Question 7.2

College Answer

(a)        How would you manage stridor in this boy?

•     Oxygen
•    Maintain spont vent in position of comfort until airway secure
•    Nebulised adrenaline
•     Heliox
•    Prepare difficult airway equipment
•    Call for assistance

(b)        How will you secure his airway? Give reasons.

Options 
•    Awake fibreoptic intubation -may risk further laryngotracheal separation
•    Tracheostomy under LA – the safest option available
•    Gas induction with surgeon present for emergency tracheostomy
•    Avoid cricothyroidotomy -  risk of further damage
•    RSI contraindicated – cricoid pressure may cause laryngotracheal separation

Discussion

This boy has either an acute traumatic upper airway injury (eg. fracture of laryngeal cartilage or hyoid) or injury to the surrounding tissues which is now causing airway obstruction due to swelling. Either way, he needs to be intubated.

This question benefits from a systematic approach.

a)

• Administer oxygen, to preoxygenate
• Administer nebulised adrenaline
• Prepare for difficult intubation:
  • Get the difficult intubation equipment trolley
  • Contact senior anaesthetic staff and ENT surgeon
  • Organise drugs for an awake fiberoptic intubation

Generic measures for the management of stridor may apply:

• Corticosteroids
•  Nebulised adrenaline
• Helium-oxygen gas mixture
• Non-invasive ventilation is contraindicated; the patient may have laryngeal mucosal injury and positive pressure may dissect into the tissues, causing subcutanous emphysema and impairing the laryngoscopy. One presumes that this is what the college meant when they recommended to maintain "spont vent" in the model answer.

b)

• Ideally, emergency tracheostomy should be performed (in the operating theatre, by a skilled surgeon and under local anaesthesia), as this is the procedure which is least likely to result in further laryngeal trauma; furthermore it allows the ENT surgeon unobstructed access to the larynx.
• Awake fiberoptic intubation; why?
  • allows visualisation of the damage to laryngeal structures
  • least likely to produce further laryngeal injury
  • HOWEVER: railroading the tube might result in further damage.
• Totally unfeasible approaches:
  • RSI (cricoid is contraindicated)
  • Cricothyroidotomy (the larynx is injured and distorted)

Schaefer, Steven D. "Management of acute blunt and penetrating external laryngeal trauma." The Laryngoscope 124.1 (2014): 233-244.

This article is probably more useful:

Peady, "Initial Airway Management of Blunt Upper Airway Injuries: A Case Report and Literature Review" Australasian Anaesthesia 2005