1. Airway Management For Neck Trauma Alex Sigalovsky, CRNA
As anesthesia providers / airway managers our primary concern in patients with neck injuries is to secure the airway.
Distorted anatomy, hemorrhage, edema, foreign bodies and the urgency of the situation at times make this task challenging and often intimidating.
The methods of airway management of in these patients remains a controversial topic. There is no consensus. In fact, experts often have very conflicting opinions.
The choice will ultimately depend on the patient's situation and the expertise of the airway team.
My goal today: 1) Teach you something you don’t already know
2) Provide insight on how we handle these airways at WFST
3) Offer suggestions you may wish to consider incorporating into your practice

2. Objectives Anatomy Classifications Mechanisms Airway Cases Summary
The literature on penetrating and blunt neck trauma in emergency medicine, trauma, anesthesia, radiology, and otolaryngology is enormous, often contradictory, and concentrates more on specific diagnostic modalities and
surgical treatment than initial management. The majority of studies are retrospective reviews of various diagnostic modalities, as opposed to initial management

3. Anatomy of Neck
A complex network of muscles, vessels, and nerves – all supported by fascial planes
Two primary classifications utilized in description of neck injuries:
Zones
Triangles
The high density of vascular, aerodigestive and neurologic structures within the neck makes the management of injuries difficult, especially penetrating ones, and contributes to the morbidity and mortality seen in these patients.
Leonardo da Vinci. Study of a Man with his Head Turned, c. 1495

4. Anatomy: Neck Contents
Musculoskeletal structures: vertebral bodies; cervical muscles, tendons, and ligaments; clavicles; first and second ribs; and hyoid bone.
Neural structures: spinal cord, cervical roots of phrenic nerve and brachial plexus, recurrent laryngeal nerve, cranial nerves (specifically IX-XII), and stellate ganglion.
Vascular structures: carotids, vertebral arteries, & vertebral vein, brachiocephalic vein, and jugular veins.
Visceral structures: thoracic duct, esophagus and pharynx, and larynx and trachea.
Glandular structures: thyroid, parathyroid, submandibular.
Fascia: superficial and deep cervical fascia.

5. Anatomy: Neck Zones

6. Anatomy: Neck Zones Zone I: sternal notch – cricoid cartilage
Proximal subclavian, vertebral, carotids; lung apices, trachea, esophagus, thoracic duct, glands
Zone II: cricoid – angle of mandible
Carotid, vertebrals, trachea, larynx, esophagus, cord, vagus/ recurrent laryngeal
Zone III: above angle of mandible
Pharynx, salivary glands, distal carotid/ vertebrals, cranial nerves
Zone II injuries = most common, best prognosis. Easiest anatomy to expose, apply pressure, control vascular injury.
Zone I = highest mortality due to intrathoracic injury (hemothorax, pneumothorax, aortic injury are common).

7. Anatomy: Triangles
Anterior and posterior triangles of the neck : separated by the sternocleidomastoid muscle (SCM):
Anterior triangle, defined:
Anteriorly – by midline
Posteriorly – by SCM
Superiorly – by mandible
Posterior triangle, defined:
Anteriorly – by SCM
Inferiorly – by the clavicle
Posteriorly – by the anterior
border of the trapezius muscle
Anterior: easier access

8. Anatomy: Triangles Anterior triangle structures:
Carotid artery
Internal jugular vein
Vagus nerve
Thyroid gland
Larynx
Trachea
Esophagus
Posterior triangle structures:
Subsclavian artery
Brachial plexus
Anterior triangle has many more vital structures, yet provides an easier access

9. Anatomy: Fascial Planes
Platysma:
superficial muscle that overlaps the sternocleidomastoid
Covers anterior triangle completely
Covers anteroinferior aspect of posterior triangle
Critical landmark in injury diagnosis
Deep Cervical Fascia:
Pretracheal portion communicates with mediastinum
May lead to mediastinitis
Platysma is a broad sheet arising from the fascia covering the upper parts of the pectoralis major and deltoid; its fibers cross the clavicle, and proceed obliquely upward and medially along the side of the neck.

