Major Bronchial Trauma in the Pediatric Age Group

Pediatric surgical interventions on ECMO

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

Blunt Traumatic Tracheobronchial Injury: a Clinical Pathway

Background

Motor vehicle collisions (MVC) are a major burden on healthcare systems. Saudi Arabia is one of the countries with a high mortality rate of MVC. Blunt tracheobronchial injuries are rare; however, it is a catastrophic event that requires a high center of care. Lack of experience and advanced faculty prompt early stabilization and transfer of the victim for advanced care. Due to the uncertainty of management of these injuries, we would like to share our experience in dealing with such injuries.

Objective

To address the difficulties in initial management and transfer of patient with blunt traumatic tracheobronchial injuries.

Methods

This is a single-center retrospective case-series study including patients admitted as cases of trauma including all age groups with blunt acute tracheobronchial injuries confirmed by imaging or bronchoscope.

Results

In our study, four patients with tracheobronchial injuries were identified, and a retrospective analysis was performed. Two of the males and one of the females are adults, while the other two are pediatrics. Two of them have a right main bronchial injury and the other two have a left main bronchial injury. Posterolateral thoracotomy and bronchial anastomosis were performed on all four patients and were followed up.

Conclusion

In Saudi Arabia, blunt trauma is a prevalent type of injury, although tracheobronchial injuries are uncommon. In the event of trauma, a high index of suspicion of tracheobronchial injuries in a high mechanism injury warrants prompt treatment. Due to a lack of experienced and specialized hands in this field, management may be delayed, and eventually lead to unfavorable outcomes, hence we thought of a guide to facilitate the decision-making.

Pediatric tracheal injuries: Report on 5 cases with special view on the role of bronchoscopy and management

INTRODUCTION

The purpose of these case reports is to draw the attention to the difficulties of diagnosing trachea injuries in children, who are often part of a polytrauma scenario.

MATERIALS

A retrospective multicenter analysis of 5 cases were analysed. The age of the children was between 1 and 16 years old. Injury mechanism was blunt thoracic trauma, misintubation and shot injury.

RESULTS

Case No.1. a three-year-old child suffered a train accident. Resuscitation and decompression of the tension pneumothorax were performed. CT found a pneumomediastinum and bubbles along the trachea. Thoracolaparotomy was performed. Bronchoscopy could not rule out a tracheal injury. The child died of a cerebral edema. Case No. 2: a 13 month drowned and was resuscitated. A chest drain was inserted to treat the pneumothorax. CT revealed a pneumomediastinum, which was drained and a small tear of the trachea. Bronchoscopy was not preformed. Case No. 3: 9 year-old polytrauma patient was airlifted with bilateral mini thoracostomies and chest drains for pneumothorax. CT revealed bilateral pneumothorax and pneumomediastinum. The chest drains were repositioned oxygenation improved, but some ventilation difficulties remained. CT revealed pneumomediastinum and a tracheal injury. This was bridged by a tube, and the mediastinum drained. The ventilation difficulties were resolved. Case No. 4: an eight-year-old boy was shot on the neck. The region was explored surgically and the laceration of the trachea was sutured. Case No. 5: 12-year-old girl suffered blunt thoracic trauma. CT revealed bilateral pneumothorax and pneumomediastinum. Bilateral thoracic drainage was performed, some ventilation problems persisted. CT and fiberoscopy revealed a rupture of the trachea. Thoracotomy was performed and the laceration was closed.

CONCLUSION

Pneumomediastinum and persistent ventilation difficulties should raise suspicion of a tracheal injury in a typical clinical scenario. Bronchoscopy is recommended for early diagnosis, despite the possibility of misdiagnosis. In certain cases CT scan only and close observation may be considered.

