Reviewed and revised 28 February 2015
- potentially a life-threatening emergency with a difficult airway
- need to assess rapidly and get help early
- securing definitive airway
- protecting c-spine
- 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
- 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
- Awake tracheostomy – ENT surgeon may not be comfortable or experienced with this technique, patient may not tolerate
- 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
- 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
- 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
- Rigid bronchoscopy
- 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
- 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. 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. PMID: 24576694.
- Desjardins G, Varon AJ. Airway management for penetrating neck injuries: the Miami experience. Resuscitation. 2001 Jan;48(1):71-5. PMID: 11162884.
- Demetriades D, Salim A, Brown C, Martin M, Rhee P. Neck injuries. Curr Probl Surg. 2007 Jan;44(1):13-85.PMID: 17317418.
- Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med. 2000 Mar;35(3):221-5. PMID: 10692187.
- Mercer SJ, Lewis SE, Wilson SJ, Groom P, Mahoney PF. Creating airway management guidelines for casualties with penetrating airway injuries. J R Army Med Corps. 2010 Dec;156(4 Suppl 1):355-60. PMID: 21302656.
- Pierre EJ, McNeer RR, Shamir MY. Early management of the traumatized airway. Anesthesiol Clin. 2007 Mar;25(1):1-11, vii. PMID: 17400151.
- 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. 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. 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. 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. 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 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)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.