Keywords
airway - extracorporeal life support - trachea - emergency room
Case Presentation
A 42-year-old youth worker suffered from traumatic tracheal injury during a night-time
boat trip caused by a fishing line stretched across the river. He was found conscious
and referred by paramedics to the nearest, primary emergency department (emergency
room [ER]). After rapid hemodynamic deterioration at the primary ER, he was intubated
directly through the cricotracheal wound and referred to our tertiary hospital for
further treatment. At administration, the patient was sedated and cardiopulmonary
impairment was regulated with moderate doses of norepinephrine and oxygen. A subsequent
trauma scan using computed tomography was initiated ([Fig. 1]).
Fig. 1 Computed tomography showing the direct cannulation of the trachea.
Due to the possibility of further hemodynamic instability and especially difficult
airway management during the emergent operation for trachea reconstruction, we decided
to partially support the patient using extracorporeal life support (ECLS). He was
placed in the operating room, where under radiographic guidance a 15-Fr (French) cannula
was inserted into the left subclavian vein. An additional 23-Fr cannula was inserted
into the left femoral vein and ECLS support was initiated after the application of
5,000 IE heparin at the rate of 4 L/min, SpO2 100%. The initial borderline blood gases improved, and we were subsequently able
to fully inspect the traumatic damage after the removal of wound drapings and the
cervical collar used for fixation during interhospital transfer. Close inspection
of the wound showed a 15-cm long, gaping wound down to the intact esophagus and with
the larynx detached from the trachea ([Figs. 2] and [3]). Despite the trauma, no vessels were injured, and bleeding was surprisingly minor.
After wound debridement a surgical tracheostoma was formed followed by trachea reconstruction,
which was achieved using direct, single stitched sutures. After successful reconstruction,
the patient was weaned off the veno-venous-ECLS support and the cannulas were removed
without complications. The patient was administered to the intensive care unit. He
recovered from the trauma and was administered to the outpatient clinic, but still
bearing up with tracheostoma due to paralysis of both vocal cords which is the most
commonly associated injury in approximately 50% of all patients with blunt trauma.[1]
Fig. 2 A 15-Fr cannula inserted into the left subclavian vein for ECLS support. The endotracheal
tube (ET) is fixed with gauze bandages and a cervical collar. ECLS, extracorporeal
life support.
Fig. 3 Intraoperative situs of the wound. The trachea is completely dissected; however,
despite the severe trauma, no major vessels were damaged.
Conclusion
Blunt trauma to the trachea (“clothesline injury”) is uncommon; however, several case
reports have been published.[2] Sharp trauma, causing an open transection of the trachea is even rarer and requires
distinct differences in patient management, especially airway management.[3] Airway management remains vital in such a case. Facilitating the 24 × 7 ECLS standby
can be of utmost importance in such or a similar case. By using ECLS support, we were
able to partially replace the lung function and thus we safely accessed and operated
the patient without the need for rapid and possible insecure re-intubation.
