Professional Documents
Culture Documents
www.elsevier.com/locate/injury
KEYWORDS Summary
Traumatic airway
injury; Background: Obtaining a patent airway can be difficult in patients with traumatic
Definitive airway airway injuries (TAI). There is a paucity of data available about the incidence of airway
compromise and techniques used in these patients.
Methods: Charts review of all patients with TAI treated in a Regional Trauma Center
from July 1989 to June 2005.
Results: One hundred and four patients were identified as TAI in the study period
(incidence of 0.4% for blunt and 4.5% for penetrating trauma). Sixty-eighty patients
were victims of penetrating trauma (ISS: 24 10; mortality: 16%). Thirty-six patients
were blunt trauma victims (ISS: 33 16; mortality: 36%). Overall, 65% of the patients
received a definitive airway (DA) in the pre-hospital setting or at the initial hospital
assessment. Alternative techniques for obtaining DA including wound tracheal tube,
surgical airway and intubation under fiberoptic bronchoscopy were used in 30% of the
patients. Among 24 deaths, 10 were considered primarily due to the airway injury.
Twelve patients presented with thoracic TAI with nine deaths in this subgroup.
Conclusions: Overall, the incidence of TAI is low. Blunt trauma TAI is less common, and
these patients have a different clinical presentation, higher ISS and mortality than the
penetrating TAI group. Early assessment of airways is crucial and DA was required in 2/3
of the patients with TAI. Lower airway injuries have higher mortality than upper airway
injuries. Even though most patients died as a result of other injuries, causative factors of
death included difficulty in obtaining DA and ventilation/oxygenation problems.
# 2006 Elsevier Ltd. All rights reserved.
§
This paper was presented at the Annual Scientific Meeting of the Trauma Association of Canada, March 23—25, 2006, Banff, Alberta,
Canada.
* Corresponding author. Tel.: +1 416 480 4864; fax: +1 416 480 6039.
E-mail addresses: carmen.kummer@sunnybrook.ca (C. Kummer), Fernando.spencer@sunnybrook.ca (F.S. Netto),
Sandro.rizoli@sunnybrook.ca (S. Rizoli), Doreen.yee@sunnybrook.ca (D. Yee).
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2006.09.002
28 C. Kummer et al.
Table 1 Underlying mechanisms resulting in trau- that required DA management in the pre-hospital
matic airway injury setting had a significantly higher mortality (19
Type of mechanism Number deaths among 32 patients–—p < 0.0001) and signifi-
Penetrating 68 (65%) cantly more severe injuries (ISS of 32 compared to
Stab wounds 44 22–—p = 0.01) than the patients receiving DA in the
GSW 15 operating room.
Shotgun wounds 4 Three patients never required any intervention
Other 5 for treatment of their airway injuries which were
Blunt 36 (35%) managed expectantly. One of them had a blunt
MVC 17 trauma of the neck with a mountain bike, and
Pedestrian 6 presented hoarseness, blood in oropharynx and pain
Bicycle 3 in swallowing. The CT scan showed only hyoid bone
Recreational vehicle 3 and thyroid cartilage fractures. The other two
Industrial accident 2 patients had penetrating trauma: the first had a
Motorcycle crash 2 small gunshot wound just above the sternal notch
Fall 1 and underwent fiberoptic bronchoscopy, which
Other 2 showed a small hole in the anterior trachea with
GSW: gunshot wounds; MVC: motor vehicle collision. exit in the antero-lateral tracheal wall. The second
patient was shot in the face and the bullet crossed
established either as part of the treatment of the the posterior pharynx. The pharyngeal wound was
TAI or because the patient needed surgery for diagnosed by CT scan. All these patients were
injuries unrelated to the airway injury. Overall, stable, had isolated injuries, were admitted for
71 patients (68%) required a DA during initial monitoring, and were discharged home in 72 h.
assessment either at the scene of the accident A total of 61 (59%) patients required tracheost-
or en route to the hospital. omy as part of the TAI management, 18 patients
The interventions used to establish a definitive after blunt trauma (50% of all blunt traumas) and 43
airway are shown in Table 3. Difficulties in intubat- after penetrating trauma (63% of all victims of
ing the patients were charted in only 15 patients. penetrating trauma). Fifteen patients did not
Orotracheal intubation was the most common inter- undergo any form of surgical repair of their TAI,
vention regardless of the location in which the DA even when submitted to surgery for indications
was obtained, before or after arrival to a hospital. other than the airway injury. These patients were
Thirty patients (29%) required more complex inter- treated with tracheostomy or endotracheal intuba-
ventions than simple intubation under laryngoscopic tion with the cuff inflated distal to the airway lesion.
vision to secure DA, including FOB in 11 patients, Upper airway injuries (UAI) occurred more fre-
surgical airway in 10 patients and temporary intu- quently than lower airway injuries (LAI) in both
bation through the wound in 9 patients. Patients blunt and penetrating trauma groups. The blunt
group had 28 patients with UAI and 8 with LAI while determine whether the clinical presentation of a
the penetrating group had 62 patients with UAI and 6 TAI is due to an injury to the thoracic trachea or
with LAI. The anatomical location of the airway main bronchi.
