Traumatic review Blunt Esophageal and Tracheal injury

Traumatic Review
26-04-56
Kusuma Chinaroonchai, M.D.
Aj.Burapat Sangthong

Friday, April 26, 13

Case History
Muslim 21 year-old woman
Refered from outside hospital
Motorcycle crushed with pick-up with Hx loss of
consciousness 5 mins PTA
Rescuers sent her to the hospital.


Primary Survey at outside Hospital
A : can talk in sentence, no stridor, but cannot ﬂex her neck due to
pain >> on philadelphia collar
B : RR 24 /min, SpO2 91% RA, 100% with O2 mask, equal breath
sound both lungs, subcutaneous emphysema at neck, trachea in
midline, no wound at chest wall
C : BP 124/81mmHg, P 122 /min, no external active bleeding
wound seen
D : E4V5M6, pupil 2 mm BRTL, Motor V left arm and right leg,
right arm and left leg limited movement due to pain and deformities
E : deformities with bone exposed at right forearm and left thigh >>
wood splint


Adjunct to Primary Survey at outside Hospital

Film C-spine : not seen Fx, subcutanous emphysema at
neck area
CXR : widening mediastinum, not seen
pneumohemothorax
FAST : negative
Film pelvis : no fracture seen


What’s the problem list
and differential diagnosis?


Problem list
MC crush
Hx of loss of consciousness at scene
Desaturation with subcutaneous emphysema
with no pneumothorax both lungs
Shock grade II with widening mediastinum with
no hemothorax
Deformities with exposed bone at right forearm
and left thigh

Differential Diagnosis
Desaturation with subcutaneous emphysema
with no pneumothorax both lungs
Tracheal or bronchial injury
Shock grade II with widening mediastinum with
no hemothorax
Traumatic aortic and its branches injury
Deformities with exposed bone at right forearm
and left thigh
Open fracture right forearm and left femur

Secondary Survey : AMPLE
10.10 11-4-56 : She rode on a motorcycle pillion
that was crushed by pick-up. After the event she
was loss of consciousness and was sent by
rescuers to the hospital.
At ER of outside Hospital : no hoarseness, no
spliting blood, complaint retrosternal chest pain
that radiate to back , generalized abdominal
pain and pain at her right forearm and left thigh


Physical Examination
V/S : P 122 /min RR 24 /min
BP Right arm 102/70 mmHg Left arm 70/50 mmHg
GA : Alert, good consciousness, no stridor
Neck : on philadelphia collars, palpable subcutanous
emphysema, trachea in midline, limit ROM due to pain
Chest : not seen external contusion or wound, equal
breath sound, CCT negative
CVS : normal S1S2, no murmur


Physical Examination
Abdomen : Generalized guarding, no external contusion
or wound seen
PCT : negative
Ext : Deformities exposed bone at right forearm, and left
thigh, Right radial pulse 2+, capillary reﬁll <3 sec, Left
DPA and PTA 2+, capillary reﬁll < 3 sec
PR : good sphincter tone, no bleeding per rectum


What’s the optimal initial
management ?


Traumatic thoracic aortic
and tracheal injury were
suspected then refer to
PSU

At ER PSU : Repeat Primary Survey
A : patent, no hoarseness, can talk, no stridor,
neck edema with subcutaneous emphysema at
neck, not seen hematoma nor contusion
B : equal breath sound
C : BP 120/70 mmHg, PR 116-130/min, pulse
full, no external source of bleeding seen
D : E4V5M6, pupil 2 mm BRTL
E : Deformities at right forearm and left thigh
that exposed bone with not seen active bleeding

Adjunct to Primary Survey
C-spine : not adequate, subcutaneous
emphysema
CXR : widening mediastinum 9 cm, no
pneumohemothorax both lungs, fracture right
1st and 2nd ribs
Film Pelvis AP : not seen fracture
FAST : negative


Secondary Survey : AMPLE
Denied Hx of medication allergy and current
medication used
Denied previous UD
Denied chance to get pregnancy
Last meal 6.00 am
Cannot remember about TT vaccine Hx


