Airway injuries. The first priority in trauma

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.     

Steroid administration potentiates urinary nitrogen losses in head-injured children

Exogenous steroid administration has been shown to increase post-traumatic nitrogen excretion in adults. Children sustaining head injuries and treated with steroids have previously been shown to have markedly increased total urinary nitrogen levels; the amount of nitrogen excreted is also directly related to the degree of injury, as evidenced by the Modified Injury Severity Score (MISS). It is unclear whether the increased protein breakdown in these patients is a result of the head injury or a result of the catabolic effects of steroids. Nineteen children aged 4-14 years, suffering head injuries, were prospectively studied. In ten children, management included steroid administration (1-1.5 mg/kg/day dexamethasone X 3-5 days); the remaining nine were similarly managed; however, without steroids. The groups were matched for age, weight, MISS, and Glasgow Coma Scale Score. The steroid-treated group showed a significantly higher urinary nitrogen excretion (mean, 256 +/- 24 mg/kg/day) than the nonsteroid-treated group (mean, 172 +/- 29 mg/kg/day) (p less than 0.02). These data suggest that steroids potentiate an already accelerated post-traumatic catabolic response seen in children with head injuries. Our data suggest that steroid use, which is common, mandates aggressive nutritional support in the management of children with head injuries.     

Management of airway trauma. I: Tracheobronchial injuries

One hundred six consecutive patients with injuries to the tracheobronchial tree who were admitted to the emergency room of the Tulane Medical Center Hospital or the Charity Hospital of Louisiana at New Orleans over a period of almost 20 years were analyzed retrospectively. Penetrating trauma of the neck or chest was reported in 100 of the patients, and only 6 had blunt trauma to the neck or thorax as the cause of injury. There were 18 deaths among the 106 patients (16.98%), including 11 (13.75%) of 80 with injuries of the cervical trachea. Seven (53.8%) of 13 with principal injuries of the thoracic trachea died; all 13 patients with major bronchial injuries survived. On admission to the emergency room, all patients had signs of airway compromise such as tachypnea, dyspnea, cyanosis, subcutaneous emphysema, or an abnormal respiratory pattern. Severe airway compromise was evident in 46 patients; 24 (23%) were treated with oral or nasal intubation, 19 (18%) with emergency tracheostomy, and 3 (2%) with intubation of a tracheal injury. Hemoptysis was an unreliable signal of serious injury, being present in only 28 of the patients. Patients who had major vascular injuries combined with trachea involvement were generally not salvageable. In regard to morbidity and mortality, the most common preventable errors were delay in diagnosis and treatment of tracheobronchial injuries, missed esophageal injuries, massive aspiration of blood, and abdominal vascular injuries.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anaesthetic incidents - Airway management and injuries in anaesthesia - closed claims of the North German Arbitration Board

Injuries related to the airway management belong to the most often observed anaesthesia-related complications. Injuries of the trachea and the oesophagus possibly require surgical treatment. The most severe injuries caused by the airway management are the hypoxic brain damage and the patient's death. Tracheal injuries happen foremost as a result of tracheal intubation. Symptoms like subcutaneous emphysema and dyspnea are likely a sign of a tracheal lesion and need to be examined by Thorax-CT and endoscopy of the airways. In order to avoid injuries, medical treatment has to be applied with the appropriate care and strict adherence to the manufacturer's requirements regarding the use of the assisting devices necessary for the tracheal intubation. While some of he cases presented have to be assessed as of fateful origin, others are clearly the results of medical errors.     

Management of penetrating injuries of the cervical trachea.

This is a report of a 2-year experience with the management of penetrating injury of the cervical trachea. There were 29 cases. The respiratory status of the patient on admission dominated the initial management: 12 patients required emergency intubation and were immediately taken to operation, while 17 patients were more stable and could be subjected to the preoperative assessment of the oesophagus. Associated injuries were significant and dominated the postoperative morbidity and mortality. Primary repair of the trachea, without tracheostomy, was successful in a relatively high proportion of patients (55%).     

