THE HIDDEN TEAR

Abstract

Introduction: 

Tracheobronchial injury (TBI) is uncommon but potentially life-threatening. High level of suspicion is needed for early detection and immediate treatment. In this case series, two cases of TBI are discussed.

Case:

Case 1: A 42-year-old gentleman complained of right sided chest pain, shortness of breath and left shoulder pain after his motorbike skidded. Upon assessment, the positive findings were subcutaneous emphysema over the right anterior chest wall and limited movement over the left shoulder. Initial bedside scan was negative. Chest radiograph revealed distal end of left clavicle, left scapula and left humerus fracture. Upon reassessment, he was still complaining of right sided chest pain with shortness of breath. Serial bedside scans noted absent of lung sliding sign over the R1 area. Computed tomography (CT) Thorax showed features suggestive of broncho-pleural injury. Chest tube was inserted and managed conservatively.

Case 2: A 36-year-old Chinese man complained of right sided chest pain after his motorbike skidded. Upon assessment, vital signs and all examinations were normal. Initial bedside scan showed absence of lung sliding sign over the R1 area. Chest radiograph noted right clavicle fracture with right 4^th rib fracture without pneumothorax. CT Thorax showed right sided pneumothorax with pneumomediastinum, subcutaneous emphysema and multiple right ribs fracture. Chest tube was inserted and managed conservatively.

Discussion: 

Incidence of TBI cases reported in most studies is low. Therefore, it is common for patients to sustain other serious injuries along with TBI as a result of high impact injury. It should be emphasized that the clinical features of TBI are mostly non-specific and in the presence of other associated injuries, it can be easily missed. About 10% of TBI patients do not have any radiographic or clinical signs.

Conclusion: 

Two cases discussed above showed a mild form of TBI, and it cannot be detected as soon as they arrived in emergency department (ED). It requires serial reassessments and specific investigation to diagnose it. Hence, the managing team in ED must have a high index of suspicion for TBI in managing chest trauma patients.