International Journal of Pediatric Otorhinolaryngology Extra
Volume 3, Issue 2 , Pages 94-99, March 2008

Emergency call: Trachea rupture in a child

  • A.M. Fette

      Affiliations

    • Children's Hospital Lucerne, Department of Pediatric Surgery, Lucerne, Switzerland
    • SRH Zentralklinikum Suhl, Pediatric Surgery (Head: Dr F Linke), Albrecht-Schweitzer-Str 2, 98527 Suhl/Thueringen, Germany, Tel.: +49 3681 35 5580.
    • Corresponding Author InformationCorresponding author at: Drosselstr. 4, 71554 Weissach im Tal, Germany, Tel.: +49 7191 53306; mobile: +49 172 9535127; fax: +49 7191 493947.
    • ,
  • Ch. Aufdenblatten

      Affiliations

    • Children's Hospital Lucerne, Department of Pediatric Surgery, Lucerne, Switzerland
    • ,
  • F.J.W. Lang

      Affiliations

    • ENT Department, Centre Hospitalier Universitaire Vaudois, CHUV, Lausanne, Switzerland
    • ,
  • M.G. Schwöbel

      Affiliations

    • Children's Hospital Lucerne, Department of Pediatric Surgery, Lucerne, Switzerland

Received 28 September 2007; received in revised form 1 December 2007; accepted 4 December 2007. published online 13 February 2008.

Article Outline

Summary 

Trachea rupture following blunt neck trauma in childhood is extremely rare. It is therefore unsuspected and easily overlooked by the attending physician in the emergency setting. In this case report a 6-year-old boy suffered a complete transverse trachea rupture at the cervical level following a roll-over injury. Finally, a favourable outcome resulted, but proper management of such trachea lesions is still difficult as standard treatment protocols are lacking. Based on an extended literature review the emergency management is discussed from patient's initial presentation at a district hospital until his arrival at our pediatric trauma center and until specialist surgical service was performed. Trauma mechanisms and etiologies, potential diagnostic and operative procedures and leading clinical signs of pediatric tracheal lesions are discussed in detail, too.

Keywords: Trachea disrupture, Child, Emergency management

 

Tracheobronchial rupture, especially in the pediatric age group, is rare. Therefore, it can easily be overlooked by the attending traumatologists. We report on the emergency management of a young boy sustaining a complete transverse tracheal rupture besides other thoracic injuries when suffering a farmland accident.

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1. Case report 

After falling from a tractor trailer driven by his grandfather a 6-year-old boy was rolled-over and dragged on his back and neck by the vehicle. He walked with assistance from the accident scene to his parents’ home where he became dyspnoeic. The young boy was rushed immediately into the casualty department of the district hospital. His oxygen saturation was <55%. He was immediately intubated and ventilated in the emergency department. Subcutaneous emphysema of the neck region and bilateral pneumothoraces were detected. The left pleural cavity was drained, and the child transferred by road ambulance to our pediatric trauma center (distance ∼45km).

Upon arrival his right pleural cavity was drained, and his existing left drain repositioned before both (Ch 16) were connected to a Buleau drainage system (Pleur-evac Sahara, S-1100-08LF, Teleflex Medical, NC 27709 USA, 12mm H2O suction) to evacuate his bilateral tension pneumothoraces. The oral tracheal tube was changed to the nasal route and further invasive monitoring was instigated.

Immediately after stabilization of his vitals a CT-scan was performed. The images were very suggestive of a tracheo-bronchial tree injury, as the underlying cause of the still enlarging emphysema. Helical CT-scan (Scanotom, Siemens Schweiz AG) revealed the complete transverse trachea rupture with displacement at the level of the 10th–11th cartilage ring. In detail, the intratracheal tube ending in-line within the ruptured proximal tracheal fragment (Fig. 1). An unstable paramedian mandibular fracture, a fracture of the clavicle, and a basal lung contusion, extending 3cm in diameter, all left-sided, were detected as additional injuries.

