From Impact to Intubation: Airway Management in Complete Tracheal Transection

Shweta Mohapatra, MA1; Pallavi Muraleedharan, BS1; Blake Fairchild2; Sally Raty, MD3

1McGovern Medical School at UTHealth Houston, Houston, TX  2Texas A&M University, College Station, TX  3University of Texas MD Anderson Cancer Center, Houston, TX

Introduction

Complete tracheal transection usually occurs due to a significant force that disrupts the trachea's structural integrity, leading to potential respiratory distress, subcutaneous emphysema, aphonia, stridor, visible neck bruising, and the loss of palpable landmarks.1 

Case Description

• Middle-aged male sustained complete tracheal transection upon impact with his steering wheel 

• Neck bruising, desaturation without respiratory distress, subcutaneous emphysema and inability to phonate 

• ETT was advanced through the vocal cords with a nasal fiberoptic technique, but tracheal rings were not visible

• Distal trachea was several centimeters to the left

• Converted to an oral fiberoptic technique

• Primary surgical repair involved a transverse neck incision and advancement of ETT past the point of disruption

• The patient was transferred to the ICU and extubated successfully several days later 

Discussion

• Clinical presentation from a transection varies and can include desaturation, subcutaneous emphysema, aphonia, and visible neck bruising.1 

• Symptoms are common in other similar injuries, such as a tracheobronchial tear, decreasing the likelihood of swift and accurate recognition.2 

• Final diagnosis relies on imaging modalities which can reveal pneumomediastinum, pneumothorax, and tracheal displacement.3 

• Initial nasal fiberoptic intubation failed because the tracheal displacement required a longer scope length.

• The patient’s C-collar, inability to phonate, obesity, and short thyromental distance made him a good candidate for fiberoptic intubation as opposed to direct laryngoscopy. 

• Rapid diagnosis and securing the airway are crucial.

• Ongoing monitoring for potential complications is essential. 

Conclusion

This case report underscores the importance of a coordinated and adaptable approach in managing severe tracheal injuries. The successful outcome was achieved through meticulous airway management, timely surgical and anesthetic intervention, and comprehensive postoperative care.