The preventive effects of mupirocin against nasotracheal intubation-related bacterial carriage

Nasotracheal intubation is often required during dental and maxillofacial surgery. The complications of nasotracheal intubation are well documented, but there have been few systematic attempts to find methods for their prevention. We examined intubation-related carriage of bacteria, especially methicillin-resistant Staphylococcus aureus (MRSA), into the trachea and evaluated the effects of topical nasal treatment with mupirocin on intubation-related bacterial colonization. Of 38 patients without mupirocin treatment (nontreatment group), 27 (71.1%) showed general bacterial colonization in the nasal cavities before intubation. MRSA was isolated from 13.2% of the patients in this group. However, 10 of 22 patients (45%) treated with mupirocin (treatment group) showed colonization by general bacteria, and 2 (9%) were MRSA carriers before intubation. After nasal intubation, general bacteria and MRSA were isolated from the endotracheal tube tip in 66.2% and 16.7% of these patients in the nontreatment group, respectively. In contrast, general bacteria were isolated from the endotracheal tube tip in 19.2% of these patients after oral intubation, but no MRSA was detected. However, after nasal intubation, general bacteria were isolated from the endotracheal tube tip in 3 of the patients in the treatment group (23.1%), and no MRSA was detected, whereas no bacteria were isolated from oral intubation tubes. These results indicate that bacteria were carried into the trachea at a more frequent rate by nasal intubation as compared with oral intubation, and nasal treatment with mupirocin eliminated the nasal carriage of S. aureus. Topical nasal treatment with mupirocin before nasal intubation is thus suggested to be effective for preventing carriage of bacteria into the trachea. IMPLICATIONS: We studied the carriage rate of bacteria into the trachea caused by nasal intubation. The bacterial carriage by nasal intubation was more frequent than that by oral intubation, and intranasal administration of mupirocin eliminated the carriage of S. aureus. These results indicate that topical nasal treatment with mupirocin is effective to prevent carriage of bacteria into the trachea.     

Reconstructive surgery of prolonged and multifocal stenoses of trachea

Overall 553 patients aged 9 to 77 years with cicatrical stenoses of trachea were treated. The causes of stenoses were tracheostomy (345 patients), intubation of trachea (155), trauma (29), unknown (24). Surgical methods of treatment were used at 448 (81.0%) patients, endoscopic methods--at 105 (19.0%); overall 1184 operations have been performed. Transplantation of donor thyrotracheal complex has been performed at 1 patient with subtotal cicatrical stenosis of trachea. Combination of staged reconstructive and plastic operations with endoscopic procedures permits to achieve good functional results. Treatment of these patients should be performed at special medical centers which have all the necessary technologies.     

Intubation injuries of the larynx and trachea--etiology, forms, therapy and endoscopic control for prevention

Severe intubation injuries of the larynx and trachea are usually caused by prolonged intubation, particularly if the primary intubation was difficult. Due to the persisting, time-consuming therapeutic problems, tracheal and laryngeal stenoses are among the most-feared sequelae of long-term intubation. Therefore many laryngologists reject endotracheal intubation for prolonged respiratory support and recommend an early tracheostomy. Advances in respiration techniques and in the development of tissue-compatible tubes with low pressure cuffs permit, in our opinion, prolonged intubation if this is controlled by repeated endoscopic examination to recognize lesions at an early, still reversible, stage.     

Tracheostomy in emergency conditions in children

Clinical observations show that intubation continuing as long as 7 days are followed by complications in 37% of cases at an average. A longer intubation results in complications twice more often. Placing tracheostoma is an alternative of prolonged intubation of the trachea. In spite of the wide introduction of this method into practice, it has both the supporters and active opponents. The indications, specific features and consequences of placing tracheostoma were studied in 69 children. The assessment of the efficiency of treatment of children in critical states with the method of placing tracheostoma is given.     

PRESSOR AND CATECHOLAMINE RESPONSE TO NASAL INTUBATION OF THE TRACHEA

The catecholamine and cardiovascular responses to nasal intubationof the trachea with and without laryngoscopy have been comparedin 23 patients allocated randomly to each treatment. Arterialpressure, heart rate and plasma concentrations of adrenalineand noradrenaline were measured before and after induction andat 1, 3 and 5 min after intubation of the trachea. There weresignificant increases in systolic and diastolic pressures aftertracheal intubation in both groups. The values at 1 min afterintubation were significantly higher in the group undergoinglaryngoscopy and intubation compared with the group undergoingblind nasal intubation.     

