history of hanging, few hours before reaching the hospital. on arrival patient has difficulty breathing, speaking, and swallowing. progressing dyspnoea (third image is an endoscopy) on examination patient is very uncomfortable, struggling spo2 - 85-90% weak voice + stridor + b/l lung sounds decreased. what is the rare but deadly condition it had resulted in. what are the differentials, emergency steps needed to save him.
I think it's the traumatic laryngo-tracheal separation due to effect of hanging. It's quite a rare phenomenon. I have heard about it during my MBBS days from a Forensic Medicine Professor. The cause may be sudden neck extension with laryngeal fixation and antero-posterior compression on trachea leading to a shearing force. CT scan is diagnostic. There may be associated thyroid cartilage injury or cricoid injury with surgical emphysema. There may be presence of RLN injury also. Initial management should be maintaining an adequate airway with tracheostomy . If the patient survives , elective tracheal reconstruction can be attempted. I only know this much. Thanks for sharing such a rare case.
this is a case of near total cricotracheal separation. total separation will result in immediate death. near total and total cricotracheal separation results in b/l pneumothorax (b/l decreased breath sounds) this is because the pretracheal and deep fascia of neck is contiguous till the main bronchi and bifurcation of trachea. so it's much more rapidly progressing than unilateral pneumothorax. the three signs of separation are 1.stridor, weak voice , blood in larynx 2. b/l pneumothorax 3.emphysema neck management: 1.emergency tracheostomy intubation is contraindicated normally during tracheostomy neck needs to be extended but in this case it should not as extension will make near total separation a total one. stridor is due to b/l rln palsy as they are mostly transected. release of pneumothorax and placement of water seal drain. repair should be taken up within 24-36hrs the further delay in the repair more chances of laryngotrac stenosis. this patient underwent next day the first two rings were totally crushed they were excised and third ring was anastomosed to cricoid. three weeks later on evaluation he was found to have stenosis. at cricoid. we took him up for cricoid split and laryngotrac reconstruction with costal cartilage. after 4 weeks of stent placement he was found to have patent airway, but rln palsy persisted I.e b/l vocal cords were medialised so he underwent posterior cordotomy. though he's got a rough husky voice now he's comfortably breathing.
This is a case of cricotracheal separation with fracture of thyroid cartilage..a laryngeal trauma with shauffer grade 4 severity....best thing is do a tracheastomy..put the patient on supportive ventilation....let the emphysema settle....repeat a scopy after 1 month till then the complete healing and fibrosis would have occured..then decide on airway reconstruction.. You could jave tried airway recon immediately after accident if it would have been a single level issue....mostly after healing he will require a extended PCTR..there is no role of montogomery t tube in such patients
this x-ray is showing lateral view of neck if you follow the air in the oropharynx and larynx below to the trachea there is a discontinuity below the cricoid cartilage this discontinuation is the diagnostic sign of cricotracheal separation
dont intubate if airway not obstructed . If airway acutely obstructed then prehoapital intubation is suggested . fluid resuscitation be proper in view of cerebral oedema or Ards or aspiration .if Endotracheal intubation itself fails or not possible then cricothyroidotomy is a option . if injuries render cricothyroidotomy impossible then percutaneous translaryngeal oxygenation of patient is a temporary option with permenant laryngotomy . MOST IMPORTANT if patient stabilised then PSYCHIATRIC COUNSELLING is very important as such tendencies have a huge rate of relapse . Please take all high risk and procedure consents with adequately explaining patients relatives ...
1) Stridor; Bl Dec.lung sound s/o...Airway Obstuction at the level either Supragl; Glottis or Subglottis or trachea 2) Any lesions in these area can be assessed clinically e.g.Pain on moving tongue suggests epiglottic injury. 3) Probably it can be laryngeotracheal injury clinically bony crepitus over larynx. 4) Dropping SPo2 is a strong indication for E- Tracheostomy to this Pt. ( Cricothroitomy for supraglottic obstruction)....Dr.Hameed Chaudhari, LATUR,Maharashtra
in such a case,priority is to maintain oxygenation of the lungs to avoid precipitation of lungs oedema by jet ventilation,as air entering in lung is poor due to injury in trachea.poor air entry in lungs will leads to fall intra alveolar pressure ,causing increased alveolar capillaries pressure causing oosing of fluids in alveolar spaces,will lead to worsening of oxygenation.
Cricotracheal seperation is seen and emergency tracheostomy to be done to secure airway first. laryngotracheal reconstruction to be planned +/- stent after that
Immediately do the tracheostomy and stabilise the vitals. Due to hanging, laryngeal oedema will worsen the scene. follow C A B protocol
First the life saving measure is tracheostomy. When the pt survives repair at a later date
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