Successful Management of Concommitant Blunt Injury to the Trachea, Esophagus, and Cervical Spine in a 6-Year-Old Girl By Oscar D. Guillamondegui, Michael L. Nance, J. William Gaynor, John M. Flynn, Perry W. Stafford, and Timothy M. Crombleholme Philadelphia, Pennsylvania A 6-year-old girl sustained an unusual constellation of injuries after blunt trauma sustained in a motor vehicle accident. Transec- tion of the trachea and esophagus were managed successfully by repair through a median sternotomy while the patient was on cardiopulmonary bypass. A cervical spinal injury was fixated with halo traction and a femur fracture with internal fixation. J Pediatr Surg 39:1130-1132. © 2004 Elsevier Inc. All rights reserved. INDEX WORDS: Blunt injury to the trachea, esophageal lac- eration, motor vehicle accident. B LUNT MAJOR thoracic injury in a child is a rare occurrence noted in only 6% of children admitted for traumatic injuries but carries a mortality rate ap- proaching 15%. 1 A tracheobronchial or esophageal in- jury was reported in less than 1% of those children with a major thoracic injury. 1 The combination of an intratho- racic tracheal injury and esophageal injury is rarer still. However, complex, clustered, mediastinal injuries have been reported. A prior case report described successful management of a tracheal, esophageal, and aortic injury in a child resulting from blunt trauma. 2 In the general adult literature, the case clustering of an esophageal, tracheal and cervical spine injury was reported in a 79-year-old woman who died of her injuries. 3 We report the case of a 6-year-old girl who survived the unique combination of a blunt tracheal, esophageal, and cervical spine injury with no long-term morbidity. Such a cluster of injuries has not been reported previously in a child. The care of this patient reinforces the importance of maintaining cervical spine immobilization, rapid transfer to an appropriate facility as recommended by ATLS protocol, and complex surgical decision making in the unstable trauma patient. CASE REPORT A 6-year-old girl was involved in a motor vehicle crash in which she was a restrained (automatic shoulder harness only), front seat passenger in a compact car. The car veered from the road and struck a tree. There was intrusion into the front compartment, and the child was found on the floorboards under the dash. Paramedics initially found the child unresponsive with an oxygen saturation of 40%. Intubation was per- formed in the field, and supplemental oxygenation was provided, which raised the oxygen saturation to 65%. Difficulty was noted with hand- bag ventilation of the child. Paramedics placed bilateral 16-gauge angiocatheters in the second intercostal spaces for suspected pneumo- thoraces. An incremental improvement of the oxygen saturation to 75% was noted. The child was transported to the nearest level 1 trauma center for evaluation and treatment. Her initial vital signs showed a blood pres- sure of 116/58 and a heart rate of 170. The Glasgow Coma Score was 3T. Bilateral chest tubes were placed, a foley catheter was inserted, and attempted nasogastric tube placement was unsuccessful. Direct laryn- goscopy in the emergency department confirmed endotracheal intuba- tion. The physical examination revealed diffuse cervical crepitus and ecchymosis along her right neck suggestive of a seatbelt injury. A cervical collar was in place. Additionally noted was a right thigh deformity with open wound. The initial arterial blood gas level was 7.25/60/41/26. The child was taken to the operating suite where results of a direct laryngoscopy and flexible bronchoscopy showed a tracheal injury. Because of the severity of the airway injury and the need for additional pediatric expertise, the child was transferred expeditiously via helicop- ter to our regional Level 1 Pediatric trauma center. On arrival, approx- imately 2 hours after injury, her resuscitation and evaluation continued. During this phase of her care, her oxygen saturations were maintained in the mid to high 80s. Because of the tenuous nature of her airway, the patient was taken directly to the operating suite. Flexible bronchoscopy findings showed a complete transection of the trachea with an inability to visualize the distal trachea. The tip of the endotracheal tube was noted to be in the mediastinal soft tissues. Because of the complete disruption and dis- traction of the trachea, a median sternotomy and cardiopulmonary bypass with a single venous cannula was performed despite the risk of systemic heparinization. The choice of median sternotomy was the conscious decision of the trauma and cardiothoracic attending physi- cians, based on the findings of a complete tracheobronchial disruption. From the Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine and Divisions of General, Cardiothoracic, and Orthopedic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, Philadel- phia, PA. Address reprint requests to Michael L. Nance, MD, Department of Surgery, Children’s Hospital of Pennsylvania, 34th and Civic Center Boulevard, Philadelphia, PA 19104. © 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3907-0029$30.00/0 doi:10.1016/j.jpedsurg.2004.03.078 1130 Journal of Pediatric Surgery, Vol 39, No 7 (July), 2004: pp 1130-1132