Airway injuries due to blunt chest trauma

Although the incidence of blunt chest trauma is very high, the mediastinal tracheobronchial injuries are quite rare. The airway injuries are thought to be one of the most urgent clinical conditions in thoracic surgery, and we are requested to make not only a rapid and sharp diagnosis but also an appropriate treatment plan considering combined injuries. We present 9 cases of tracheobronchial injuries due to blunt chest trauma in recent years. The average age of these patients is 26.1 years, and they are consisted of 6 male and 3 female. The cause of trauma is traffic accident in 7, and occupational crane accident in 2. Bronchoplasty were done in 5 cases (right main bronchus in 2, left main bronchus in 1, trunks intermediate bronchus in 1, and the spur between middle and lower lobe in 1), membranous-tracheoplasty with right pneumonectomy in 1, left pneumonectomy in 1, conservative treatment in 2. Postoperative mortality is occurred in 1 case who was suffering from multiple injuries including severe head injury and contralateral lung contusion. Tracheobronchial plasties should be chosen if possible to preserve lung function for the patient suffering from airway injuries.     

Airway management in laryngotracheal injuries from blunt neck trauma in children

Pediatric laryngotracheal injuries from blunt neck trauma are extremely rare, but can be potentially catastrophic. Early diagnosis and skillful airway management is critical in avoiding significant morbidity and mortality associated with these cases. We present a case of a patient who suffered a complete tracheal transection and cervical spine fracture following a clothesline injury to the anterior neck. A review of the mechanisms of injury, clinical presentation, initial airway management, and anesthetic considerations in laryngotracheal injuries from blunt neck trauma in children are presented.     

Airway trauma

Airway trauma can be considered according to the mechanism of injury, which may guide further management. Trauma may be mechanical, either blunt or penetrating, be due to burns or be iatrogenic as a result of instrumentation of the airway. Immediate airway intervention will be required for obvious airway compromise. Such patients may be difficult to manage, and may be complicated by polytrauma. It is important to appreciate the potential for rapid deterioration in patients with an injury to the aerodigestive tract. Delayed diagnosis can result in poor outcomes from airway and neck trauma, and a structured approach to resuscitation, investigations and ongoing care should be adopted. Iatrogenic airway trauma is not confined to patients in whom intubation is difficult or prolonged, although these are risk factors. Pharyngeal and oesophageal perforation are associated with greater risk of mortality than other iatrogenic airway injuries. Cricoarytenoid joint dysfunction, vocal cord palsy, granuloma, haematoma and tracheal stenosis can all occur as a result of airway instrumentation, and may not be apparent until some time later. Specialist referral of these patients is appropriate, and prompt treatment may improve outcomes. Careful sizing of endotracheal tubes and close monitoring of cuff pressures are important in minimizing airway trauma through intubation.     

Airway trauma

Traumatic airway injuries fortunately are rare. While sometimes injuries are obvious and initial management straightforward, frequently the diagnosis is difficult. Prompt diagnosis of airway injuries requires a high index of clinical suspicion, complemented by judicious use of endoscopy and radiological imaging. Initial management can be complicated by associated head, neck, and thoracic injuries. Importantly, a patient's airway can be lost because of injudicious use of sedation or failure to be properly cautious during attempts at airway management and endotracheal intubation. Mortality rates and the incidence of late complications remain high and have been related to delays in diagnosis and definitive treatment.     

Airway trauma

Airway trauma can be considered according to the mechanism of injury, which may guide further management. Trauma may be mechanical, either blunt or penetrating, be due to burns or be iatrogenic as a result of instrumentation of the airway. Immediate airway intervention will be required for obvious airway compromise. Such patients may be difficult to manage, and may be complicated by polytrauma. It is important to appreciate the potential for rapid deterioration in patients with an injury to the aerodigestive tract. Delayed diagnosis can result in poor outcomes from airway and neck trauma, and a structured approach to resuscitation, investigations and ongoing care should be adopted. Iatrogenic airway trauma is not confined to patients in whom intubation is difficult or prolonged, although these are risk factors. Pharyngeal and oesophageal perforation are associated with greater risk of mortality than other iatrogenic airway injuries. Cricoarytenoid joint dysfunction, vocal cord palsy, granuloma, haematoma and tracheal stenosis can all occur as a result of airway instrumentation, and may not be apparent until some time later. Specialist referral of these patients is appropriate, and prompt treatment may improve outcomes. Careful sizing of endotracheal tubes and close monitoring of cuff pressures are important in minimizing airway trauma through intubation.     

