Nonoperative Management of a Pediatric Blunt Traumatic Distal Tracheal Injury.

Introduction: Blunt traumatic tracheal injury in children is rare and potentially life-threatening. Operative management has traditionally been recommended, though recent reports suggest that nonoperative management may be appropriate in selected patients.

Case presentation: A previously healthy 10-year-old boy presented after an unwitnessed helmeted all-terrain vehicle crash with severe hypoxia, facial swelling, and diffuse subcutaneous emphysema. Initial evaluation at an outside hospital demonstrated bilateral pneumothoraces requiring bilateral chest tube placement. Following transfer, CT imaging revealed a 1 × 1.1 cm posterior tracheal laceration at the carina, pneumomediastinum, pneumopericardium, pneumoperitoneum, extensive subcutaneous emphysema, pulmonary contusions, and rib fractures. Bronchoscopy confirmed a carinal rupture with mediastinal tissue abutting the defect. Attempts to position the endotracheal tube distal to the injury were unsuccessful; therefore, the patient was intubated proximally with a 5.5 Microcuff® tube. Given the patient's hemodynamic stability, absence of active air extravasation, and ability to maintain ventilation with low pressures, operative repair was deferred. The patient was maintained on low-pressure ventilation, sedation with paralytics, and empiric antibiotics, with daily bronchoscopy for airway clearance and assessment. The injury progressively granulated, and the patient was successfully extubated 10 days after the injury. He was discharged uneventfully on hospital Day 17 and was clinically asymptomatic at follow-up.

Conclusion: Severe blunt pediatric tracheal injury may be successfully managed nonoperatively when patients are hemodynamically stable and air extravasation remains controlled and minimal.