Management of Upper Airway Trauma

INITIAL STABILIZATION

1. Position Patient

     - allow to self posture when able, to maintain airway potency. Hard collar if cervical spine injury is suspected.

2. Airway

Complete Obstruction

• Summon help from the doctor most experienced in airway management
• Use basic airway opening man oeuvres
• Attempt incubation without use of muscle relaxants initially
• If unsuccessful, proceed to emergency surgical airway

Partial Obstruction

     Based on presence of stride, hoarse voice and or respiratory distress.

• Humidified oxygen
• Notify anesthetist / surgeon
• Transfer to operating theater accompanied by skilled staff for examination under anesthetic / incubation / tracheotomy
• Do not transfer patient to another facility until incubation has occurred

Potential Obstruction

     Based on the presence of sore throat, swollen face, swollen tongue, external neck trauma. Consider incubation by a doctor experienced in airway management, especially prior to transfer. Consult with a retrieval service if necessary.

• Mandibular fractures : where the tongue cannot be cleared by special techniques a towel clip or large suture can be used to retract and anchor it.
• Foreign bodies penetrating the face and mouth should not be removed and the wound not explored until the patient is in the operating theater.
• In laryngeal fracture resulting in airway obstruction, needle hypothyroidism is the procedure of choice. Formal hypothyroidism should not be performed as this may further disrupt the anatomical structures.
• The trachea can be incubated directly through the neck in a penetrating wound.

3. Breathing

• Measure respiratory rate. If inadequate, assist ventilation with bag valve mask attached to oxygen
• Measure SA O 2. If <95% and not requiring assisted ventilation, administer high flow oxygen via mask.
• Examine for associated pneumonia or other chest injury.

4. Circulation

• Measure PR, BP, and capillary refill
• Attach to cardiac monitor and assess rhythm
• Insert IV annular
• Take blood for F B C, biochemistry, crosspatch
• If shock is present, give crystallized rapidly

5. Hemorrhage Control

• Reduce fractures immediately, especially if mid third of face is involved
• Pack pharynx if necessary
• Pack or suture other wounds

6. Monitor

     - SA O2, BP, ECG

7. Summon

     a doctor with airway skills

DIRECTED HISTORY AND EXAMINATION

     Ask about :

        Event

• mechanism of injury

Symptoms

• voice changes
• painful swallowing
• noisy breathing/dyspepsia

Past History

• medications
• allergies
• medical problems

Look for :

• stride
• swelling of the neck, palate, tongue
• subcutaneous emphysema in the neck or face
• laryngeal deformity or tenderness
• middle third of face mobility
• significant hemorrhage especially pharyngeal

Tests

     None per - stabilization

     Once stable, consider :

• facial X rays/CT
• C X R
• cervical spine X ray
• CT neck and larynx if possible

SPECIFIC TREATMENT

Laryngeal trauma - where there is no clinical evidence of airway compromise, but there is subcutaneous emphysema due to blunt neck trauma, administer humidified oxygen and commence IV antibiotics for possible salivary contamination of the deep tissues of the neck.

DISPOSITION

     For complete obstruction with surgical airway in place, or partial obstruction:

1. Notify anesthetist/NET or local equivalents

2. Notify operating theater

3. When all resources are assembled transfer to operating theater accompanied by skilled staff, oxygen, suction, bag valve mask system, difficult incubation tray and surgical airway setup.

IMPORTANT POINTS

1. Always maintain a well prepared crash trolley.

2. Ensure that before incubation the staff, equipment and patient are prepared as much as time allows.

3. Check all equipment before commencing.

4. If asphyxia occurs, assume tube malfunction or positional first. If in doubt, extenuate, ventilate, re-oxygenate and re- incubate with a fresh tube.