injuries as well as overall mortality and mortality Furthermore, to facilitate analysis in the present
related with airway injuries is shown in Table 4. LAI review, we arbitrarily opted to divide the airway
had the highest mortality rate in both groups, blunt injuries into upper and lower airway injuries. This
and penetrating ( p < 0.05). classification allowed a better evaluation of the
Ten of the 24 deaths (42%) were deemed as impact of the anatomical location of the injuries
related with the TAI. These cases are summarized during the two initial steps of the ATLS protocol
in Table 5. Seven patients had LAI and all had major assessment for trauma patients: (1) secure the air-
problems with regard to adequate ventilation and way/neck stabilization and (2) provide satisfactory
oxygenation. Of the patients who died following lung ventilation and oxygenation.
UAI, three were victims of penetrating trauma In the present study, TAI was identified in 0.9% of
and arrived at Sunnybrook with absent vital signs, all trauma patients, in 0.4% of the blunt and 4.5% of
profound hypoxia and shock. All three patients were the penetrating trauma patients. Similarly, the lit-
described as being very difficult to secure patent, erature reports that TAI is rare and occurs in less
definitive airways. than 1% of all trauma patients, being more frequent
in penetrating trauma.4,8 The relatively high inci-
dence of penetrating TAI in our population might be
Discussion the result of referring bias to our Trauma Centre. Of
note, 20 of the penetrating TAI cases were self-
There are not many studies on traumatic airway inflicted injuries (29% of penetrating TAI), 18 of
injuries. The available studies are not homogenous them being stab wounds.
in their approaches. Therefore, rendering compar- In this series of patients, the initial clinical pre-
isons and recommendations is very challenging. sentation of the patients with TAI varied accordingly
While some trauma-related studies consider the to the underlying mechanism and location of the
pharynx part of the airways,6,9 others restrict the airway injuries. Subcutaneous emphysema was the
airways to the larynx, trachea and bronchi.4,5 In the most common presentation related to TAI in blunt
present study, the pharynx was included as part of trauma, followed by oral bleeding and hoarseness. In
the upper airways. In clinical practice, it may be penetrating trauma, the three most common presen-
difficult during the initial assessment of a cervical tations were external bleeding, air leak through the
trauma to accurately diagnose whether the patient wound, and subcutaneous emphysema. Although the
had an injury to the larynx, pharynx or cervical retrospective nature of the data collection may fail to
trachea. Likewise, it might also very difficult to capture less prominent signs and symptoms, the
31
32 C. Kummer et al.
different clinical presentations are consistent with tution, in isolation or in association with other air-
the mechanism of injury. If a wound is present, then way surgical procedures.
external bleeding is frequently seen. The wound In this study, the mortality varied according to
itself will also allow air leak from the underlying the anatomical location of the airway injury, with
injured structures. In contrast, in blunt traumas, lower injuries (LAI) having the highest mortality
often without external wounds, the air leaking from rate. Because the injury may extend beyond the
the underlying traumatised airway will collect in the end of the tracheal tube, patients with LAI, parti-
subcutaneous tissues resulting in subcutaneous cularly when extensive, are often difficult to venti-
emphysema, common among these patients. late/oxygenate, even after tracheal intubation and
In the penetrating group, stab wounds repre- mechanical ventilation. Other investigators have
sented the most common cause of TAI, followed suggested that extra corporeal membrane oxygena-
by gunshot wounds. We noticed a high number of tion (ECMO) might be beneficial for the treatment of
self-inflicted injuries associated with stab wounds to such complex airway injuries.13
the neck in our hospital. The most frequent mechan- Of the nine patients that died of a LAI, seven were
ism of blunt trauma was motor vehicle collision, related with the airway injury. In this series,
followed by pedestrians. patients with LAI had more severe injuries besides
As expected, patients sustaining blunt TAI had a the airway one, the airway injury was considered as
higher ISS compared to the penetrating group.4 The being of difficult surgical access and consequently
higher severity and often multiple associated inju- had the highest mortality. Of the seven patients that
ries account for the higher mortality in this group. died, difficulties in ventilation were reported in
In 32 patients, a definitive airway was established five, and there was enough evidence to suspect that
at the scene of the accident. These patients suf- the other two patients also had a similar problem.