  • View full-size image.
  • Fig. 1. 

    Sagittal CT scan of the patient showing the displaced trachea at the level of the 10th–11th cartilage ring. The tracheal tube ending in-line within the burst trachea fragment.

All CT scans and results were discussed between ENT-, thoracic- and pediatric surgeons, intensivists and anesthetists, especially with regard to how dangerously close the patient came to being killed by endotracheal intubation. And as a result it was decided to transfer the patient to the ENT department of the Centre Hospitalier Universitaire Vaudois (CHUV) in Lausanne (distance ∼200km), a Swiss center of excellence for trachea surgery. At that time the little boy was in stable condition (BP 110/60mmHg, HR 64/min, O2-saturation 97%). His neck and cervical spine were immobilized by a rigid collar, and he was anesthetized and mechanically ventilated (Evita 4, Dräger Medical Deutschland GmbH, Lübeck/Germany) in our pediatric surgical ICU.

Unfortunately, due to terrible snowy weather conditions it was impossible for the CHUV and the Swiss REGA (Swiss EMS helicopter service) to send out a specialist team or to evacuate the patient by EMS-helicopter in that night. Thus, the ENT specialist team arrived in the morning evacuating the patient by EMS-helicopter to Lausanne. There, fiberoptical intubation of the distal trachea fragment was performed under perioperative antibiotic coverage to securely splint the airway. Thereafter, open trachea repair of the lesion was performed via an exclusive cervical approach (Fig. 2). The trachea fragments were smoothly approximated and anastomosed using interrupted absorbable sutures (Vicryl® 4-0). Ten days later he was discharged home. No significant tracheal stenosis was detected during 1-year follow-up.

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2. Discussion 

Blunt and penetrating neck injuries are an infrequent cause of morbidity and mortality in the pediatric population. Ford et al. reported 9 blunt and 14 penetrating injuries representing 0.5% of their trauma admissions in 1995 [1]. Although less common than penetrating injuries, blunt neck injuries are more often life-threatening because of an associated laryngo-tracheal disruption [1], [2], [3], [4], [5].

Focusing on isolated tracheal injuries caused by road traffic accidents (RTA) several case reports and case series were found, where the lesion was described as being longitudinal, varying in size from 1 to 5cm, and being located in the membraneous (posterior) trachea wall. The age of the children ranged from 3 to 13 years, and boys’ injuries outnumbered girls [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]. Regarding anterior trachea wall lesions, several cases are reported, too, with patients 6–13-year-old and males dominant [8], [11]. One lesion was further described to be 1.5cm in size and linear [11]. Almasi et al. reported on tracheal ring fractures in two patients, one after attempting suicide by a cable (19-year-old), the other after striking his bicycle handlebar (11-year-old) [19]. Other authors simply described tracheal wounds without stating any location [8], or the lesions have been caused by non-incidental [20], obstetrical [8], [21], or iatrogenic [8], [22], [23], [24], [25] injuries, therefore being out of scope in this discussion. Focusing on complete trachea rupture Slimane et al. described treatment of a 7-year-old male after a RTA who underwent open repair [8]. A single complete transection of the intrathoracic trachea after blunt injury was reported by Harold et al. but this happened to an adult not a child [26]. Whereas a concommitant blunt injury to a comparable trachea level, the esophagus, and cervical spine in a 6-year-old girl was managed successfully by Guillamondegui et al. [27], respectively to the trachea and esophagus by Gill [28]. While in the case of a 12-year-old girl a perforating neck injury resulted in a disrupted cervical trachea at the level of the lower pole of the thyroid gland and lacerations of her esophageus [38]. Now this case with a complete horizontal transection of the cervical trachea combined with serious thoracic injuries is added.

