Hemoptysis in trauma

Delayed systemic air embolism in a child with severe blunt chest trauma treated with high-frequency oscillatory ventilation

PURPOSE

Trauma is the leading cause of death in children over one year of age. Even with optimal field care, blunt chest trauma with hemoptysis is a potentially fatal injury due to exsanguination or arterial air embolism. Most often, cardiovascular collapse that is unresponsive to therapy develops shortly after endotracheal intubation and initiation of positive pressure ventilation. We present a case of arterial air embolism after blunt chest trauma that manifested atypically late, i.e., one hour after initiation of positive pressure ventilation.

CLINICAL FEATURES

A 13-yr-old Caucasian boy was admitted to the emergency room after he had been run over by a car. While lung protective ventilation, including high frequency oscillatory ventilation, was performed, an alveolar to pulmonary venous fistula developed. Although the complication was diagnosed quickly, involvement of the cerebral and coronary arteries resulted in irreversible cerebral damage and fatal hemodynamic collapse. Necropsy confirmed severe damage of the right pulmonary lower lobe with involvement of the pulmonary vessels.

CONCLUSION

Patients with blunt chest trauma and hemoptysis present a diagnostic dilemma with limited therapeutic options.

Successful Use of Recombinant Activated Coagulation Factor VII in a Patient with Massive Hemoptysis From a Penetrating Thoracic Injury

Acute massive hemoptysis is a rare complication of pulmonary injury and contusion, and it is particularly difficult to manage in the nontertiary care setting. Recombinant activated coagulation factor VII (rFVIIa) is a prothrombotic drug that is increasingly being used to treat coagulopathy in massively exsanguinating trauma patients. We report a case in which recombinant activated coagulation factor VII successfully controlled massive hemoptysis and improved ventilation from a severe pulmonary contusion in a noncoagulopathic patient who suffered a penetrating thoracic injury in a military setting in Afghanistan.

Indications for surgery in tracheobronchial ruptures

OBJECTIVE

Ruptures of the tracheobronchial tree present a life-threatening situation. Nevertheless, therapy is still controversial. Though conservative treatment by antibiotics and intubation with the cuff inflated distal to the tear is favored by some authors, surgical repair is unavoidable in many cases.

METHODS

We present a series of 31 patients (mean age 43.6 years, range 8--72 years) with iatrogenous or post-traumatic tracheobronchial ruptures treated since 1975. Fifteen ruptures were longitudinal tears of the trachea, not extending lower than a distance of 3 cm from the bifurcation, 11 involved the bifurcation and/or the main bronchi. The total length of the longitudinal tears ranged from 2 to 12 cm, five were transverse near complete abruptions of the trachea or main bronchi. Involvement of the full thickness of the wall with free view into the pleural space or to the esophageal wall was present in 29 cases. Twenty-nine out of the 31 patients underwent surgical repair and two were treated conservatively. The length and depth of the lesion, the degree of subcutaneous emphysema, pneumothorax and/or pneumomediastinum as well as clinical signs suggesting incipient mediastinitis were considered when making the decision for surgery.

RESULTS

Twenty-five out of the 29 patients experienced an uneventful recovery. Four patients died of sepsis unrelated to the tracheobronchial trauma. One of the two patients who underwent conservative therapy also recovered uneventfully. The other one died because of multi-organ failure due to underlying myocardial infarction.

CONCLUSIONS

Conveniently localized short lacerations, especially if they do not involve the whole thickness of the tracheal wall, can be treated with antibiotics and intubation with the cuff inflated distal to the tear, avoiding high intra-bronchial pressures also after eventual extubation. In all other cases surgical repair is to be preferred.

Traumatic and iatrogenic lesions of the trachea and bronchi

OBJECTIVE

The traumatic lesions of the trachea and the main bronchi appear to be rare, but as complications of the severe chest and neck injuries they require urgent surgical treatment. Unfortunately for the last few years the incidence of such traumas has increased.

METHODS

During the last 15 years we have treated 28 patients (20 male and eight female) with traumatic lesions of the tracheobronchial tree aged from 8 to 64 years. The tracheal lesions were predominantly iatrogenic caused by difficult endotracheal intubation. The lesions of the bronchi (12 of the main and three of the lobar) were caused mainly by blunt traumas (car accidents and falling from heights). Total disruption of the right main bronchus was observed in five cases and of the left main bronchus - in seven cases. Emergency operative treatment was performed in all patients within 6 to 12 h after the incident. Cervical approach was performed in eight patients and postero-lateral thoracotomy in the other cases.

RESULTS

We had one death in the early post, which was due to a severe trauma. Excellent and good results were obtained in 27 patients, which recovered well within 3 months and were followed up for periods ranging from 1 to 10 years.

CONCLUSION

The traumatic lesions of the trachea and main bronchi require emergency surgical treatment. The proper choice of operative approach is largely dependent on the precise early diagnosis and on the determining of the exact location of the lesions. Operative tactics must aim at optimal preservation of the functional lung parenchyma and have to include reconstructive and plastic procedures.