Tracheobronchial injuries in childhood: review of two cases

Management of chest trauma in children

Chest trauma in children is caused by high-energy blows, due in general to traffic accidents, that involve several other body regions. They occur mainly in the first decade of life and can be penetrating but are more often non-penetrating. Rib fractures and lung contusions, sometimes associated with pneumothorax or haemothorax, are the more usual injuries, but tracheobronchial rupture, cardiac, oesophageal or diaphragmatic injuries may also occur. These injuries are treated with supportive respiratory and haemodynamic measures, drainage of air or blood from the pleural space and, at times, surgical repair of the injured organ(s). Ruptures of the airway may be difficult to treat and occasionally require suture, anastomosis or resection. Oesophageal injuries can be treated conservatively with antibiotics, drainage and parenteral nutrition. Diaphragmatic tears should be repaired operatively. Overall mortality ranges from 6 to 20%. Mortality is high but this is mainly due to the associated presence of extra-thoracic trauma, and particularly to head injuries.

[Tracheobronchial rupture in childhood]

Tracheobronchial rupture after blunt trauma is rare, especially in a pediatric population. In this paper, we report the case of a 3-year-old child who presented with a rupture of the tracheobronchial tree as a result of multiple injuries (thoracic and cerebral) sustained from a traffic accident. The surgical repair consisted of a sleeve resection (right upper lobectomy with reanastomosis of the bronchus intermedius to the right stem bronchus). As tracheobronchial rupture is a rare condition, particularly in children, physicians must have a high index of suspicion. The diagnosis and treatment of this condition are discussed.

Paediatric chest trauma (part 2) — Hidden Injuries

Chest trauma is the second greatest cause of mortality from trauma, a leading cause of death in children over the age of one. Prompt diagnosis can be difficult as the underlying thoracic injuries are often disproportionately severe compared to the visible surface injury and symptoms may not appear for several hours. Diagnosis are easily underestimated, delayed or missed. This is the second of a 2 part article reviewing Paediatric chest trauma and its current management. The injuries are usefully classified into 6 lethal injuries that need excluding in the primary survey and 6 hidden injuries that must be considered in the secondary survey. The 6 lethal injuries are covered in the first part of this article along with biomechanics and mechanisms of injury. This article looks in depth at the 6 hidden injuries, along with a review of chest trauma in non-accidental injury.

The lung and pediatric trauma

Thoracic trauma is relatively frequent in children and causes considerable mortality. This is mainly due to the multiorganic nature of the trauma. The lung is more often affected even in the absence of rib fractures because of the considerable pliability of the chest wall that allows direct transfer of energy to this organ. Injuries to the heart, the aorta, the esophagus, and the diaphragm are rare. Lung contusion and laceration cause parenchymal hemorrhage and consolidation sometimes accompanied by pneumothorax and/or hemothorax. Tracheobronchial disruption is rare but life-threatening. Most traumatic lung injuries may be treated with rest, respiratory support, and eventually intercostal drainage. Large hemorrhage may require thoracotomy, and persistent pneumothorax (indicative of tracheobronchial disruption) may require intubation with fiberoptic bronchoscopic assistance and eventually reparative or ablative surgery. Adult respiratory distress syndrome is very rarely seen in children with thoracic trauma, but it remains highly lethal.

Injuries to the major airway after blunt thoracic trauma in children: review of 2 cases

Tracheobronchial injuries in children occur rarely. Their diagnosis is often very difficult and needs a high degree of suspicion, with in-depth knowledge of the anatomy of and radiological findings for the chest. With proper surgical management, even a delayed diagnosis can result in normal lung function. We discuss 2 cases of major airway injuries with successful outcomes and present some interesting surgical maneuvers.