10. Anatomy: Larynx
Four basic anatomic components of the larynx: a cartilaginous skeleton, intrinsic and extrinsic muscles, and a mucosal lining.

11. Anatomy: Larynx
Cartilaginous skeleton, which houses the vocal cords, is comprised of the thyroid, cricoid, and paired arytenoid cartilages.
These cartilages are connected to other structures of the head and neck through the extrinsic muscles.
The intrinsic muscles of the larynx alter the position, shape and tension of the vocal folds

12. Mechanism of Injury Penetrating Blunt Stangulation
For the purpose of this presentation, neck trauma is divided into penetrating, blunt, and strangulation injury.

13. Neck Trauma: Penetrating
Stab
Gun shot wounds (GSW)
Motor vehicle collisions (MVC)
Clothesline / wire
Questions
Is the platysma penetrated?
Stable vs Unstable?
Penetrating neck trauma tends to cluster in specific urban areas and is often cared for at Level I trauma centers. At other hospitals, this lack of familiarity and the complexity of the problem make this a “high-risk” situation for both the patient and the provider.
Penetrating neck injuries account for 5%-10% of all traumatic injuries and have an overall mortality of up to 10%. Most injuries to the neck are in Zone II (between the cricoid and angle of the jaw). The majority of penetrating neck injuries in the civilian population are produced by knives or firearms.
Pathophysiology of penetrating neck trauma varies greatly with mechanism. An powerful assault rifle fired from a distance into the neck region will produce a much more extensive tissue damage than a handgun.
Shotgun pellets are generally low-velocity and follow path of least resistance, which results in unpredictable patterns and may lead to distal emboli, such as in heart.
Stab wounds may initially look innocuous, but estimation of depth of tract is difficult.
Carotid injuries can produce a rapidly expanding hematoma that may distort or occlude the airway. Large lacerations of the jugular venous system can generate an air embolism, causing hypotension and respiratory distress.
Follow the little metal fragments: they go in the left maxillary sinus, turn 90 degrees when the base of the skull is hit, and track down the neck.

14. Neck Trauma: Blunt Blunt: Much more rare
MVC (especially unrestrained)
Assault
Hanging
Clothesline accident
Sports injury
Much more rare
Symptoms may be minimal or delayed
Causes 3-10% of all cervical vascular injury
Blunt neck trauma is less frequent and dramatic, yet it is equally life-threatening. While vascular injuries predominate in penetrating trauma, airway injuries prevail in blunt trauma.
Common mechanisms include a motor vehicle collision involving an unrestrained passenger decelerating against the dash (“the padded dash syndrome”), a shoulder harness creating shearing injury to the neck, and blunt neck trauma secondary to airbag deployment, clothesline, and bicycle handlebar injuries.
The neck’s complex framework of supporting fascial planes, musculature, and cartilage can result in minimal physical findings and delayed complications.
s/p high speed MVC. Old cervical fusion. Now with complete spinal cord transection.
Classic symptoms include dysphonia, hoarseness, dysphagia, dyspnea, pain, hemoptysis, and stridor.

15. Neck Trauma: Strangulation
Hanging
Clothesline accident
Severe hoarseness and stridor signal impending airway obstruction
Death from three mechanisms:
Injury to the spinal cord or brain stem
Mechanical constriction of the neck structures
Cardiac arrest

16. Evaluation
Patients with signs of significant neck injury and hemodynamic instability will require prompt exploration. However, initial assessment and management of the patient should be carried out according to ATLS principles.
The major initial concern in any patient with a penetrating neck wound is early control of the airway.

17. Evaluation
A characteristic of neck injuries is rapid airway distortion with obstruction due to edema and hematoma, and often difficult intubation. The key to management is early intubation. The route of intubation must be considered carefully in these patients since it may be complicated by distortion of anatomy, hematoma, dislodging of clots, laryngeal trauma, and a significant number of cervical spinal injuries. These patients should be intubated as soon as possible, with appropriate neck protection.

