Anesthetic Management for Traumatic Left Mainstem Injury

HPI:  56M restrained driver of pickup truck in MVC with "big rig" at moderate speed and prolonged extrication. CT chest showed extensive diffuse pneumomediastinum with massive soft tissue emphysema, bilateral pneumothoraces,... [ view full abstract ]

HPI: 

56M restrained driver of pickup truck in MVC with "big rig" at moderate speed and prolonged extrication. CT chest showed extensive diffuse pneumomediastinum with massive soft tissue emphysema, bilateral pneumothoraces, and possible airway injury. Flexible bronchoscopy showed transection of Left mainstem bronchus. 

Anesthetic management:

Pre-op a-line and central line placement. Patient preoxygenated with 4L O2 via nasal canula, started on remifentanyl, dexmedetomidine, and phenylephrine drip with boluses of ketamine. Awake fiberoptic intubation performed with 37Fr Right-sided double lumen tube. Patient developed ST elevations in setting of hyperkalemia, chest trauma, subdural hematoma, decision was made to keep patient intubated. After repair of left main stem bronchus, the left lung was carefully re-expanded under direct visualization. At the end of the case, the patient was breathing spontaneously, double lumen tube was removed and patient was re-intubated with a single lumen tube, and he was transferred to the SICU. The patient was extubated POD#1. 

Discussion:

• Anesthetic management of Left main stem bronchus injury
• Intraop treatment of hyperkalemia