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CASE REPORT
Year : 2009  |  Volume : 53  |  Issue : 3  |  Page : 348-351 Table of Contents     

Airway Management of Two Patients with Penetrating Neck Trauma


1 PG Student, Department Of Anaesthesiology. North Bengal Medical College, P.O.-Susrutanagar, PIN-734012, District-Darjeeling, West Bengal, India
2 Assistant professor, Department Of Anaesthesiology. North Bengal Medical College, P.O.-Susrutanagar, PIN-734012, District-Darjeeling, West Bengal, India
3 Professor and Head, Department Of Anaesthesiology. North Bengal Medical College, P.O.-Susrutanagar, PIN-734012, District-Darjeeling, West Bengal, India

Date of Web Publication3-Mar-2010

Correspondence Address:
M C Mandal
Assistant professor, Department Of Anaesthesiology. North Bengal Medical College, P.O.-Susrutanagar, PIN-734012, District-Darjeeling, West Bengal
India
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Source of Support: None, Conflict of Interest: None


PMID: 20640146

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Direct trauma to the airway is a rare injury which can lead to disastrous consequences due to compounding effect of bleeding, aspiration of blood, airway obstruction and severe sympathetic stimulation. Here we are presenting two cases of open tracheal injury in two adult males following assault with sharp weapon. Two different techniques of securing the airways were employed depending upon the severity and urgency of the situation. In the first case, orotracheal intubation helped the surgeon to repair airway around the endotracheal tube whereas in the second patient this stenting effect was absent as he was intubated through the distal cut-end of trachea in the face of airway emergency.

Keywords: Penetrating neck trauma, Open tracheal injury, Airway emergency, Airway management


How to cite this article:
Bhattacharya P, Mandal M C, Das S, Mukhopadhyay S, Basu S R. Airway Management of Two Patients with Penetrating Neck Trauma. Indian J Anaesth 2009;53:348-51

How to cite this URL:
Bhattacharya P, Mandal M C, Das S, Mukhopadhyay S, Basu S R. Airway Management of Two Patients with Penetrating Neck Trauma. Indian J Anaesth [serial online] 2009 [cited 2020 May 28];53:348-51. Available from: http://www.ijaweb.org/text.asp?2009/53/3/348/60302


   Introduction Top


Penetrating neck trauma is responsible for 5% to 10% of all trauma admissions. These injuries are chal­lenging and encountered as a small component of an anaesthesiologist's overall clinical experience. The neck contains a dense concentration of vital structures that are not always easy to assess by physical examination or surgical exploration. [1] Irrespective of these prob­lems the overall mortality is relatively low, ranging from 0 to 11%. [2] Laryngeal injuries are quite rare due to the protection offered to the laryngeal apparatus by the mandible and cervical spine. However acute blunt la­ryngeal trauma can be a life threatening event and often poses a difficult airway problem. [3]


   Case report Top


We got two male patients in close proximity of time in our emergency department sustaining wide open wound in front of the neck at the level of cricothyroid membrane. They presented with frequent cough, dys­pnoea, aphonia, haemoptysis, odynophagia, some de­gree of local surgical emphysema, occasional bouts of vomiting mixed with swallowed blood and were con­scious. The first patient had pulse 114/min, BP 150/90 mmHg, clear chest, warm extremities. Expiratory air was coming out of the open tracheal wound, but there was neither visible active bleeding nor any inspiratory sucking. Whereas the second patient had worse haemodynamics (pulse 146/min, BP 90/60 mmHg), cold clammy extremities, coarse pulmonary crepitations and severe respiratory distress even in sitting position. The patient was breathing through the distal tracheal end which was retracted and could be identified by gush of expiratory air coming out of it. There was sucking-in of the blood clots during inspiration.

In emergency ward, wide-bore intravenous(iv) cannula was inserted, blood sample was sent for group­ing and cross matching. In the operation theatre, ECG, NIBP and pulse-oximeter were attached. Patients were premedicated with iv ranitidine 50 mg, ondansetron 4 mg, glycopyrrolate 0.2 mg and fentanyl 50 mcg. In­formed consent was taken.

We intubated the first patient orotracheally under topical anaesthesia with ten percent lidocaine spray. The tube came out of the proximal airway defect which was guided into the open distal tracheal rent [Figure 1], [Figure 2]. Anaesthesia was provided with fentanyl 2mcg/kg, propofol; vecuronium and O 2 / N 2 O. The surgical pro­cedure involved primary repairs of the pharynx (around a nasogastric tube) and the airway defect[around the endotracheal tube(ETT)], followed by mid-tracheostomy.