Clinical features, even with major trachea lesions, can be minimal, delaying diagnosis in 25–70% of cases from 1 to 4 weeks [8]. Initial symptoms may be minor before suddenly deterioration occurs—from awake with mild discomfort to agitated and dispnoeic, progressing to cyanosis and eventual cardio-respiratory arrest [1], [5], [7], [9], [10], [11], [12], [14], [29], [30], [31], [32], [33], [34]. Here it is important to recall that our patient was initially awake and even walked home assisted from the scene, before he suddenly deteriorated and required emergency intubation and ventilation.

Subcutaneous emphysema is considered to be the most specific sign of trachea disruption. It can be limited to a single radiolucent line visible against the grey colour of the adipose tissue on the initial X-ray, where it is reported in 80% of cases. It usually appears in the minutes following the trauma but it can also be delayed, with a maximum delay of up to 2h [11], [35]. Respiratory distress is not constant but it is obviously the determining factor in the management [1], [10], [12], [31], [36]. Right from the beginning the prominent and enlarging neck emphysema and the chest X-ray of this patient were misinterpreted as some sort of chest emphysema caused by the (primarily) identified left-sided pneumothorax. Consequently, only this one was drained in the district hospital. However, because of (unnoticed) bilaterality, this unilateral drain could only bring mild improvement. As soon as a contralateral drain was placed and the first repositioned, a remarkable improvement of the respiratory distress and in ventilation parameter settings was seen. Another explanation might be that the initial tube went past the proximal tracheal segment and this in addition to positive pressure ventilation caused the deterioration and possible increased subcutaneous emphysema. The subsequent improvement might have been due to the repositioning of the tube from orotracheal to nasotracheal, which might have been shorter. Since the real sequence of events could not be clarified further, finally, the – despite now adequate drainage – refractory neck emphysema, however, confirmed the suspected trachea lesion clinically, before it was visualized in the CT scan.

Diagnosis of airway rupture must always be referred to the mechanism of the accident, then each of it give rise to a distinct pattern of injury that is unique to childhood [11]. Blunt thoracic injuries in association with a compromised airway in childhood are exceptional because the pliability of the chest wall allows transmission of massive external force directly into the mediastinum. This means that children presenting after blunt chest trauma may have complete disruption of the airway with only very little external signs of injury. Several mechanisms may appear to play a role in blunt laryngotracheal injury: the mandible, the elasticity of the cartilaginous support of the airway, and the mobility of the supporting tissues collectively act to protect the laryngo-trachea. Although relatively minor direct trauma to the anterior neck can result in significant laryngotracheal trauma, in reality, it is more often associated with great force [1]. Regarding the exact mechanism of injury to the trachea and bronchus four theories have been evolved: first, compression of the chest and trachea while the glottis is closed. Second, a direct trachea hit leads to trachea rupture by crushing of the airway between a causative object and the vertebral column. Third, a sudden, forceful compression of the chest, decreasing the anterior–posterior diameter while widening the transverse diameter, causing the trachea to rupture. Forth, a rapid deceleration produces a shearing force, causing rupture of the trachea and bronchi. The first two theories are mainly explaining isolated ruptures of the membraneous (posterior) tracheal wall, the third may be the dominant mechanism involved in crush injuries, and the fourth the one experienced in MVA [6], [7], [8], [10], [11], [12], [13], [26]. Judging from the nature of the longitudinal split in the trachea as seen at operation and the regularity with which the same split could be reproduced experimentally on eight cadavers, Mc Grath concluded that the trachea ruptures in the following manner: a violent compression of the chest with the glottis closed causes a sudden elevation of the intratracheal pressure. If then a sharp blow on the front of the trachea is added by the in-driven sternum, the trachea bursts longitudinally. He concluded that the trachea had burst as a result of the sudden increase in intraluminal pressure against a closed glottis rather than that the injury was due to shearing forces [30]. Hager et al. investigated the mechanism related to bursting injuries of the posterior wall in case of moderately increased pressure when combined with a simultaneous blow to the anterior trachea or thoracic wall, too, and revealed that even a pressure created for instance by a forced cough can cause a longitudinal rupture, if the trachea is simultaneously hit anteriorly. The site of the trachea injury was always located exactly opposite to the site of the blow [12]. According to Gaebler et al. the rupture is usually longitudinal at the locus minoris resistentiae, at the edge where the cartilaginous part turns into the membraneous part [6]. Location of tracheobronchial injuries has been found to be relatively constant: 80% occur within 2.5cm of the carina, while 15% involve the trachea [6], [13]. A combination of theories 1–4 might apply in this patient. The concomitant mandibular and clavicular fractures may give an estimation of the forces that have been acting upon his neck region. But no experimental studies to prove to our best knowledge exist.

