AIRWAY TRAUMA & ITS EMERGENCY MANAGEMENT MODERATOR : PROF. RAJESHWARI PRESENTORS : DR. CHITRA DR. GURURAJ www.anaesthesia.co.in anaesthesia.co.in@gmail.com

TOPICS Airway anatomy Definition Incidence Classification Mechanisms Airway injuries Associated injuries Concerns

ANATOMY

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

CLASSIFICATION According to site of injury : Supraglottic Transglottic Cricoid Tracheal

CONTD… According to the mechanism of injury : Blunt trauma Penetrating trauma Superficial deep

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

CONTD… Cervical spine Cervical nerve roots Spinal cord

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

ASSOCIATED FACTORS Aspiration risk Intraocular injury Intracranial injury Thoracic trauma

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 anaesthesia.co.in@gmail.com