Discussion
TBI following blunt trauma is rare due to the high percentage of
patients dying before reaching the hospital. (1) Due
to its low incidence and high mortality rates, a high degree of
suspicion and prompt airway management is essential. TBI should be
suspected in any patient following blunt trauma that presents with
respiratory distress, dyspnea, hemoptysis, SOB, and clinical signs
involving subcutaneous emphysema, pneumomediastinum, and pneumothorax.
Evaluation for all patients concerning TBI should include flexible
bronchoscopy as it helps identify the location and characteristics of
the injury. In unstable patients, bronchoscopy-guided endotracheal
intubation is preferred over blind intubation to avoid further airway
injury.
In hemodynamically stable patients CT imaging provides an important role
in identifying TBI and concomitant injuries in the neck or chest.
Scaglione et al performed CT imaging in all non-complicated patients
with suspected TBI and demonstrated 94% accuracy in localizing
tracheobronchial injury. The sole remaining patient showed adjacent air
leaks which have been demonstrated in other studies to be associated
with TBI and were confirmed via bronchoscopy. (1)Historically TBI has been primarily managed with surgical correction
regardless of etiology. Recently conservative approaches have been
advocated for patients with iatrogenic injuries with certain clinical
and morphological properties.
There is insufficient information regarding conservative management in
patients following blunt trauma due to its low incidence. However,
Gomez-Caro et al established strict criteria where conservative
management can be employed in patients regardless of the mechanism of
trauma, location, or length. The clinical criteria consist of
hemodynamically stable patients without worsening subcutaneous or
mediastinal emphysema, no open tracheal injury, or signs of sepsis
related to an injury. (2) Meanwhile, Caretta et al
establishes criteria for conservative management based on bronchoscopy
findings. These are non-complex linear injuries involving only partial
thickness of the tracheal wall. (3) Finally, Cardillo
et al propose a morphological classification based on the depth of
injury and states, that in an uncomplicated iatrogenic TBI, patient
depth not length should direct treatment. Cardillo’s study advocated
that only patients with evidence of esophageal or mediastinal injury
(level IIIB) should undergo primary surgery. (4)
In our case, bronchoscopy revealed an uncommon longitudinal posterior
right membranous tracheal wall laceration measuring 4.0 cm with minimal
nonperforated esophageal herniation. A decision to undergo conservative
management was supported by the patients age, clinical aspect and
flexible endoscopy evaluation. There is not enough evidence regarding
management of TBI following blunt trauma regarding length, depth, and
location. Our case report imparts another successful conservative
management focusing on clinical and bronchoscopy presentation.