A paediatric case of severe tracheobronchial injury successfully treated surgically after early CT diagnosis and ECMO safely performed in the hybrid emergency room

BACKGROUND

In paediatric trauma patients, tracheobronchial injury can be a rare, life-threatening trauma. In 2011, we instituted a new trauma workflow concept called the hybrid emergency room (Hybrid ER) that combines a sliding CT scanning system with interventional radiology features to permit CT examination and emergency therapeutic intervention without moving the patient. Extracorporeal membrane oxygenation (ECMO) can lead to cannula-related complications. However, procedures supported by moveable C-arm fluoroscopy and ultrasonography equipment can be performed soon after early CT examination. We report a paediatric patient with tracheobronchial injury diagnosed by CT examination who underwent rapid resuscitation and safe installation of veno-venous (VV) ECMO in our Hybrid ER and was successfully treated by surgery.

CASE PRESENTATION

A 11-year-old boy was admitted to our Hybrid ER suffering blunt chest trauma. His vital signs were unstable with low oxygen saturation. Early CT examination was performed without relocation. CT revealed bilateral hemopneumothorax, bilateral lung contusion, left multiple rib fractures, and right bronchus intermedius injury. Because his oxygenation was severely low with a PaO2/FiO2 ratio (P/F) of 109, he was at very high risk during transport to the operating room and changing to one-lung ventilation. Thus, we established VV ECMO in the Hybrid ER before we performed thoracotomy under left lung ventilation in the operating room. After the P/F ratio improved, he was transferred to the operating room under VV ECMO. We performed middle- and lower-lobe resection and sutured the stump of the right bronchus intermedius to treat the complete tear of this branch. After his respiratory function recovered, VV ECMO was removed on postoperative day 5. After in-patient rehabilitation, he was discharged home on postoperative day 68 without sequelae.

CONCLUSIONS

It is feasible to perform VV ECMO in the Hybrid ER, but one case does not conclude it is safe. In this case, the blood oxygenation improved, but there are no evidence to support the safety of the procedure or the advantage of ECMO initiation in the Hybrid ER rather than in the operating room.

The art and science of pediatric damage control

Damage control is a surgical strategy that has evolved and expanded considerably over the past 25 years. The approach was initially developed as a "bail out" procedure to control bleeding with severe abdominal injuries in the setting of unmitigated hemorrhagic shock. Damage control is now more broadly applied as a comprehensive management plan for the resuscitation and surgical treatment of injured patients with exhausted physiologic and metabolic reserve. This article reviews the most current concepts in damage control that are important and relevant to the practicing pediatric surgeon. It also provides evidence-based recommendations about how damage control principles can be pragmatically applied to severely injured children. This review focuses specifically on the fundamentals of damage control with respect to resuscitation and the operative treatment of children with severe abdominal, thoracic, and extremity injuries.

Management of blunt tracheobronchial trauma in the pediatric age group

INTRODUCTION

Tracheobronchial rupture (TBR) due to blunt chest trauma is a rare but life-threatening injury in the pediatric age group. The aim of this study was to propose a treatment strategy including bronchoscopy, surgery and extracorporeal membrane oxygenation (ECMO) to optimize the emergency management of these patients.

METHODS

We reviewed a series of 27 patients with post-traumatic TBR treated since 1996 in our pediatric trauma center.

RESULTS

Seven cases had persistent and large volume air leaks. Flexible bronchoscopy was performed in cases of persistent or large volume air leaks. It permitted accurate visualization of the rupture and its extent. It allowed for a clear-cut positioning of the endotracheal tube. Five were managed operatively. Four cases were considered to be life-threatening because of the combination of severe respiratory distress with hemodynamic instability. One of them had severe tracheal laceration and died. Another one had bilateral bronchi disconnection. Based on clinical and endoscopic findings, surgical repair was performed using extracorporeal membrane oxygenation as a ventilatory support. It provided quick relief from the injury, which was previously expected to result in a fatal issue.

CONCLUSIONS

Prompt diagnosis and accurate management of surviving patients admitted to emergency rooms are necessary. Bronchoscopy remains a critical diagnosis step. Surgery is warranted for large tracheobronchial tears and ECMO could be beneficial as supportive therapy for selected cases.

