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You are caring for a 9 year old boy involved in a motor vehicle accident. He has a seatbelt sign on his left neck and you palpate subcutaneous emphysema of his upper chest.
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August 11, 2020 at 10:20 pm
D) Most plain chest radiographs are normal; chest CT is needed for diagnosis
Tracheobronchial injuries are relatively uncommon; common mechanisms for pediatric patients include high-speed motor vehicle accidents, falls, and crush injuries. Penetrating injuries are more frequent in adults. Symptoms and signs are often nonspecific and a high index of suspicion is required: tachypnea, hemoptysis, dyspnea, stridor, hoarse voice, subcutaneous emphysema (particularly spreading), Hamman’s sign, pneumomediastinum, pneumothorax that does not resolve with tube thoracostomy, high-riding hyoid bone. Only 10-20% have no evidence on plain radiograph. Findings include: pneumomediastinum, subcutaneous emphysema, hyoid bone above C3, overinflated ETT cuff, and “fallen lung” sign, where the transected lung appears collapsed posterolaterally, mimicking pneumothorax. CT scan is used to fully characterize the injury. Airway management should be done by placement of the ETT over flexible bronchoscope and cuff inflation distal to the injury site if possible.