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KEY POINTS

KEY POINTS Injury to Trachea and Bronchi

  • Direct laryngoscopy, video laryngoscopy, bronchoscopic-guided intubation, and a surgical airway are all methods to establish a secure airway in a patient with a tracheal injury.

  • The classic presentation of a distal tracheal or proximal bronchial injury is a large pneumothorax and a significant air leak and/or persistent pneumothorax following insertion of a thoracostomy tube.

  • The distal half of the trachea, the right mainstem bronchus, and the proximal left mainstem bronchus are best approached through a right posterolateral thoracotomy.

  • During repair of a mainstem bronchus, a single-lumen endotracheal tube in the contralateral mainstem bronchus allows for ventilation and an easier repair.

  • Tracheal repair is accomplished with interrupted absorbable sutures.

Injury to Esophagus
  • The accuracy of combining a contrast esophagram and esophagoscopy approaches 100%.

  • As opposed to the trachea, the blood supply to the esophagus courses longitudinally in the submucosa, allowing for full mobilization.

  • The extent of the mucosal defect is exposed by incising the muscular layer until both ends of the mucosal tear are visualized.

  • A tension-free esophageal repair is performed in two layers, with absorbable sutures on the mucosa and permanent interrupted sutures on the muscular layer.

  • A vascularized intercostal muscle pedicle is ideal to buttress a repair of the thoracic esophagus.

INTRODUCTION

Thoracic trauma can result in a variety of clinical entities that demand thoughtful management in order to achieve optimal outcome. The bony thorax, major vascular structures, esophagus, trachea, and lung are all vital structures at risk following injury to the chest. Even potential spaces between these structures can manifest serious acute pathologies, such as a pneumothorax or hemothorax, that require knowledge of both emergent and less acute management considerations. In an effort to optimally address each of these traumatic pathologies most effectively, the editors of Trauma have thoughtfully distributed their discussion across several chapters constructed by experts. The focus of this chapter will be injuries specifically to the trachea, bronchi, and esophagus. The other aforementioned entities, including the thoracic wall, pneumothorax, and hemothorax, are discussed elsewhere (see Chapter 28).

INJURIES TO THE TRACHEA AND BRONCHI

Tracheobronchial injuries are infrequent but potentially life threatening. The incidence of blunt and penetrating injury is 0.4% and 4.5%, respectively.1 Although these injuries occur more commonly in the cervical trachea and may be the result of either mechanism, thoracic tracheobronchial trauma generally is related to blunt injuries from high-speed motor vehicle crashes.2-6 Most penetrating injuries to the cervical trachea, although straightforward to repair, may be associated with significant injuries to blood vessels, esophagus, and thoracic duct.7

Presentation and Evaluation

Cervical tracheal injuries are often obvious on physical examination.8 A large volume of subcutaneous air and/or air exiting from the missile tract may be observed. Patients often present in respiratory distress requiring urgent airway control. Direct laryngoscopy, video laryngoscopy, bronchoscopic guided ...

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