Management of intractable and extensive tracheal stenosis by implantation of cartilage graft

A variety of methods have been developed to solve the problem of extensive tracheal stenosis. Endoscopic resection with injection of steroids was performed with some success. Resection with end-to-end anastomosis has been attempted in localized tracheal stenosis, but it is not practical in extensive tracheal stenosis. As an alternative to the above procedures, we performed a simpler operation to increase the diameter of the narrow trachea. We treated three children (a 7-month-old, a 2-year-old, and a 3-year-old) who had severe tracheal stenosis. The trachea was explored through a cervical transverse incision. The anterior wall of the trachea at the level of the stenosis was opened longitudinally and the scar in the tracheal lumen was resected. A free-cartilage graft measuring 1 X 4 cm was taken from the third costochondral junction and was wedged and sutured in place into the tracheal opening. This resulted in increasing the internal diameter of the stenotic trachea. A nasotracheal tube was left in place at the end of the procedure for 48 hours. The children are still asymptomatic 19, 10, and 8 months postoperatively. The careful selection and preparation of the patients for this procedure is discussed.     

Bluntly traumatic tracheal transection: usefulness of percutaneous cardiopulmonary support for maintenance of gas exchange.

Respiratory management of tracheal injuries is a crucial key to successful treatment. We present herein a patient with a traumatic tracheal transection in whom we confronted difficulty in airway management after false intratracheal intubation. No associated injuries were seen in the patient, then, primary repair of the trachea was carried out under ventilatory support via percutaneous cardiopulmonary support system (PCPS). For a short period in the application of PCPS, the use of a heparin-coated circuit made systemic heparinization unnecessary during and after operation, and the outcome was satisfactory. In a carefully selected patient, ventilatory support via PCPS is useful.     

The role of immediate operative intervention in severely head-injured children with a Glasgow Coma Scale score of 3.

In an attempt to improve and expedite the care of head-injured children, data have been published recommending burr hole exploration in lieu of computed tomography for children with signs of brain stem compression or with a Glasgow Coma Scale score of 3. Exploratory burr holes revealed a high incidence of subdural hematomas, and removal of the hematomas improved survival. We are reporting 19 consecutive children with Glasgow Coma Scale scores of 3. Coma score evaluation was confounded by intubation, sedation, pharmacological paralysis, and posttraumatic seizures. We found no radiographical or postmortem pathological evidence of intracranial hemorrhage, which would warrant operative intervention. A high incidence of multisystem injuries and high cervical spine injuries would have made early intervention both dangerous and inappropriate. Although there is a definite role for emergency trephination, routine exploratory burr holes for children with a Coma score of 3 is not justified.     

Neglected Hangman's fracture in association with rupture of the trachea.

BACKGROUND CONTEXT: Rupture of the trachea combined with a Hangman's fracture has been reported rarely in the literature. We present a case of a rupture of the trachea combined with a type IV Hangman's fracture that remained undiagnosed for 7 weeks, in a 25-year-old woman after a road traffic accident. PURPOSE: To underline the necessity that physicians treating patients with multiple injuries including the trachea and the mediastinum should be aware of the fact that injuries of the trachea can be accompanied by trauma to other contents of the mediastinum and of the cervical spine. STUDY DESIGN: A 24-year-old woman was involved in a head on collision road traffic accident. She has suffered from a rupture of the trachea combined with a type IV Hangman's fracture that remained undiagnosed for 7 weeks. METHODS: Emergency surgical repair of the rupture of the trachea was performed. A halo vest for a total period of 4 months was applied. RESULTS: The patient followed a rehabilitation program, and, at her last visit, 12 months after her injury, had remained asymptomatic. A computed tomography scan of her cervical spine showed union through callous formation, and she had returned to her previous job and recreational activities. CONCLUSIONS: Physicians treating patients with multiple injuries including the trachea and the mediastinum should be aware of the fact that injuries of the trachea can be accompanied by trauma to other contents of the mediastinum and of the cervical spine.     

