Tracheal Rupture After Trauma: A Successful Conservative Management

Tracheobronchial injury (TBI) is a rare life-threatening injury that can result from either penetrating or blunt trauma. Treatment may be surgical or conservative, but the evidence regarding which is the best approach is still very scarce. This case report describes the successful conservative management of a 32-year-old male with a traumatic tracheal laceration. The alarming signs and symptoms, the imaging modalities of choice, the rationale behind the treatment strategy, and the most common complications are detailed here. Through this case, the authors wish to highlight the features that should lead to the suspicion of this potentially fatal traumatic injury, as well as raise awareness on how to adequately manage these patients.

Pediatric tracheal trauma

Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.

Emergency Airways After Himalayan Black Bear Attacks in Bhutan

INTRODUCTION

Although bear attacks on humans are uncommon, the incidence has slowly risen as human populations increasingly encroach on wilderness habitat. In the Kingdom of Bhutan, Himalayan black bear attacks occur regularly. Bears preferentially attack the face, often causing injuries that require surgical airway management. We sought to determine how often patients injured by Himalayan black bears required airway management during initial resuscitation.

METHODS

We conducted a retrospective review of emergency department and admission records of the 3 referral hospitals in Bhutan. We identified all victims of bear attacks in Bhutan who received emergency airway management, including surgical airway management during the period from August 2013 to December 2017.

RESULTS

There were 21 patients who were treated for injuries from bear attacks during the study period. Of these, 12 required emergency airway management. Three patients who required emergency airways (2 intubations, 1 surgical airway) were attacked near a regional referral hospital and received care at that hospital. The remaining 9 patients received care from the helicopter emergency medical services (HEMS) retrieval team (1 intubation, 8 surgical airways).

CONCLUSIONS

The use of highly trained HEMS critical care retrieval teams may improve outcomes in critically injured patients who require time-critical airway management in remote areas. Countries such as Bhutan with populations far from emergency and critical care might benefit from the establishment of HEMS critical care retrieval services. HEMS teams providing care while retrieving patients from austere environments should be expert in emergency airway management.

Laryngeal fracture presentation and management in United States emergency rooms

OBJECTIVES/HYPOTHESIS

There are limited data on laryngeal fracture presentation and management in US emergency departments (EDs). We aimed to characterize patients who are diagnosed with laryngeal fractures in the ED and identify management patterns.

STUDY DESIGN

Retrospective review of the Nationwide Emergency Department Sample (NEDS) from 2009 to 2011.

METHODS

The NEDS was queried for patient visits with a primary diagnosis of open or closed laryngeal fracture (International Classification of Diseases, Ninth Revision codes 807.5 and 807.6). Patient demographics, comorbidities, ED management, and hospital characteristics were extracted.

RESULTS

There were 3,102 ED visits with a diagnosis of laryngeal fracture during the study period. Mean patient age was 40.9 years (range, 3-93 years). The majority of patients were male (85.5%) and sustained a closed (vs. open) fracture (91.4%), with an overall mortality rate of 3.8%. The majority of patients were treated for more than one injury during the same visit (76.2%). Most patients were evaluated at a trauma hospital (53.9%), and most patients were admitted to the hospital (71.9%). Emergent intubation or tracheostomy was rarely reported (2.6% and 0.1% of all cases), and a minority of patients underwent fiberoptic flexible laryngoscopy in the ED (1.9%). Laryngeal fractures occurred more frequently during summer months (28.2%). Mean charge for the entirety of the ED stay was $4,957.34.

CONCLUSIONS

Laryngeal fracture is rare and frequently associated with other injuries. The frequency of emergent airway procedure, imaging, and flexible fiberoptic laryngoscopy is lower than expected, raising concerns about appropriate workup and management or recognition of injury in the ED setting.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2341-2346, 2019.

Awake tracheal intubation for blunt airway trauma

A 64-year-old man sustained blunt trauma to the anterior neck following a mechanical fall resulting in an isolated laryngeal fracture of the left cricoarytenoid complex. Although there was no acute airway compromise, he developed worsening airway oedema which necessitated tracheal intubation. He underwent oral awake tracheal intubation with a flexible bronchoscope to facilitate formation of a tracheostomy under general anaesthesia. The challenges encountered in the clinical management of this case relate to decision making for the patient with airway trauma in the absence of the need for emergency tracheal intubation. We describe the advantages and pitfalls of various airway management strategies in the context of blunt airway trauma.

Airway Management in Severe Combat Maxillofacial Trauma

OBJECTIVES

Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma.

STUDY DESIGN

Retrospective database analysis.

SETTING

Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers.

SUBJECTS

In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes.

METHODS

Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy.

RESULTS

A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001).

CONCLUSIONS

There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

Airway management in trauma

Trauma has assumed epidemic proportion. 10% of global road accident deaths occur in India. Hypoxia and airway mismanagement are known to contribute up to 34% of pre-hospital deaths in these patients. A high degree of suspicion for actual or impending airway obstruction should be assumed in all trauma patients. Objective signs of airway compromise include agitation, obtundation, cyanosis, abnormal breath sound and deviated trachea. If time permits, one should carry out a brief airway assessment prior to undertaking definitive airway management in these patients. Simple techniques for establishing and maintaining airway patency include jaw thrust maneuver and/or use of oro- and nas-opharyngeal airways. All attempts must be made to perform definitive airway management whenever airway is compromised that is not amenable to simple strategies. The selection of airway device and route- oral or -nasal, for tracheal intubation should be based on nature of patient injury, experience and skill level.

Managing the difficult airway in craniomaxillofacial trauma

Securing the airway in the patient with craniomaxillofacial trauma can be an extremely difficult challenge for health care practitioners. This article provides several approaches to airway management. Presented here are several options for securing the airway under a variety of conditions and scenarios.