fered the most severe injuries, thus had the highest As previously mentioned, of the 24 deaths in this
injury severity score (ISS) and predictably the high- study, 10 patients (42% of deaths) died as conse-
est mortality rate. These findings are consistent quence of the TAI, 7 with a lower and 3 with an upper
with a previous study by Bhojani et al. demonstrat- airway injury. Most of those deaths occurred early in
ing that the urgent requirement for a patent airway admission, less than 24 h in eight patients, confirm-
is an independent predictor of mortality.4 ing the immediate physiological consequences of
Orotracheal intubation was the most common the lack of a patent airway and failure of oxygena-
procedure in both the pre- and in-hospital settings. tion and ventilation. The other two deaths occurred
The number of nasotracheal intubations was higher following hypoxic brain injury and sequential fail-
in the pre-hospital setting. Surgical airways and ures in the suture line of an extensive tracheo-
intubation through the wound were done in both, bronchial injury. This last patient was transiently
pre- and in-hospital settings as the first approach to treated with ECMO but died in consequence of
secure a patent airway when intubation attempts complications of this injury.
were unsuccessful. This study has limitations, many common to all
Three patients did not require any type of airway retrospective studies. The data collection depended
management for TAI and were discharged from the on the information contained in the chart. Details
hospital after a short admission period. Upon admis- about the airway management at the scene of the
sion, these patients were not in respiratory distress accident, the referring hospital or en route were
and the definitive diagnosis of TAI was done by CT limited. It was not possible to evaluate the training
and/or fiberoptic bronchoscopy. Among the 78 of all those involved in managing the airway of these
patients undergoing any type of surgery, 15 patients patients or even the number of difficult airways.
(19%) were tracheally intubated (oral or nasatra- Such information could be important in preparing a
cheal) for the surgery but did not have the airway trauma team to receive a patient with known TAI.
injury itself surgically repaired. These findings cor- Furthermore, the link between death and the air-
roborate the principle that in selected cases, non- way injury was determined subjectively when there
operative management with oxygen supplementa- was no clear statement in the patients’ charts.
tion or a tracheal tube placed below the level of the
injury is effective to treat TAI.3 However, most
patients (81%) required some form of direct surgical Conclusion
repair of the injured airway.
Tracheostomy was performed as part of the defi- The overall incidence of TAI remains low. Airway
nitive management of the TAI in 61 patients (59% of injury from blunt trauma is less common, has a
all patients). It remains the most common form of different clinical presentation but higher ISS and
surgical treatment for patients with TAI in our insti- mortality compared to penetrating TAI. The early
Traumatic airway injuries 33
assessment of airways is crucial and a definitive air- 2. Baumgartner FJ, Ayres B, Theuer C. Danger of false intuba-
way is required in most patients with TAI. Alternative tion after traumatic tracheal transaction. Ann Thorac Surg
1997;63:227—8.
techniques for obtaining DA are frequently required 3. Beiderlinden M, Adamzik M, Peters J. Conservative treatment
and include: tracheal intubation through the neck of tracheal injuries. Anesth Analg 2005;100:210—4.
wound, surgical airway and intubation using fiberop- 4. Bhojani RA, Rosenbaum DH, Dikmen E, et al. Conteporary
tic bronchoscopy. Patients that required a definitive assessment of laryngotracheal trauma. J Thorac Cardiovasc
airway at the scene of the accident, en route and/or Surg 2005;130:426—32.
5. Flynn AE, Thomas AN, Schecter WP. Acute tracheobronchial
sustain LAI have a higher mortality. Surgery and injury. J Trauma 1989;29:1326—30.
tracheostomy are commonly used for the definitive 6. Fuhrman GM, Stieg FK, Buerk CA. Blunt laryngeal trauma:
treatment of patients sustaining TAI. Even though classification and management protocol. J Trauma
most patients died as a result of their other injuries 1990;30(1):87—92.
7. Hagr A, Kamal D, Tabah R. Pharyngeal perforation caused
besides the TAI, causative factors in UAI patients
by blunt trauma to the neck. Can J Surg 2003;46(1):
included difficulty in establishing a definitive airway 57—8.
and ventilation/oxygenation problems were contrib- 8. Kelly JP, Webb WR, Moulder PV, et al. Management of airway
utory in LAI patients. trauma. I. Tracheobronchial injuries. Ann Thorac Surg
1985;40:551—5.
9. Mussi A, Ambrogi MC, Ribechini A, et al. Acute major airway
injuries: clinical features and management. Eur J Cardio
Acknowledgment Thorac Surg 2001;20:46—52.
10. Peralta R, Hurfored WE. Airway trauma. Int Anesthesiol Clin
This research was undertaken at Sunnybrook Health 2000;38(3):111—27.
Sciences Centre, University of Toronto. 11. Shah S, Forbess JM, Skaryak LA, et al. Emergent thoracotomy
for airway control after intrathoracic tracheal injury. J
Trauma 2000;48(6):1163—4.
12. Shweikh AM, Nadkarni AB. Laryngotracheal separation with
References pneumopericardium after a blunt trauma to the neck. Emerg
Med J 2001;18:410—1.
1. American College of Surgeons Committee of Trauma.. 13. Symbas PN, Justicz AG, Ricketts RR. Rupture of the airways
Advanced life support for doctors. Ed Am Col Surg (Chicago) from blunt trauma: treatment of complex injuries. Ann
2004;391. Thorac Surg 1992;54:177—83.