Traumatic airway injury is a rare type of trauma that is potentially life-threatening and occurring in less than 4.5% of cases . It is usually seen in multiple-trauma patients and may be unrecognized and undertreated owing to its rarity . Dyspnea and respiratory distress occur in most patients with TBI, with subcutaneous emphysema, pneumomediastinum, and pneumothorax also common findings in TBI. If possible, spontaneous breathing should be permitted as positive ventilation can exacerbate air leaks and rapidly worsen symptoms caused by airway injury . Blind intubation may dislocate fractured cartilage or entirely disrupt a partial tracheal transection, leading to complete airway obstruction. The ideal initial management of TBI is pre-oxygenation followed by awake flexible bronchoscopy for the evaluation of airway injuries and safe endotracheal intubation . However, in the clinical setting, rapid sequence intubation is frequently performed as there is difficulty in performing bronchoscopy based on a patient’s urgent clinical condition and resource limitations. CT is a good diagnostic tool in that it provides information on trachea transection, tracheal ring fracture, and associated injuries. The treatment of TBI should be individualized based on clinical manifestations and the injury extent and severity. While many cases of TBI eventually require definitive surgery, some minor injuries can be treated conservatively with follow-up bronchoscopy .
Tracheostomy or cricothyroidotomy directly through the fractured tracheal ring is another option for securing the airway in cases in which initial airway management fails. However, these procedures were not available in the present case as the subcutaneous emphysema was too extensive to approach the transected trachea with good visualization. As the patient’s hemodynamics began to worsen, we applied VV-ECMO considering the low probability of his survival without providing immediate oxygenation. As VV-ECMO support started, his condition stabilized enough to proceed with definitive surgery. If the decision had been delayed, there would have been no chance to stabilize the patient.
ECMO is currently considered a good and safe option for complex surgical cases and in patients with near-total airway occlusion . The uses of ECMO in airway surgery range from reconstruction of tracheal stenosis to the repair of iatrogenic tracheal rupture. One case report described the successful repair of tracheal transection with VV-ECMO support . In VV-ECMO, the jugular-femoral configuration is the treatment of choice for its low recirculation rate, which provides more efficient oxygenation and carbon dioxide clearance .However, in an emergency, aseptic painting must be performed in two separate locations, and ultrasound is often required; thus, it is sometimes not perfect in terms of expediting treatment . In the present case, bi-femoral VV-ECMO was instituted as an alternative technique because the subcutaneous emphysema was too extensive for rapid cannula insertion. As subcutaneous emphysema accompanies in up to 87% of TBI cases , the femoro-femoral configuration should be considered when developing a cannulation strategy. The femoro-femoral configuration may be sufficient for temporary support as a short-term bridge to definitive surgery. Likewise, this configuration may be a reasonable option when accessing the jugular vein is difficult for other reasons such as severe edema, severe obesity, or neck site infection.