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Initial Airway Management of Blunt Upper Airway Injuries: A Case Report and Literature Review

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... In fact, prehospital mortality has been reported to vary from 15% to 81% if intrathoracic injuries are included. 3 Laryngotracheal trauma can occur by varying mechanisms. Based on the mechanism of injury it can either be a blunt or penetrating trauma. ...
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Laryngeal trauma is exceptionally rare due to the protective effect of the mandible and sternum and the laryngotracheal framework's elastic nature. Trauma to the larynx can be life-threatening and cause not only mortality but longterm upper aerodigestive morbidity. Here is a case of a 37 year-old male with electric burn of laryngotracheal region.
... The treatment options for stable airway include observation in monitored setting, humidified inspired air, reverse Tredlenberg position, broad spectrum antibiotics, steroids and antireflux therapy 13,14,15 . The management options for unstable airway includes intubation, cricothyroidotomy or tracheostomy in local or general anesthesia. ...
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Laryngotracheal trauma can be an immediately life-threatening injury if diagnosis or treatment is delayed. Failure to recognize acute injuries or to observe the principles of management can lead to laryngotracheal stenosis. Emergency room physicians, trauma surgeons, anesthesiologists, and especially otolaryngologists should maintain a high level of awareness of and suspicion for laryngotracheal trauma whenever a patient presents with multiple injuries in general or with cervical trauma in particular. Treatment in experienced hands will usually result in a favorable outcome. A case of laryngotracheal trauma was brought to emergency. After securing airway, complete laryngotracheal separation with tear in anterior wall of oesophagus was found. Laryngotracheal anastomosis with closure of oesophageal perforation was performed. A glove finger filled with two merocel was used as a stent for support.
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Laryngotracheal trauma is life-threatening. We identified 23 patients between 1992 and 1998 with laryngeal (12), tracheal (8), and combined injuries (3). Nineteen patients had penetrating trauma (gunshot wound, 12; stab wound, 7), and four patients had blunt injury. Flexible laryngoscopy identified the injury in 8 of 12 patients (75%), and computer tomography scan was positive in 9 of 9 patients (100%). Twelve of the 19 patients with penetrating wounds were managed by primary repair, 4 had endotracheal intubation without surgical repair, and 3 were observed. No patient with a blunt tracheal injury required repair. Two had endotracheal intubation, and two were observed. A high index of suspicion is essential to identifying laryngotracheal injury. Computer tomography scan is a sensitive diagnostic test for laryngotracheal injury, and may be indicated despite normal flexible laryngoscopy. The decision to repair injuries or observe injuries is primarily based on respiratory distress and associated injuries.
Article
In 23 patients with laryngotracheal trauma at the Louisville General Hospital during a ten-year period, 19 survived. One death was directly atributable to the airway injury. The most common postinjury complication was hoarsensess attributable to direct injury to the cords or recurrent nerve paralysis. One patient had further operation for subglottic stenosis. In general, blunt injuries were more severe than penetrating injuries. Subcutaneous emphysema, aphonia or dyshonia, hemoptysis, signs of injuries, a sucking wound, are presumptive findings of laryngotracheal injury. Appropriate endoscopy and radiographic studies should confirm the diagnosis. Control of the airway is achieved by emergency tracheostomy or intubation followed by tracheostomy. Prompt operative intervention and primary repair follow.
Article
Laryngotracheal trauma (LTT) is a rare but clinically important injury that may be missed without a high index of suspicion. Forty patients with LTT admitted to the University of Tennessee, Memphis from 1984 through 1989 were retrospectively reviewed. Twenty-six patients sustained penetrating (P)-LTT and 14 had blunt (B)-LTT. Three patients with P-LTT and one with B-LTT arrived in full arrest. Sixty-five per cent of blunt injuries, and 100 per cent of penetrating injuries had neck tenderness or overlying evidence of trauma. A combination of angiography, barium swallow, esophagoscopy, CT scan, bronchoscopy and/or laryngoscopy was used for evaluation, depending on the mechanism. Twenty-two of the 23 surviving P-LTT patients underwent surgery; 11 (50%) had concomitant esophageal injury. All patients with complications from P-LTT were in the group with esophageal injury. B-LTT was classified as either mild5, moderate3, or severe6; all 6 severely injured patients had preoperative airway compromise. All complications of B-LTT occurred in the severely injured group. The following conclusions were reached: LTT usually presents with symptoms and/or signs, but they may be minimal and nonspecific. Emergency tracheostomy should not be delayed if ventilation is compromised. Concomitant esophageal injuries are frequent in P-LTT and predispose the patient to postoperative complications. Airway compromise frequently correlates with severity of injury in B-LTT and these patients are also at high risk for complications.
