Perioperative management of tracheobronchial injury following blunt trauma

Abstract

We describe tracheobronchial injury (TBI) in a 17-year-old teenager following blunt trauma resulting from a road traffic accident. The patient presented to a peripheral hospital with swelling over the neck and face associated with bilateral pneumothorax for which bilateral intercostal drains were inserted and the patient was transferred to our institute. Fiber-optic videobronchoscopy (FOB) was performed, the trachea and bronchi were visualized, and the site and extent of injury was assessed. Spontaneous respiration was maintained till assessment of the airway. Then the patient was anesthetized with propofol and paralyzed using succinylcholine and a double-lumen endobronchial tube was inserted; thereafter, the adequacy of controlled manual ventilation and air-leak through intercostal drains was assessed and the patient was transferred to operating room (OR) for repair of the airway injury. The OR was kept ready during FOB to manage any catastrophe. This case describes the need for proper preparation and communication between health care team members to manage all possible scenarios of traumatic TBI.

Pneumomediastinum and (bilateral) pneumothorax after high energy trauma: Indications for emergency bronchoscopy

“…Previous studies report most patients with tracheobronchial injury to die at the scene of the accident, due to associated fatal injuries [2,3] . In patients who survive, tracheobronchial lesions are not always diagnosed immediately [3,5] , resulting in delay of proper treatment. This can eventually lead to stenosis, stricture, and scarring.…”

Blunt traumatic bronchial transection in a 28-month-old child

“…[3] Although rare in children, rupture of the central airway is still more common in children than in adults and there are two peaks of incidence: 5-6 years old children tend to be pedestrians involved in traffic accidents and falls at home and 12-14 years old children tend to be involved in motorbike accidents. [56] The prognosis depends on early diagnosis and improvement of the respiratory balance, which is achieved by a combination of endotracheal intubation, optimal respiration and early surgical intervention. The clinical symptoms of TBI, including chest pain, dyspnea, deep cervical emphysema, pneumothorax, pneumomediastinum, subcutaneous emphysema and persistent air leakage after tube thoracostomy, are well-known.…”

“…Nevertheless, the immediate diagnosis of blunt injury to the trachea and bronchus is sometimes difficult, resulting in delayed diagnosis and treatment in many cases. [1678] Children suffering from lesions of the tracheobronchial tree often show only minimal clinical symptoms such as chest pain and hemoptysis and they may lack the serial rib fractures typical of adults after massive thoracic trauma because a child's chest is much more elastic than an adult's chest. The clinical presentation depends also on the status of the peribronchial connective tissue, communication between the wound and the pleural space and the site and extent of the injury.…”

“…[2389] In an emergency situation, bronchoscopy may not be appropriate and surgery may be performed depending on the patient's clinical condition. For adequate repair and pulmonary preservation, the surgery should be performed within 48 h.[36] Delayed surgical repair carries a higher risk for infection and stricture formation. In our case, the diagnosis was made by clinical presentation, chest X-ray and CT findings.…”

Management of Blunt Pulmonary Injury

“…Although surgical cricothyrotomy is usually the procedure of choice for emergent surgical creation of an airway, placement of the airway through the cricothyroid membrane may be well above the injury level, failing to adequately secure the airway. [25][26][27][28][29] Emergency tracheostomy may be the best option in this circumstance.…”