Traumatic review Blunt Esophageal and Tracheal injury
Upcoming SlideShare
Loading in...5
×
 

Traumatic review Blunt Esophageal and Tracheal injury

on

  • 523 views

One of the most nice case of rare co blunt esophagotracheal injury

One of the most nice case of rare co blunt esophagotracheal injury

Statistics

Views

Total Views
523
Views on SlideShare
523
Embed Views
0

Actions

Likes
0
Downloads
2
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Traumatic review Blunt Esophageal and Tracheal injury Traumatic review Blunt Esophageal and Tracheal injury Presentation Transcript

  • Traumatic Review 26-04-56 Kusuma Chinaroonchai, M.D. Aj.Burapat Sangthong Friday, April 26, 13
  • Friday, April 26, 13
  • Case History Muslim 21 year-old woman Refered from outside hospital Motorcycle crushed with pick-up with Hx loss of consciousness 5 mins PTA Rescuers sent her to the hospital. Friday, April 26, 13 View slide
  • Primary Survey at outside Hospital A : can talk in sentence, no stridor, but cannot flex her neck due to pain >> on philadelphia collar B : RR 24 /min, SpO2 91% RA, 100% with O2 mask, equal breath sound both lungs, subcutaneous emphysema at neck, trachea in midline, no wound at chest wall C : BP 124/81mmHg, P 122 /min, no external active bleeding wound seen D : E4V5M6, pupil 2 mm BRTL, Motor V left arm and right leg, right arm and left leg limited movement due to pain and deformities E : deformities with bone exposed at right forearm and left thigh >> wood splint Friday, April 26, 13 View slide
  • Adjunct to Primary Survey at outside Hospital Film C-spine : not seen Fx, subcutanous emphysema at neck area CXR : widening mediastinum, not seen pneumohemothorax FAST : negative Film pelvis : no fracture seen Friday, April 26, 13
  • What’s the problem list and differential diagnosis? Friday, April 26, 13
  • Problem list MC crush Hx of loss of consciousness at scene Desaturation with subcutaneous emphysema with no pneumothorax both lungs Shock grade II with widening mediastinum with no hemothorax Deformities with exposed bone at right forearm and left thigh Friday, April 26, 13
  • Differential Diagnosis Desaturation with subcutaneous emphysema with no pneumothorax both lungs Tracheal or bronchial injury Shock grade II with widening mediastinum with no hemothorax Traumatic aortic and its branches injury Deformities with exposed bone at right forearm and left thigh Open fracture right forearm and left femur Friday, April 26, 13
  • Secondary Survey : AMPLE 10.10 11-4-56 : She rode on a motorcycle pillion that was crushed by pick-up. After the event she was loss of consciousness and was sent by rescuers to the hospital. At ER of outside Hospital : no hoarseness, no spliting blood, complaint retrosternal chest pain that radiate to back , generalized abdominal pain and pain at her right forearm and left thigh Friday, April 26, 13
  • Physical Examination V/S : P 122 /min RR 24 /min BP Right arm 102/70 mmHg Left arm 70/50 mmHg GA : Alert, good consciousness, no stridor Neck : on philadelphia collars, palpable subcutanous emphysema, trachea in midline, limit ROM due to pain Chest : not seen external contusion or wound, equal breath sound, CCT negative CVS : normal S1S2, no murmur Friday, April 26, 13
  • Physical Examination Abdomen : Generalized guarding, no external contusion or wound seen PCT : negative Ext : Deformities exposed bone at right forearm, and left thigh, Right radial pulse 2+, capillary refill <3 sec, Left DPA and PTA 2+, capillary refill < 3 sec PR : good sphincter tone, no bleeding per rectum Friday, April 26, 13
  • What’s the optimal initial management ? Friday, April 26, 13
  • Traumatic thoracic aortic and tracheal injury were suspected then refer to PSU Friday, April 26, 13
  • At ER PSU : Repeat Primary Survey A : patent, no hoarseness, can talk, no stridor, neck edema with subcutaneous emphysema at neck, not seen hematoma nor contusion B : equal breath sound C : BP 120/70 mmHg, PR 116-130/min, pulse full, no external source of bleeding seen D : E4V5M6, pupil 2 mm BRTL E : Deformities at right forearm and left thigh that exposed bone with not seen active bleeding Friday, April 26, 13
  • CXR Friday, April 26, 13
  • C-spine Friday, April 26, 13
  • Adjunct to Primary Survey C-spine : not adequate, subcutaneous emphysema CXR : widening mediastinum 9 cm, no pneumohemothorax both lungs, fracture right 1st and 2nd ribs Film Pelvis AP : not seen fracture FAST : negative Friday, April 26, 13
