Management of tracheal tears can prove to be challenging in the perioperative setting. This is a rare condition that can be life threatening. Here, we present a case of seven-year-old boy involved in a high-speed motor vehicle collision. The child sustained multiple injuries including a near fatal head injury, multiple facial fractures, and a tracheal injury associated with pneumomediastinum. Due to the imminent threat of brainstem herniation while being imaged in the CT scanner, the patient underwent an emergent craniotomy to evacuate his evolving intracranial bleed. Imaging prior to the craniectomy suggested a possible tracheal injury, given the extensive pneumomediastinum. However, initial perioperative ventilation was without any difficulty. After stabilization of intracranial pressure (ICP) and hemodynamics, on hospital day 4, the patient returned to the operating room to diagnose and repair his tracheobronchial injury. This is a unique polytrauma case in which a tracheal tear was managed in the midst of other life-threatening injuries.
Tracheal bronchial injuries, whether iatrogenic or traumatic, can be challenging to manage perioperatively due to challenges in securing the airway, ventilation difficulty, and hemodynamic instability [
In this report, we present this interesting case in which the mechanism of injury was likely to be consistent with a possible burst fracture type of phenomenon where increased intrathoracic pressure occurred against a closed glottis at the time of injury.
The patient was a seven-year-old, 22 kg boy who was a backseat, restrained passenger involved in a high-speed motor vehicle collision. He sustained severe head trauma with a depressed frontal skull fracture and subdural hematoma. He was intubated in the field by the paramedics, with a 6.0 cuffed ET tube. He was taken emergently to the operating room for a decompressive craniectomy after he was noted to be unstable in the CT Scanner due to an imminent brainstem herniation. In the preoperative scans, there was evidence of air tracking from the right mediastinum up to the right common carotid artery, continuing up to the C2-C3 disk level.
The patient underwent a bilateral frontal and right temporal craniectomy. A 6.0 cuffed ETT was
He was kept intubated in ICU with similar ventilator parameters. CT scan of chest on the next day revealed minimal pneumomediastinum and a right posterolateral tracheal wall defect/tracheal diverticulum. (Figure
Hospital Day number 2. Noncontrast CT scan of chest. Extensive pneumomediastinum has diminished. There is a persistent right posterolateral tracheal wall defect/tracheal diverticulum.
On hospital day 4, the patient was cleared from the neurological standpoint to proceed to surgery for his tracheal repair. Again, the child had an
Prerepair bronchoscopic view of the tracheal tear.
A thoracic epidural was placed at T5-T6 for postoperative pain control. He was placed in a left lateral decubitus position; left lung ventilation begun and was deemed adequate for a right sided thoracotomy.
The tracheal lesion was successfully repaired with a bovine pericardial patch (Figure
Location of the tracheal tear in the distal trachea.
Postrepair bronchoscopic view of the tracheal tear.
Pediatric tracheobronchial lesions secondary to blunt injury are rare with mortality rates as high as 30%, and death likely occurring within an hour of the traumatic injury [
In this case, the 7-year-old boy sustained a head injury and facial fractures. The patient’s clinical presentation was also significant for a possible tracheal injury suggested by CT imaging which has a 85% sensitivity of detecting airway lesions [
The mechanism of injury was likely a possible burst fracture type of phenomenon where increased intrathoracic pressure occurred against a closed glottis at the time of injury. It is also possible that this injury occurred during intubation in the field from laceration by a protruding stylet. The tracheal tear could also have resulted from overinflation of the cuff, as a 6.0 cuffed tracheal tube was relatively large for this boy.
Given the stability of the patient during his initial surgery (stable peak pressures and no signs of pneumothorax), it was theorized that the endotracheal tube was likely below the tracheal lesion, and positive pressure ventilation was delivered for 4 days without complication. Bronchoscopy to diagnose or rule out tracheal injury was delayed until the patient’s neurological status had improved.
The lesion measured approximately 3.5 to 4 cm in length, at the right membranocartilaginous junction, above the carina and just proximal to the entrance of the right mainstem bronchus. Right-sided bronchial injuries in the setting of chest trauma occur more frequently than on the left [
Surgical repair with right thoracotomy was performed due to size of lesion. Primary anesthetic management would be to secure the airway with endotracheal intubation with care not to exacerbate the injury. Fiberoptic bronchoscopy should be used to facilitate this. We placed the endotracheal tube distal to the lesion to facilitate positive pressure ventilation without creating tracheal perforation or rupture in this weakened part. Lack of double lumen tubes small enough for this particular patient at our institution also posed another added source of difficulty. Instead, a bronchial blocker was used. The bronchial blocker offered the advantage of allowing us to leave the
Tracheal tears in the pediatric population are rare and have the potential of being difficult to manage. The imminent threat of brainstem herniation in this 7-year-old polytrauma victim prompted immediate surgical decompression despite concerns for tracheal injury. With the diagnostic assistance of the CT Scan, the anesthesiologists were acutely aware of possible ventilation difficulties associated with a tracheal injury. While the patient was ventilated in the ICU for 4 days with the tip of the tracheal tube placed distal to the lesion, the perioperative management included one lung ventilation with a bronchial blocker and a throacic epidural for postoperative analgesia.
No conflict of interests for either of the authors.