SESSION TITLE: Airway Cases II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM
INTRODUCTION: Neck and chest trauma in the pediatric population resulting in tracheal rupture is a rare, life-threatening situation. Prompt diagnosis can be difficult and imaging studies may fail to recognize lesions initially. Conservative and surgical management have been described; yet there is paucity of literature emphasizing on the pediatric population.
CASE PRESENTATION: A 9-year-old female suffered a gunshot wound to right thorax with entry and exit. Upon arrival to trauma unit, she was intubated and had a right chest tube placed. Initial thorax CT scan confirmed pneumomediastinum, subcutaneous emphysema, right tension pneumothorax with right lung collapse, ipsilateral hemothorax and a severe T5 comminuted fracture. On the PICU, patient was noted with no exhaled tidal volume (Vte), flow, pressure nor capnography waveforms registered during mechanical ventilation and presence of massive airleak on chest tube, while maintaining peripheral saturation 96-99%. The endotracheal tube (ETT) was advanced into the right main stem bronchus due to suspected tracheal defect. New chest CT scan revealed right tracheal cortical discontinuity 0.5 cm AP by 1 cm long located 1 cm above the carina bifurcation. The ETT was distal to the rupture, with almost complete re-expansion of the right lung and interval improvement of previously seen pneumomediastinum. After multidisciplinary evaluation, a conservative approach was decided upon. A left double lumen tube (DLT) was used to bypass the tracheal defect and ventilate the left lung. 72 hours later, she had interval progression of pneumomediastinum and subcutaneous emphysema. Bilateral bronchial intubation was decided upon, but in order to fit two ETT’s by the vocal cords of a pediatric patient, and due to the length of ETT required to bypass the lesion safe and effectively; a customized extra-long tube was created using two 4.5 mm ID ETT’s for each bronchus. Right bronchial intubation was performed and left endobronchial tube was inserted using a stylet. Each cuff was gently inflated and correct positioning confirmed by fiberoptic visualization. The ongoing air leak resolved and the patient was able to receive long-term ventilatory support with bilateral bronchial tubes.
DISCUSSION: Surgical repair of tracheobronchial injuries has been regarded as treatment of choice; yet successful conservative management has been achieved and should be considered as a starting point when appropriate. In our case, the surgery and anesthesiology teams opted for a conservative approach. The size of the lesion was small, there was no associated esophageal injury, and the defect was deemed bridgeable by an artificial airway.
CONCLUSIONS: Although an initial attempt to isolate the defect with a DLT proved ineffective, bilateral bronchial intubation was successful. The fabricated tubes proved to be a reliable, safe and stable alternative for proper bronchial intubation on a pediatric patient.
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DISCLOSURE: The following authors have nothing to disclose: Carlos Ocasio-López, María Sánchez, Miguel Marrero, Ricardo García-De Jesús
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