicion of TBI can be reached based on clinical examination, especially in the presence of large lacerations, which will likely cause respiratory distress with cyanosis, rapidly increasing subcutaneous and mediastinal emphysema, and severe cough [ 1 , 4 ]. Advanced trauma life support management should be initiated for all trauma patients as it was proven to significantly decrease mortality for patients with TBIs [ 1 ].…”

“…Surgical management used to be a mainstay treatment of tracheal lacerations. However, a recent review of contemporary management strategies of blunt TBIs advocates that a conservative approach in certain cases can be an equally effective alternative [ 1 ]. Jougon et al also suggested considering a non-surgical approach for delayed diagnosis or late presentation.…”

“…Tracheal lacerations are serious and life-threatening injuries that require immediate emergency care and often surgical intervention. These injuries are uncommon (with tracheobronchial injuries [TBIs] making up only 0.2-0.8% of trauma cases reaching the emergency department), especially in the paediatric population, and most of them are fatal at the scene of the incident [ 1 ].…”

“…Tears are presumed to arise due to expansion of the U-shaped tracheal cartilage secondary to a sudden increase in pressure in the tracheobronchial tree [ 1 , 4 , 5 ]. Most tears are located within 2-3 cm from the carina and the right bronchus is more predominantly affected due to its fixation in the thorax [ 1 , 2 ].…”