Tracheal injury

Background

Tracheal anatomy.

• Usually occurs at junction of trachea and cricoid cartilage
• Direct trauma to airway is rare due to protection by sternum and mandible
• Associated with cervical spine injury, head injury, multisystem trauma

Common causes

• Motor vehicle accident: extended neck impacts on steering wheel or dashboard
• "Clothes line injury", assaults/strangulation
• Penetrating trauma (usually stabbings or gunshot wounds)

Clinical Features

• Respiratory distress
• Hoarseness, dysphonia, cough, stridor, dysphagia
• Subcutaneous emphysema
• Cervical ecchymosis
• Hemoptysis
• Tracheal deviation or abnormal laryngeal contour

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Evaluation

Investigate only once airway secure

• Plain films, CT
  • Air in soft tissues
  • Pneumomediastinum, pneumothorax
  • Cervical spine fractures
  • Hematomas, cartilage fractures
  • Evaluate for other injuries

Management

While preparing to secure airway

• Mobilize specialists/back-up (ENT, cardiothoracics, surgery, anesthesia)
• Keep patient breathing spontaneously for as long as possible
• High-flow O2
• May by time with nebulized epinephrine and IV dexamethasone
• Anti-reflux medications (e.g. ranitidine, metoclopramide)
• Glycopyrrolate to reduce secretions

AIRWAY MANAGEMENT

Avoid cricoid pressure!

• Awake fiberoptic intubation
• Awake direct laryngoscopy/intubation
• Inhalational induction/intubation (keep patient breathing spontaneously)
• Awake tracheostomy
• Consider intubating through open wound if transected trachea visible

Disposition

• Admit

See Also

• Thoracic Trauma