In the second patient, due to airway emergency, we introduced a lubricated bougie through distal tra­cheal rent after topical anaesthesia. The tracheal rent was retrieved with Allis' forceps. We slid an endotra­cheal tube over the bougie. Intubation was followed by low-tracheostomy.[Figure 3], [Figure 4]. Then the endot­racheal tube was withdrawn. Anaesthesia was pro­vided with iv ketamine, vecuronium, fentanyl 2mcg/kg and O 2 / N 2 O. The tracheal end was sutured to the cricoid cartilage and repair of the oesophageal injury was done.

At the end of the procedure, both the patients were reversed satisfactorily. The patients were shifted to the recovery room with supplemental O 2 through a T-piece via tracheostomy. Unwanted neck extension was prevented with a supporting cast behind the neck. Nutrition through nasogastric tube was maintained for 2weeks. After 2 weeks, oesophagoscopy and fibreoptic laryngoscopy was done which confirmed fair recovery of soft tissues. Thereafter oral feeds were al­lowed. Tracheal decannulation was done after 3 weeks and the patient were discharged after 4weeks. Both patients are still under monthly follow up and doing well, though the first patient having minor degree of dys­phonia and the second patient is suffering from some problems with swallowing of solid foods.


   Discussion Top


Direct trauma to the airway is a rare injury, ac­counting for less than 1% of traumatic injury [4] . These injuries are quite challenging to the anaesthesiologist as these are compounded by great vessel injury, impend­ing airway obstruction and severe sympathetic stimula­tion [5] . Most of the penetrating neck injuries (50-80 %) involve zone II of the neck i.e. from the cricoid carti­lage to the angle of the mandible [4],[5] . The prevailing site of tracheal transection is extrathoracic and involves the cricotracheal junction, because the connective tis­sues in this area are weak [6] . Injury at or below the cricoid carries the risk of partial or total airway ob­struction with resultant asphyxiation and definite air­way management of such patients is a life saving mea­sure [4] . These patients can be managed with different airway techniques such as intubation through the vis­ible airway defect, conventional orotracheal intuba­tion, or tracheostomy.

The description and treatment of penetrating tracheo-oesophageal injuries was first reported in Scotland in 1792 [7]. The open tracheal injuries most commonly result from violent crime, primarily of bal­listic and knife injuries [4] . Penetrating injuries occur most commonly (75%) in the cervical trachea because of its exposed position. [6],[8] Despite severe tracheo-pha­ryngeal injuries, carotid sheath with its contents was spared in our two patients probably due to posteri­orly tilted head pulling the carotid sheath behind a taut sternocleidomastoid which was injured instead. In­jury to minor peripheral vessels may lead to signifi­cant hypotension, as occurred in our second patient and ligation of the bleeding vessels effectively pre­vented further degradation.

Hoarseness, subcutaneous emphysema, dysp­noea, dysphagia and haemoptysis strongly suggest dis­ruption of laryngo-tracheal continuity [4] . Oesophageal injury frequently accompanies tracheal injury, as it is intimately associated with the trachea at all levels and may lead to fatal mediastinitis [6],[9]. Controversy exists about immediate surgical exploration in asymptomatic patients, taking into account the significant number of negative explorations but there is consensus opinion regarding immediate exploration in cases of associated oesophageal injury, progressive subcutaneous or me­diastinal emphysema, pneumothorax and severe dysp­noea requiring intubation. [5] In any patient with neck in­jury, the first priority is to establish an airway [10] . If the patient is asphyxiating, the quickest way to secure the airway in a patient with open cervical wounds is to in­tubate the distal open end of the trachea through the wound itself followed by a tracheostomy and repair of the tracheal defect [4],[6]. Occasionally, because of com­plete transection, the distal cut-end of the trachea may retract into thorax, which can be retrieved and intu­bated, as in our second patient [6] . Now, in the first pa­tient, the airway was not severely compromised, but airway control was necessary nevertheless. Davari HR and Malekhossini SA mentioned that orotracheal intu­bation should be attempted in all such cases except those with massive maxillofacial trauma. [8] Orotracheal intubation as a stent also helps in primary repair of the trachea. Sedative, hypnotic and opioid should be avoided or given cautiously and muscle relaxant should be employed only if there is capability to perform an immediate tracheostomy should intubation fail [4],[11]. Oxy­genation of these patients using face mask is not effec­tive due to airway disruption [12] . Agitation, straining and coughing may result in increased intratracheal pressure, spread of subcutaneous emphysema, complete airway obstruction and increased venous pressure leading to dislodgement of clots and torrential bleeding [10] . Topical application of anaesthetic seems a suitable option, as field blocks can be difficult to perform in these cases.