Benefits of extracorporeal membrane oxygenation for major blunt tracheobronchial trauma in the paediatric age group

Tracheobronchial rupture due to blunt chest trauma is a rare but life-threatening injury among children. The severity of this condition ranges from death before hospital admission to clinical stability resulting in delayed management. Diagnosis is difficult because there is sometimes no evidence of external trauma, in spite of severe chest crush injury and consecutive rupture of airways. Here, we report the case of a 32-month-old girl whose torso was crushed by a van, resulting in bilateral bronchi disconnection. She was admitted to our hospital with cardiac and respiratory arrest. After prompt resuscitation, flexible bronchoscopy permitted the accurate visualization of the rupture and its extent. The life-saving procedure consisted of surgical repair using extracorporeal membrane oxygenation (ECMO) as ventilatory support. This provided rapid relief from the injury, which was previously expected to result in death. These data suggest that ECMO could be beneficial as supportive therapy for selected paediatric patients with major tracheobronchial traumas.

Use of pre and intra-operative bronchoscopy in management of bronchial injury following blunt chest trauma

Blunt chest trauma resulting in right bronchial tear in an 8-year-old girl is reported. Use of bronchoscopy in the management of such an injury is highlighted.

[Tracheobronchial rupture in childhood]

Tracheobronchial rupture after blunt trauma is rare, especially in a pediatric population. In this paper, we report the case of a 3-year-old child who presented with a rupture of the tracheobronchial tree as a result of multiple injuries (thoracic and cerebral) sustained from a traffic accident. The surgical repair consisted of a sleeve resection (right upper lobectomy with reanastomosis of the bronchus intermedius to the right stem bronchus). As tracheobronchial rupture is a rare condition, particularly in children, physicians must have a high index of suspicion. The diagnosis and treatment of this condition are discussed.

Paediatric chest trauma (part 2) — Hidden Injuries

Chest trauma is the second greatest cause of mortality from trauma, a leading cause of death in children over the age of one. Prompt diagnosis can be difficult as the underlying thoracic injuries are often disproportionately severe compared to the visible surface injury and symptoms may not appear for several hours. Diagnosis are easily underestimated, delayed or missed. This is the second of a 2 part article reviewing Paediatric chest trauma and its current management. The injuries are usefully classified into 6 lethal injuries that need excluding in the primary survey and 6 hidden injuries that must be considered in the secondary survey. The 6 lethal injuries are covered in the first part of this article along with biomechanics and mechanisms of injury. This article looks in depth at the 6 hidden injuries, along with a review of chest trauma in non-accidental injury.

Injuries to the major airway after blunt thoracic trauma in children: review of 2 cases

Tracheobronchial injuries in children occur rarely. Their diagnosis is often very difficult and needs a high degree of suspicion, with in-depth knowledge of the anatomy of and radiological findings for the chest. With proper surgical management, even a delayed diagnosis can result in normal lung function. We discuss 2 cases of major airway injuries with successful outcomes and present some interesting surgical maneuvers.

Tracheal rupture in a child with blunt chest injury

A 10-year-old boy fell from a tree and sustained blunt injury to his chest. He was brought to the hospital (6 h later) with difficulty in breathing and inability to speak. There was a bruise on the neck and extensive subcutaneous emphysema over the neck and chest and decreased air entry over the right hemithorax. Radiographs revealed a right-sided pneumothorax, pneumomediastinum and tracheal deviation. An intercostal drain (with underwater seal) was inserted and he was transferred to the operating room for bronchoscopy. Anesthesia was induced with IV midazolam and ketamine. The trachea was intubated orally and anesthesia maintained with spontaneous breathing of halothane in oxygen. Flexible fiberoptic bronchoscopy performed via the tracheal tube revealed no injury to bronchi or carina. Bronchoscopy through the tracheal tube withdrawn to the level of the vocal cords revealed a 1-cm long posterior longitudinal tear approximately 2-3 cm below the cords. The surgeons planned a definitive tracheostomy distal to the traumatic tracheal opening. This was difficult and initially unsuccessful because of subcutaneous emphysema. A ureteric catheter was introduced through the tracheal tube and a tracheostomy tube mounted on the fiberoptic bronchoscope, which was then inserted through the surgical tracheostome. This followed the ureteric catheter into the distal trachea and the trachea was successfully cannulated. We review the mechanism of tracheal injuries with special reference to its occurrence in children with blunt injury. We discuss the airway management in these potentially life-threatening injuries.