Fig 19.4b. The aortogram in this patient reveals a complete transection of the aorta. Aortic continuity is preserved only by periaor-tic connective tissue. The patient underwent uneventful aortic tube graft replacement using left atrial-femoral bypass. Courtesy Dr. Michael Janusz, University British Columbia vision with the bronchoscope used to stent the airway.

Injuries to the trachea like laryngeal injuries, should be managed in a similar way. These injuries are usually from unrestrained passengers who crash their car and smash their neck against the top of the steering wheel resulting in tracheal injury. The most common location of the tracheobronchial injuries from blunt trauma occurs within 2-1/2 cm of the carina, i.e. usually a mainstem bronchial injury. Symptoms include respiratory distress, subcutaneous, emphysema and crepitus. It is important to remember that the clinical presentation of tracheo-bronchial injuries and blunt trauma vary, and the initial diagnostic evaluation is often misleading. Early intervention is important because 50% of deaths from this injury occur within an hour after the injury. Also, if the patient does survive days after the initial injury, the chance of subsequent serious complications— including persistent atelectasis with pneumonia and bronchiectasis, empyema, and stenosis and stricture of the injured segment—is extremely high. One point is that all patients with major tracheobronchial injuries will eventually develop a pneumothorax or subcutaneous emphysema (Figs. 19.7, 19.8). Sometimes this is

Fig 19.5b. The aortogram in this patient reveals a pseudoaneurysm from an aortic tear in the region of the ligamentum arteriosum (arrow). Repair was done using left atrial-femoral bypass. Courtesy Dr. Michael Janusz, University British Columbia.

a delayed finding and the initial presentation may not include a pneumothorax or subacute emphysema (Fig. 19.9).

Initial management should be directed at securing the airway either by cricothyroidostomy or endotracheal intubation over a flexible bronchoscope. A chest tube is inserted if there is evidence of pneumothorax. If there is a large air leak with subcutaneous emphysema, a tracheobronchial injury should be suspected. At this point, flexible fiberoptic bronchoscopy should be performed, preferably in the operating room to identify a tracheobronchial injury. If one is identified, definitive surgery should be done at that time. If no tracheobronchial injury is identified on flexible bronchoscopy but there is a massive air leak and a large amount of subcutaneous emphysema, other techniques should be used. These include rigid bronchoscopy and bronchography (Fig. 19.10). When the injury is identified, early operative management is indicated.

The incision depends on the location of the tracheobronchial injury. If the trachea is injured, a cervical incision is usually adequate for injuries in the upper half of the trachea. For injuries in the lower half of the trachea or in the region of the carina or mainstem bronchi, a right posterolateral thoracotomy is performed through the fourth intercostal space which gives good access to the region of the carina and lower trachea. It is important to remember that access to the left mainstem bronchus can also be achieved from the right side. If it is known that

Fig 19.6a. Aortogram of unrestrained driver sustaining a motor vehicle accident. The aorta is completely transected.

Fig 19.6b. The patient underwent interposition tube graft replacement of the aortic tear. The upper vessel loops are retracting the phrenic and vagus nerves. Repair was done with the "clamp and go" method.

Fig 19.7. CXR of a young woman sustaining blunt chest trauma in an MVA. There is massive subcutaneous emphysema tracking along the fibers of the pectoralis muscles. A right-sided pneumothorax is decompressed with a chest tube. She was found to have a transection of the right mainstem bronchus and underwent definitive repair.

Fig 19.8. CXR of a boy sustaining a bicycle versus auto accident 3 days earlier. Initial bilateral pneumothoraces were treated with chest tubes, with persistent air leaks. On the third day, complete collapse of the left lung is demonstrated on the CXR (a).

Fig 19.8b. CT scan. The patient was found to have a major left bronchial injury.

Fig 19.9a. The most common presentation of bronchial rupture includes a pneumothorax. This is immediately evident if the rupture is intrapleural.

Fig 19.9b. If the rupture is extrapleural, the air may track within the mediastinum but may not initially present as a pneumothorax.

the only bronchial injury is on the left side, then a left posterolateral thoracotomy is justified.

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