Right Main Bronchus Transection After Blunt Thoracic Trauma

Tracheobronchial injury is a rare occurrence in people with blunt thoracic trauma, and it is associated with significant mortality (1). The majority of patients with tracheobronchial injuries die before reaching the hospital because of the associated mechanism of high-energy impact injuries. However, for those who survive, signs and symptoms can be nonspecific, and a high index of suspicion should be adopted (2).

The Patient

A fifty-three-year-old female with known scoliosis suffered a blunt thoracic trauma when crushed from the neck down by a stack of wooden boards approximately 1.5m in height. She was brought to the emergency department with signs of traumatic asphyxiation, including petechial hemorrhage of the face and neck, cyanosis, and decreased Glasgow Coma Scale of 3/15. While she remained hemodynamically stable, her saturation remained low at around 70% despite endotracheal tube intubation. There was also a noted diffuse subcutaneous emphysema and reduced chest wall movement, especially over the right side. An emergent 28 Fr chest drain was inserted, which improved saturation levels but revealed continuous air leak from the drain. A whole-body trauma CT was performed and showed bilateral multiple rib fractures, sternal fracture, bilateral pneumothorax, pneumomediastinum, bilateral multiple lung contusions, and extensive subcutaneous emphysema. There was tracheobronchial injury to the right main bronchus, with focal discontinuity of the bronchus seen, and with the distal end distracted approximately 2cm away from the proximal stump. No other injuries were noted.

The Procedure

Emergency operation was performed, initially with examination of the pleural space with a 10mm 30-degree thoracoscope, then proceeding to a full right posterolateral thoracotomy. The right main bronchus was found completely transected, with an additional longitudinal tear along the posterior wall of proximal stump noted. The longitudinal tear was repaired with 4-0 Vicryl sutures in an interrupted fashion. The right main bronchus transection was also repaired with 4-0 Vicryl interrupted sutures. A bovine pericardial patch was placed between the anastomosis and the right main pulmonary artery, which was bruised, to act as a barrier.

The underlying scoliosis of the patient was proposed to be one of the factors in which the transection occurred. The transected bronchus was seen overlying the convexity of the scoliotic spine, which acted as a pressure point when the anteroposterior force from the crush injury likely pushed the bronchus against the vertebrae, causing the tear.

Post-Op

The patient recovered uneventfully, weaned from mechanical ventilation two days postoperatively in the ICU and was discharged home without significant morbidity on postoperative day thirteen. Her rib and sternal fractures were managed conservatively. A flexible bronchoscopy performed one month after the operation showed satisfactory recovery with minimal narrowing of the right main bronchus proximally only, and the patient remained symptom free.

References

1. Baugartner F, Shepperd B, De Virgilio C, et al. Tracheal and main bronchial disruptions after blunt chest trauma: presentation and management. Ann Thorac Surg. 1990;50:569–74.
2. Zarama V, Velásquez M. Mainstem bronchus transection after blunt chest trauma. J Emerg Med. 2013 Jan;44(1):187-8.

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