Article
To examine and compare the mechanism of injury, diagnostic findings, initial methods of airway management, and outcome of patients who had upper airway injuries. A retrospective review of hospital records. A large metropolitan, university-affiliated trauma center. Forty-six cases of upper airway injuries admitted between 1984 and 1988. Diagnostic methods included clinical examination, cervical and thoracic radiographs, bronchoscopy and computerized tomographic (CT) scan. Therapeutic interventions ranged from conservative management with or without endotracheal intubation to operative reconstruction. Mechanism of injury was knife stab wound in 9 cases, gunshot wound in 17 cases, and blunt trauma in 20 cases. Location was the larynx in 13 cases, trachea in 24 cases, cricoid cartilage in 5 cases, and multiple sites in 4 cases. Diagnostic findings varied considerably according to the mechanism of injury, but radiographic evidence of soft tissue air and wounds opening into the airway were common findings. CT scan and bronchoscopy also were useful diagnostic tools. Overall mortality was 24%, which did not vary according to patient age or mechanism of injury. The airway injury itself was a primary or contributory cause of death in four cases, two of which were tracheal injuries and two injuries at the cricotracheal junction. In any patient with possible upper airway injury, plain radiographs of the chest and neck should be obtained to aid in the diagnosis. Elective intubation should be attempted only with a surgical team present and prepared for emergency tracheotomy. Fiber-optic bronchoscopy could be a valuable aid for both intubation and evaluation in such cases.
Article
Retrospective chart analysis was carried out on 13 patients presenting to the trauma service at the Humana Hospital University in Louisville, from January, 1984 through December, 1987 with a diagnosis of acute laryngeal injury. The most common cause of injury was blunt trauma suffered in a motor vehicle accident. Stridor was the most common presenting symptom and the thyroid cartilage was the most common site of fracture. Seven patients underwent immediate open exploration and repair, three underwent tracheostomy without exploration, and three were treated conservatively with voice rest, humidity, and steroids. All 13 patients had a favorable result. The purpose of this paper is to review the findings of our study and to discuss diagnostic and management recommendations for laryngeal trauma.
Article
The low incidence of blunt trauma to the cervical portion of the trachea limits management experience in most centers. Hence, we combined our patients with those in published reports containing essential information on injury, treatment, and results. Among 51 patients (93% male), ages ranged from 3 to 65 years. There were 32 complete transections, 15 partial transections, and four tears. There were associated injuries of the recurrent laryngeal nerve (49%), esophagus (21%), larynx (14%), and cervical spine (9%). Presenting signs and symptoms included subcutaneous emphysema in 84%, respiratory distress in 76%, hoarseness/dysphonia in 46%, and hemoptysis in 21%. Tracheostomy was the best means of airway control; 13 of 17 (76%) attempted oral/nasotracheal intubations failed, necessitating emergency tracheostomy. Five patients with no respiratory distress and minimal tissue injury were successfully managed without tracheal repair. Ten patients had tracheal repair without tracheostomy. The only poor result occurred in a patient with a treatment delay of several days. Tracheal repair with tracheostomy was used in 27 patients, with good results in 19. Two patients died of other injuries, and six patients (four with delayed repair) required subsequent tracheal reconstruction. Repair over a stent was used in seven patients, four of whom had satisfactory results. From this review we conclude that (1) the diagnosis of blunt trauma to the cervical trachea requires a high index of suspicion, since this injury can easily be overlooked; (2) tracheostomy (vs intubation or cricothyroidotomy) is the preferred means of airway control; (3) preoperative laryngoscopy/bronchoscopy should be done to assess vocal cord function, possible laryngeal damage, and level of tracheal injury; (4) good long-term results, measured by voice and airway quality, are best obtained by immediate repair of significant injuries.
Article
During the last 12 years, 20 patients with significant airway injuries have been treated for lesions involving the trachea, larynx, and/or bronchus. Fourteen of the injuries were the result of penetrating wounds, nine gunshot wounds, and five stab wounds. Six patients presented with blunt trauma, four as a result of motor vehicle accidents, one from a clothesline injury, and one from a crush injury. Sixteen of the 20 were males; average age was 29.6 years. Eleven patients had injuries involving only the trachea, six had isolated laryngeal injuries, two had bronchial injuries, and one patient had a combined injury of the trachea and larynx. Eleven had subcutaneous emphysema, four had hemoptysis, and three stable patients experienced sudden respiratory arrest while being evaluated for the repair of their injuries. Twelve patients required immediate intubation or tracheostomy. Most airway injuries were closed primarily. In one instance segmental resection of a perforated trachea and primary anastomosis was necessary. Two patients died after proper management of the airway injury. One died of an associated brain stem injury and the other of profuse hemorrhage from a liver injury. Of the 18 surviving patients, all but two recovered totally without residual impairment. Described here is a protocol for the evaluation and immediate treatment of airway injuries that is consistent with the guidelines of the Subcommittee of Advanced Trauma Life Support of the American College of Surgeons Committee on Trauma. Aggressive initial management, high index of suspicion for injury, and meticulous repair of the injured airway are equally important steps in the successful management of these patients.
