Acute Penetrating Tracheal Trauma

Acute Penetrating Tracheal Trauma Panagiotis N. Symbas, M.D., Charles R. Hatcher, Jr., M.D., and Gerhard A. W. Boehm, M.D. ABSTRACT During the past ten years, 20 patients with acute penetrating tracheal injury (15 cervical and 5 thoracic) have been treated at Grady Memorial Hospital. Ten of the 20 patients had other major associated injuries: 6 had esophageal wounds, 5 had arterial injuries, and 2 had additional wounds. In the first 5 patients treatment of the tracheal injuries consisted of alone. Later on, the tracheal wounds were managed according to type, site, size, and the type of other organ injury. Repair of the tracheal wound and were done in 3 patients, repair of the tracheal wound and temporary tracheal intulbation in 4 patients, tracheocutaneous stoma in 1 patient, temporary tracheal alone in 4 pakients, and observation alone in 3 patients. Seventeen patients recovered from their injuries and 3 died frlom sepsis, respiratory insufficiency, or cerebrovascular accident. All 3 deceased patients had other major injuries. This experience suggests that the treatment of penetrating tracheal injury should depend upon the type, size, and site of the wound and the type of coexistent in:iury to other organs, and that primary repair of the iracheal wound can be carried out in the majority of the patients. With improved transportation of victims from the site of injury to medical facilities, more patients with severe penetrating injuries, including injuries to the tracheobronchial tree, survive the initial insult [l-61. The purpose of this communication is to review our last ten years experience with penetrating injuries to the trachea, with special emphasis on their management. From the Joseph B. Whitehead Department of Surgery, and Chrdiovascular Surgery Division, Emory University School of Medicine and Grady Memorial Hospital, Atlanta, GA. Presented at the Twelfth Annual Meeting of The Society of Surgeons, Washington, DC, Jan 26-28, 1976. Address reprint requests to Dr. Symbas, 69 Butler St, SE, Atlanta, GA 30303. Material and Methods From 1966 to 1975, 20 patients with penetrating wounds of the trachea were treated at Grady Memorial Hospital (Table). Seventeen of them were male and 3 were female with ages ranging from 15 to 49 years, the average being 27 years. Fifteen of the patients had sustained injury to the cervical trachea, 12 from a bullet and 3 from a knife wound, and 5 had injuries to the thoracic trachea, all of them from a bullet wound. Ten of the 20 patients had other major injuries in addition. Six had perforation of the esophagus, 5 had major arterial injuries, and 2 had other serious wounds. The esophagus was injured in the cervical region in 5 patients and in the thoracic region in 1 patient. The innominate artery was injured in 1 patient, the common carotid in 2, the subclavian in 1, and both the vertebral and the internal mammary arteries in 1. The other major injuries were a bullet wound of the urinary bladder in 1 patient and 8 bullet wounds of the small bowel, a bullet wound of the duodenum, and one of the spinal cord, region Tl-T2, in another patient. Upon admission to the hospital, 11 patients were in some respiratory distress and 6 had hemoptysis. In 2 of them, 1 of whom had complete transection of the cervical trachea, the hemoptysis was so severe that immediate tracheal was performed to protect them from massive aspiration of blood. Subcutaneous emphysema in the supraclavicular and cervical region was observed in 17 patients; in 3 of them air was escaping from the cutaneous wound. Roentgenograms of the chest or the cervical region, which were obtained in all patients, showed subcutaneous air in the neck in 10, pneumomediastinum in 4, pneumothorax in 4, and hemothorax in 3 patients. Due to the close proximity of the wound to the esophagus or because the missile had traversed the mediastinum, an esophagogram was obtained in 17 of 473

474 The Annals of Surgery Vol 22 No 5 November 1976 Site, Extent, Management, and Results of Penetrating Tracheal Wounds in 20 Patients Patient s Site of Age (yr) Tracheal Means of Management of & Sex Injury Extent of Injury Diagnosis Tracheal Wounds Result 22, F 32, M 17, M 35, M 45, M 23, M 24, M 21, M 49, M 31, M 32, F 22, M 17, M 28, M 31, M 30, M 28, M 15, F 25, M 29, M Through-and- through Transection Not visualized Not visualized Bullet expectoration Not confirmed Not confirmed Tracheocutaneous stoma Hoarseness the 20 patients. Esophageal perforation was demonstrated in 4 of them. The diagnosis of tracheal injury was suspected from the location of the external wound, the history, the physical examination, and the roentgenographic findings. The diagnosis was confirmed by tracheoscopy in 9 patients, at the time of exploratory operation in 8 patients, and when a bullet was expectorated in 1 patient; in 2 patients the diagnosis was not confirmed. Exploratory operations were performed because a vascular or an esophageal injury was suspected. In 8 of the patients the tracheal wound was a through-and-through type, in 9 it involved only one side of the trachea, in 1 the cervical trachea was completely transected, and in 2 patients the tracheal injury was not visualized (see the Table). The treatment of tracheal injury during the early part of our experience consisted of alone, performed in 5 of our patients. In the later period the tracheal wounds were managed according to their clinical presentation, the extent of injury, and other coexisting organ injuries. Repair of the tracheal wound and were done in 3 patients, repair of the tracheal wound and temporary orotracheal or nasotracheal in 4 patients, tracheocutaneous stoma in 1 patient, temporary orotracheal or nasotracheal in 4 patients, and observation alone in 3 patients (see the Table). The temporary tracheal was maintained for 24 to 48 hours. All cervical esophageal perforations and the innominate and common carotid artery wounds were primarily repaired, whereas the other in-

