zaria thoracic club meeting ahmadu bello university teaching hospital,zaria,nigeria tracheal...

ZARIA THORACIC CLUB MEETINGAHMADU BELLO UNIVERSITY TEACHING

HOSPITAL,ZARIA,NIGERIA

TRACHEAL INJURIESDR SANNI R. O

25th - 02 - 2011

• INTRODUCTION• RELEVANT ANATOMY• AETIOLOGY• PATHOPHYSIOLOGY• CLINICAL FEATURES• INVESTIGATION• TREATMENT• COMPLICATION• PROGNOSIS• CONCLUSION

INTRODUCTION

• Tracheal injuries are rare, life threatening.

• Seen in penetrating or blunt neck, chest injury.

• Increasing incidence of iatrogenic causes.

• Difficult to diagnose & treat.

• Broncoscopy for evaluation of lesion.

• Primary repair treatment of choice.

Historical perspective

• 100% Mortality through out most of history.

• 1871- healed TBI in a Duck noted by Winslow.

• 1873-earlier report in medical literature.

• 1927- 1st documented survival.

• 1945- 1st attempt at repair.

epidemiology

• Most common injury to the airway.0.5-2%• 2.1-5.3% blunt trauma pt reaching Hospital alive.• 30-80% die b/4 emergency care.• Noted in 2.5-3.2 autopsies post trauma.• 0.5% poly traumatised pt.• 1/20,000 pt intubated, 15% emergency

intubation.• M > F.

RELEVANT ANATOMY

• Trachea situated btw lower larynx & middle mediastinum.

• 4.5 inch length, 1inch diameter.

• 15-20 cartilages .

• Posteriorly covered by membrane.

• Ciliated columnar epithelium.

Aetiology

• Blunt, penetrating trauma from RTA.• Gunshot injury.• Fall from height ,crush chest injury.• Stab wound, assault, suicide.• Explosion.• iatrogenic-intubation, bronchoscopy,

tracheostomy.• Inhalational injury.

Pathophysiology

• Increased pressure in airway ,shearing force.

• Sudden chest deceleration in RTA, Shearing force.

• Rapid ant. –post. Chest compression, pressure at carina .

• Perforation by styelet, ETT.

• Penetrating injury.

Classification

• Transverse ,most common.

• Longitudinal/spiral.

• Complex.

• Complete or incomplete.

Clinical feature

• Depend on location, severity

• Hx of trauma, surgery.

• Dyspnoea, cough, haemoptysis

• hoarseness ,stridor,

• Subcutenous emphysema, cyanosis.

• Airway obstruction.

• Evidence penetrating/blunt trauma.• Air leak.• Pneumothorax.

• Other injuries (50%)• Pulmonary contusion, lacerations, • # sternum, rib, clavicle,• Aortic, Spinal cord, head, facial, abdominal

injury.

INVESTIGATION

• 30-50% not discovered at first.• 10% no sign on CXR.• CXR- sub. emphysema deformity, defect in trachea. high seated hyoid ,sub.emphysema. pneumothorax, pneumomediastinum ETT out of place. fallen lung sign.

• CT Scan.

• Bronchoscopy -most effective, fastest reliable.

• Oesophagoscopy.

Treatment

• Based on location severity stability of pt.

• Aim- keep airway patent.

• Non-operative.

• Operative.

• Resuscitate-

• ETT to bypass at Bronchoscopy.

• Supplemental oxygen, mech. ventilation.

• Tracheostomy.

• Chest tube.

• Pulmonary toileting.

• Fluid mgt.

• Antibiotics.

• Analgesia.

• Monitoring of vital signs.

Indication for surgical mgt

• Tracheal tear affecting ventilation.

• Mediastinitis.

• Persistent air leak despite chest tube.

• Tear >0.5 circumference airway.

• Tear with loss of tissue.

• Positive pressure ventilation.

Surgical repair.

• Rt. Post. Lateral Thoracotomy.

• +/- limited debridement

• Sutured, +/- butressed.

Complications

• Death- pneumothorax, insuffitient airway.

• Infection.

• Atelectasis.

• Stenosis.

PROGNOSIS

Conclusion

• Though rare, tracheal injury is potentially life threatening and difficult to diagnose therefore high index of suspicion is needed for prompt intervention.