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.