475 Symbas, Hatcher, and Boehm: Acute Penetrating Tracheal Trauma jured vessels were ligated. The patient with thoracic esophageal perforation and injury of the trachea just above the carina (Figure), because of her very precarious condition and the gross contamination of the mediastinum, had primary repair of the tracheal wound, transection of the esophagus at the site of injury, exteriorization of its cephalad end as a cervical esophagostomy, suture of its distal end, and gastrostomy. Seventeen patients recovered from their injuries and 3 died (see the Table). One patient with a gunshot wound of the cervical trachea and of the urinary bladder died on the fifth day after injury from aspiration pneumonia and a cerebrovascular accident. A patient with a bullet wound of the thoracic esophagus and trachea died on the sixth day following injury from pulmonary insufficiency and infection. The third patient, who had a bullet wound in the spinal cord (Tl-T;?) and paraplegia, a bullet wound of the cervical esophagus and duodenum, and multiple bullet wounds of the small bowel, died on the twenty-third day after injury from sepsis and respiratory insufficiency. Fifteen of the 17 patients who recovered from their trauma have had no difficulty associated with the tracheal injury. One patient with a through-and-through penetrating cervical tracheal wound and esophageal perforation underwent repair of all wounds and. After the wounds had healed he had persistent hoarseness. Laryngoscopy showed right vocal cord paralysis, which was still unchanged at the fifth postoperative week when he was lost to follow-up. One patient has a permanent. He had suffered complete transection of the cervical trachea, which had retracted into the mediastinum, and perforation of the esophagus. The esophageal wound was primarily repaired, and after the end that had retracted into the mediastinum was retrieved, a tracheocutaneous stoma was created. On the fifth postoperative day he developed an esophagocutaneous fistula with some spilling of esophageal contents into the. After prolonged nasogastric feeding, the esophageal fistula closed and he was reoperated upon. At the time of the second operation the end of the proximal tracheal segment was B Admission radiological studies of a 32-year-old woman who had a bullet wound of the rightsecond intercostal space. (A) Frontal chest roentgenogram shows thp missile in the left lung field and widening of the mediastinal shadow. (B) Esophagogram showing a tracheoesophageal and pleuroesophageal fistula. revised, the tracheocutaneous stoma was removed, and end-to-end anastomosis of the trachea was performed. Postoperatively he developed severe subglottic stenosis necessitating an emergency, which he still has.

476 The Annals of Surgery Vol 22 No 5 November 1976 Comment Penetrating wounds of the trachea are usually due to stab or bullet wounds, the latter being more common. The most frequent site of injury is the anterolateral wall of the cervical trachea, perhaps because that is its most unprotected part. The clinical manifestations of tracheal wounds depend upon the site and size of the wound and the type of injury to other organs. In general, hemoptysis and dyspnea of various degrees and subcutaneous emphysema of the neck are the most common symptoms and signs of penetrating tracheal injury. Small, isolated wounds of the cervical trachea usually become evident from subcutaneous emphysema in the neck, with or without blood-stained sputum. Larger, isolated wounds in this area may manifest themselves in the form of hemoptysis or massive subcutaneous emphysema if the cutaneous wound is sealed; if it is open, there may be air blowing through the cutaneous wound. Isolated penetrating wounds of the thoracic segment of the trachea may appear with various degrees of hemoptysis and subcutaneous emphysema. Pneumothorax, with or without tension, or various degrees of respiratory and circulatory embarrassment may also be present. The latter findings depend upon the size of the wound, whether there is communication between the pleural space and tracheal lumen, and bidirectional or unidirectional flow of air from the lumen into the pleural space. Patients with unidirectional air flow from the trachea to the pleural space, because they frequently develop tension pneumothorax, are more likely to be severely symptomatic, whereas patients with an airway defect sealed with adjacent tissue are usually in no respiratory distress. The diagnosis of a penetrating wound of the trachea should be suspected in all patients with a penetrating wound of the chest or neck, particularly when a bullet or knife has traversed the upper anterior mediastinum and when any of the previously mentioned clinical findings are present. The diagnosis should be confirmed with tracheoscopy if the patient's condition permits it. The management of penetrating tracheal wounds should depend upon the type, size, and site of the wound and on the type of injury coexisting in other organs. Tracheal wounds shown by tracheoscopy to be small, with no loss of tracheal tissue, and with edges well apposed to each other can be treated effectively by temporary orotracheal or nasotracheal. The cuff of the endotracheal tube should be inflated below the tracheal wound so that leakage of air through the wound into the mediastinal or subcutaneous tissue is prevented and the possible danger of contamination of these areas is avoided. The tracheal tube should be left in place for 48 hours, which is usually sufficient to allow the tracheal wound to seal. Large wounds of the trachea should be primarily repaired, as should the small ones that are explored on account of a suspected vascular or other organ injury. The repair should be done with interrupted 2-0 or 3-0 chromic catgut or other absorbable suture. When both the trachea and the esophagus have been injured, they should be repaired primarily. In such a case, however, a flap of muscle if the injury is in the neck or in the inlet of the chest, or a flap of parietal pleura or pericardium if it is in the chest, should be appropriately constructed and interposed between the two suture lines so that the best possible healing of the wounds can be secured. In selected patients who have wounds of both the thoracic trachea and esophagus with gross contamination of the mediastinum, the trachea should be primarily repaired and a spit fistula, gastrostomy, and feeding jejunostomy should be performed. Two or three weeks later, after the tracheal wound heals, the esophagus can be appropriately reconstructed. References 1. Beall AC Jr, Noon GP, Harris HH: Surgical management of tracheal trauma. J Trauma 7948,1967 2. Chavez CM, Pandeli A, Conn JH: Surgical approach to injuries of the cervical trachea. South Med J 65:659, 1972 3. Ecker RL, Libertini RL, Rea WJ, et al: Injuries of the trachea and bronchi. AnnThorac Surg 11:289,1971 4. Hood RM, Sloan HE: Injuries of the trachea and major bronchi. J Thorac Surg 38:458, 1959 5. Lemay SR Jr: Penetrating wounds of the larynx and cervical trachea. Arch Otolaryngol 94:558, 1971

