Trachea/Bronchial Injury


Background

  1. Injury to tracheobronchial tree
  2. Rare injuries
  3. A delayed threat to life
  4. Etiologies

Pathophysiology

  1. General concepts
  2. Classification is by location of injury

Diagnostics

  1. Signs / symptoms
  2. Diagnostic imaging

Treatment

  1. ATLS
  2. Management specific to tracheobronchial injury
  3. Treatment by anatomical site
  4. Untreated tracheal tears risk severe mediastinitis
  5. Tetanus prophylaxis

Disposition

  1. Admit all pts for definitive surgical repair
  2. Prognosis


  Physical Exam Investigations Management
Pulmonary Contusion - Blunt trauma to chest
- Interstitial edema impairs compliance and gas exchange
- CXR: areas of opacification of lung within 6 hours of trauma - maintain adequate ventilation
- monitor with ABG, pulse oximeter and ECG
- chest physiotherapy
- positive pressure ventilation if severe
 
Ruptured Diaphragm - Blunt trauma to chest or abdomen (e.g. high lap belt in MVC) - CXR:  abnormality of diaphragm/lower lung fields/NG tube placement   
- CT scan and endoscopy - sometimes helpful for diagnosis
- laparotomy for diaphragm repair and because of associated intra-abdominal injuries
Esophageal Injury - Usually penetrating trauma (pain out of proportion to degree of injury) - CXR: mediastinal air (not always)
- Esophagram (Gastrograffin)      
- Flexible esophagoscopy
- Early repair (within 24 hrs.) improves outcome but all require repair
Aortic Tear    
 
- 90% tear at subclavian (near ligamentum arteriosum), most die at scene
- salvageable if diagnosis made rapidly
- Sudden high speed deceleration (e.g. MVC, fall, airplane crash), complaints of chest pain, dyspnea, hoarseness (frequently absent)

- Decreased femoral pulses, differential arm BP (arch tear)
- CXR, CT scan, transesophageal echo (TEE), aortography (gold standard)
- see below for CXR features
- Thoracotomy (may treat other severe injuries first)
Blunt Myocardial Injury (Rare) - Blunt trauma to chest (usually in setting of multi-system trauma and therefore difficult to diagnose)      
- Physical examination: overlying injury, i.e. fractures, chest wall contusion
- ECG: arrhythmias, ST changes
- Patients with a normal ECG and normal hemodynamics never get dysrhythmias
- O2
- Antiarrhythmic agents
- Analgesia