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