Traumatic atlanto-occipital dislocation in children

BACKGROUND: Traumatic atlanto-occipital dislocation in children and adolescents is a rare and often fatal injury. Although historically most reported cases have been fatal, the advent of modern prehospital care has led to an increase in survival following this injury. As a consequence, some patients may achieve or maintain satisfactory neurologic function following early intervention, stabilization, and definitive management. We analyzed the data on children and adolescents in whom traumatic atlanto-occipital dislocation had been treated with modern resuscitation techniques at our institution. METHODS: Atlanto-occipital dislocation is defined as disruption of the ligaments and other supporting soft tissues as indicated by displacement in either a transverse or vertical direction. With use of the Trauma Registry database at our institution, we identified sixteen such injuries that had occurred between 1986 and 2003. The hospital charts, clinic notes, and radiographs were reviewed. A careful neurological evaluation was performed for all of the survivors at the time of the latest follow-up. RESULTS: The mean age of the sixteen patients at the time of the injury was 7.6 years. The mechanisms of injury were diverse. The mean Glasgow Coma Scale score was 7.4 points. Eleven of the sixteen patients underwent intubation in the field, two were intubated in the emergency department, and three were not intubated. Eight of the sixteen patients were declared dead on arrival in the emergency department. The eight surviving patients initially were immobilized with either a halo vest or another orthosis. All patients except one received intravenous steroids in the emergency department. Three of the patients who survived the initial injury subsequently died while undergoing neurosurgical procedures for the treatment of extensive intracranial injuries. Four of the remaining five survivors underwent occiput-C2 fusion, and one was managed with a Minerva cast. At the time of the final follow-up, at a mean of 4.2 years after the injury, one patient was neurologically normal, three had mild spastic hemiparesis and were very functional, and one had spastic quadriplegia and was ventilator-dependent. CONCLUSIONS: Prompt recognition and treatment of traumatic atlanto-occipital dislocation in children and adolescents can result in improved survival. Early diagnosis, prompt intubation, early and adequate immobilization of the head and neck, and the use of intravenous steroids appear to facilitate survival. We recommend arthrodesis from the occiput to C2 (or the nearest adjacent intact and stable vertebra caudad to C2) for all children who survive a traumatic atlanto-occipital dislocation, particularly those with an incomplete spinal cord injury.     

Verification of endotracheal tube position.

The goals of tracheal intubation are to place the tube in the trachea and to position the tube at an appropriate depth inside the trachea. Various clinical signs and technical aids are described to verify tracheal intubation and to diagnose esophageal intubation. Many of these methods fail under certain circumstances. Not all these methods can be applied in every intubation, but it is essential that the clinician involved in tracheal intubation have the necessary airway management skills, perform these tests accurately, and interpret the results correctly. Prioritization of these tests depends on many factors, including familiarity, availability of monitors, and the location of intubation. Viewing the tube passing between the cords during direct laryngoscopy and visualization of the tracheal rings and carinae with a fiberoptic scope after intubation are the only fullproof methods of confirming tracheal intubation. In the nonarrested patient, carbon dioxide monitoring quickly can differentiate tracheal from esophageal intubation. In the arrested patient, however, carbon dioxide monitoring can be unreliable, although it can be useful as a prognostic indicator of the efficacy of resuscitation. Devices such as [figure: see text] the self-inflating bulb and esophageal detector device may be more useful in patients with cardiac arrest, but they also can yield false results. Placing the distal tip of the tube in the middle of the trachea can be accomplished by positioning the upper end of the cuff 2 cm below the cords during direct laryngoscopy or by placing the distal tip of the tube 4 cm above the carinae with the aid of a fiberoptic scope. The position of the tube always should be verified by clinical assessment (e.g., auscultation). If direct visualization cannot be done, referencing the marks on the tube, transillumination techniques, or cuff maneuvers can be helpful. In the emergency and critical care settings, a chest radiograph easily can detect malpositioned tracheal tubes that may not be detected by routine clinical assessment. Other techniques (e.g., use of fiberoptic scopes, cuff maneuvers, transillumination) can decrease the need for frequent chest radiographs. Based on available information, two algorithms are proposed: one for emergency intubation (Fig. 9) and the other for verification of tracheal tube position in elective intubation (Fig. 10). These algorithms are designed [figure: see text] to assist the clinician and should not be substituted for clinical judgment. Under no circumstances should clinical signs be ignored in the presence of conflicting information from monitors and technical aids.     

