Management of thoracic traumaTracheobronchial Injury
Section snippets
Anatomy
The anatomy of the tracheobronchial tree traverses two areas of the body: the neck and the thorax. While in the neck, the trachea is in close association to the carotid sheath and recurrent nerves laterally, to the esophagus posteriorly, and to the skin anteriorly, which makes it relatively prone to external injury. It continues through the thoracic inlet into the chest, where it is in close association to the great vessels and heart anteriorly, the pleura and lungs laterally, and to the
Incidence and Presentation
The true incidence of TBI is difficult to establish, as a large proportion (30% to 80%) of these patients will die before reaching the hospital.2 However, it is estimated on the basis of autopsy reports that 2.5% to 3.2% of patients who die as a result of trauma may have associated TBI.3, 4 More than 80% of TBI due to blunt trauma is located within 2.5 cm of the carina.4 Resuscitation of a patient with TBI can be difficult, as obtaining adequate ventilation may require novel approaches to
Associated Injuries
Pneumothorax is the presence of free air in the pleural space resulting in partial or total lung collapse. Pneumothorax may or may not be seen on plain radiograph. The parietal and visceral pleurae lie next to each other, forming a potential pleural space in which the lung normally lies in apposition to the chest wall. Expansion of the intrathoracic space causes a negative pressure, which in turn is transmitted to the pleural space, which then behaves like a bellows pulling air into the lungs
Diagnosis
The diagnosis of TBI is often times difficult, and a high index of suspicion is necessary. It is a relatively rare injury diagnosed in patients presenting to the emergency department that have sustained blunt chest trauma, with a reported incidence of 0.3% to 2%.56, 57 Physical examination is important in screening, and findings may include hoarseness, subcutaneous emphysema, diminished breath sounds, hemoptysis, and tachypnea. Although plain chest radiograph is helpful for the assessment of
Surgical Treatment
Depending on the severity of associated injuries and on airway compromise directly due to TBI, surgical treatment can be either immediate or delayed. Delayed repair of TBI can be successful, even if performed months out from the original injury.59 This is a common scenario seen in patients who present later with collapsed lung on radiograph, dyspnea, and a history of blunt force trauma where diagnosis of their TBI was missed at the time of injury. However, late complications of untreated TBI
Summary
In summary, tracheobronchial injuries, although relatively rare, encompass a heterogeneous group of injuries that often require skillful and creative airway management, careful diagnostic evaluation, and operative repairs that are often resourceful and necessarily unique to the given injury. An experienced surgeon with a high level of suspicion and the liberal use of bronchoscopy constitute the major tools necessary for diagnosing and treating these injuries. Most TBI can be repaired primarily
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Cited by (53)
Comparison of chest CT scan findings between COVID-19 and pulmonary contusion in trauma patients based on RSNA criteria: Established novel criteria for trauma victims
2022, Chinese Journal of Traumatology - English EditionCitation Excerpt :CT images can detect pulmonary contusion immediately after the insults when the clinical manifestations do not yet develop. However, these images lack specificity when they occurred concomitantly with viral pneumonia, especially COVID-19.18 To the best of our knowledge, few studies are available discussing the similarities and differences between COVID-19 and pulmonary contusion.
Blunt trauma related chest wall and pulmonary injuries: An overview
2020, Chinese Journal of Traumatology - English EditionCitation Excerpt :The majority of tracheobronchial injuries are anatomically close to the carina, therefore, the diagnosis of tracheobronchial injury can be difficult radiologically.213,221 CT may be preferred, but bronchoscopy is the most valuable method for early diagnosis.222–224 Although tracheobronchial injuries cause severe respiratory distress in patients, positive pressure ventilation is contraindicated in tracheobronchial injury because it may exacerbate the condition.215
Imaging and Management of Thoracic Trauma
2018, Seminars in Ultrasound, CT and MRICitation Excerpt :The lung moves toward the posterior chest wall and diaphragm in a supine patient.29 Although CT can identify upwards of 90% of TBI, confirmatory diagnosis is usually achieved in the operating room or via bronchoscopy.25,26 Diaphragmatic injury results from tear or rupture of the diaphragm musculature.
The clinical benefit of a follow-up thoracic computed tomography scan regarding parenchymal lung injury and acute respiratory distress syndrome in polytraumatized patients
2017, Journal of Critical CareCitation Excerpt :At present, thoracic computed tomography (CT) is the golden standard to quantify lung injury and to estimate the risk of expected complications [16]. The PLI can be detected by CT scans almost immediately after the bruise to the chest [17]. Nevertheless, lung contusions are evolving lesions.
Traumatic Airway Injuries: Role of Imaging
2020, Current Problems in Diagnostic RadiologyCitation Excerpt :The last is antero-posterior compression injury to the chest with the lung remaining aligned with the chest wall due to negative pressure in the pleura and the compression pull causing laceration at the level of the carina.33 The last 2 mechanisms explain why majority of the injuries are located approximately 2.5 cm proximal or distal to the carina.1,2,34 Clinical signs and symptoms are largely nonspecific.