Airway Injury - Emergency Management

Related Summaries

● Laryngotracheal trauma - emergency management

● Burns - emergency management

● Esophageal injury - emergency management

● Strangulation injury - emergency management

General Information

Description

● Injury anywhere from nasopharynx to peripheral bronchi

● Includes: partial or complete disruption of airway, mucosal injury, bleeding, obstruction, and extrinsic

compression from hematoma 1

Anatomy

● The airway is comprised of the nasopharynx, oropharynx, trachea, and bronchi 2 , 3

● Laryngeal and tracheal fractures are rare

● Laryngotracheal or tracheobronchial separation can occur

● Bronchial injuries usually occur within 1 inch of the carina 4

● GERIATRICS

⚬ Elderly patients have more calci ed and less exible airways

⚬ Risk of aspiration increases with age due to slower gastric emptying and decreased oropharyngeal
re exes
⚬ Oropharyngeal musculature relaxes with age so more di cult to maintain patency
⚬ Cervical or temporomandibular arthritis may make intubation more di cult
⚬ Dentures may be present – which can easily be displaced into the airway

Etiology

● Blunt or penetrating trauma to face, neck, or chest

● Strangulation or hanging

● Blunt injuries caused by crushing, sudden cervical hyperextension

● Gunshot wounds or lacerations to face, neck, chest

● Edema or hematomas from facial or neck injuries can cause airway compression or bleeding, resulting

in obstruction 4
● Seatbelt injury

● Burns causing thermal or chemical mucosal injury from inhalation

● External compression from full-thickness neck or chest burns

● Chemical injury from aspiration after caustic ingestion

Epidemiology

● More than 80% of all patients with major airway injuries die before or within 2 hours of reaching the

hospital due to loss of airway 5

● Tracheal injury occurs in 3%-6% of penetrating neck injury 2

● Penetrating tracheobronchial trauma constitutes 1%-2% of thoracic trauma admissions 5

● In the setting of blunt trauma, patients with airway injuries have a higher mortality rate due to

associated injuries 6 , 7

History and Physical

History

● Mechanism

⚬ Blunt or penetrating neck or chest trauma with signi cant force

⚬ Blunt injuries of the larynx and trachea most commonly result from direct trauma or sudden

hyperextension 7
⚬ In blunt chest trauma: 3 proposed mechanisms for tracheobronchial injury:

– 1. Explosive rupture where neck is crushed and quick rise in airway pressure with glottis closed
– 2. Shearing forces on xed points (cricoid and carina) from sudden deceleration
– 3. Anteriorposterior chest compression, lungs are xed from negative pressure and as

compression tries to pull them apart, tensile forces can lacerate at level of carina 8
⚬ “Dashboard” injury from an unrestrained automobile passenger with neck hyperextension during
head-on collisions, striking the neck on the steering wheel or dashboard and producing a crush
injury of the larynx or trachea; with the advent of airbags, now a rare injury 2 , 5
⚬ Clothesline injury producing crush to larynx or trachea with the force concentrated across a very

narrow band (for example, riding into a fence on a motorcycle) 2 , 5

⚬ Rapid deceleration produces shear forces at points of relative xation such as the cricoid cartilage

and carina, resulting in tearing 5

● Symptoms

⚬ Dyspnea
⚬ Chest or neck pain
⚬ Hoarseness or change in voice

Physical

● Signs will vary depending on the level and degree of injury and may be nonspeci c
● Air escaping from a penetrating wound in the neck is a pathognomonic sign of an airway laceration 5

● Check for crepitus: subcutaneous edema is the most common nding in tracheobronchial injuries 9

● A cervical air leak that ceases after intubation con rms diagnosis

● Other ndings include

⚬ Respiratory distress
⚬ Obstructed airway
⚬ Stridor
⚬ Tracheal fracture on palpation
⚬ Bruising or laceration to neck
⚬ Neck hematoma
⚬ Tracheal deviation
⚬ Face, neck edema
⚬ Persistent pneumothorax or large air leak despite tube thoracostomy
⚬ Hypoxia
⚬ Tachypnea
⚬ Decreased breath sounds
⚬ Hemoptysis
⚬ Mediastinal shift

Diagnostic Studies

Laboratory tests

● May consider obtaining

⚬ A trauma panel including complete blood count (CBC), chemistry panel, prothrombin time (PT)/INR
ratio, type and screen and venous blood gas/arterial blood gas (VBG/ABG) in the setting of
signi cant injury (no lab tests diagnostic of airway injuries)

Imaging tests

● Highly consider obtaining

⚬ Chest x-ray looking for

– Subcutaneous air
– Pneumothorax
– Tracheal deformity or abnormal tracheal contour
– High hyoid on lateral lm
– Up to 10%-20% of patients with tracheobronchial injury have no signs on chest x-ray 10

– Other thoracic injuries

 IMAGE 1 OF 1

Airway injury

Left-sided subcutaneous air along the neck from

blunt tracheal airway injury.

