Management of major tracheobronchial ruptures in patients with multiple system trauma

Major tracheobronchial injury presents special problems in the context of multiple system trauma. A 14-year review of a clinical experience revealed eight patients who had operative repair of major bronchial or intrathoracic tracheal injuries. The diagnosis was suspected by subcutaneous emphysema, and especially by persistent pneumothorax or a significant air leak. Bronchoscopy confirmed the diagnosis in all patients before thoracotomy. All eight patients had multiple system injuries. All five with abdominal injuries were hypotensive at admission and underwent celiotomy before thoracotomy. The decision to perform thoracotomy or celiotomy first in patients with major tracheobronchial injuries and concomitant abdominal trauma must be individualized. If both injuries are recognized simultaneously and the patient is hemodynamically unstable but has adequate oxygenation and ventilation, the celiotomy can be performed first. On the contrary, if oxygenation and ventilation are the most threatening problems in a hemodynamically stable patient despite evidence of hemoperitoneum, the bronchial repair should have priority.