  • Secondary Survey : AMPLE Denied Hx of medication allergy and current medication used Denied previous UD Denied chance to get pregnancy Last meal 6.00 am Cannot remember about TT vaccine Hx Friday, April 26, 13
  • Physical Examination at PSU BP 100/60 mmHg P 120 /min RR 26 /min SpO2 99-100% with O2 mask BW 40 kg Ht 164 cm GA : Alert, good consciousness Neck : On philadelphia collar, neck subcutaneous emphysema, limit neck ROM due to pain, no hematoma, contusion nor external wound seen Friday, April 26, 13
  • Physical Examination at PSU Lung : equal breath sound, trachea in midline, CCT negative, no external chest lesion seen CVS : pulse full, no murmur BP right arm 110/70 mmHg BP left arm 70/50 mmHg BP right leg 100/70 mmHg BP left leg 107/67 mmHg Friday, April 26, 13
  • Physical Examination at PSU Abdomen : mild distension, generalized guarding, hypoactive bowel sound Ext : deformities with exposed bone at right forearm and left thigh with good distal pulse palpable PR : good sphincter tone, no bleeding per rectum Friday, April 26, 13
  • What is the plan for investigation? Friday, April 26, 13
  • CT neck and CT chest Friday, April 26, 13
  • Friday, April 26, 13
  • Friday, April 26, 13
  • Investigation CT brain : no intracerebral hemorrhage CT neck : extensive emphysema along subcutanous layer extending to mediastinum could be tracheal injury , esophagus not seen grossly wall thickening CT chest : Traumatic aneurysm at brachiocephalic trunk 1.6 cm with small intimal flap and large mediastinal hematoma,fracture right 1st and 2nd ribs Friday, April 26, 13
  • Investigation CT whole abdomen : pneumohemoperitoneum in pelvic cavity, suspected hollow viscus organ injury Friday, April 26, 13
  • Diagnosis Cerebral concussion Suspected blunt tracheobronchial injury Blunt traumatic innominate artery pseudoaneurysm Hollow viscus organ injury Open fracture both bones right forearm and left femur Friday, April 26, 13
  • Bronchoscopy & EGD Friday, April 26, 13
  • Bronchoscopy & EGD Friday, April 26, 13
  • Incidence Cause from blunt chest injury Shorr RM, Ann Surg: Aug 1987 Friday, April 26, 13
  • Blunt tracheobronchial injury rare condition 80% lesion at 2.5 cm from carina Mechanism AP compression Sudden increased airway pressure Rapid deceleration force Friday, April 26, 13
  • Blunt tracheobronchial injury Multiple associated injury 40-100% orthopedic problem 21% esophageal perforation 18% major vascular injury Friday, April 26, 13
  • Blunt tracheobronchial injury : Dx Symptoms 76-100% Dyspnea with respiratory distress 46% hoarseness or dysphonia Signs 35-85% subcutaneous emphysema 20-50% pneumothorax 14-25% hemoptysis Friday, April 26, 13
  • Blunt tracheobronchial injury : Dx Late presentation (1-4 wk) after injury can came with pneumonia, bronchiectasis, atelectasis and abscess stridor or dyspnea >> late tracheal stenosis wheezing or pneumonia >> late bronchial stenosis Friday, April 26, 13
  • Blunt tracheobronchial injury : Ix X-ray C-spine : 60% deep cervical emphysema and pneumomediastinum CXR : 70% pneumothorax disruption of tracheal or bronchial air column Falling lung sign of Kumpe CT chest : inconclusive, evaluate associated injury such as mediastinal hematoma Esophagoscopy : if suspected associated esophageal injury Friday, April 26, 13
  • Blunt tracheobronchial injury : Ix Bronchoscopy : single definitive diagnostic study Friday, April 26, 13
  • Blunt esophageal injury incident < 1%, most common from penetrating < 0.1% from blunt mechanism Friday, April 26, 13
  • Blunt esophageal injury : mechanism cervical area : sudden anterior hyperextension Lower 1/3 : blast injury compressed air or acute gastric compression Friday, April 26, 13
  • Blunt esophageal injury : Diagnosis Due to signs and symptoms are non-specific Mostly occult hoarseness Spiting up blood Subcutanous emphysema Anterior tracheal deviation Friday, April 26, 13
  • Blunt esophageal injury : Ix CXR : subcutanous emphysema hydropneumothorax hydropneumomediastinum free abdominal air Friday, April 26, 13
  • Blunt esophageal injury : Ix *Esophagogram* miss 15% perforation in water-soluble contrast miss 10% perforation in thin Ba When combined ↓ false negative Esophagoscopy : miss 15-40% injury esp in proximal 2-4 cm, if combined with contrast study ↑ sentivity to 100% Friday, April 26, 13
  • Incident of associated injury Friday, April 26, 13
