Reviewed and revised 28 February 2015
- potentially a life-threatening emergency with a difficult airway
- need to assess rapidly and get help early
1. securing definitive airway
2. protecting c-spine
3. diagnosing and managing life threatening injuries
- orthopnoea, SOB
- stridor, hoarseness
- progression of symptoms
- AMPLE history (including airway grade and intubation history)
Examine the neck for evidence of life-threatening neck or thoracic injury (look for TWELVE):
- Tracheal deviation
- External markings
- Laryngeal disruption
- Venous distention
- Emphysema (surgical)
Complete primary and secondary trauma surveys
If time permits
- chest xray
- lateral c-spine xray
- nasal fiberoptic examination
- CT scan
- ultrasound neck
Treat patient while preparing to secure airway
- ATLS assessment
- keep patient breathing spontaneously
- call for help (anaesthetic technician, senior anaesthetist, ENT specialist, maxillo-facial specialist, cardiothoracic specialist, intensive care specialist, general surgeon, theatre personnel)
- stabilise neck with gentle inline immobilisation (probably will not tolerate hard collar)
- allow patient to adopt comfortable position
- apply high flow O2
- nebulised adrenaline + IV dexamethasone may buy some time
- transfer patient to theatre (preferably with cardiac bypass available, call perfusionist and cardiothoracic surgeon)
- anti-reflux medications; ranitidine, metoclopramide, Na+ citrate
- glycopyrolate IV to decrease secretions
- ENT surgeons scrubbed and ready to site emergency tracheostomy if airway obstruction occurs
- while preparing to secure airway consider asking cardiothoracic surgeon to insert a femoral bypass cannulae for possible femoral-femoral bypass
OPTIONS FOR SECURING AIRWAY IN BLUNT NECK TRAUMA
1. Awake percutaneous cricothyroid puncture with insertion of an endotracheal tube – anatomy may be too abnormal
- examine neck and attempt to palpate
- apply anti-septic
- infiltrate LA
- make a punch stab through crico-thyroid membrane
- dilate with handle of scalpel
- insert a size 6 or 7 cuffed ETT into trachea
2. Awake tracheostomy – ENT surgeon may not be comfortable or experienced with this technique, patient may not tolerate
3. Awake direct laryngoscopy after topicalisation – to facilitate intubation, then allow fiberoptic examination of defect, can advance ETT pass the lesion
- topicalise airway with 10% lignocaine (5 sprays)
- insert bite block
- perform laryngoscopy
- topicalise trachea with 4mL of 4% ligocaine with cannula injection
4. Awake fiberoptic intubation – topicalise with LA as you go, cannulate trachea, assess whether trachea normal with bronchoscope, intubate passed defect, may need remifentanil for analgesia, may be limited by blood and debris
- if able use nasal approach
- topicalise with co-phenylcaine forte (5 sprays to each nostril while inspiring)
- 5 sprays of 10% lignocaine to oro-pharynx
- trans-tracheal injection via cannula to crico-thyroid membrane
- insert successive nasopharyngeal airways up to #7.0
- insert fiberoptic scope into naso-pharnyx
- cannulate trachea
- advance #7.0 ETT over scope
5. Inhalational induction – keep patient spontaneously breathing, may be able to induce sitting upright but laying patient down to intubate may produce airway obstruction
- 2 anaesthetists
- vasoconstrictor + LA to nose
- surgeon scubbed for emergency tracheostomy
- sevoflurane/O2 induction
- sitting up
- proceed slowly
- if become apnoeic -> don’t bag -> allow CO2 to rise and then to start spontaneously breathing again
- if obstructs insert nasopharyngeal airway
- once pupils midline and small -> laryngoscopy
- attempt intubation twice only
- if intubation fails -> tracheostomy while breathing spontaneously
- if there is sudden, complete airway obstruction -> immediate tracheostomy or single attempt with rigid bronchoscope
6. Rigid bronchoscopy
7. Urgent femoral-femoral bypass if airway is unsecured and life-threatening hypoxia ensues
For a patient with blunt trauma to the neck and stridor/ respiratory compromise:
- 1. awake percutaneous crico-thyroid puncture with insertion of endotracheal tube
- 2. awake fiberoptic intubation, if fails
- 3. awake tracheostomy, if fails
- 4. inhalational induction
- 5. if in extremis, RSI without cricoid pressure with rigid bronchoscopy/tracheostomy available
OPEN NECK TRAUMA
Consider intubating directly through open wound if transected trachea on view
- use forceps to stabilise distal trachea so that it does not recede into the mediastinum during intubation
- intubation from above (i.e. translaryngeal) is unlikely to be successful and may further disrupt the injury
- attempts at an emergency surgical airway must be below the level of the injury (i.e. tracheostomy) and are likely to be be very difficult given distorted anatomy
References and Links
- Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci [serial online] 2014 [cited 2014 Apr 19];4:50-6. Available from: http://www.ijciis.org/text.asp?2014/4/1/50/128013
- Cicala RS, Kudsk KA, Butts A, Nguyen H, Fabian TC. Initial evaluation and management of upper airway injuries in trauma patients. J Clin Anesth. 1991 Mar-Apr;3(2):91-8. PubMed PMID: 2039650.
- Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006 Jun;104(6):1293-318. Review. PubMed PMID: 16732102.
- Daniel Y, de Regloix S, Kaiser E. Use of a gum elastic bougie in a penetrating neck trauma. Prehosp Disaster Med. 2014 Apr;29(2):212-3. doi: 10.1017/S1049023X14000193. Epub 2014 Feb 28. PubMed PMID: 24576694.
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- Rehm CG, Wanek SM, Gagnon EB, Pearson SK, Mullins RJ. Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy. Crit Care. 2002 Dec;6(6):531-5. Epub 2002 Sep 17. PubMed PMID: 12493076; PubMed Central PMCID: PMC153438.
- Robitaille A. Airway management in the patient with potential cervical spine instability: continuing professional development. Can J Anaesth. 2011 Dec;58(12):1125-39. doi: 10.1007/s12630-011-9597-0. Epub 2011 Oct 27. English, French. PubMed PMID: 22033859.
- Shearer VE, Giesecke AH. Airway management for patients with penetrating neck trauma: a retrospective study. Anesth Analg. 1993 Dec;77(6):1135-8. PubMed PMID: 8250303.
- Tallon JM, Ahmed JM, Sealy B. Airway management in penetrating neck trauma at a Canadian tertiary trauma centre. CJEM. 2007 Mar;9(2):101-4. Review. Erratum in: CJEM. 2007 May;9(3):181. PubMed PMID: 17391580. [Free Full Text]
- Youssef N, Raymer KE. Airway management of an open penetrating neck injury. CJEM. 2013;15(0):1-5. PubMed PMID: 24192521.
- Walls RM. Management of the difficult airway in the trauma patient. Emerg Med Clin North Am. 1998 Feb;16(1):45-61. Review. PubMed PMID: 9496314.
FOAM and web resources
- Trauma Professional’s Blog — Spinal Cord Injury From Airway Management (2013)
- Trauma Professional’s Blog — Cervical Spinal Cord Injury: Who Needs A Tracheostomy? (2013)