1 Department of Anaesthesia and 2 Department of Surgery, Padhar Hospital, Betul, Madhya Pradesh-460005, India
* Corresponding author. E-mail: neipe{at}yahoo.com
Accepted for publication August 23, 2004.
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Keywords: airway, management ; burns, electric ; complications, tracheo-oesphageal-cutaneous fistula
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Case report |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
|
He remained stable and the continuous ECG was normal.
The airway was a priority and tracheostomy and chest tube insertion was planned in the Intensive Care Unit (ICU). The airway was secured awake and with the patient breathing spontaneously, using a 6.5-mm Portex cuffed tracheostomy tube (Portex Ltd, Hythe, CT21 6JL Kent, UK), inserted into the traumatic tracheal opening. When connected to a Bain's circuit, the patient breathed comfortably through this tracheostomy, with improved air entry over the right lung and decreasing s.c. emphysema. An intercostal drainage tube was inserted under local anaesthesia and the pneumothorax connected to an underwater seal.
He was moved to the operating theatre where flexible fibre-optic bronchoscopy and oesophagoscopy was performed under local anaesthesia and sedation (midazolam 2 mg i.v.). This revealed a subglottic tracheo-oesophageal-cutaneous fistula. Examination of the laryngeal inlet was difficult because of the oedema of the glottis and no vocal cord movement could be ascertained. An elective low tracheostomy was planned, in view of the extensive tracheo-oesophageal burn, the need to protect the lower airways and for reconstructive surgery.
Assisted ventilation was possible using the traumatic tracheostomy, without evidence of gastric distension. Anaesthesia was induced with ketamine 75 mg i.v. and maintained with a mixture of oxygennitrous oxide and halothane. A formal low tracheostomy was then carried out with a Portex cuffed tracheostomy tube 6.5 mm ID (Portex Ltd) and the traumatic tracheostomy tube was removed after satisfactory ventilation was established. A feeding jejunostomy was performed and the patient was returned to ICU. Elective tracheo-oesophageal separation and free flap reconstruction was planned.
After fasting overnight and no pre-medication, the patient was taken to the operating theatre and monitoring instituted. The tracheostomy was connected to the breathing circuit and anaesthesia was induced with the patient breathing a mixture of oxygen and nitrous oxide (1:1) with increasing concentrations of halothane (0.51.5%), followed by pancuronium bromide 4 mg i.v. to facilitate mechanical ventilation.
The surgeons explored the neck and found a defect in the posterior wall of the trachea extending inferiorly approximately 5 cm. The injury appeared to extend posteriorly through the oesophagus to the prevertebral fascia. The oesophageal burn was extensive and required reconstruction with a stomach free flap, taken from the greater curvature based on the right gastro epiploic artery and vein and anastomosed to the facial artery and superior thyroid vein. Omentum was used to interpose the new oesophagus and trachea. The patient had an uneventful postoperative period. The chest tube was removed on the fifth day after a chest radiograph showed full expansion. He was discharged with the tracheostomy tube and is planned for a tracheal reconstruction at a later date.
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Electric burns to the neck resulting in an tracheo-oesophageal-cutaneous fistula and its anaesthetic management to our knowledge has not been reported previously. Electrical injuries currently remain a worldwide problem. Accidental electrical injury is more common in children, particularly males (1118 yr).1 Electrical burns differ from thermal and chemical burns in that they tend to have deeper surface penetration resulting in extensive tissue damage. Voltage, point of entry, pathway of current, associated multiple trauma or flame burns, and surgical treatment seem to be the main factors influencing the lesion and the morbidity. Sequelae include limb fractures and amputations, renal failure, cardiac arrhythmias, cataracts, and neurological complications.2 Entry points are most commonly in the hand. This patient was haemodynamically stable and the continuous ECG monitoring did not reveal any conduction abnormality; hence a formal 12-lead ECG was not done. This is indicated in all patients with electric burns and especially those with injury as a result of electric current pathways that cross the chest.
Penetrating injuries to the neck may result in major vessel injury and laryngotracheal injury, with or without oesophageal injury. Oesophageal injury is infrequent3 but may go unnoticed and present later. Therefore, a high index of suspicion of oesophageal injury is required in these patients.
Tracheo-oesophageal-cutaneous fistulas are uncommon. In a series of seven patients with complete laryngotracheal disruption all but one had intact cutaneous tissue of the neck.4 The presenting symptoms of traumatic TOF are predominately a result of the laryngotracheal injury. These include respiratory distress and s.c. crepitus, hoarseness, dysphonia, cough, noisy breathing stridor, and dysphagia.3
Diagnostic evaluation in a series of 32 patients described by Grewal and co-workers3 included: laryngoscopy/tracheoscopy (17), oesophagoscopy (12), contrast oesophagography (9), angiography (8), and bronchoscopy (3). Emergency airway management in this series included: tracheostomy (15), endotracheal intubation (14), and cricothyroidotomy (3). Fitzhugh and Powell5 recommended tracheostomy as the method of choice to establish an airway in the acutely injured patient with neck trauma, as attempts at tracheal intubation may result in the creation of a false passage, compromising the airway. A tracheostomy below the level of the injury is the preferable option. When the diagnosis of TOF has been made, the immediate goal should be to minimize tracheobronchial soilage by placing the cuff of a tracheostomy tube distal to the fistula7 so as to effect adequate ventilation.
Tracheo-oesophageal-cutaneous fistulas may be managed with the logical technique as described in 1969 by Geffin8 and co-workers that consisted of tracheal intubation above or sometimes through the lesion to facilitate lung ventilation. After exploration or resection the surgeon inserts a new sterile tracheal tube or tracheostomy tube into the distal trachea so that ventilation can be resumed. Cardiopulmonary bypass is an alternative and usually reserved for low lesions that prevent adequate access and ventilation.9
Anaesthetists treating tracheal injuries should be prepared to manage the resulting difficult airway. The management is centred on securing the airway preferably awake with the patient breathing spontaneously. Early surgery is required to prevent long-term morbidity. The management of the emergency difficult airway in any penetrating neck injury can be extremely difficult and requires a planned multi-disciplinary approach in which anaesthetists should assume a leading role.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
2 Ferreiro I, Melendez J, Regalado J, Bejar FJ, Gabilondo FJ. Factors influencing the sequelae of high-tension electrical injuries. Burns 1998; 24: 64953[CrossRef][ISI][Medline]
3 Grewal H, Rao PM, Mukerji S, Ivatury RR. Management of penetrating laryngotracheal injuries. Head Neck 1995; 17: 494502[ISI][Medline]
4 Wu MH, Tsai YF, Lin MY, Hsu IL, Fong Y. Complete laryngotracheal disruption caused by blunt injury. Ann Thorac Surg 2004; 77: 12115
5 Fitzhugh GS, Powell JB. IIIManagement of laryngotracheal injuries. Virginia Medical Monthly 1970; 97: 4903[Medline]
6 Deshpande S. Laryngotracheal separation after attempted hanging. Br J Anaesth 1998; 81: 6124
7 Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin N Am 2003; 13: 27189[Medline]
8 Geffin B, Bland J, Grillo HC. Anesthetic management of tracheal resection and reconstruction. Anesth Analg 1969; 48: 88490[Medline]
9 Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anaesth 1999; 46: 43955[Abstract]