TRACHEOBRONCHIAL INJURIES AFTER BLUNT CHEST TRAUMA IN CHILDREN - HIDDEN PATHOLOGY

Background: Blunt thoracic injuries in children are unique because the pliability of the chest wall allows transmission of massive external force directly into the mediastinum. Child ren presenting after blunt chest trauma may have complete disruption of the airway with little ex ternal sign of injury. Without prompt diagnosis and appropriate treatm ent, the risk for progressive respiratory failure is high. Methods: Fo ur children with tracheobronchial injuries were referred to a pediatri c trauma center from 1994 to 1997. All children, age 18 months to 13 y ears, suffered unusual crush injuries. Ail diagnoses were based on unr esolved pneumothorax or pneumomediastinum. Results: Bronchoscopy ident ified the location of injury as posterior trachea (n = 1)and right mai nstem bronchus(n = 2). A tertiary bronchial injury (n = 1) was missed by initial tracheogram and subsequent bronchoscopy but identified duri ng surgical exploration. All children survived after thoracotomy and p rimary repair of the injury. Conclusions: Tracheobronchial disruption is a rare, life-threatening injury. Suspicion should be high when pneu mo mediastinum and pneumothorax are refractory to adequate pleural dra inage. Flexible bronchoscopy with intubation distal to the injury may be necessary to prevent loss of the airway. Advance preparation should include setups for bronchoscopy, thoracotomy, and cardiopulmonary byp ass. Patient survival depends on preparation and prompt surgical inter vention. Copyright (C) 1998 by W.B. Saunders Company.