Penetrating neck trauma: awake tracheostomy, intubation, or both?
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CORRESPONDENCE
Penetrating neck trauma: awake tracheostomy, intubation, or both? John O’Connor, MD, FCAI
. Shawn Hicks, MD, MSc, FRCPC
Received: 13 May 2020 / Revised: 20 May 2020 / Accepted: 21 May 2020 Ó Canadian Anesthesiologists’ Society 2020
To the Editor, Herein we describe the management of a case of penetrating neck injury resulting in a difficult airway due to a knife blade remaining embedded in the trachea. Penetrating neck injury is responsible for approximately 5% of trauma admissions in North America.1 Its reported mortality is approximately 11%, largely due to laceration of the great vessels or airway disruption.2,3 There is a lack of evidence regarding the evaluation and management of traumatized airway patients; however, if there are no signs that the airway should be immediately secured, then computed tomography (CT) angiography can be used to determine the extent of the injury.4 If the airway must be secured emergently, various techniques including direct laryngoscopy, video laryngoscopy, or flexible bronchoscopy (FB) can be used.5 We recently managed a 32-yr-old male (who consented to this report) who presented to the emergency department with a stab wound and knife blade still embedded in his anterior neck. On his primary trauma survey, the peripheral oxygen saturation was 98% without stridor or subcutaneous emphysema. He was hemodynamically stable, cooperative, but could not lie flat nor extend his neck because of discomfort from the injury. There was no hemoptysis and visible blood loss was minimal. As a cervical spine collar could not be placed because of the protruding blade, manual inline stabilization was maintained at all times until his airway was secured. A lateral neck radiograph showed the knife blade was embedded approximately 7.5 cm in the midline of zone 2
J. O’Connor, MD, FCAI (&) S. Hicks, MD, MSc, FRCPC The Ottawa Hospital, Ottawa, ON, Canada e-mail: [email protected]
of his neck (Figure A). He was transferred to the operating room for further management with both an ear, nose, and throat surgeon and a trauma surgeon in attendance. While in the in the seated position, his airway was prepared for FB examination including administering glycopyrrolate (0.3 mg iv), topical lidocaine, plus judicious boluses of fentanyl and midazolam. A Williams airway was well tolerated and oxygen was administered via a nasal cannula. Figure B shows the initial view obtained on FB and showed that the blade was covering 75% of the proximal subglottic area and minimal view of the true vocal cords. The anesthetic considerations included potential difficulty in advancing an endotracheal tube (ETT) beyond the blade without damaging the ETT cuff. Given the lack of space around the blade, an airway exchange catheter was also thought to be at risk of causing total airway obstruction. Other options such as a retrograde wire-guided intubation and extra-corporeal membrane oxygenation were also not chosen. An awake tracheostomy was also considered but thought to be difficult because of the blade location
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