Asian Cardiovasc Thorac Ann 2000;8:389-390
© 2000 Asia Publishing EXchange Pte Ltd
Traumatic Tracheal Tear Successfully Treated After Remote Area Retrieval
Santiago A Endara, MD,
Steven P Cook, MBBS,
Kang Dong, MD,
Benjamin P Bidstrup, FRACS,
Gary J Lopez, RICN
Cardiothoracic Unit
Townsville General Hospital
Townsville, Queensland, Australia
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For reprint information contact: Santiago A Endara, MD Tel: 61 7 4781 9511 Fax: 61 7 4781 9215 email: endaras{at}health.qld.gov.au Cardiothoracic Unit, Townsville General Hospital, Eyre Street, North Ward, Townsville, Queensland 4810, Australia.
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Abstract
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A 44-year-old man injured in a motor vehicle accident in rural Australia was resuscitated at a local hospital 9 hours later. Bronchoscopy revealed a large tracheal tear. After transfer to the regional cardiothoracic center, surgery was performed under cardiopulmonary bypass 18 hours after the injury was sustained. The patient required surgical tracheostomy as well as ventilatory and inotropic support. There were no postoperative complications and he was discharged after 27 days.
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Introduction
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Tracheobronchial injuries are rare but many go un-recognized. Such a major injury is associated with high mortality and it should be identified and treated early to restore respiratory function and avoid complications. The exact mechanism of tracheal injuries in blunt trauma is unknown.
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Case Report
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A 44-year-old man traveling as an unrestrained passenger was involved in a rollover motor vehicle accident in rural Australia and had a prolonged and difficult extrication. He was transported to a local hospital where on arrival 9 hours after the accident, he was found to be 6/15 on the Glasgow coma scale with bilateral tension pneumo-thoraces, respiratory distress, significant subcutaneous emphysema, and fractured mandible and ribs. He was immediately intubated and resuscitated with bilateral needle thoracostomy followed by bilateral chest tube place-ment and intravenous volume replacement. Fiberoptic bronchoscopy (FOB) identified a tracheal laceration. The patient underwent computed tomography scans of the head, chest, and abdomen (Figure 1
). He was then transferred by air ambulance to our institution which is the regional center for cardiothoracic surgical services in the North Queensland area. On arrival, he went im-mediately to the operating room for repair 18 hours after the accident.
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Figure 1. Preoperative computed tomography scan of the chest revealing peritracheal air (arrow) and massive subcutaneous emphysema.
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A right posterolateral thoracotomy approach was used. A 5-cm longitudinal tear was identified in the membranous portion of the distal trachea close to the carina. Attempts to selectively intubate the left bronchus were made; these were unsuccessful. In order to adequately oxygenate the patient and expose the lesion, he was placed on cardiopulmonary bypass. A vascularized intercostal muscle flap was taken down from the fifth intercostal space. Debridement of the tracheal edges was performed and the laceration was repaired using the onlay patch technique. Upon completion, the suture line was inspected using FOB and tested under water with positive ventilatory pressure to assess adequacy of water seal. The patient was weaned from cardiopulmonary bypass and the chest was closed. He was transferred to the intensive care unit in a critical condition on inotropic and ventilatory support. Inotropics were weaned over 48 hours, radiological examination on day 6 revealed reexpanded lungs and resolution of the large subcutaneous emphysema (Figure 2). Surgical tracheostomy was performed on day 7 and the patient was weaned from ventilatory support on day 16. During this period, tracheal toilet was performed using FOB every 8 hours to carefully aspirate copious secretions and to assess the suture line anastomosis. The tracheostomy was removed on day 24 and the patient was discharged from hospital on day 27. He was able to return to a normal lifestyle.
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Figure 2. Postoperative chest radiograph demonstrating resolution of subcutaneous air and normal appearance of the trachea.
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Discussion
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The unique feature of this case is that the patient survived severe trauma in an isolated setting before definitive care was initiated. The incidence of traumatic rupture of the tracheobronchial tree is difficult to establish as many patients die before reaching hospital or before diagnosis. In 1972, Bertelsen and Howitz1 reviewed 1,178 patients in Denmark who died following blunt trauma from 1961 to 1966; 33 patients (2.8%) had tracheobronchial injuries, of whom 27 died instantly. There were associated serious injuries in 24 of these patients; a tracheobronchial injury existed in relative isolation in only 3, as in our case.
Although tracheobronchial rupture is rare, it is important to recognize it quickly and treat it early. Clinically, the diagnosis should be suspected if subcutaneous emphy-sema, persistent pneumothoraces, air leak from chest tubes and associated stridor and hemoptysis are present. FOB is the definitive investigation and clinicians should have a high index of suspicion in view of the mortality rate of up to 30%.2 FOB is indicated in the presence of the above clinical indicators.3 In 80% of these injuries, the lesion involves the distal trachea within 2.5 cm of the carina. Bilateral lesions are rare and lesions may or may not communicate with the pleural cavity. Serious associated injuries occurred in over 50% of reported cases.4 Repair of major tracheobronchial disruption should be a priority unless the patient has severe associated injuries such as abdominal injury causing hemodynamic instability, in which case, the abdominal component should be controlled first. It is well recognized that priority of thoracotomy or laparotomy should be decided on an individual basis.5 Many bronchial tears are initially missed and after the lung reexpands, stenosis results with distal atelectasis and subsequent infection, often necessitating lobectomy or pneumonectomy. Late airway stenosis is a well recognized complication of repair of a tracheobronchial injury. The onlay patch repair which widens a small bronchus, allows for an increase in circumference, it is tension-free and has a decreased risk of stenosis.3 Some advocate the use of omentum to reinforce the repair, increasing vascularity and stimulating angiogenic factors in an otherwise avascular area.6 It was not used in this case as the repair was adequate. The patient survived a long pre-hospital delay possibly because the tracheal laceration was partially contained by the peritracheal soft tissues.
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References
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Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27:188–94.[Abstract/Free Full Text]
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Mulder DS, Burkun JS. Injuries of the trachea, bronchus and esophagus. In: Moore EE, Mattox KL, Feliciano DV, editors. Trauma. 2nd ed. Norwalk: Appleton & Lange, 1991:343–55.
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Crouch RD, Nelson LE, Hawley PC, Frank DA, Williams TE Jr. Onlay patch repair of tracheobronchial rupture. Ann Thorac Surg 1997;64:1158–60.[Abstract/Free Full Text]
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Wilson RF, Trunkey DD. Tracheal injuries. In: Trunkey DD, Lewis FR, editors. Current therapy of trauma. 3rd ed. Philadelphia: McGraw-Hill, 1991:223–5.
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Ramzy AI, Rodriguez A, Turner SZ. Management of major tracheobronchial ruptures in patients with multiple system trauma. J Trauma 1998;28:1353–7.
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Hasegawa T, Endo S, Sohara Y, Kamisawa O, Murayama F, Yamaguchi T, et al. Successful surgical treatment of a complete traumatic tracheal disruption. Ann Thorac Surg 1997;63:1479–82.[Abstract/Free Full Text]
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Abstract
Introduction