Physical Examination at PSU
BP 100/60 mmHg P 120 /min RR 26 /min
SpO2 99-100% with O2 mask
BW 40 kg Ht 164 cm
GA : Alert, good consciousness
Neck : On philadelphia collar, neck
subcutaneous emphysema, limit neck ROM due
to pain, no hematoma, contusion nor external
wound seen

Lung : equal breath sound, trachea in midline,
CCT negative, no external chest lesion seen
CVS : pulse full, no murmur
BP right arm 110/70 mmHg
BP left arm 70/50 mmHg
BP right leg 100/70 mmHg
BP left leg 107/67 mmHg

Abdomen : mild distension, generalized
guarding, hypoactive bowel sound
Ext : deformities with exposed bone at right
forearm and left thigh with good distal pulse
palpable
PR : good sphincter tone, no bleeding per
rectum


What is the plan for
investigation?


CT neck and CT chest


Investigation
CT brain : no intracerebral hemorrhage
CT neck : extensive emphysema along
subcutanous layer extending to mediastinum
could be tracheal injury , esophagus not seen
grossly wall thickening
CT chest : Traumatic aneurysm at
brachiocephalic trunk 1.6 cm with small intimal
ﬂap and large mediastinal hematoma,fracture
right 1st and 2nd ribs

Investigation

CT whole abdomen : pneumohemoperitoneum
in pelvic cavity, suspected hollow viscus organ
injury


Diagnosis
Cerebral concussion
Suspected blunt tracheobronchial injury
Blunt traumatic innominate artery
pseudoaneurysm
Hollow viscus organ injury
Open fracture both bones right forearm and left
femur


Bronchoscopy & EGD


Incidence
Cause from blunt chest injury

Shorr RM, Ann Surg: Aug 1987

Blunt tracheobronchial injury
rare condition
80% lesion at 2.5 cm from carina
Mechanism
AP compression
Sudden increased airway pressure
Rapid deceleration force


Blunt tracheobronchial injury

Multiple associated injury
40-100% orthopedic problem
21% esophageal perforation
18% major vascular injury


Blunt tracheobronchial injury : Dx
Symptoms
76-100% Dyspnea with respiratory distress
46% hoarseness or dysphonia
Signs
35-85% subcutaneous emphysema
20-50% pneumothorax
14-25% hemoptysis


Blunt tracheobronchial injury : Dx

Late presentation (1-4 wk) after injury can came
with pneumonia, bronchiectasis, atelectasis and
abscess
stridor or dyspnea >> late tracheal stenosis
wheezing or pneumonia >> late bronchial
stenosis


Blunt tracheobronchial injury : Ix
X-ray C-spine : 60% deep cervical emphysema
and pneumomediastinum
CXR : 70% pneumothorax
disruption of tracheal or bronchial air column
Falling lung sign of Kumpe
CT chest : inconclusive, evaluate associated injury
such as mediastinal hematoma
Esophagoscopy : if suspected associated
esophageal injury

Blunt tracheobronchial injury : Ix

Bronchoscopy : single deﬁnitive
diagnostic study


Blunt esophageal injury

incident < 1%, most common from penetrating
< 0.1% from blunt mechanism


Blunt esophageal injury : mechanism

cervical area : sudden anterior hyperextension
Lower 1/3 : blast injury compressed air or acute
gastric compression


Blunt esophageal injury : Diagnosis
Due to signs and symptoms are non-speciﬁc
Mostly occult
hoarseness
Spiting up blood
Subcutanous emphysema
Anterior tracheal deviation


Blunt esophageal injury : Ix

CXR :
subcutanous emphysema
hydropneumothorax
hydropneumomediastinum
free abdominal air


Blunt esophageal injury : Ix
*Esophagogram*
miss 15% perforation in water-soluble contrast
miss 10% perforation in thin Ba
When combined ↓ false negative
Esophagoscopy : miss 15-40% injury esp in
proximal 2-4 cm, if combined with contrast
study ↑ sentivity to 100%


Incident of associated injury


What’re your plan of
management
- Airway managment, Tracheostomy ??
- Priorities for operation in all condition??
- Surgical technique?