Article
Laryngotracheal trauma is rare and complications are frequent. Twelve major series totalling 392 cases have been published over the past decade, with complication rates as high as 40%. We have treated over 30,000 trauma victims at our Level I Trauma Center over the past 5 years, of which 109 had neck injuries, but only 12 suffered cervical laryngotracheal trauma. The mechanism of injury was penetrating in eight and blunt trauma in four. The time to tracheostomy decannulation varied from 7 to 60 days. Airway patency was assured without stenosis or significant granulation tissue in 10 of the 12 patients. Three patients suffered permanent voice changes. Based on review of the 392 previously reported cases and a critical analysis of our 12 cases, a detailed management algorithm is proposed.
Article
Traumatic rupture of the trachea or the bronchi is reported with increasing frequency. Such rupture may follow penetrating wounds, but the common cause is blunt trauma of the throat or thorax. When the proximal trachea is damaged other cervical structures are usually involved. By contrast the distal trachea or bronchi are not infrequently the only thoracic structures damaged. In particular there may be no rib fractures, or obvious fractures may be uncomplicated and insignificant. Thoracic rupture usually occurs in the vicinity of the carina. Central rupture generally presents with emphysema of the mediastinum and neck. Diagnosis can usually be confirmed by tracheobronchoscopy. Rupture of the peripheral bronchi generally presents with pneumothorax and atelectasis. Central rupture should be treated by primary suture. Lobectomy is often necessary when small bronchi are ruptured.
Article
The management of 87 laryngeal trauma patients over the past 17 years is reported. During the last four years, 35 of these patients were prospectively studied by the author after drawing upon the treatment policies of the earlier experience. The results of this study demonstrate a successful program to preserve or restore the phonatory and airway function of the acutely injured larynx.
Article
Local external evidence of neck trauma (bruising, subcutaneous emphysema, cuts, abrasions, and so on), signs of upper airway obstruction, dysphonia, and dysphagia are hallmarks of laryngotracheal lesions. 1-5 We describe a case of severe traumatic laryngotracheal lesion in which the diagnosis proved very difficult, since any visible external evidence of trauma to the neck was lacking and the patient could breath spontaneously through a nasotracheal tube, which was inserted for neurological problems.
Article
To demonstrate the diverse causes and manifestations of blunt laryngotracheal trauma in children, and to recommend an appropriate treatment protocol for these patients. A retrospective review of the medical records of patients treated at a tertiary care children's hospital for blunt laryngotracheal trauma during the 12 years before March 1, 1995 was performed. Clinical signs and symptoms, mechanisms of injury, and the results of laryngoscopy were included. The study included 23 patients ranging from 2 1/2 to 18 1/2 years of age. The medical records of patients who had sustained an injury as a result of penetrating trauma, intubation, or foreign body were excluded. Four patients urgently required tracheotomies; 2 of these patients required subsequent reconstructive airway procedures. One child required a microlaryngoscopy with relocation of the arytenoid cartilage. The remaining 18 patients were treated conservatively with continuous pulse oximetry, cool mist room air, and serial flexible fiberoptic laryngoscopy. The 18 patients were discharged from the hospital after 24 to 48 hours of observation without sequelae. The signs and symptoms of blunt laryngotracheal trauma in children are not always specific to the extent or type of injury. A prompt diagnosis and treatment plan are needed to prevent potentially catastrophic complications. Patients with obvious airway compromise require immediate intervention. Those without acute airway symptoms often can be treated conservatively, provided that flexible fiberoptic laryngoscopy confirms a safe airway.
Article
Aerodigestive tract injuries in the neck are found in about 7% of penetrating neck injuries and are very rare in blunt trauma. A combination of a good physical examination with endoscopy and esophagography can reliably diagnose all significant injuries. Airway control in laryngotracheal trauma is the most urgent priority and is often a difficult procedure. Although selected small pharyngeal and laryngotracheal injuries may be managed nonoperatively, all other aerodigestive tract injuries should be managed with early operation.
Article
Implications: We describe three patients with difficult airways in which fiberoptic endotracheal intubation was used to insert breathing tubes into the patients' windpipes. Airway injury occurred during the use of this technique. Although largely a safe technique, care should be exercised when anesthesiologists choose equipment and when they perform this technique.