  • What’re your plan of management - Airway managment, Tracheostomy ?? - Priorities for operation in all condition?? - Surgical technique? Friday, April 26, 13
  • Management Secure airway Flynn series (36%: 8/22) >> immediate airway with emergency tracheostomy Gussack series (92%) >> emergency airway 73% ET tube via oral 3% intubate ET tube at neck wound Friday, April 26, 13
  • Management Anesthesia technique airway control and intubation technique may need awake intubation via fiberoptic bronchoscopy High frequency jet ventilation (↓airway pressure) during airway reconstruction Friday, April 26, 13
  • Management **Extubation consideration** No indication for prolong intubation for support ventilation >> Off If need tube to support ventilation >> Large no. single lumen ET-tube Friday, April 26, 13
  • Management Priorities for operation Life threatening condition as subdural hematoma or intraabdominal bleeding or major vascular injuries ***before repaired tracheobronchial injury*** Friday, April 26, 13
  • Operative Management Only small primary mucosal injuries size < 1/3 of all diameter with no devascularized tissue No air leak No distal obstruction Patulous blow out mucosa like from bronchoscope >> can progress to ball-valve caused obstruction Friday, April 26, 13
  • Operative Management Location of lesion Proximal 1/2-2/3 trachea Low cervical collar incision extend to T incision Distal 2/3 trachea - carina Rt main bronchus Rt posterolateral thoracotomy Lt main bronchus Friday, April 26, 13 Incision Lt posterolateral thoracotomy
  • Friday, April 26, 13
  • Friday, April 26, 13
  • Operative Management Injury < 50% of lumen diameter + no devascularized tissue >> primary repaired Injury < 50% of lumen diameter + devascularized tissue >> primary repaired with tissue flap Injury > 50% or < 50% + devascularized tissue >> resection with end to end anastomosis Friday, April 26, 13
  • Surgical Technique Trachea can resected left 1/2 of total length but can resected only 3-4 cm of airway that involve carina Suprahyoid laryngeal release for ↑ 1-2 cm length Mobilized pericardium at inferior aspect of hilum can ↑ 1-2 cm length Friday, April 26, 13
  • Surgical Technique Repaired in simple interrupted technique absorbable 4-0 vicryl or permanent or absorbable monofilament If have associated esophageal injury >> interposition flap used to prevent fistula Friday, April 26, 13
  • Post operative concern Aggressive pulmonary toilet Beware aspiration low airway pressure bronchoscopy at 7-10 days to evaluate earl stenosis Friday, April 26, 13
  • Esophageal Management Concept Control leakage Debridement and drainage Nutritional support Early used of broad spectrum ATB Friday, April 26, 13
  • Surgical Technique Location of lesion cervical part Incision collar incision : bilateral repaired and buttress with sternocleidomastoid or dtap carotid incision : muscle flap unilateral upper 2/3 thoracic Rt posterolateral thoracotomy lower thoracic at level below inferior pulmonary vein 5th -7th Lt posterolateral thoracotomy Friday, April 26, 13 Other Technique intercostal muscle flap
  • Surgical Technique Choose incision at lesion level Unstable patient for primary repaired nor resection >> Created control fistula by tracheal T-tube 28 Fr + ICD x 2 70% mortality in this unstable group Friday, April 26, 13
  • Progression Operation Exploratory for repaired jejunal perforation with feeding jejunostomy EGD + Bronchoscopy Innominated stent insertion with right subclavian artery to right carotid artery bypass Right posterolateral thoracotomy for repaired trachea and esophagus with intercostal muscle flap Friday, April 26, 13
  • Operative findings Tear of trachea 5 cm in size just 1 cm above carina Serosal tear of posterior and anterior esophagus at 20 - 25 cm from incisor Right innominate artery injury from its origin 3 mm and 3 cm in length Distal jejunal perforation Friday, April 26, 13
  • Friday, April 26, 13
  • Friday, April 26, 13
  • Take Home Message Blunt tracheobronchial injury 80% lesion at 2.5 cm from carina 21% of this injury with esophageal injury and other system organ injury Most common sign is subcutaneous emphysema Bronchscopy is only single definitive diagnostic study Friday, April 26, 13
  • Take Home Message Blunt esophageal injury, its sign and symptoms are nonspecific. High degree of suspicious to make diagnosis Esophagoscopy can miss 15-40%, but if combined with esophagography sensitivity is 100%. Friday, April 26, 13
  • Thank You for Your Question and Discussion Friday, April 26, 13