Ann Thorac Surg 2004;77:1422-1423
© 2004 The Society of Thoracic Surgeons
Case report
Complete tracheal rupture after a failed suicide attempt
Victor S. Costache, MDa*,
Claire Renaud, MDa,
Laurent Brouchet, MDa,
Tudor Tomab,
François Le Balle, MDa,
Jean Berjaud, MDa,
Marcel Dahan, MD, PhDa
a Department of Thoracic Surgery, CHU Purpan, Toulouse, France
b Department of Pneumology and Respiratory Diseases, The Royal Brompton Hospital, London, United Kingdom
Accepted for publication April 18, 2003.
* Address reprint requests to Dr Dahan, Service de Chirurgie Thoracique, CHU Larrey, 24 Chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex 9, France
e-mail: dahan.m{at}chu-toulouse.fr
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Abstract
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Tracheal rupture is life-threatening and its management poses a considerable challenge to both anesthesiologists and surgeons. We report the case of a 44-year-old patient with a complete tracheal rupture after a failed suicide attempt by hanging. A rare bilateral injury of the laryngeal nerves was associated. An original tracheal intubation was performed using the video unit for thoracoscopy. The severity of the lesions required the placement of a tracheostomy cannula after the tracheal repair. The postoperative course was uneventful. The patient was discharged on the 12th day, with a remaining moderate dysphonia.
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Introduction
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Ruptures of the tracheobronchial tree are common after blunt trauma, penetrating or gunshot wounds, explosion injuries, hanging, and iatrogenic injuries. They often present as a life-threatening situation with the development of tension pneumothorax, mediastinal and cervical emphysema, stridor, and respiratory distress. Management is usually difficult and involves emergency physicians, anesthesiologists, and surgeons.
Hanging as a method of attempting suicide is increasing in incidence. Most of the victims are males younger than 40 years old with a history of suicide attempts. Unlike judicial hanging, where the body falls from a great height resulting in certain death, suicide hanging has a rather optimistic survival prognosis, as the fatal spinal cord and skeletal injuries are rare with a favorable neurologic outcome. Patients with spontaneous circulation on scene usually survive; therefore, aggressive resuscitation and management of hanging victims are justified.
We report the case of a 44-year-old patient with a history of a depressive disorder and a previous failed suicide attempt who was brought to our service a few hours after a suicide attempt by hanging. Paramedics found the patient prone within minutes after his relatives cut down the rope. On examination at the scene the patient's airway was partially occluded by his tongue; however, he was ventilating normally and he presented an obvious strangulation mark. Neurologic examination was unremarkable. He complained of progressive discomfort in the neck, and developed progressive subcutaneous emphysema of the face and neck, accompanied by stridor and hoarseness.
On arrival at the hospital he was stable, with pulse 76 beats/minute, blood pressure 120/70 mm Hg, respiratory rate 18 breaths/minute, and oxygen saturation 97% on 2 L/minute oxygen. A cervical x-ray revealed prevertebral air, massive cervical and upper thoracic surgical emphysema, and no other abnormality. Cervical and thoracic computed tomography (CT) revealed a complete tracheal rupture starting from the 3rd cervical vertebrae up to the 5th cervical vertebrae (Fig 1).
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Fig 1. Cervical and thoracic computed tomography showing a complete tracheal rupture from the third to the fifth cervical vertebrae.
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The patient was taken to the operating room for surgical repair of his tracheal rupture 10 hours after his suicide attempt. We performed intubation with a small-caliber No. 7F-gauge Mallinckrodt endotracheal catheter under direct videothoracoscopic control, while the patient was under general anesthesia without curarization. The cuff was carefully placed and inflated under the tracheal rupture. The patient was placed under controlled ventilation. Because the lesion was in the upper third of the trachea, we approached it through a large transcervical incision; the infrahyoid muscles were separated along the midline down to the sternum and the pretracheal fascia was opened longitudinally.
