Pediatric emergency medicine trisk 3723 3723

Tracheobronchial injuries are difficult to diagnose in children, and may
be indicated by the presence of subcutaneous air,
pneumomediastinum, or persistent air leak following tube thoracostomy
for pneumothorax.
In patients with suspected tracheal injury, endotracheal intubation
should be performed under bronchoscopic guidance in the operating
room when possible, to avoid converting a partial tracheal injury to a full
tear.
Symptoms of esophageal injury will depend on the region that
perforates, and symptoms may therefore refer to the neck, chest, back,
or abdomen. Delay in diagnosis has a significant impact on morbidity
and mortality.
While the finding of abdominal contents in the chest on radiograph is
specific for diaphragmatic rupture, it is insensitive, and this injury must
be considered any time there is significant blunt force to the abdomen
or penetrating injury to the chest.
The findings of traumatic asphyxia are dramatic, but patients who
survive the initial injury are most at risk from associated intra-abdominal
and intrathoracic injuries.

Tracheobronchial Injuries
Injury to the tracheobronchial tree in children occurs rarely, with an incidence of
less than 1% of injured children. This injury typically results from a high-energy
mechanism or a focused direct blow. Major vessels or pulmonary parenchyma are
more likely to be injured in penetrating trauma than the tracheobronchial tree.
Cervical tracheal rupture may be caused by a direct blow to the trachea or violent
flexion and extension of the patient’s head. This whiplash effect can cause a tear
between two cartilaginous rings. Lower tracheobronchial injury usually occurs
from a sudden increase in intrabronchial pressure. Because the child’s chest wall
is elastic, the trachea and main bronchi can be compressed between the chest wall
and the vertebral spine. Compression of the chest against a closed glottis can

cause a sudden increase in intrabronchial pressure, resulting in a tracheobronchial
tear. Shear forces, traction, and crushing the airway between the chest and
vertebral column may also cause a tracheobronchial injury. Approximately 80%
of tracheobronchial injuries occur on the posterior wall of the airway within 2 cm
of the carina.