Management of tracheal trauma

Abstract

I In nc ci id de en nc ce e Blunt injury to the lower airway is uncommon, due to anatomic protection by the mandible and sternum anteriorly, the spinal column posteriorly, and the mobility and the elasticity of the upper airway itself. The larynx or cervical trachea is injured in < 1% of patients admitted to the hospital for blunt trauma. 1 Over a ten-year period, Angood and co-workers reported that only 16 patients with laryngeal injury and four patients with cervical tracheal injury were treated at the Montreal General Hospital. 2 Of 46 patients with blunt upper airway injuries reported by Cicala and colleagues, 11 (24%) died and four (36%) of these deaths were primarily due to airway injury. 3 Other authors reported that 21% of patients with blunt airway injuries died in the first two hours after admission. 4 Penetrating airway injuries in the neck are also relatively uncommon. Capan and colleagues reviewed 17 reports published between 1965-1989 describing acute cervical airway injuries. 5 Approximately 300 patients were identified accounting for an average of less than three cases per year per reporting centre. Penetrating injuries of the neck involved the larynx in up to 5-15% of patients, with the patients who had carotid artery or digestive track injuries being at least twice as likely to have airway injuries. 6,7 About one-third of airway injuries involved the larynx and two-thirds involved the cervical trachea. 3 The sites of non-penetrating upper airway injuries vary among patients. In a review of a series of blunt injuries to the upper airway, Cicala and co-workers reported seven (35%) laryngeal injuries above the cricoid, three (15%) involving the cricoid cartilage, nine (45%) involving the cervical trachea, and one (5%) involving other sites. 3 Thyroid cartilage was the most commonly fractured site in blunt and penetrating laryngeal injuries (47%), followed by arytenoid cartilage (24%), and cricoid cartilage (22%). 8 The prevailing site of tracheal transection is the junction of the cricoid with the trachea, because the connective tissues in this area are relatively weak.

Urgent surgical repair is pivotal in the management of major airway injury due to blunt trauma

“…Postoperative use of bronchoscopic examination, nasotracheal suction, or forced coughing is important, and the patients should be reassessed by bronchoscope 3 months after repair [18,19]. Tracheal stenosis is Fig.…”

“…Because it is difficult to ventilate/oxygenate, even after tracheal intubation and mechanical ventilation, and even get worsened [18]. Thus, those who survive the accident were those with upper injuries while those who die at the scene were those with lower injuries [19].…”

Prehospital tracheotomy in a case of avulsion of the larynx with a comminuted fracture of the jawbone

“…Fractures of the larynx are rare injuries with an incidence rate of one in 30,000 because the larynx is relatively protected by the sternum and the mandible [1-4]. Typically, the massive traumatic impact required to cause laryngeal fracture usually results in additional injuries such as midfacial fractures, fractures of the body of cervical vertebra, and craniocerebral trauma; in addition, the patients commonly develop pneumothorax [2,4,5]. Overall, the patient population shows a high rate of mortality [2,4].…”

Lobar Bronchial Rupture with Persistent Atelectasis after Blunt Trauma

“…Although rapid sequence endotracheal intubation is frequent in trauma patients in those with airway injury may result disastrous. The pressure over a fractured cricoid may dislocate it enough to completely distort the upper airway, change the view of the physician performing the intubation or even lead to complete airway transection and obstruction [16]. Attempts to blindly overpass an upper airway injury may worsen the laceration and/or create false passage of the tube [36].…”

“…Tracheostomy is not routinely performed in airway trauma. It should be done under local anesthesia in patients with significant laryngo-tracheal injuries with complete or pending airway obstruction and when endotracheal intubation is considered unwise and unsafe as in the presence of concomitant craniomaxillofacial injuries [16,45]. Moreover, it should be performed in every patient with TBI after failed attempts for endotracheal intubation [2,46].…”