Tracheal rupture in a child with blunt chest injury

A 10-year-old boy fell from a tree and sustained blunt injury to his chest. He was brought to the hospital (6 h later) with difficulty in breathing and inability to speak. There was a bruise on the neck and extensive subcutaneous emphysema over the neck and chest and decreased air entry over the right hemithorax. Radiographs revealed a right-sided pneumothorax, pneumomediastinum and tracheal deviation. An intercostal drain (with underwater seal) was inserted and he was transferred to the operating room for bronchoscopy. Anesthesia was induced with IV midazolam and ketamine. The trachea was intubated orally and anesthesia maintained with spontaneous breathing of halothane in oxygen. Flexible fiberoptic bronchoscopy performed via the tracheal tube revealed no injury to bronchi or carina. Bronchoscopy through the tracheal tube withdrawn to the level of the vocal cords revealed a 1-cm long posterior longitudinal tear approximately 2-3 cm below the cords. The surgeons planned a definitive tracheostomy distal to the traumatic tracheal opening. This was difficult and initially unsuccessful because of subcutaneous emphysema. A ureteric catheter was introduced through the tracheal tube and a tracheostomy tube mounted on the fiberoptic bronchoscope, which was then inserted through the surgical tracheostome. This followed the ureteric catheter into the distal trachea and the trachea was successfully cannulated. We review the mechanism of tracheal injuries with special reference to its occurrence in children with blunt injury. We discuss the airway management in these potentially life-threatening injuries.

Tracheobronchial rupture due to blunt chest trauma: report of a case

Tracheobronchial injuries following blunt chest trauma are uncommon in children. The involvement of both the trachea and right main bronchus separately is highly unusual. We herein report the case of a 13-year-old boy who presented with both a tracheal and right main bronchial rupture following blunt chest trauma. While the tracheal laceration required a tracheotomy, a delayed repair of right main bronchial disruption was performed with a complete preservation of the right lung. The features of this uncommon entity are discussed, with special emphasis on early diagnosis and surgical management.

Trauma and the paediatric lung

Thoracic injury is a serious cause of morbidity and mortality in paediatric patients. This review will present cases to assist the clinician in the epidemiology, assessment and management of airway injury, pulmonary contusion, rib fracture, musculoskeletal injury and pneumothorax.

Posterior tracheal wall laceration after blunt neck trauma in children: a case report and review of the literature

Adults seem to be more vulnerable than children to tracheal lacerations. Tracheal lacerations have been described particularly after surgical procedures and penetrating trauma, but they may also result from minor blunt trauma. We report the case of a 7-year-old boy who sustained a posterior tracheal wall laceration after a direct frontal fall on a wooden strut. We also review the literature on posterior wall tracheal laceration as an isolated feature after blunt cervical trauma in children, the diagnostic features and management options.

Tracheobronchial rupture: a considerable risk for young teenagers

Tracheobronchial (TB) ruptures are ten times lower in children than in adults. Despite its rarity in the literature, we found that it is as common as in adults in our series. We investigated TB ruptures in childhood regarding age, trauma presentation, injury localization and treatment options. From 1994 through 2001, eight children (six male, two female) were admitted to our department with TB injury. All patients were healthy prior to trauma. The average and median ages were 9.8 and 11, respectively. All patients except one (iatrogenic) were suffering from blunt thoracic trauma. There were seven main bronchial (five right, two left) and one tracheal wounds. Six of the ruptures were circumferential. Urgent (n=6) and delayed (n=2) thoracotomies were performed; 'end-to-end' anastomosis (n=4), pneumonectomy (n=2) and 'primary suturing' (n=2) were applied. We had no mortality. Main bronchus rupture was overlooked in two patients as one of them had almost totally normal clinical appearance, and the other one had negative endoscopic findings. Both of these patients were successfully operated within 3 months. Our limited experience showed us that these kinds of injuries threaten school age population as well. False negative bronchoscopic results increase when additional injuries accompany. TB ruptures should be always taken into consideration after blunt chest trauma. Early or late repair of the lesion should be decided depending on the patient's clinical course.