Tracheobronchial injuries after blunt chest trauma in children--hidden pathology.
BACKGROUND: Blunt thoracic injuries in children are unique because the pliability of the chest wall allows transmission of massive external force directly into the mediastinum. Children presenting after blunt chest trauma may have complete disruption of the airway with little external sign of injury. Without prompt diagnosis and appropriate treatment, the risk for progressive respiratory failure is high. METHODS: Four children with tracheobronchial injuries were referred to a pediatric trauma center from 1994 to 1997. All children, age 18 months to 13 years, suffered unusual crush injuries. All diagnoses were based on unresolved pneumothorax or pneumomediastinum. RESULTS: Bronchoscopy identified the location of injury as posterior trachea (n = 1) and right mainstem bronchus (n = 2). A tertiary bronchial injury (n = 1) was missed by initial tracheogram and subsequent bronchoscopy but identified during surgical exploration. All children survived after thoracotomy and primary repair of the injury. CONCLUSIONS: Tracheobronchial disruption is a rare, life-threatening injury. Suspicion should be high when pneumomediastinum and pneumothorax are refractory to adequate pleural drainage. Flexible bronchoscopy with intubation distal to the injury may be necessary to prevent loss of the airway. Advance preparation should include setups for bronchoscopy, thoracotomy, and cardiopulmonary bypass. Patient survival depends on preparation and prompt surgical intervention.