Major tracheobronchial injury presents special problems in the context of multiple system
trauma. A 14-year review of a clinical experience revealed eight patients who had operative repair of major bronchial or intrathoracic tracheal
injuries. The diagnosis was suspected by
subcutaneous emphysema, and especially by persistent
pneumothorax or a significant air leak. Bronchoscopy confirmed the diagnosis in all patients before
thoracotomy. All eight patients had multiple system
injuries. All five with
abdominal injuries were hypotensive at admission and underwent celiotomy before
thoracotomy. The decision to perform
thoracotomy or celiotomy first in patients with major tracheobronchial
injuries and concomitant abdominal
trauma must be individualized. If both
injuries are recognized simultaneously and the patient is hemodynamically unstable but has adequate oxygenation and ventilation, the celiotomy can be performed first. On the contrary, if oxygenation and ventilation are the most threatening problems in a hemodynamically stable patient despite evidence of
hemoperitoneum, the bronchial repair should have priority.