Fibreoptic bronchoscopy allows identification of tracheal lumen and injury and helps in smoother entry of ETT through the cut-end of trachea but may not be feasible in emergency situation. Also blood, secretions and oedema can interfere with visualization [4] .Intubation by direct laryngoscopy would be ideal considering the speed with which it could be performed but surprises could always await and emergency surgical access should always be considered as another alternative [13] . The options for surgical management of injuries to extrathoracic trachea are primary repair, resection and anastomosis and tracheostomy and maintenance of neck flexion in the early postoperative period. Inser­tion of a tracheal graft may be necessary.

Postoperative mechanical ventilation may be re­quired in many cases, but may disrupt the repaired tra­chea. Pain control is essential in order to provide ad­equate pulmonary ventilation, clearance of secretions and alleviation of sympathetic over-activity. Adequate systemic hydration, prophylactic nebulisation and hu­midification help to prevent drying up of secretions.

A new air leak, haemoptysis, worsening medias­tinal or subcutaneous emphysema warrant bronchos­copy to assess suture line.



 
   References Top

1.Demetriades D, Asensio JA, Velmahos G, Thal E. Com­plex problems in penetrating neck trauma. Surg Clin NorthAm1996;6:661-83.  Back to cited text no. 1      
2.Asensio JA, Valenziano CP, Falcone RE, Grosh JD. Man­agement of penetrating neck injuries. The controversy surrounding zone II injuries [review]. Surg Clin North Am 1991;71:267-96.  Back to cited text no. 2      
3.Goldenberg D, Golz A, Flex Goldenberg R, Jaochism HZ.Severe laryngeal injury caused by blunt trauma of the neck. J Laryngol Otol 1997; 111: 1174-76.  Back to cited text no. 3      
4.Crosby ET. Airway management in trauma patients. In: D. John Doyle and Alan N. Sandler (Eds). Anesthesiol­ogy Clinics of North America-The Difficult Airway II,W.B.Saunders Company 1995;13:645-663.  Back to cited text no. 4      
5.Nason RW, George NA, Gray PR, et al. Penetrating neck injuries: analysis of experience from a Canadian trauma center. Journal Canadien de chirugie, Avril 2001;44:122-6.  Back to cited text no. 5      
6.Devitt JH, Boulanger BR. Lower airway injuries and ana­esthesia. Can J Anaesth 1996; 43: 148-59.  Back to cited text no. 6      
7.Meade RH. The management of wound of the chest. In: A History of Thoracic Surgery, Springfield: Charles C Thomas 1961; 3-22.  Back to cited text no. 7      
8.Davari HR, Malekhossini SA. Management of tracheo­bronchial injury. Case presentation and review of litera­ture. Acta Medica Iranica 2005; 43 : 291-98.  Back to cited text no. 8      
9.Mulder DS, Barkun JS. Injury to the trachea, bronchus and esophagus. In: Moore EE, Mattox KL, Feliciano DV (Eds). Trauma, 2nd ed. East Norwalk: Appleton and Lanze, 1991; 343-55.  Back to cited text no. 9      
10.Kohli A, Bhadoria P, Bhalotra A et al. An unusual laryn­geal injury. Indian J Anaesth 2007; 51:57-9.  Back to cited text no. 10    Medknow Journal  
11.Shearer VE, Giesecke AH: Airway management for pa­tients with penetrating neck trauma: A retrospective study. Anesth Analg 1993; 77:1135-8.  Back to cited text no. 11      
12.Kumar Sandeep, Singh B, Kumar S, et al. Management of complete cricotracheal separation following sharp edge injury. J Anaesth Clin Pharmacol 2004; 20:79-82.  Back to cited text no. 12      
13.Francis J, Menezes J, Kilpadi K, et al. Anaesthetic airway management in penetrating neck injury- a retrospective analysis. J Anaesth Clin Pharmacol 2004; 20:83-85.  Back to cited text no. 13      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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