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.

Discussion

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

References

Caron, Guy, et al. "Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures." Journal of Trauma and Acute Care Surgery 48.2 (2000): 235-240.

Barriot, P. A. T. R. I. C. K., and B. R. U. N. O. Riou. "Retrograde technique for tracheal intubation in trauma patients." Critical care medicine 16.7 (1988): 712-713.

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

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

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

Kelly, James P., et al. "Management of airway trauma I: Tracheobronchial injuries." The Annals of thoracic surgery 40.6 (1985): 551-555.

Kelly, James P., et al. "Management of airway trauma II: combined injuries of the trachea and esophagus." The Annals of thoracic surgery 43.2 (1987): 160-163.

Shearer, Vance E., and A. H. Giesecke. "Airway management for patients with penetrating neck trauma: a retrospective study." Anesthesia & Analgesia 77.6 (1993): 1135-1138.

Devitt, J. Hugh, and Bernard R. Boulanger. "Lower airway injuries and anaesthesia." Canadian journal of anaesthesia 43.2 (1996): 148-158.

Jain, Uday, et al. "Management of the Traumatized Airway." The Journal of the American Society of Anesthesiologists 124.1 (2016): 199-206.

Bhojani, Rehal A., et al. "Contemporary assessment of laryngotracheal trauma." The Journal of thoracic and cardiovascular surgery 130.2 (2005): 426-432.

Kummer, Carmen, et al. "A review of traumatic airway injuries: potential implications for airway assessment and management." Injury 38.1 (2007): 27-33.

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