In any case of suspected trachea rupture the diagnostic procedures should consist of clinical examination, X-ray of chest and neck, followed by CT scans of these regions [6], [8], [9], [11], [12], [14], because CT according to Cooper has revolutionized the management of airway trauma [37]. On the other hand, almost all referenced authors agree that tracheo-bronchoscopy is the most reliable means of establishing the diagnosis and to determinate the site, nature and extent of tracheobronchial injury, and to guide the intubation or prior to surgery, if it is indicated [1], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [26], [31], [33], [34], [35], [36], [38] like in our case. It is also most valuable of passing a flexible endoscope down an endotracheal tube in any patient who remains in respiratory distress after intubation. But endoscopy can worsen the condition, too [11].

Since conservative treatment by simple thoracic drainage or lesion intubation has proved to be effective as well, surgery is not the only therapy [5], [8], [16], [17]. For this reason, some authors recommend conservative management for minimal lesions, less then 1/3 of circumference or longitudinal laceration, with no respiratory distress. Their operative management depends on widely dehiscent and devitalised margins, complete disruption, associated esophageal and vessel injuries or persistent subcutaneous emphysema [1], [6], [7], [8], [9], [12], [13], [18], [19], [26], [29], [33], [34], [38], [39], [40], [41]. Immediate surgery is highly recommendable but not always possible. Ideally, it should be performed within 24h of injury to avoid a higher complication rate (infection, perichondritis, stenosis), more difficult surgery (local inflammation) and to help in the identification of specific damage before the onset of edema and inflammation [42]. In literature overview, surgery was performed within a time frame of hours to days [6], [10], [13], [42]. In our case, definitive surgery under perioperative antibiotic coverage was performed the following morning after tracheoscopic airway splinting. The boy was extubated and discharged soon. In contrast, several authors reported a prolonged stay in ICU with even long-term ventilation [6], [9], [11], [12], [29], [31], [34], or in some cases even tracheostomy was needed [18], [28], [30].

Peri- or postoperative complications may include blood loss [31], ARDS and multiorgan failure, re-operation and even rescucitation, suture leak, pneumonia [6] and even death [31]. Or damage to the recurrent nerve, especially after repair of laryngotracheal lesions [6], [7], [8], [10], [28], [31]. Granulation tissue formation, usually self-limiting [8], [10], [11], or tracheal stenosis by undue scar formation [6], [8], [13], including segment resection [26] were also reported. But the majority of patients return to normal daily activities [6], [26], [29], [34]. Average follow-up ranged from days to several weeks [9], [10], [11] to months [6], [7], [12], [14], [18], [29], [31] to 1–3 years [32], [34]. Our patient went back to his daily activities within 2 weeks and no tracheal stenosis could be detected over a follow-up period of 2 years.

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Conflict of interest 

All authors have no financial and personal relationships with other people or organisations to disclose that inappropriately influence (bias) our work.

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Acknowledgements 

We are very grateful to David M. Lawrence, PhD student, Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Stockholm/Sweden and Editor of SafetyLitSM. Injury Prevention Literature Update for his kind assistance in language editing of this manuscript.

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PII: S1871-4048(07)00093-7

doi:10.1016/j.pedex.2007.12.003

International Journal of Pediatric Otorhinolaryngology Extra
Volume 3, Issue 2 , Pages 94-99, March 2008

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