⚬ Computed tomography (CT) of the neck and/or chest in stable patients 11

– May demonstrate tracheal or bronchial disruption, pneumothorax, and subcutaneous air

– Complete transection of a mainstem bronchus will demonstrate collapse of the lung away from
the hilum toward the diaphragm
– Follow the trajectory of penetrating injuries to fully evaluate the extent of airway injury and
injuries to adjacent structures
– Highly diagnostic for laryngeal trauma but less so for tracheobronchial injury, though if CT

performed with multiplanar reformatting (MPR)/3D reconstructions this increases sensitivity 9

● May consider obtaining

⚬ Direct laryngoscopy or beroptic laryngoscopy to evaluate pharynx 8

⚬ Bronchoscopy to evaluate for tracheal and bronchial injuries

⚬ Surgical consult for surgical neck exploration

Management

Overview

● Initial assessment: focus on the primary survey, as described in Advanced Trauma Life Support (ATLS),
aimed at recognizing and treating life threats

● Secondary survey: once patient is stabilized, identify and evaluate related injuries

● Airway management is critical in these patients 12 , 13 , 14 , 15

⚬ Personnel: surgical airway equipment and a surgical colleague should always be present when

attempting to secure the airway in these patients; 2 , 16 attempts at intubation without adequate
skill or planning may lead to loss of airway and death
⚬ Positioning: if a patient is maintaining airway in a sitting position and/or leaning forward, do not
force them to lie down
⚬ TIP: emergent endotracheal intubation should NOT be attempted in patients who are
hemodynamically stable, maintaining their own airway, and are not in respiratory distress; these
 should be managed by elective intubation or tracheotomy in the operating room
⚬ If intubation is required

– Fiber optic or bronchoscope may be needed

– Visualization may be di cult due to blood or tissue debris
– Awake intubation may be necessary; 16 consider nasotracheal intubation in spontaneously

breathing patients without facial fractures 16

– If having di culty managing the airway, paralytics will not improve the situation and may lead
to catastrophe
– Maintain in-line cervical stabilization in patients with blunt injury or evidence of neurologic

injury; 2 do not allow cervical spine immobilization to impede airway management - it is rarely
indicated in the patient with penetrating trauma 17
– Airway control must be performed distal to the injury
– Be prepared for a surgical airway

● Cricothyroidotomy or tracheostomy may be necessary

● Tracheostomy is preferred

⚬ Intubation of the trachea through a penetrating neck wound can be lifesaving; however, airway

obstruction may result if unsuccessful 5

⚬ In the setting of burn patients the following are indications for considering early intubation 18

– Stridor
– Shortness of breath
– Facial burns or singed nasal hairs
– Soot in the oral cavity
– History of being in a re in an enclosed space

⚬ TIP: for distal tracheobronchial injuries, a long endotracheal tube needs to be passed beyond the
injury; it may be necessary to pass the endotracheal tube into the mainstem bronchus of the
uninvolved lung to provide single lung ventilation 4 , 5
⚬ Double lumen endotracheal tubes should be avoided

● After securing the airway and ventilation, management of bleeding and other life-threatening
associated injuries should occur before de nitive repair of the airway injury
⚬ Place thoracostomy tube for patients with pneumothorax or hemothorax
⚬ Control epistaxis and oropharyngeal bleeding with packing, if necessary

● Operative exploration and repair at the discretion of the surgeon 2 , 11

● Operative repair involves debridement of devitalized tissue and in most uncomplicated cases, simple

repair with absorbable suture 5

Medications

● Intravenous crystalloid uids for ndings of hypovolemia or need to maximize preload (for example,
endotracheal intubation, pericardial tamponade)
⚬ Give 1 L boluses of isotonic uid
⚬ In patient with hypotension and evidence of ongoing hemorrhage, consider emergent blood
transfusion
● Induction medications

⚬ Etomidate: 0.3 mg/kg IV (typical adult dosage of 20-40 mg IV)

– Has limited hemodynamic side e ects but may cause adrenal suppression

⚬ Ketamine: 1-2 mg/kg IV (typical adult dosage of 60-200 mg IV)

– Maintains hemodynamic stability, is unlikely to elevate ICP and helps with cerebral perfusion 19

● Paralytic medications

⚬ TIP: avoid paralytics, if possible, for intubation when a di cult airway is suspected (loss of smooth
muscle tone) may lead to collapse of injured airway
⚬ Succinylcholine: 1-2 mg/kg IV with typical adult dosage of 70-200 mg IV

– Short-acting agent that may, theoretically, cause increased ICP

⚬ Rocuronium: 0.6-1.2 mg/kg IV with typical adult dosage of 60-100 mg IV

– Not associated with increasing ICP but does lead to longer paralysis (30-60 minutes)

● Pain medications

⚬ Fentanyl: 1-2 mcg/kg IV, if concern for hemodynamic instability or early in resuscitation because of
short-acting duration (typical adult dosage 50-100 mcg)
⚬ Morphine: 0.1 mg/kg IV (typical adult dosage 4-10 mg)

