Question 12

This is an image (Figure 12) of a 13-year-old male who rode his motorbike into a single strand of fencing wire, was thrown off and walked 500 metres for help. He now complains of difficulty in breathing. On examination he has stridor.

a)    List the potential associated injuries possible in this patient.    (30% marks)

b)    Discuss the specific management options for securing his airway. Include in your answer the advantages and disadvantages of each and your preferred option.    (70% marks)

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College answer

Not available.


This question is virtually identical to Question 7.2 from the first paper of 2010. Presumably they used the same image of the boy (this dude would surely be in his thirties by now). In another act of what appears to be a slow process of improving the phrasing of old SAQs,  the colloquial "How will you secure his airway? Give reasons" has given way to "Discuss the specific management options for securing his airway". Also, the list of potential injuries is new.

List of potential injuries: This is essentially blunt trauma to Zone II of the neck; or rather, one's knowledge of neck anatomy is tested here; one must think, "what could possibly have gotten in the way of that fence wire?". Thus:

  • Laryngeal or cricoid injury
  • Tracheal injury (eg. cartilage fracture)
  • Trauma to the internal jugular veins (could lead to thrombosis)
  • Carotid or vertebral artery dissection
  • Brachial plexus nerve root injury
  • Recurrent laryngeal nerve injury 
  • Spinal cord and C-spine injury
  • Thyroid contusion
  • Soft tissue haematoma of the neck

Management options for securing his airway are numerous.

Strategy Advantages Disadvantages
Do nothing 
  • Noisy breathing is better than no breathing
  • Could be better to buy time with pharmacological management of airway swelling (eg. nebulised adrenaline)
  • Requires no additional airway skills 
  • Could be the safest option of all if senior ENT/anaesthetic help is available but delayed
  • Delays potentially inevitable intubation
  • During the delay, swelling/haematoma might get worse, making the subsequent intubation difficult or impossible 
  • Airway trauma progresses towards obstruction insidiously, over hours
  • It may be difficult to detect impending airway failure 

Modified rapid sequence induction

  • No cricoid pressure: laryngeal injuries may be exacerbated by cricoid pressure
  • Passive pre-oxygenation (no manual bagging)
  • No positive pressure until the cuff is up
  • The intubation may convert a partially transected trachea into a completely transected trachea
  • C-spine precautions could make it more challenging
  • Presence of airway swelling may make it impossible

Awake fiberoptic bronchoscopy

  • Avoids the potential loss of airway with anaesthetic-related loss of airway tone 
  • Allows inspection of the airway structures on the way in
  • Airway swelling decreases access
  • The patient may be obtunded and uncooperative
  • Copious blood and mucus in the airway will frustrate the view
  • There may not be time to set up the appropriate equipment
Elective tracheostomy or cricothyroidotomy
  • Bypassess the injured sections of the upper airway 
  • A definitive solution to upper airway trauma
  • Appropriate if the upper airway cannot be traversed with a tube, or where laryngoscopy is difficult because of swelling
  • Unskilled or blind approach could produce a complete disruption of a partially disrupted trachea
  • A disrupted trachea will retract into the thorax, and will need to be surgically retrieved.

"Own practice" could consist of something like...

  • Initially, do nothing:
    • Start the patient on oxygen and give an adrenaline neb
    • Take the patient to CT to image the airway
  • If the CT is non-reassuring, or the patient's condition is deteriorating, go to Plan B:
    • Plan B is modified RSI with a second operator preparing for airway scalpel/bougie/tube rescue
    • "Modified" because:
      • No cricoid pressure: laryngeal injuries may be exacerbated by cricoid pressure
      • Passive pre-oxygenation (no manual bagging)
      • No positive pressure until the cuff is up
  • If CT is relatively reassuring, proceed with Plan A:
    • Plan A is to have a fiberoptic intubation with anaesthetics and ENT in theatre


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Mohan, Raja, Rajiv Iyer, and Seth Thaller. "Airway management in patients with facial trauma." Journal of Craniofacial Surgery 20.1 (2009): 21-23.

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