Tracheal injuries are relatively rare, but their mortality rate is fairly high. Complete disruption of trachea is extremely rare, and a systematic approach is needed for early diagnosis and favourable outcome. This is a case report of 17-year-old man who arrived in the emergency room after a motor vehicle accident .He was agitated and in respiratory distress with labored breathing and urgently intubated orotracheally. In the first flexible bronchoscopy ,diagnosis of tracheal transection was missed. On the seventh day due to saturation drop and high peak ventilator pressures ,the flexible bronchoscopy examination was carried out in the operating room. This showed complete tracheal transection in midportion. Neck exploration demonstrated complete tracheal transection. The area was debrided ,and primary end-to-end anastomosis was performed. . The patient was extubated at the end of surgery.
Traumatic tracheal injury after blunt neck trauma is rare; however, most patients with complete tracheal transection usually die at the scene due to loss of airway . The few, who survive and arrive at a hospital, pose a diagnostic and therapeutic challenge to the trauma team. These patients may suffer fatal outcomes when misdiagnosed or long-term complications, if treated improperly.
Diagnosis is usually obscure as the symptoms may not be directed towards the disease. Early diagnosis and treatment of tracheal injuries lead to the best outcome . In this paper, our experience with one survivor of complete tracheal transection caused by blunt trauma that diagnosed after one week, was reported.
A 17-year-old man arrived in the emergency room after a
motor vehicle accident .He was agitated and in respiratory distress
with labored breathing and urgently intubated orotracheally. The
vital signs included a blood pressure of 110/80 mmHg, a heart rate
of 115 beats/ min, and an axillary temperature of 36.4°C. Patient
had crepitus on his neck and chest area. . Pneumomediastinum
and subcutaneous emphysema were seen on a supine chest
radiograph (Figure1). Computed tomographic scan (CT) of
the neck and chest revealed pneumomediastinum, pulmonary
contusion and subcutaneous emphysema in the neck and chest
(Figure2). Because of concern for suspected tracheobronchial
injury ,flexible fiberoptic bronchoscopy in the emergency room
was performed but no finding in favor of tracheal injury was
reported and tracheal transection was miss. During one-week
admission of the patient in the ICU ,he had occasionally high peak
ventilator pressures but saturated well. On the seventh day due
to saturation drop and high peak ventilator pressures ,the flexible
bronchoscopy examination was carried out in the operating room.
This showed complete tracheal transection in midportion (Figure
3). Neck exploration demonstrated complete tracheal transection.
The area was debrided, and primary end-to-end anastomosis was
performed. . The patient was extubated at the end of surgery .
After one week the patient was discharged.
Complete tracheal transection in blunt cervical trauma is
uncommon occurrence. Tracheal injuries are life threatening with
mortality rate of 40%. Timely and proper airway management
is life-saving . Signs and symptoms may be subtle in tracheal
injuries and also relatively non-specific correlating poorly with
the severity of the underlying injuries. Intact peritracheal tissue
may provide a life-saving conduit for gas exchange through the
disruption . Most common presentations are respiratory
distress, dyspnea, poor gas exchange and hemoptysis .
Cyanosis and serious respiratory embarrassment is present
in 30% of the cases. Another common symptom is hoarseness
or dysphonia, occurring in 46% of the patients . The most
common signs of airway injury reported in most series are
subcutaneous emphysema (35–85%), pneumothorax (20–50%)
and hemoptysis (14–25%); however, the lack of specificity and the
occult nature of the injury frequently result in a delayed diagnosis
. Deep cervical emphysema and pneumomediastinum are seen
in 60% of the patients with tracheobronchial injuries . Many
tracheobronchial injuries are not diagnosed immediately (25–
68%) . Physicians need to maintain a high index of suspicion
related to non-specific signs such as dyspnea, cough, subcutaneous
emphysema and hemoptysis. The mechanism of injury, vocal
changes and rapidly expanding subcutaneous emphysema in the
neck are important clues . Clinical examination is followed
by radiologic imaging, angiography, CT and tracheo-bronchioesophagoscopy
Accurate interpretation of the chest radiograph is essential
in the early diagnosis of occult upper-airway injury. A CT scan
can be performed if diagnosis is uncertain on plain films .
Preoperative CT can be useful in assessing associated laryngeal
injuries or other unsuspected chest injuries that should be dealt
with at the time of surgical exploration. CT is contraindicated
in hemodynamically unstable trauma patients or patients with
unstable airways . Helical CT with 3D reconstruction should
be considered a suitable ‘screening’ test in a trauma patient
suspected of tracheal rupture and may help the clinician in the
decision to perform a bronchoscopy on the patient . The best
diagnostic investigation is bronchoscopy. Flexible bronchoscopy
should be carried out first to determine the location and extent of
the injury . Some reports agreed that there is a slight possibility
that airway problems could be missed and therefore repeat
fiberoptic bronchoscopy follow-up should be performed if the
clinical situation suggests an abnormality [10,11]. Principles of
management includes prompt airway establishment, immediate
exploration of the wound with appropriate investigation. Surgical
repair is the treatment of choice for tracheal transection that
includes complete repair of trachea with end-to-end anastomosis.
Complete transection of the trachea should be managed by careful
suturing and being cautious to avoid damage to the recurrent
laryngeal nerves .
Complete tracheal transection in blunt trauma is uncommon
occurrence and is life threatening. Signs and symptoms may be
subtle in tracheal injuries. This report agreed that there is a slight
possibility that airway problems could be missed and therefore
repeat fiberoptic bronchoscopy follow-up should be performed if
the clinical situation suggests an abnormality .Timely diagnosis,
skillful airway management and prompt surgical repair are
important for positive outcomes.