Traumatic review Blunt Esophageal and Tracheal injury

Traumatic Review26-04-56

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 DiagnosisDesaturation 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


CXR


C-spine


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 Incision

Proximal 1/2-2/3 trachea Low cervical collar incision extend to T incision

Distal 2/3 trachea - carinaRt main bronchus Rt posterolateral thoracotomy

Lt main bronchus 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 Incision Other Technique

cervical partcollar incision : bilateral

carotid incision : unilateral

repaired and buttress with sternocleidomastoid or dtap

muscle flap

upper 2/3 thoracic Rt posterolateral thoracotomy

intercostal muscle flap

lower thoracic at level below inferior

pulmonary vein

5th -7th Lt posterolateral thoracotomy


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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Transcript of Traumatic review Blunt Esophageal and Tracheal injury