American Journal of Emergency Medicine (2008) 26, 837.e3–837.e4
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Case Report Survival after traumatic complete laryngotracheal transection Abstract Laryngotracheal trauma may result in lifelong complications or even death if diagnosis or treatment is delayed. Emergency department physicians, trauma surgeons, anesthesiologists, and especially thoracic surgeons should maintain a high level of awareness of and suspicion for laryngotracheal trauma whenever a patient present with multiple trauma in general or with cervical-thoracic trauma in particular. A blunt or penetrating laryngotracheal injury can result in acute airway obstruction and death at the scene of an accident or crime. In recent years, advances in emergency services, including better evacuation procedures and heightened training, have improved survival rates. In this article, we present a case of survival after complete laryngotracheal transection for blunt cervical and thoracic trauma. A 24-year-old man had a cervical and thoracic trauma by crushing with a plate of approximately 300 kg. In the emergency department, his Glasgow Coma Score was 15. His vital signs were as follows: heart rate, 86 beats per minute; blood pressure, 177/102 mm Hg; and initial pulse oximetry saturation (SpO2), 55%. Rapidly, he became drowsy, developed respiratory distress with labored breath, and lost consciousness. An attempt to orotracheal intubation was unsuccessful and produced an important subcutaneous emphysema in the patient's neck and anterior chest. Emergency tracheostomy was performed, finding a complete tracheal transection. Significant findings from the computed tomography scans included a fracture involving the seventh cervical vertebral body, right hemopneumothorax, multiple rib fractures on the right side, bilateral pulmonary contusion, intrahepatic hematoma, and complete laryngotracheal transection with cricoid fracture. Under general anesthesia, a cervicotomy was performed. A sterile flexible armored endotracheal tube was used to facilitate ventilation across the surgical field once the airway was exposed. The thyroid gland was sectioned with destruction of the right lobe. There was a complete laryngotracheal transection with a 3-cm gap between the cricoid and the first tracheal ring. The cricoid 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
cartilage was undressed of its mucosa which was hit at the level of the vocal cords. A cricotracheal anastomosis using interrupted 3-0 absorbable sutures was performed. The suture was performed including the cricoid mucosa to diminish the risk of necrosis of cricoid cartilage. The patient was extubated after 7 days as a result of respiratory distress secondary to bad evolution of the pulmonary contusion. He was discharged home on the 15th postoperative day. At day 60, after surgical procedure, the tracheoscopy only showed a bilateral vocal cord paralysis in abduction, and decannulation was performed. After 12 months of follow-up, the boy was well, his respiration was normal, and tracheoscopy was unchanged (Figs. 1 and 2). Perioperative management of an acute blunt traumatic tracheal injury is a rare event because, in part, of the significant high mortality in the prehospital course and the delay in diagnosis until days or even months after the initial trauma [1]. As shown in the case presented here, in the presence of a complete laryngotracheal transection, initial survival of the patient was sustained by an airway created by the peritracheal fascial tissues and intact pleura. This patient survived despite a delay in definitive intervention until he was transferred to the authors' hospital, approximately 2 hours after the tracheal disruption.
Fig. 1 Complete laryngotracheal transection with cricoid fracture and subcutaneous emphysema.
837.e4
Case Report Primary repair is the gold standard for tracheobronchial injuries, and the key to successful treatment is airway management before and during surgery. The postoperative mortality rate was reported to be 59% after tracheobronchial rupture [5]. Dysphonia, as shown in our case, can be explained by a laryngeal palsy. It occurs in only 10% of cases, generally when the gap between tracheal rings is ≥2 cm [5].
Fig. 2
Tracheal ring over tracheostomy.
In closed trauma, 80% of tracheobronchial injuries occur near the carina at the distal trachea, probably because of their relative fixation compared with the cervical trachea. Injuries of the cervical trachea are rarer, and from 80% to 95% of them occur from the cricoid to the forth tracheal ring [2], as in our case. The diagnosis of tracheal transection secondary to nonpenetrating trauma is often difficult to make because most patients present with nonspecific signs such as dyspnea, cough, subcutaneous emphysema, and/or hemoptysis. However, as shown in the case presented here, this seemingly stable situation can progress suddenly to acute respiratory arrest. In general, radiographic studies are important adjuvants in the diagnosis of tracheal trauma. Although computed tomography provides enhanced images of anatomical structures, Chen et al [3] found only an 85% sensitivity for detecting tracheal rupture. Because bronchoscopy remains the most reliable modality for defining the site, nature, and extent of tracheobronchial injury, it should be used by experienced clinicians. Early diagnosis and treatment are associated with decreased morbidity, including risk of infection and tracheobronchial stricture [4].
Perna Valerio MD Macia Ivan MD Rivas Francisco MD Anna Ureña MD Ramos Ricard MD Morera Ricardo MD Saumench Josep MD Escobar Ignacio MD Villalonga Rosa MD Juan Moya MD Thoracic Surgery Department, Hospital Universitario de Bellvitge, Feixa Llarga s/n – L'Hospitalet de Llobregat 08907 Barcelona, Spain E-mail address:
[email protected] doi:10.1016/j.ajem.2008.01.031
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