Management
Secure airway
Flynn series (36%: 8/22) >> immediate
airway with emergency tracheostomy
Gussack series (92%) >> emergency airway
73% ET tube via oral
3% intubate ET tube at neck wound


Management
Anesthesia technique
airway control and intubation technique
may need awake intubation via
ﬁberoptic bronchoscopy
High frequency jet ventilation (↓airway
pressure) during airway reconstruction


Management

**Extubation consideration**
No indication for prolong intubation for
support ventilation >> Off
If need tube to support ventilation >>
Large no. single lumen ET-tube


Management

Priorities for operation
Life threatening condition as subdural
hematoma or intraabdominal bleeding or
major vascular injuries ***before repaired
tracheobronchial injury***


Operative Management
Only small primary mucosal injuries
size < 1/3 of all diameter with no devascularized
tissue
No air leak
No distal obstruction
Patulous blow out mucosa like from
bronchoscope >> can progress to ball-valve
caused obstruction


Location of lesion
Proximal 1/2-2/3 trachea

Low cervical collar incision
extend to T incision

Distal 2/3 trachea - carina
Rt main bronchus

Rt posterolateral thoracotomy

Lt main bronchus


Incision

Lt posterolateral thoracotomy

Injury < 50% of lumen diameter + no
devascularized tissue >> primary repaired
Injury < 50% of lumen diameter +
devascularized tissue >> primary repaired with
tissue ﬂap
Injury > 50% or < 50% + devascularized tissue
>> resection with end to end anastomosis


Surgical Technique
Trachea can resected left 1/2 of total length but
can resected only 3-4 cm of airway that involve
carina
Suprahyoid laryngeal release for ↑ 1-2 cm length
Mobilized pericardium at inferior aspect of
hilum can ↑ 1-2 cm length


Surgical Technique

Repaired in simple interrupted technique
absorbable 4-0 vicryl or permanent or
absorbable monofilament
If have associated esophageal injury >>
interposition flap used to prevent fistula


Post operative concern
Aggressive pulmonary toilet
Beware aspiration
low airway pressure
bronchoscopy at 7-10 days to evaluate earl
stenosis


Esophageal Management Concept

Control leakage
Debridement and drainage
Nutritional support
Early used of broad spectrum ATB


Surgical Technique
Location of lesion

cervical part

Incision

collar incision : bilateral repaired and buttress with
sternocleidomastoid or dtap
carotid incision :
muscle ﬂap
unilateral

upper 2/3 thoracic

Rt posterolateral
thoracotomy

lower thoracic at level
below inferior
pulmonary vein

5th -7th Lt
posterolateral
thoracotomy


Other Technique

intercostal muscle ﬂap

Surgical Technique

Choose incision at lesion level
Unstable patient for primary repaired nor
resection >> Created control ﬁstula by tracheal
T-tube 28 Fr + ICD x 2
70% mortality in this unstable group


Progression
Operation
Exploratory for repaired jejunal perforation
with feeding jejunostomy
EGD + Bronchoscopy
Innominated stent insertion with right
subclavian artery to right carotid artery bypass
Right posterolateral thoracotomy for repaired
trachea and esophagus with intercostal muscle
ﬂap

Operative ﬁndings
Tear of trachea 5 cm in size just 1 cm above
carina
Serosal tear of posterior and anterior esophagus
at 20 - 25 cm from incisor
Right innominate artery injury from its origin 3
mm and 3 cm in length
Distal jejunal perforation


Take Home Message
Blunt tracheobronchial injury 80% lesion at 2.5
cm from carina
21% of this injury with esophageal injury and
other system organ injury
Most common sign is subcutaneous emphysema
Bronchscopy is only single deﬁnitive diagnostic
study


Take Home Message
Blunt esophageal injury, its sign and symptoms
are nonspeciﬁc.
High degree of suspicious to make diagnosis
Esophagoscopy can miss 15-40%, but if
combined with esophagography sensitivity is
100%.


Thank You for Your
Question and Discussion


Traumatic review Blunt Esophageal and Tracheal injury

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