双腔支气管导管插管错位原因的影像学分析

目的 探讨双腔支气管导管插管不能进入对应支气管的原因和解决办法.方法 选取87例开胸手术需行双腔支气管导管插管进行双肺隔离通气病例.对每例预设和改变的双腔支气管导管型号、气管及支气管内径和走行情况、双腔支气管导管插管定位情况、气管内镜使用情况及所见、特殊情况等,结合CT所见进行分析.测如下数据:左支气管内径(ZN),右支气管内径(YN),左支气管与气管下半段轴线的夹角(ZJ),右支气管与气管下半段轴线的夹角(YJ),气管下半段轴线与身体纵轴夹角(QJ),右左支气管开口垂直直线距离在气管后段内径中的占比(YB、ZB)和其占比差(YB-ZB).结果 87例中27例气管偏移或变异,其中13例有右支气管导管插管顺利倾向定义为特殊右(TY),另14例有左支气管导管插管顺利倾向定义为特殊左(TZ);其余60例气管基本正常,49例选左支气管导管插管顺利定义为正常左(ZZ),11例选右支气管导管插管顺利定义为正常右(ZY).TY与TZ在ZJ、YJ、QJ和YB-ZB间,与ZZ在YJ、QJ和YB-ZB间,与ZY在QJ和YB-ZB间比较,差异有统计学意义(P＜0.05).TY表现为:QJ右倾(8.08±5.94)°;ZJ角度偏向正常高限(47.46±7.28)°;YB-ZB明显大;YN相对其ZN宽,差异无统计学意义(P＞0.05).TZ表现为:ZJ相对较小;YJ相对较大,与TY相比,差异有统计学意义(P＜0.05),与ZZ、ZY相比,差异无统计学意义(P＞0.05).以上因素决定了气管后半段的趋向性,影响着双腔支气管导管插管的走向,双腔支气管导管插管不能进入对应支气管.结论 插管前根据CT定位像中气管后半段趋向性,选择左或右双腔支气管导管插管,是解决双腔支气管导管顺利插入对应支气管的最简捷方法之一.     

Prevention and treatment of tracheal injuries in children.

Endotracheal intubation and tracheostomy, both procedures used to treat life-threatening respiratory problems, may in themselves produce internal tracheal or laryngeal injury and subsequent airway obstruction. A knowledge of the anatomy of the larynx and trachea in children and the proper techniques and equipment which are available for infants and small children is mandatory if complications are to be prevented. It is essential that all physicians who deal with respiratory problems in children be aware of the differences between children and adults and knowledgeable of special techniques and equipment necessary for children.     

Bronchial rupture. Diagnosis and therapy of a rare complication of the use of double-lumen tubes

For anesthesia during thoracic surgery, it is common to use a double-lumen endotracheal tube for one-lung ventilation. Double-lumen tubes protect the bronchial system of the healthy lung from being occluded by blood or pus coming from the operated lung. Therefore, in cases of lung abscess, bronchial hemorrhage, lung cyst, or localized lung infection the use of a double-lumen tube is advisable. Facilitating operation and reduced operating time are further advantages of intubation with a double-lumen tube for independent ventilation of both lungs. Due to the rigidity of these tubes, however, there are disadvantages such as injuries to the trachea and bronchial system. We report a case of rupture of the left main bronchus after insertion of a Carlens tube. The intraoperative symptoms of airway leakage are demonstrated, the process of locating and repairing the injury is described. In our case the postoperative course was not complicated; the patient left the hospital 10 days after operation. Causes of bronchial rupture, its therapy, and prophylactic measures are also discussed.