Airway trauma

Airway trauma should be considered according to location and mechanism of injury. Mechanism of airway trauma can be broadly classified as blunt, penetrating and thermal/chemical. Airway strategy and planning is key to safe management. These patients may be challenging to manage and complicated by polytrauma. It is essential to remember that the patient's airway may deteriorate rapidly and contingency planning for this should be in place. A structured approach to the patient is essential and delayed diagnosis may worsen outcome.     

Airway trauma

Airway trauma should be considered according to location and mechanism of injury. Mechanisms of airway trauma can be broadly classified as blunt, penetrating and thermal/chemical. Airway strategy and planning is key to safe management. These patients may be challenging to manage and complicated by polytrauma. It is essential to remember that the patient's airway may deteriorate rapidly and contingency planning for this should be in place. A structured approach to the patient is essential and delayed diagnosis may worsen outcome.     

Airway trauma

Trauma to the airway should be considered according to its anatomical location and the mechanism of injury, which can broadly be classified as blunt, penetrating and thermal/chemical. Patient management may be clinically challenging, and is often complicated by polytrauma. A comprehensive airway management strategy is key to safe patient care. Patients’ airway control may deteriorate rapidly, such that contingency planning must be in place. A structured approach to patient assessment is essential to avoid delayed diagnosis, which may worsen patient outcome.     

Missed injuries. The trauma surgeon's nemesis

The multiply injured trauma patient presents a diagnostic and therapeutic challenge: that of discovering all injuries while simultaneously proceeding with resuscitation and maintaining life. Many factors involved in the initial resuscitation of the multiply injured patient, such as altered level of consciousness, hemodynamic instability, or inexperience and diagnostic oversight, may lead to missed injuries. Injuries may be missed at any stage of the management of the trauma patient, including intraoperatively, and may involve all regions of the body. Established protocols in the initial management of the multiply injured patient, such as the primary and secondary surveys of the Advanced Trauma Life Support Course, will minimize the chance of missing immediately life-threatening injuries in the emergency department. A careful intraoperative approach must be used in all patients, but especially in those with hemodynamic instability, so that all areas are examined for possible injury, rather than concentrating simply on what is known to be injured. Use of the tertiary survey, a careful re-examination of the multiply injured trauma patient, especially when he or she awakes, will help detect injuries missed during the initial evaluation. Injuries will be missed. Rather than dismissing these as occurrences that happen only to the inexperienced or incompetent, one should approach the multiply injured trauma patient with both special alertness and the humility necessary to search for diagnostic oversights. This approach will lead to early discovery of missed injuries and will minimize the consequences.     

Airway trauma in ENT

Airway trauma in ENT surgery is broadly divided into external laryngeal injury caused by blunt or penetrating injuries to the neck, or iatrogenic injury related to intubation trauma, prolonged intubation or tracheostomy. The management of these conditions is described and factors predisposing to intubation trauma are listed.     

Missed injuries in pediatric trauma.

Missed injuries in trauma continue to be a nemesis to the trauma surgeon. Missed injuries in adult trauma patients range in frequency from 9 to 28 per cent, with some being life threatening or permanently disabling. We report the incidence of missed injuries in pediatric trauma to be 20 per cent, in our retrospective review of 107 severe pediatric trauma patients. These missed injuries, however, were neither life threatening nor permanently disabling. We also found that mechanism of injury and patient age affected the incidence of missed injuries in our population.     

Airway choices in maxillofacial trauma

Successful management of the patient's airway is central to the safe practice of anaesthesia. Whilst anaesthetists are faced with an ever increasing range of equipment, they must still select appropriate equipment for each patient and be competent in its use.Understanding the advantages and limitations of the available devices in particular situations is an important element of clinical education. Our article focuses on approaches to airway management in cases of maxillofacial trauma and on the equipment available for such cases.After a brief overview of the changing patterns of maxillofacial injury, issues affecting the airway management of the maxillofacial trauma patient are addressed.Differentiating devises in to those that use supraglottic or infraglottic approaches or are blind or under direct vision techniques, we outline the possible uses of a wide range of clinically available devises.Unfamiliarity with equipment and technical options has been associated with poorer clinical outcomes as has inability or lack of preparedness to escalate treatment. Should other more easily applied and less invasive techniques fail, cricothyroidotomy remains the fallback approach.     

Small-bowel and mesentery injuries in blunt trauma.