477 Symbas, Hatcher, and Boehm: Acute Penetrating Tracheal Trauma 6. Urschel HC Jr, Razzuk MA: Management of acute traumatic injuries of the tracheobronchial tree. Surg Gynecol Obstet 136:113, 1973 Discussion DR. JOHN R. BENFIELD (Los Angeles, CA): Dr. William Spenler and I recently summarized our experience with esophageal injuries from external sources (Arch Surg, 111:663, 1976). Because of the proximity of the esophagus to the trachea, our findings are relevant to today s nice presentation. As anticipated, our patients in whom the injuries were recognized promptly did well, and those in whom there was delayed recognition suffered a considerable incidence of complications. Two of 11 patients had false-negative esophagograms in the face of traumatic esophageal perforation. Thus, one lesson we learned is that patients suspected of having esophageal injury should undergo esophagoscopy and bronchoscopy as well as esophagography. Second, we included the first known report of esophageal disruption after a whiplash injury. Thus, I would urge that esophageal injury be kept keenly in mind and that the esophagus be fully evaluated to the limits of practicality whenever there is tracheal trauma of penetrating or blunt origin. DR. AGUSTIN ARBULU (Detroit, MI): In a series of 22 tracheal lesions that we have observed at the Detroit General Hospital in the past five years, 6 were due to trauma, mainly stab wounds. It is extremely interesting to note that most of the injuries reported by Dr. Symbas were from gunshot wounds. In our area, gunshot wounds are usually close to the heart, so that the trachea is spared. I think lesions of the trachea should be repaired later on-not as an emergency procedure. Ventilatory support can be provided through a, and the tracheal reconstruction can take place when other organ injuries have healed. In our experience, the majority of patients with gunshot wounds have multiple organ injuries and develop so-called shock lung, which requires repeated bronchoscopies in order to take care of respiratory problems. So I would like to utter a word of caution in relation to primary repair of tracheal injuries: our philosophy has been to reserve the permanent repair for a later date. DR. SYMBAS: I thank Dr. Benfield and Dr. Arbulu for their fine comments. As to considering the possibility of a coexisting esophageal injury, we agree wholeheartedly that all patients with a penetrating tracheal wound should be investigated for this by esophagography, esophagoscopy, or at the time of exploratory operation. In contrast to Dr. Benfield s experience, we have not had a false-negative esophagogram. The esophagogram is obtained in both frontal and lateral views, and chest roentgenograms are taken after the contrast material has passed into the stomach. This way, if a small amount of barium is extravasated from the esophageal lumen and is obscured by the barium in the esophagus, it would not be missed. Dr. Arbulu, in Atlanta, too, victims are shot in the heart but also in the trachea. As was pointed out, we prefer to repair the tracheal wounds primarily whenever possible. This is done with chromic catgut, which, due to absorption of fluid after it is placed in the tissues, obliterates the needle holes and prevents air leak through them. Nor does it result in the formation of granulation tissue at the suture line, as is frequently the case when nonabsorbable suture is used, which necessitates later repeat bronchoscopies to extract suture material as well as granulation tissue.