Patient Report Successful repair in a child with traumatic complex bronchial rupture Maruf Sanli, Ahmet Feridun Isik, Bulent Tuncozgur and Levent Elbeyli Gaziantep University, Medical School, Thoracic Surgery Department, Gaziantep, Turkey Key words automatic door, bronchial rupture, child, trauma. Tracheobronchial ruptures (TBR) are dramatic injuries, rarely observed in children, that can have fatal consequences, even threatening life. Etiologically, especially high-impact blunt trauma, penetrating trauma with perforating/penetrating instru- ments or firearms and iatrogenic injuries may result in TBR. 1,2 These can be difficult to diagnose in emergency room conditions and the diagnosis may be delayed. Delay in the diagnosis causes acute or delayed complications. Treatment methods change depending on the type of the injury, its localization and comorbid pathologies. By presenting this case from our clinic with frag- mented bronchial rupture due to a blunt trauma, we aimed to point out the maneuvers during the operation together with treat- ment methods and their results. Case report A 2-year-old girl had dyspnea and change in consciousness as a result of being compressed by an automatic door. She was admit- ted to the emergency room 2.5 h after the accident. The patient was awake but confused. She was hemodynamically stable but had progressive respiratory distress. On physical examination, there was generalized ecchymosis on the right side of the chest and the trachea was deviated to the left side. Her blood pressure was 100/50 mmHg and heart rate was 120/min. Respiratory sounds were absent on the right hemithorax with auscultation. Blood gases obtained with the oxygen face mask were: pH, 7.41; pCO2, 21.3 mmHg; pO2, 90.9 mmHg; and BE, -10.8. On the chest X-ray, there was a fracture of the right clavicle and total collapse of the right lung with mediastinal shift (Fig. 1a). Abdominal ultrasonography performed in the emergency room was evaluated as normal. The pediatric trauma score was +7 according to Tepas and collegues. 3 Tube thoracostomy was per- formed from the right anterior axillary fifth intercostal space in the emergency room again. There was continuous, massive air drainage. The patient underwent rigid bronchoscopy under general anesthesia in the operation room. In observation with 0° pediatric telescope through rigid bronchoscopy, the right main bronchus was seen totally ruptured with hemorrhage at a distance of 1.5 cm distal to the carina. An emergency thoracotomy was performed. Because the patient could not tolerate the lateral position (due to decreased saturation), she was turned to the anterolateral posi- tion. With an anterolateral thoracotomy incision, the thoracic cavity was entered from the fifth intercostal space. After a quick evaluation, the right upper lobe bronchus and intermediary bron- chus were found to be ruptured and each separated completely from the main bronchus (Fig. 1c). The saturation of the patient decreased gradually and significantly. The endotracheal tube was guided from the operative field to the left main bronchus manu- ally and with the help of a clamp. The right main pulmonary artery was explored, suspended and occluded with a bulldog clamp. Following an increase in the saturation, the medial walls of the upper and intermediary bronchus were sutured to each other with 4/0 polydioxanone (PDS, Ethicon) interrupted sutures. This new root was further sutured to the main bronchus from the posterior wall with interrupted 4/0 polyglactin 910 (Vicryl, Ethicon) sutures. The remaining parts of the wall were sutured with 4/0 PDS continuously to complete the anastomosis (Fig. 1d). The endotracheal tube was retrieved to the tracheal position and all lobes of the right lung were seen to have expanded. Meanwhile, the pulmonary artery clamp was released. An air leakage check was performed. The anastomosis line was not covered with any other structure. Bronchoscopies were per- formed for anastomosis control during the intraoperative period and for aspiration of secretion on the 3rd postoperative day. The anastomosis field was identified as not having any problems. The patient was discharged as cured on the 8th postoperative day. The patient’s recovery was uneventful during three months of follow up (Fig. 1b). In her bronchoscopic evaluation, the anastomotic region was patent. Discussion Tracheobronchial ruptures are seen at a frequency of less than 1% in adults following a blunt trauma. 4 This rate is even lower in children. 5,6 Following a blunt trauma, possible mechanisms resulting in TBR are various. With the impact to the chest, antero- posterior diameter decreases and transverse diameter increases. During the attempt of the lungs to adapt to this change, the traction in the carina may result in a rupture. If the impact to the chest occurs while the epiglottis is closed, traction forces gener- ated at fixation points like carina and cricoid cartilage may also result in rupture because of increased pressure in the lumen or Correspondence: Maruf S ¸ anlı, MD, Gaziantep Üniversitesi, Tıp Fakül- tesi, Gög ˘üs Cerrahisi AD, 27310-S ¸ehitkamil, Gaziantep, Turkey. Email: sanli@gantep.edu.tr Received 25 December 2007; revised 21 July 2008; accepted 5 September 2008. Pediatrics International (2010) 52, e26–e28 doi: 10.1111/j.1442-200X.2009.03000.x © 2010 Japan Pediatric Society