Complete cervical tracheal transection from blunt trauma

Cervical tracheal transection after scarf entanglement in a go-kart engine

BACKGROUND

Tracheal disruption secondary to blunt force occurs infrequently. Most individuals suffering such an injury die before arriving at a hospital. Diagnosis for those who do present alive is often delayed, as signs and symptoms typically do not match the severity of injury.

OBJECTIVE

The objectives of this case report are to present a unique mechanism for tracheal disruption and to discuss our management strategy.

CASE REPORT

We describe an 18-year-old man who suffered tracheal disruption after entanglement of his scarf in a go-kart engine. His initial workup was conducted by emergency physicians and included computed tomographic evaluation of the neck. After diagnosis, the patient was transported to an operating suite. Awake tracheostomy was performed in this controlled environment to secure the airway, after which the trachea was repaired via primary anastomosis.

CONCLUSIONS

Prompt recognition and appropriate intervention are critical in the care of patients with suspected tracheal transection to prevent mortality.

Multiplanar reconstruction: a new method for the diagnosis of tracheobronchial rupture?

OBJECTIVE

To compare multiplanar reconstruction with operative techniques (bronchoscopy, surgery and/or autopsy) for the diagnosis of tracheobronchial rupture.

DESIGN

Prospective, observational study.

SETTING

Surgical intensive care unit.

PATIENTS AND PARTICIPANTS

Tracheobronchial rupture was suspected on clinical grounds and from radiological findings.

INTERVENTIONS

An initial helical computed tomography scan was performed on all patients meeting the inclusion criteria, and operative techniques were then performed. Multiplanar reconstructions were reformatted and reviewed by two independent radiologists.

MEASUREMENTS AND RESULTS

Twenty-four consecutive patients met the inclusion criteria. Tracheobronchial rupture was diagnosed in 13 patients by at least one operative technique. Multiplanar reconstructions were positive in 15 patients. The diagnostic sensitivity and specificity of multiplanar reconstructions were 100% (95%CI, 85-100) and 82% (95%CI, 64-82), respectively. The positive and negative predictive values were 87% (95%CI, 74-87) and 100% (95%CI, 78-100), respectively. For tracheobronchial rupture, the positive and negative likelihood ratios were 5.5 (95%CI, 2.35-5.5) and 0 (95%CI, 0-0.24), respectively. The Kappa coefficients were 0.83 (95%CI, 0.6-1.06) for agreement between operative techniques and multiplanar reconstruction, and 0.91 (95%CI, 0.59-0.91) for agreement between the two radiologists.

CONCLUSIONS

Multiplanar reconstruction appears to be a sensitive technique for the identification of tracheobronchial rupture because of its excellent negative likelihood ratio. In clinical practice, negative multiplanar reconstruction can exclude a diagnosis of tracheobronchial rupture, making bronchoscopy unnecessary. When multiplanar reconstruction is positive, tracheobronchial rupture should be confirmed by bronchoscopy.

DESCRIPTOR

Trauma.

Complete laryngotracheal disruption caused by blunt injury

BACKGROUND

We reviewed the clinical courses and evaluated the surgical results of 7 patients with complete laryngotracheal disruption caused by blunt injury.

METHODS

Seven patients with complete laryngotracheal disruption caused by blunt injury were successfully treated in a 13-year period. Six of the seven incidents involved men younger than 30 years on motorcycles. All but one had intact cutaneous tissue of the neck. Six of seven laryngotracheal disruptions were at the cricotracheal junction and the other was at the junction of second and third tracheal ring. In the emergency departments, 4 of these 7 patients underwent endotracheal intubation and three others underwent tracheostomy after failed intubation. Two of 7 patients underwent delayed surgery (posttrauma day 3 and day 5) because of delayed diagnosis. All patients underwent laryngotracheoplasty with (n = 3) or without (n = 4) concomitant tracheostomy.

RESULTS

Total hospital stays ranged from 9 to 28 days (average 15 days). Intensive care unit stay ranged from 2 to 10 days (average 5.8 days). All 7 patients had paralysis of bilateral vocal cords that were revealed by postoperative bronchoscopy. In 3 patients who underwent concomitant tracheostomy, the tracheostomy tubes were removed within 3 to 5 months after surgery. In the other 4 patients who underwent laryngotracheoplasty only, the endotracheal tube was used as an airway support for 2 to 6 days (average 3.5 days). All patients had patent airways. Vocal cord function partially recovered in one side (n = 6) or both sides (n = 1). Their voices were audible but still husky 5 months or 1 year later.

CONCLUSIONS

Complete laryngotracheal disruption can be treated by laryngotracheoplasty with or without concomitant tracheostomy, and phonation can be partially recovered.