BACKGROUND: The purpose of this study was to identify factors that would aid in the diagnosis of small-bowel and mesentery injuries (SBMI) in blunt trauma patients. METHODS: Retrospective review of 15,779 blunt trauma patients admitted to a Level I trauma center between January 1991 and December 1996. RESULTS: A total of 5,303 patients sustained abdominal injuries, 70 of whom had more than 111 SBMI. Seventy-nine percent were victims of motor vehicle collisions. Thirty patients had isolated SBMI and 40 had associated intra-abdominal injuries. Twelve patients arrived with systolic blood pressure < 90 mm Hg, eight of whom died. Mean base deficit was -7.3 +/- 6.3 in 52 patients who had arterial blood gases determined. Fifty-three of 60 patients had hematuria. Sixty-seven patients required laparotomy. Delayed exploration occurred in 15 patients who underwent initial computed tomography but had subsequent changes in physical status. Two of 20 patients had negative diagnostic peritoneal lavage on admission and were eventually explored based on abdominal computed tomographic findings and changes in physical examination. There were 15 deaths. Delay in diagnosis (>12 hours after arrival) occurred in nine patients with no deaths or significant morbidities. Mean Injury Severity Score was 29 +/- 16.7: 43 +/- 17 in nonsurvivors and 25 +/- 14.3 in survivors (p < 0.05). CONCLUSION: The diagnosis of SBMI is often made in the presence of associated intra-abdominal injuries. Isolated SBMI are common, however, and special attention to the mechanism of injury, abdominal examination, presence of hematuria, and significant base deficit should raise suspicion to the possibility of SBMI. Findings on abdominal computed tomography that may suggest SBMI and should prompt further evaluation include free fluid, thickened bowel, and extraluminal air. Because delay in diagnosis does not seem to affect morbidity or mortality, dedication to observation and serial physical examinations will aid in the proper identification of elusive SBMI. Mortality, however, does appear to be related to the presence of hypotension on admission and associated injuries.     

The diagnosis of gastrointestinal tract injuries resulting from blunt trauma.

BACKGROUND: This review studies the efficacy of the methods of assessment of the abdomen in blunt trauma for the detection of gastrointestinal tract injuries (GITI). METHODS: MEDLINE searches of English language publications on the subjects of diagnostic peritoneal lavage, abdominal computed tomography (CT) in blunt trauma and gastrointestinal tract injuries between 1980 and 1998 were used to identify relevant material. Earlier publications were identified from reference lists. The methodology, data and conclusions of all studies were examined in detail. The contemporary roles of clinical assessment, diagnostic peritoneal lavage, CT and other diagnostic modalities in detection of significant GITI were determined based on the best available evidence. CONCLUSIONS: The most accurate and safest methods of assessment of the abdomen in haemodynamically unstable patients with suspected abdominal injuries following blunt trauma are immediate laparotomy or diagnostic peritoneal lavage (DPL). The goal of assessment of the abdomen in stable patients is to accurately define the site and extent of intra-abdominal injury, in order that further management may be tailored to the specific injuries. The most recent evidence suggests that CT of the abdomen fulfils these criteria better than the other modalities of assessment available. The risk of overlooking a significant GITI on CT scan is minimal provided that unexplained free fluid, bowel wall thickening or enhancement, mesenteric fat streaking and bowel dilatation are taken as evidence of GITI. When scan quality is suboptimal or expert interpretation is unavailable, DPL is recommended. Fully cooperative patients with negligible abdominal signs can be safely observed clinically.     

Major trauma with multiple injuries in Swedish children.

OBJECTIVE: To describe the demographics, mechanisms, pattern, and severity of injury, the prehospital and hospital care during the first 24 hours, and the outcome in the most severely injured children in a paediatric intensive care unit (PICU). DESIGN: Retrospective review. SETTING: Paediatric intensive care unit (PICU), Sweden. SUBJECTS: 45 children (0-16 years of age) with multiple injuries admitted to the PICU in Gothenburg from January 1990 to October 2000, inclusive. MAIN OUTCOME MEASURE: Mortality within 30 days after injury. RESULTS: About 2/100000 children with multiple injuries were admitted to the PICU from the greater Gothenburg area each year from 1990-2000 inclusive. Injuries were more common in boys (n = 29, 64%). The mean age was 7 years (SD 5). Traffic related events (n = 29, 64%) and falls (n = 11, 24%) were the leading causes of injury. Thoracic and abdominal injuries were the most common (17% and 16% respectively). Three children died. CONCLUSION: Major trauma with multiple injuries is rare in Swedish children. When they are cared for at a centre with the necessary facilities and trained personnel they have a good chance of survival.