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AIRWAY TRAUMA & ITS EMERGENCY
MANAGEMENT
MODERATOR : PROF. RAJESHWARIPRESENTORS : DR. CHITRA
DR. GURURAJ
www.anaesthesia.co.in [email protected]
TOPICS
Airway anatomy Definition Incidence Classification Mechanisms Airway injuries Associated injuries Concerns
ANATOMICAL CONSIDERATIONS Every major vital structure is represented Platysma is the anatomical landmark that
determines whether penetrating neck trauma is superficial or deep
Attachment of larynx to trachea is by the cricotracheal ligament
Cricotracheal ligament is quite weak & is the most likely point of airway separation
PEDIATRIC AIRWAY Cricoid shielded by mandible Cartilage pliable More susceptible to edema &
hematoma
DEFINITION An injury that directly involves the
airway in any location from nasopharynx to bronchioles
Such trauma may involve actual damage to the airway or injure bony or vascular structure that distorts airway anatomy
INCIDENCE Laryngotracheal injuries occur in 0.03 – 2.8
% 70 – 80 % patients who sustain airway
injuries die before reaching medical care Of those patients who do survive to reach
tertiary care 21% die during the first two hours of admission
Cervical spine injury occurs in 4% of all trauma patients
CONTD… According to severity:
Group 1 : minor endolaryngeal hematoma , edema , laceration without detectable fracture
Group 2 : edema , hematoma , minor mucosal disruption without exposed cartilage & non displaced fracture on CT
Group 3 : massive edema , mucosal disruption , displaced fracture , exposed cartilage , cord immobility
CONTD… Group 4 : group 3 + two or more fracture
lines , skeletal instability or significant anterior commissure trauma
Group 5 : complete laryngotracheal separation
Group 1 , 2 : mild Group 3 : moderate Group 4 , 5 : severe
CONTD… According to areas :
Zone 1 : cephalad border of clavicle to cricoid cartilage
Zone 2 : cricoid cartilage to angle of mandible
Zone 3 : angle of mandible to base of skull
MECHANISM OF BLUNT TRAUMA
Motor vehicle accidents , clothesline injury , strangulation injuries
Frontal impact MVA victim’s head is forced back , neck is hyperextended & the exposed larynx hits the edge of the dashboard & is crushed against the cervical spine
Strangulation injuries : manual compression or hanging
INJURIES Tearing of thyroarytenoid ligaments Separation of false VC from true VC Edema of arytenoids Displacement of arytenoids Fracture of thyroid cartilage Separation of epiglottis from larynx
CONTD…. Cricoid injury Recurrent laryngeal nerve injury Laryngotracheal disruption Tear of trachea or bronchi Concurrent cervical spine injuries ,
oesophageal injuries , pneumothorax , blunt thoracic trauma
MORTALITY RATES Thyroid cartilage injuries – 11 % Tracheal injuries – 25 % Cricoid injuries – 43 % Intrathoracic tracheal injuries or
bronchial injuries – higher mortality rates
PENETRATING NECK TRAUMA Zone 1 : 3 – 7 % At risk structures :
Subclavian vessels , brachiocephalic veins , common carotid arteries , jugular veins , aortic arch
Trachea Oesophagus Apices of lung
ZONE 2 INJURIES 82 % At risk structures :
Carotid artery , vertebral artery , jugular vein Pharynx Larynx Trachea Oesophagus Cervical spine
CONTD…. One third patients with zone 2
injuries require emergency airway management
Airway compromise occurs due to : Laryngeal injury Hematoma Subcutaneous emphysema
ZONE 3 INJURIES 15 % At risk structures :
Salivary glands Oesophagus Trachea Cervical spine Carotid artery , jugular vein , 9 – 12
cranial nerves
ASSOCIATED INJURIES
Vascular injuries : 25 – 40 % Injury to pharnyx , oesophagus : 5 –
15 % Mortality
20 % in penetrating trauma 40 % in blunt trauma
THERMAL INJURY Facial & perioral swelling
pharyngeal obstruction Thermal injury to upper airway
laryngeal obstruction Chemical injury to lung impaired
gas exchange
Suspect oropharyngeal airway obstruction whenever full thickness facial & anterior cervical burns are present
Suspect laryngeal thermal injury when carbonaceous material is present in the mouth , nares or pharynx
LOWER AIRWAY BURNS Unusual because of heat absorptive
properties of upper airway Due to steam inhalation , chemical
burns , inhalation of burning gases Maximal airway edema may be
delayed for upto 24 hours
CERVICAL SPINE INJURIES
Occur in :• 2 – 8 % of blunt trauma victims• 4.5 % of motor vehicle accidents• 5 – 15 % of head injury patients• 4 – 5% of high velocity type of facial
fractures
CONTD…
Diagnosis delayed or missed in 25 % of patients
No neurological deficits on arrival in 5 – 10 % of patients with cervical spine injury
Lateral view cervical spine films – 30 % missed
AP , lateral , transoral odontoid detects 99%
TRANSPORT Cervical collar , spine board ,
sandbags to stabilise cervical spine During intubation , anterior portion
of cervical collar should be removed Apply cricoid pressure & manual in
line stabilization & intubate orally
ASPIRATION Aspiration risk due to
Ingested foods immediately before trauma Altered level of consciousness Cranial nerve injury & attenuation of gag
reflex Injury , pain , anxiety delay gastric
emptying Gastric dilatation Blood aspiration
PREVENTION
Metoclopramide H 2 blockers Sodium citrate NG tube aspiration Cricoid pressure Secure airway
INTRACRANIAL & INTRAOCULAR INJURIES
Direct trauma to the brain Secondary brain injury : hypoxia,
hypotension Injury to the globe
THORACIC TRAUMA
Blunt thoracic trauma - higher mortality than penetrating thoracic trauma
Rib fracture Flail segments Chest wall contusion Pulmonary contusion
CONTD… Hemothorax Pnemothorax Pneumomediastinum Interstitial emphysema Bronchial tear Intrapulmonary bleed Air emboli
POINTS TO REMEMBER Larngotracheal trauma is a rare but
potentially lethal injury Patients may appear deceptively normal
for several hours after injury ER physicians , general surgeons ,
thoracic surgeons , anesthesiologists & otolaryngologists should be well versed in the manifestations & management of airway injuries
www.anaesthesia.co.in [email protected]