TRACHEAL RUPTURE DURING CARDIOPULMONARY RESUSCITATION

Abstract

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Tracheal rupture is a rare but life-threatening complication that most commonly occurs after blunt trauma to the neck and chest but can also occur after various procedures and operation including tracheostomy, bronchoscopy and to a lower incidence cardiopulmonary resuscitation. We hereby present a case of tracheal tear diagnosed after CPR that survived with conservative care. CASE PRESENTATION: 44-year-old female current smoker with severe asthmatic type COPD on chronic steroid therapy presented from home to the emergency department with 2 days of respiratory distress, wheezing and was found to have acute on chronic hypercapnic hypoxic respiratory failure and was admitted to the Intensive care unit. Patient was initially managed on BiPAP but 2 hours after ICU admission, patient had an acute cardiorespiratory arrest. CPR was performed and airway placement with intubation and mechanical ventilation was started after ROSC. Immediately post-intubation, physical examination showed massive subcutaneous emphysema confirmed by Chest X-ray. CT chest and abdomen performed the next day showed disruption of the posterior wall of the trachea with pneumomediastinum and subcutaneous emphysema ( Image 1). Patient had worsening of subcutaneous emphysema with difficulty on mechanical ventilation, hence was bronchoscopically evaluated and demonstrated a 2.5 cm long disruption of the posterior tracheal wall with the mediastinum evaginating through the opening( Image 2 & 3). Patient was referred to our tertiary care center for further management, during the process the patient was hemodynamically stable on continuous ventilator support. Given the extent and location of the defect and the absence of PTX, and clinical stability patient was managed conservatively with eventual discharge to an LTAC with a tracheostomy tube and PEG tube. Follow up CT chest 1 week later showed residual pneumomediastinum and the previously seen defect in the trachea was no longer visualized. DISCUSSION: Tracheal rupture after endotracheal intubation is extremely rare, with a reported incidence of approximately 0.005%. It is most common in women, in patients with tracheal wall weakness due to inflammatory disease and in patients on corticosteroid therapy. The clinical presentation can be brutal, with respiratory failure, subcutaneous emphysema, pneumothorax, and pneumomediastinum. There are also less symptomatic presentations. Fiberoptic bronchoscopy is believed to be the best subsequent method to confirm the diagnosis and to determine the location and extent of the lesion.Traditionally early surgical repair has been the mainstay of treatment however recently conservative management is opted for small ruptures ( less than 2-4 cm) and in patients with minimal nonprogressive symptoms and hemodynamic stability. CONCLUSIONS: Tracheal tear during CPR is most likely not well reported because of most likely poor survival. Reference #1: Borasio P, Ardissone F, Chiampo G. Post-intubation tracheal rupture. A report on ten cases. Eur J Cardiothorac Surg. 1997;12(1):98-100 Reference #2: Massard G, Rougé C, Dabbagh A, Kessler R, Hentz JG, Roeslin N, et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg. 1996;61(5):1483-7. Reference #3: Jougon J, Ballester M, Choukroun E, Dubrez J, Reboul G, Velly JF. Conservative treatment for postintubation tracheobronchial rupture. Ann Thorac Surg. 2000;69:216–220. DISCLOSURES: No relevant relationships by Taha Ahmed, source=Web Response No relevant relationships by TALHA AHMED, source=Web Response No relevant relationships by Basma Ricaurte, source=Web Response