Trachea and bronchial trauma: causes, symptoms, diagnosis, treatment

Trachea can be damaged, deflected or squashed in the cervical and thoracic areas. Damaging factors may include firearms (bullets, fragments, etc.), stabbing and cutting weapons, blows with blunt objects, compression, bruises from falls from a height, etc. Trachea and bronchial injuries can be open and closed, direct and indirect. Traumatic injuries to the trachea and bronchi also include foreign bodies.

Injuries of the cervical trachea. This section of the trachea from above is limited by the cricoid cartilage of the larynx, from below - with a jugular notch, in front it is well protected by fatty tissue, the isthmus and the body of the thyroid gland and anterior cervical muscles.

Open wounds of the cervical region of the trachea are divided, as well as the injuries of the larynx, into gunshot, stab-cut and ruptures due to strokes penetrating deep into the neck of solid objects.

Gunshot wounds are the heaviest, since they are not limited to tracheal damage, but cause significant damage to surrounding tissues and organs, which are caused both by the direct action of the wounding projectile and the hydrodynamic shock wave. Frontal penetrating wounds, especially bullet wounds, usually damage the upper part of the esophagus, they can penetrate into the bodies of the sixth, seventh cervical and 1st thoracic vertebrae, into the spinal canal. Diagonal and lateral gunshot wounds damage the neurovascular bundle with deadly bleeding in the wound of the common carotid artery.

The most severe are the fragmentary gunshot wounds of the trachea, which are often associated with injuries of the larynx, thyroid, large vessels and nerves. Such injuries on the battlefield, as a rule, result in the death of the victim. Only in rare cases in the absence of injuries of large arteries and veins, emergency breathing and urgent evacuation of the injured to the surgical department of the field military hospital, the life of the wounded manages to be preserved.

Stab wounds occur with careless handling of stitching objects, most often when they fall on them (knitting needle, scissors), during fencing competitions (sword, rapier) or during hand-to-hand combat or bayonet exercises. The stabbed wound of the trachea can be negligible, but deep, with subcutaneous emphysema and hematoma. If the wound is caused by a piercing-cutting weapon and is sufficiently sized, then bloody air bubbles are released through it during exhalation and coughing. When you cough into the mouth, bloody, foamy, bubbling sputum is excreted, the voice is weakened, the respiratory movements are superficial. Many of these wounds, if not damaged by the thyroid gland, large vessels, heal spontaneously with the preventive use of antibiotics and the appointment of antitussives. In other cases, bleeding occurs with the penetration of blood into the trachea, emphysema of the mediastinum, compressing the trachea, and as a consequence, rapidly increasing obstructive asphyxia. In these cases urgent surgical intervention with revision of the wound is shown, providing breathing, stopping bleeding and draining the wound cavity. In emergency cases, the wound of the trachea is used to insert a tracheotomy cannula into it, then the patient is transferred to the breath through an ordinary tracheostomy, and the wound of the trachea is sutured.

Cutting wounds in the vast majority of cases are applied with a knife or a razor. In the transverse wound, as a rule, the uppermost parts of the trachea are damaged, with the same phenomena appearing, but only in a more pronounced form, as in the case of punctured wounds. In the case of cut wounds, one or both return nerves can be damaged, which leads to a corresponding paralysis of the posterior cricoid muscles. Large vessels are usually not damaged, but bleeding from smaller vessels can be quite abundant, which leads to significant blood loss. Usually, such victims should be provided with qualified medical assistance at the scene, which should consist in the rehabilitation of breathing, the temporary stop of bleeding, and only after that - in evacuation to a specialized surgical department (operating room). With such a wound, when the sternocleidomastoid and other muscles meet, the wound appears extensive, the head of the victim is thrown back, independent bending of the cervical spine is impossible. With each exhalation from the wound, a bloody foam splashes, when inhaled, blood and foamy sputum are sucked into the trachea. The victim is immobile, silent, his eyes are filled with horror. In such conditions, the victim should be placed on his side, the edges of the wound should be diluted and try to insert a canula or an endotracheal tube into the trachea, take the bleeding arteries for clamps and bandages, zap them with "sweaty" tampons and apply a bandage. If signs of traumatic shock are absent, then we should confine ourselves to the introduction of sedatives, dimedrol and atropine, and in this form and condition, evacuate the patient to a nearby specialized surgical department.

Closed injuries of the cervical region of the trachea occur most often due to a strong blow by a blunt object applied to the area of the front surface of the neck, when hanging "by the method of leaping from a stool" or by wrapping a lasso loop on the neck followed by a strong jerk. In these cases, a fracture may occur, fracture or compression of the trachea. Very rarely, a tracheal rupture can occur spontaneously with a strong coughing thrust, sharply increasing pressure in the underlay space or sudden sharp extension in the cervical spine with tracheal tension.

The contusion of the trachea is most often masked by the manifestations of contusion of the soft tissues of the anterior surface of the neck, unless it is manifested by the discharge of bloody sputum. Usually, with immobilization of the neck and physical rest, recovery comes quickly. But often such a trauma is combined with a bruise of the larynx, as evidenced by a sharp pain syndrome, aphonia, laryngeal edema, and stridor breathing. This combination is a danger of acute asphyxia, especially if there are fractures of the cartilages of the larynx.

Tracheal fractures can occur as a result of a bruise or sudden strong inspiration, which dramatically increases the intra-tracheal air pressure. In the first case, longitudinal fractures of several cartilages appear along the middle line of their arches, in the second case, the inter-ring ligament ruptures. Rapidly developing hematoma and emphysema of the mediastinum and often - asphyxiation. Emergency assistance in such cases consists in intubation of the trachea or lower tracheotomy.

Internal injuries of the trachea should be attributed and wedged foreign bodies, which with their sharp edges can damage the mucosa and cause secondary inflammation by infection of the wound. Usually, after the removal of such a foreign body, healing quickly begins.

Damage to the thoracic region of the trachea and bronchi occurs due to a severe bruise or crushing of the chest (a chest falling from a height to a protruding solid object, moving the wheel, bruising the steering wheel in a frontal collision of cars, etc.). Often, damage to the thoracic part of the trachea is accompanied by a corresponding damage to the main bronchi, from crushing and fracture to complete rupture. As a rule, the lung tissue with ruptures of parenchyma, small bronchi and alveoli is also affected by traumatic effects. In this case, there is hemato- and pneumothorax, atelectasis of the corresponding part of the lung.

With such injuries, the patient is in the shock state from the very beginning, with a marked reflex violation of respiratory and cardiac activity. With the concomitant bruise or compression of the heart, especially with the rupture of the pericardium, the heart stops with an immediate death. The aortic rupture leads to the same outcome.

The outcome of damage to the thoracic trachea and bronchus depends on the severity of the trauma, which is often incompatible with life, and the timeliness of life support (anti-shock therapy, pacemaking, oxygen and hemostatic therapy), complete tracheal rupture leads to death at the scene, compression and fracture of the tracheal rings, an emergency thoracotomy is performed when the recovery of respiration is ineffective by a non-operative route. Treatment of such victims is the responsibility of the resuscitator and thoracic surgeon.