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Swat Surgeon,
This is a great case. I am enjoying all of these posts and comments.
If I might, I would like to add a few things if that is alright.
First, get this young man out of danger and evacuate him to a safe area NOW!!! If it is in a combat zone, please do not let him go back out there. If he is in the United States and this happens out in the streets, get him to a level one trauma center. A respiratory death is closer than you realize.
We only have one airway and if you lose it, that could be it. He may not understand because he wants "payback" but he will go on to live many years with a wife kids, mortgage, grand kids, if you do this correct the first time. Remember, it was the cardiologist that invented the ABC's and they got it correct. Airway, Breathing, Circulation. Now, today "C" may first come in front of "A and B" but that is for blast injuries that rip legs or arms off or AK-47 injuries to femoral arteries that can get QuikClot, Hemcon, a tourniquet and pressure to the area. A surgical cricothyrotomy is nice to talk about and very dramatic, but in this patient, it is not a given and there are many injured structures just waiting for you to make a cut, release the clot, and then they will stat bleeding into the airway.
Moving on, the location of this injury is a zone 2 entrance and a zone 2 landing but you may need better access than just a standard anterior sternocleidomastoid incision. To get to this injury the anterior trachea will be easily repaired through the anterior exposed neck or SCM incision, but the zone 2 posterior trachea injury . . . the specter for the need for a median sternotomy lurks. It is in a bad location but I would start with the left SCM incision but have a chest surgeon in the back of my mind if I have to go into the chest for proximal control. Usually when the thorax surgeon returns my page I have fixed it, but this could still be trouble.
If this projectile not only injured the anterior trachea but also got the posterior trachea, then it may have injured the membranous trachea. You know what that means . . . the esophagus. It lies there behind the trachea in wait for the unsuspecting to miss an injury to it. A thorough evaluation must be done with endoscopy, gastrograffin (if you have time pre-op and if he is stable) and if not an open evaluation during your repair of the trachea with full anterior and posterior visualization and NGT placement with air pushed through a syringe to look for more bubble. CT scan would be nice but not necessary. Think about methylene blue in the esophagus by the NGT to look for a hidden injury.
Now, I want to share this with everyone as I remember a ghost from my past. The X-ray with the endotracheal tube is a wonderful x-ray that is highly instructive and if the hair on your back did not stand up looking at it then I am afraid you missed it. If there was an anterior and posterior injury, the person that intubated could have shovel nosed onto either edge of the injured trachea and dislodged the remaining attachments of the trachea thereby separating the proximal and distal trachea. (Whoever intubated this young man should go to church twice and the patient three times on Sunday.) The chance of getting the ETT into the distal trachea will be lost if the trachea is cut in half by shovel nosing it and with the bleeding that one stirred up with this attempt at intubation. Saw this once in a child sledding that was "clothes-lined" by barbed wire. The attempt at intubation in th ED and loss of the distal trachea was horrifying as the child had come in crying. Even a fast trip to the OR for a neck exploration by my attendings could not save this child as he lost his airway and coded within minutes and all of the messing around to figure it out while in the ED only lead to his death. Going to the OR then was just an on-table autopsy. This was a lesson I learned as a young intern. Consider when intubating using a bronchoscopy to follow the ETT down and across the injuries.
So, while Airway is critical, remember that if the patient is talking, breathing, holding his own and able to cough up the blood or sputum to protect his airway, but again, doing well, let sleeping dogs lie, get him out of the combat zone and get him to a trauma or combat hospital. Also, if they want to sit up, because they feel like they are choking when they try to lay down, please let them sit up. Do not force them to lay down despite what ATLS says. Hold off on occlusive dressings. A gauze to collect the blood is fine.
Finally, intra-op and post-op at extubation, think about recurrent laryngeal nerve injury. If both recurrent laryngeal nerves are out you could have the rapid need for a reintubation after a repair or you are back to a surgical airway. The vocal cords slam shut if both are out. Even if one is out, patients can struggle with their airway. Extubate with direct fiberoptic laryngoscope or bronchoscopy within the ETT and watch the cords.
As for thyroid damage, well, that is why Synthroid was invented.
Simply an incredible case, Swat Surgeon, with lots of teaching points!
Thank you,
Dutch
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