Disposition

Prognosis and complications

Prognosis

● All airway injuries should be considered life-threatening

● Patients have good outcomes with prompt recognition and surgical intervention

Complications

● In penetrating neck injuries with airway injury, esophageal rupture is the most common

accompanying injury, in up to 43% of patients 20

● Early 21

⚬ Loss of airway
⚬ Aspiration of blood or gastric contents
⚬ Death

● Late 21

⚬ Anastomotic dehiscence after surgical repair

⚬ Bronchopleural stula
⚬ Recurrent laryngeal nerve injury
⚬ Tracheoesophageal stula
⚬ Tracheomalacia
⚬ Tracheal stenosis
⚬ Tracheoinnominate stula
⚬ Vocal cord dysfunction
Associated conditions

● Cardiac injury, especially pericardial tamponade

● Carotid, jugular injuries

● Esophageal injury

● Facial fractures, especially La Forte fractures

● Great vessel injury

● Head injury

● Pneumothorax, hemothorax, or pulmonary contusion

● Rib fractures

● Recurrent laryngeal nerve injury

● Spinal fractures and injuries

Indications for hospital admission

● All should be admitted to the hospital; if signi cant injury, will require admission to the intensive care
unit (ICU) for airway management and monitoring

● Patients with asymptomatic, minor injuries require inpatient observation in the hospital for at least 24
hours

Discharge planning

● These patients should not be discharged from the emergency department (ED)

Consultations

● TIP: early surgical consultation is essential

● Trauma or general surgeon, depending on institution

● Ear, nose, throat (ENT) surgeon

● Anesthesia if suspected di cult airway

References

General references used

1. PEMSoft. Airway Trauma. 2012. Available at:

http://www.pemsoft.net/content/PPacCore/UID872598.html#. Accessed May 21, 2012

2. Nelson LA. Airway trauma. Int Anesthesiol Clin. 2007 Summer;45(3):99-118

3. Gray, H. Anatomy of the Human Body. Philadelphia, PA: Lea and Febiger; 1918
 4. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors
Student Manual. 8th ed. Chicago, IL: American College of Surgeons; 2004

5. Karmy-Jones R, Wood DE, Jurkovich GJ. Esophagus, Trachea, and Bronchus. In: Feliciano DV, Mattox KL,
Moore EE, Trauma. 6th ed. New York, NY: McGraw Hill Medical; 2008:553-568

6. Kummer C, Netto FS, Rizoli S, Yee D. A review of traumatic airway injuries: potential implications for
airway assessment and management. Injury. 2007 Jan;38(1):27-33

7. Mathisen DJ, Grillo H. Laryngotracheal trauma. Ann Thorac Surg. 1987 Mar;43(3):254-62

8. Kiser AC, O'Brien SM, Detterbeck FC. Blunt tracheobronchial injuries: treatment and outcomes. Ann
Thorac Surg. 2001 Jun;71(6):2059-65

9. Prokakis C, Koletsis EN, Dedeilias P, Fligou F, Filos K, Dougenis D. Airway trauma: a review on
epidemiology, mechanisms of injury, diagnosis and treatment. J Cardiothorac Surg. 2014 Jun 30;9:117
full-text

10. Chu CP, Chen PP. Tracheobronchial injury secondary to blunt chest trauma: diagnosis and
management. Anaesth Intensive Care. 2002 Apr;30(2):145-52

11. Francis S, Gaspard DJ, Rogers N, Stain SC. Diagnosis and management of laryngotracheal trauma. J
Natl Med Assoc. 2002 Jan;94(1):21-4 PDF

12. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal
intubations: a risk-bene t analysis. Ann Emerg Med. 2007 Dec;50(6):653-65

13. Rajani RR, Ball CG, Montgomery SP, Wyrzykowski AD, Feliciano DV. Airway management for victims of
penetrating trauma: analysis of 50,000 cases. Am J Surg. 2009 Dec;198(6):863-7

14. 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

15. Weitzel N, Kendall J, Pons P. Blind nasotracheal intubation for patients with penetrating neck trauma. J
Trauma. 2004 May;56(5):1097-101

16. Shapiro ML. Neck and Upper Airway Injuries. In: Aghababian RV, ed. Essentials of Emergency
Medicine. Sudbury, MA: Jones and Bartlett Publishers; 2006:916-919

17. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good?
J Trauma. 2010 Jan;68(1):115-20

18. Vivó C, Galeiras R, Del Caz MD. Initial evaluation and management of the critical burn patient. Med
Intensiva. 2016 Jan-Feb;40(1):49-59

19. Ballow SL, Kaups KL, Anderson S, Chang M. A standardized rapid sequence intubation protocol
facilitates airway management in critically injured patients. J Trauma Acute Care Surg. 2012
Dec;73(6):1401-5
20. Riley RD, Miller PR, Meredith JW: Injury to the esophagus, trachea and bronchus. In Trauma. 5th
edition. Edited by Moore EE, Feliciano DV, Mattox KL. New York: McGraw-Hill; 2004:539-552

21. Randall DR, Rudmik LR, Ball CG, Bosch JD. External laryngotracheal trauma: Incidence, airway control,
and outcomes in a large Canadian center. Laryngoscope. 2014 Apr;124(4):E123-33

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