Complete laryngotracheal disruption caused by blunt injury

Anesthetic management of tracheal laceration from traumatic dislocation of the first rib: a case report and literature of the review

Background

Tracheobronchial lacerations from trauma can be life-threatening and present significant challenges for safe anesthetic management. Early recognition of tracheal injuries and prompt airway control can be lifesaving.

Case presentation

A 56-year-old man with no significant medical history presented with difficulty breathing after a blunt trauma to his chest to the emergency room and was diagnosed with dislocation of the first rib and tracheal laceration after a chest tomography (CT) study. Subcutaneous emphysema in neck area quickly worsened indicating continuous air leak. Emergent surgical repair was scheduled. General anesthesia with maintaining spontaneous ventilation was performed and a 5.5 mm endotracheal tube was placed under the guidance of flexible bronchoscopy. Depth of anesthesia was maintained to achieve a Bispectral Index Score of 40–60. Once the offending first rib was removed, a 7.5 mm endotracheal tube was inserted distal to the laceration site with the guidance of flexible bronchoscopy. Once confirmed location of the endotracheal tube, cisatracurium was administered intravenously and the patient was managed on mechanical ventilation with interval positive pressure ventilation. The operation was successful and he was transferred to the ICU intubated. He then received elective surgical repairs for sternum fracture, multiple rib fractures and hemopneumothorax under general anesthesia on day 5 after the first surgery and was extubated on postoperative day 7. The subsequent course was uneventful. Comprehensive rehabilitation was done for 2 weeks and he was discharged home on postoperative day 41.

Conclusions

Early diagnosis and multidisciplinary collaborations are keys to the successful management of this patient. Flexible bronchoscopy is particularly useful in airway management for urgent trachea tracheal laceration repair.

Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma

INTRODUCTION

Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns.

METHODS

A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763).

RESULTS

A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns.

CONCLUSIONS

The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety.

Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

Acquired subglottic stenosis: aetiological profile and treatment results

Objectives:

To analyse the aetiological profile and surgical results of patients with acquired chronic subglottic stenosis, and formulate a surgical scheme based on an audit of various surgical procedures.

Methods:

Thirty patients were treated by 65 procedures (31 endoscopic and 34 external) between 2004 and 2009.

Results:

Isolated subglottic stenosis was noted as unusual in the majority (27 cases), demonstrating contiguous tracheal or glottic involvement. The major aetiologies were intubation injury (n = 8) and external injury (n = 21) (i.e. blunt trauma, strangulation or penetrating injury). Vocal fold immobility and cartilage framework involvement were frequent with external injury and infrequent with intubation injury. Luminal restoration was achieved by endoscopic procedures in 2 cases, external procedures in 19 cases, and external plus adjuvant endoscopic procedures in 8 cases. The preferred surgical options were: endoscopic procedures, restricted to short, recent, grade I or II mucosal stenosis cases; and external procedures for all other stenosis situations, including isolated subglottic (anterior cricoid split plus cartilage graft), subglottic and glottic or high subglottic (anterior plus posterior cricoid split with cartilage graft), and subglottic and tracheal (cricotracheal resection with anastomosis).

Conclusions:

External injury stenosis has a worse profile than intubation injury stenosis. Anatomical categorisation of subglottic stenosis guides surgical procedure selection. Endoscopic procedures have limited indications as primary procedures but are useful adjunctive procedures.

Clinical features and management of closed injury of the cervical trachea due to blunt trauma

Background

We retrospectively reviewed the presentation, diagnosis, treatment, and outcomes of patients with closed injury of the cervical trachea. We evaluated factors that improve diagnosis and treatment, reduce mortality, and avoid tracheal stenosis.

Methods

We reviewed the clinical data of 17 patients with closed injury of the cervical trachea. All patients underwent CT scanning or endoscopy, tracheal exploration, low tracheotomy, and tracheal repair.

Results

In 12 patients, breathing, phonation, and swallowing functions had returned to normal at 2 weeks. In three patients, breathing and swallowing functions had recovered at 2 weeks, but hoarseness continued. In two patients, tracheal stenosis prevented extubation and required further surgery; in these patients breathing and swallowing functions had recovered at 6 months.

Conclusions

Closed injury of the cervical trachea may cause airway obstruction and is potentially life-threatening. Early diagnosis and repair to restore structure and function are important to ensure survival and avoid tracheal stenosis.

Complete traumatic laryngotracheal disruption--a case report and review

Blunt neck trauma is an infrequent cause of injury in the pediatric population; however, significant injury is possible even with minor trauma to the neck. The authors present the previously unreported case of a combined laryngotracheal and esophageal disruption as well as a severe laryngeal crush injury in a pediatric patient following a blunt, clothesline neck injury. Immediate management of laryngotracheal or esophageal separation is frequently discussed, but little information exists concerning long-term treatment and management of total laryngotracheal disruption and crush injuries in pediatric patients. A review of the literature is presented to address these concerns.

Survival after traumatic complete laryngotracheal transection

Laryngotracheal trauma may result in lifelong complications or even death if diagnosis or treatment is delayed. Emergency department physicians, trauma surgeons, anesthesiologists, and especially thoracic surgeons should maintain a high level of awareness of and suspicion for laryngotracheal trauma whenever a patient present with multiple trauma in general or with cervical-thoracic trauma in particular. A blunt or penetrating laryngotracheal injury can result in acute airway obstruction and death at the scene of an accident or crime. In recent years, advances in emergency services, including better evacuation procedures and heightened training, have improved survival rates. In this article, we present a case of survival after complete laryngotracheal transection for blunt cervical and thoracic trauma.

Tracheal Rupture After Blunt Trauma

Tracheal injuries are uncommon after blunt trauma. Early diagnosis and urgent treatment are primordial to reduce both mortality and morbidity. We describe the case of a 45-year-old man who met with a traffic accident and was brought to the emergency department. Progressively, he developed dyspnoea and coughing. The diagnosis of a tracheal rupture was established and the rupture was closed surgically. The management of the patient with suspected tracheal rupture is discussed.

Burns and tracheo-oesophageal-cutaneous fistula

We report an unusual case of electric burns suffered by a 15-yr-old boy. The patient's neck had come in contact with a high voltage broken electric wire and by reflex he had pulled it away with his right hand. He presented with a tracheo-cutaneous fistula with a right-sided pneumothorax. Emergency airway management included insertion of a tracheostomy tube through the traumatic opening in the neck and insertion of an intercostal tube drain. When the diagnostic endoscopy revealed an externally communicating tracheo-oesophageal fistula, protecting the lower airways from gastrointestinal contamination became a priority. The patient was anaesthetized through the traumatic tracheostomy and a formal low tracheostomy was done below the level of the fistula. The patient then underwent oesophageal reconstruction with a stomach free flap. Tracheo-oesophageal-cutaneous fistula is a rare presentation of electric burns. The anaesthetic management of the emergency difficult airway in any penetrating neck injury can be extremely difficult requiring a carefully planned multi-disciplinary approach.