We found a complete tracheal section between the cricoid bone and the first tracheal ring associated with a bilateral injury of the superior laryngeal nerves. On the left side the nerve was completely ruptured with the remaining ends 25 mm apart, while on the right we noticed a pulling and no sign of a tear. We performed an end-to-end anastomosis; the tracheal edges were retracted laterally, the pars membranosa was closed using a 3-0 Vycril running suture, and the anterior wall of the trachea was closed with interrupted sutures. These stitches were passed through both the rings and the intercartilaginous membranes to prevent the tracheotomy edges from overlapping. Laryngeal nerve lesions required tracheotomy at the level of the 4th tracheal ring.
Postoperative recovery was uneventful except for phonation and swallowing problems caused by the bilateral laryngeal nerve deficit. An endoscopy was performed on the 11th postoperative day showing a complete left vocal cord paralysis and a mild right vocal cord paresis. After the patient was seen by a speech therapist, the tracheostomy cannula was safely removed on the 21st postoperative day. After 2 months follow-up the patient underwent a second endoscopy that showed no sign of stricture and a well-compensated unilateral nerve paresis.
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Comment
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Here we describe a case of complete tracheal rupture after a suicide attempt and its management and postoperative course.
Tracheal rupture describes any injury between the cricoid cartilage and the carina. Its etiology includes iatrogenic mechanisms, blunt chest trauma, penetrating wounds, avulsion, and explosion injuries [1]. The most common cause of posttraumatic injury is sudden deceleration after high-speed motor vehicle accidents [1, 2]. Suicidal hanging is seldom a cause of tracheal rupture presenting in A&E, however: as the body does not usually fall from a great height, fatal spinal cord and skeletal injuries are rare [3].
Aggressive resuscitation and management of the vic-tim are justified to diminish the extent and the gravity of the possibly fatal lesions [3, 4]. Physical signs and radiology usually suggest the diagnosis of tracheal rupture, while endoscopy confirms it. In the case presented here, CT established the diagnosis, showing that the trachea was completely ruptured and surrounded by massive subcutaneous emphysema. Tracheal intubation was difficult, but was helped by the use of a fine-caliber thoracoscopic camera, which allowed a safe placement of the cuff after the distal end of the transected trachea.
The therapy of tracheal lesions is controversial. A decisive factor in selecting the right management option is the extent and topography of the lesion [2, 5]. Some centers advocate a conservative approach for tears <2 cm [6]. On arrival in A&E our patient was in respiratory distress with massive subcutaneous emphysema with an increased risk of developing severe mediastinitis. We chose to operate immediately using a cervical approach, which provides an excellent exposure for upper tracheal pathology [5]. Tracheal intubation is challenging in the setting of complete tracheal rupture. We preferred an original approach by placing a fine thoracoscopic camera through an endotracheal catheter. The end-to-end anastomosis proved viable, respecting the vascular supply of the tracheal wall. We believe that the avulsion of the laryngeal nerves justifies the use of a protective tracheotomy that is believed to be unnecessary in uncomplicated cases [5]. The cannula should be placed under the suture line to minimize the risk of infection and mechanical disruption.
The present case was unusual because of the rarity of its etiology and the associated laryngeal nerve injury complicating the operative procedure and the postoperative course. We advocate early surgical treatment as the therapy of choice for tracheal injuries, ensuring a rapid relief from a life-threatening situation with an excellent operative outcome.
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Acknowledgments
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Our thanks to Bernard Meusberger, Karim Taj and Bruno Degano for their patience and support.
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References
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- Gabor S., Renner H., Pinter H., et al. Indications for surgery in tracheobronchial ruptures. Eur J Cardiothorac Surg 2001;20:399-404.[Abstract/Free Full Text]
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- Martin de Nicolas J.L., Gamez A.P., Cruz F., et al. Long tracheobronchial and esophageal rupture after blunt chest trauma: injury by airway bursting. Ann Thorac Surg 1996;62:269-272.[Abstract/Free Full Text]
- Grillo H.C. Development of tracheal surgery: a historical review. Ann Thorac Surg 2003;75:610-619.[Free Full Text]
- Hofmann H.S., Rettig G., Radke J., Neef H., Silber R.E. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg 2002;21:649-652.[Abstract/Free Full Text]
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Abstract
Introduction
