Pearls and pitfalls in blunt laryngotracheal injuries—a case series

Background: Blunt laryngotracheal trauma is an uncommon injury due to motor vehicle collisions (MVCs) and is associated with maxillofacial, cervical, and thoracic injuries. The presence of concomitant injuries often overshadows the non-specific signs of underlying tracheal injury. A high index of suspicion resulting in early detection of tracheal trauma is one of the most crucial factors in reducing mortality and morbidity. Also, establishing a patent airway is particularly challenging in these patients, in whom complex airway management techniques may be required. Despite the clinical relevance, many concerns on blunt tracheal trauma remain under investigated. This case series is unique in depicting the initial clinical picture of blunt trauma patients suggesting the possibility of an underlying laryngotracheal injury. It also highlights the technical challenges of airway management in patients with tracheal injury, especially in low-resource emergency departments (EDs). Case Description: We present a case series of six patients who sustained laryngotracheal injuries secondary to blunt neck trauma. The mechanisms of injury in our patients were MVC and throttling. Two patients presented in respiratory failure requiring emergency surgical airway, and were later diagnosed to have complete tracheal transaction and underwent surgical repair. The other four patients presented with clinical signs of blunt neck trauma with minimal or no respiratory distress. Three of these four patients were managed non-surgically with conservative measures, while one patient required surgical repair of laceration with tracheostomy. Signs of air leak, such as pneumomediastinum, pneumothorax, and subcutaneous emphysema over neck or chest, were found in four of six patients, and tube thoracostomy was performed in all four patients. The two patients with complete tracheal transection who presented with respiratory failure had in-hospital mortality, while the other four patients survived to hospital discharge. Conclusions: The clinical and radiographic signs most frequently seen with blunt tracheal injury were dyspnoea, pneumomediastinum, pneumothorax, and subcutaneous emphysema. Early detection triggered by a high degree of suspicion is essential to avoiding rapid sequence intubation (RSI) that may worsen a tracheal injury. The ideal method to secure airway in patients with tracheal injury is awake intubation over a flexible bronchoscope and inflation of the cuff distal to the injury site. Tracheostomy should be considered in those with complete or pending airway obstruction or after failed attempts of endotracheal (ET) intubation, or when ET intubation is unsafe as in the presence of concomitant craniofacial injuries.