Airway management of an open penetrating neck injury

Abstract

Although penetrating neck injuries (PNIs) represent a small subset of patients presenting to the emergency department (ED), they can result in significant morbidity and mortality. The approach to airway management in PNI varies widely according to clinical presentation and local practice, such that global management statements are lacking. Although rapid sequence intubation (RSI) may be safe in most patients with PNI, the high-risk subset (10%) of patients with laryngotracheal injury require particularly judicious airway management. It is not known if RSI is safe in such patients, nor has there been reported use of videolaryngoscopy in patients with open PNI. Established principles of airway management in patients with an open airway injury include the avoidance of both positive pressure bag-mask ventilation and blind tube passage and the early consideration of a surgical airway. Because this high-risk subset may not be clinically apparent on initial presentation in the ED, such guiding principles apply to all patients with PNI until the nature of the injury is more accurately defined. In this report, we present the case of a patient who presented to the ED with a zone II open PNI, which occurred as a result of a stab wound. RÉ SUMÉBien que les plaies pé né trantes du cou (PPC) repré sentent un faible pourcentage des cas traité s dans les services d'urgence (SU), elles peuvent né anmoins entraîner une forte morbidité et une forte mortalité . Les interventions en vue du maintien de la permé abilité des voies aé riennes dans les cas de PPC varient é normé ment selon le tableau clinique et les pratiques locales, au point que les dé clarations sur la prise en charge gé né rale manquent. Si l'intubation en sé quence rapide (ISR) est sans danger chez la plupart des patients souffrant d'une PPC, le maintien de la permé abilité des voies aé riennes dans le sous-groupe de patients à risque é levé (10%) pré sentant des lé sions laryngotraché ales exige des interventions particuliè rement judicieuses. On ne sait pas si l'ISR est sû re chez ces patients, et la documentation ne fait pas é tat non plus de l'utilisation de la vidé olaryngoscopie chez les patients souffrant d'une PPC bé ante. Les principes dé jà é tablis du maintien de la permé abilité des voies aé riennes dans les cas de blessure bé ante des voies aé riennes comprennent le non-recours à la ventilation par masque et ballon à pression positive et à l'intubation à l'aveugle ainsi que la possibilité d'une ouverture chirurgicale pré coce des voies aé riennes. Comme les lé sions dans ce sous-groupe de patients à risque é levé peuvent ê tre non dé celables cliniquement à la premiè re consultation au SU, ces principes de conduite s'appliquent à tous les blessé s pré sentant une PPC jusqu'à ce que la nature du trauma soit davantage pré cisé e. Sera exposé ici le cas d'une patiente traité e au SU pour une PPC bé ante de la zone II, par suite d'une agression à l'arme blanche.

Penetrating neck injuries: a guide to evaluation and management

“…[20][21][22] Bag and mask ventilation to preoxygenate in preparation for rapid sequence intubation or to reoxygenate following a failed attempt at intubation must be done with vigilance, as it may force air into injured tissue planes and distort airway anatomy or further disrupt surrounding soft tissue injury. 19,20 If tracheal intubation is deemed necessary and the airway is predicted to be difficult because of distorted anatomy, we recommend fibreoptic intubation. Fibreoptic laryngoscopy and intubation allows the clinician to determine the integrity of the interior of the supraglottic and infraglottic airway while the patient maintains spontaneous respiration.…”

Bougie-facilitated Intubation in Penetrating Neck Injury

“…Neck trauma with airway injuries is a critical condition requiring immediate action to secure the airway in the best and fastest possible way. Timely interventions to keep the airway intact are the cornerstone of obtaining positive results with no organ or function loss (7,8). Figure 1.…”

Diagnostic approach to penetrating neck trauma: What you need to know

“…A low threshold for emergent surgical airway should be maintained. 50 If there is an externally visible tracheal injury and the patient is awake and alert, the patient should be positioned sitting up. Adequate suctioning and rapid transport to the operating room may allow intubation in a controlled setting, with direct visualization of tube passage past the injury.…”

“…Even in patients who are maintaining their airway on presentation, direct injury to the larynx or trachea and compression or distortion of the oropharynx and upper airway from a hematoma can rapidly progress to loss of airway and render orotracheal intubation difficult or impossible. A low threshold for emergent surgical airway should be maintained 50 . If there is an externally visible tracheal injury and the patient is awake and alert, the patient should be positioned sitting up.…”