18. Evaluation Anatomic zone
Structures at risk, ease of access, hemorrhage control
Signs, symptoms: vascular, laryngeal, tracheal disruption
Vascular: active bleed, expanding hematoma, carotid bruit
Tracheal: stridor, bubbling bleed, voice changes, dyspnea, subcutaneous emphysema
Esophageal: dysphagia
Signs and symptoms may be divided into major and minor.
Major signs and symptoms are suggestive of significant airway injury. These major diagnostic criteria are:
1. Subcutaneous emphysema (which may develop some time after the initial injury);
2. Dyspnea;
3. Stridor; and
4. Inability to tolerate the supine position.
Minor diagnostic criteria include local swelling and tenderness, hoarseness of voice, dysphagia and hemoptysis.

19. Here is a typical algorithm for evaluation of penetrating neck trauma
Here is a typical algorithm for evaluation of penetrating neck trauma. Notice the first step after determining that the pt is unstable? “Secure the airway”

20. Airway Management
Intubating because of Acutely Failed Anatomy or Hemodynamic Instability
Can’t just wake the patient up
Once the decision to RSI has been made, the patient is committed to a surgical airway if other means to secure airway fail

23. Airway Management
Two difficult questions to answer:
When?
How?

24. Airway Management Earlier intubation is easier intubation…
Signs & Symptoms:
respiratory distress
blood/ secretions
sub-Q air
tracheal shift
altered mental status1
Injury: Consider intubating asymptomatic patient if expanding hematoma, GSW to neck1,2
1Eggen JT. J Emerg Med 1993:11(4):
2Walls RM. J Emerg Med 1993:11(4):
The ultimate goal of airway management in any type of neck injury is to secure is as soon as necessary and before doing so becomes next to impossible.
This is especially true in penetrating trauma, where rapid airway distortion with obstruction due to edema and hematoma can in minutes obliterate any remaining tracheal opening.
The major initial concern in any patient with a penetrating neck wound is early control of the airway.
The key to management is early intubation. The route of intubation must be considered carefully in these patients since it may be complicated by distortion of anatomy, hematoma, dislodging of clots, laryngeal trauma, and a significant number of cervical spinal injuries. These patients should be intubated as soon as possible, with appropriate neck protection.

25. Method of Securing Airway
If no indication of laryngeal injury:
Orotracheal intubation, RSI
Highest success rate, fewest complications3, 4
If suspected / obvious laryngeal injury:
If maintaining airway  Surgical airway in OR
Blunt laryngeal trauma  Awake fiberoptic5
Open laryngeal injury  Direct intubation of distal segment5
3Mandavia DP. Ann Emerg Med 2000;35(3):
4Shearer VE. Ahesth Analg 1993;77(6):
5Walls RM. Emerg Med Clin North Am;16(1):45-61.
Specific method of securing the airway in these patients has always been a controversial topic, with different institutions and regions having different “first choice” techniques, based on their local experiences, protocols and support mechanisms. Even here in Baltimore, what we do at Shock Trauma Center may not be accepted as the universal Golden Standard by other institutions. What I present here is largely our experience.
Penetrating neck injuries are among the most difficult airway cases to manage, but a recent literature search of airway management in the setting of penetrating neck injury revealed only 3 studies specifically addressing this
topic since 1969.
Distorted anatomy and risk of clot dislodgement make blind nasotracheal intubation more risky.
Bloody secretions make fiberoptic intubation more time consuming, challenging.

26. Open Tracheal Injury

27. Open Tracheal Injury

28. Open Tracheal Injury

29. Alternative Airway Approaches
Cricothyrotomy:
Not if expanding hematoma
Emergent option in tracheal injury pt who is not maintaining airway
Percutaneous Transtracheal Jet Ventilation6
6Patel RG. Chest 1999;116:
1689 – 1964.
Invasive airway management (eg, cricothyroidotomy) represents the standard approach when orotracheal intubation, by any method, is unsuccessful or contraindicated. Indications for a surgical airway include massive upper airway distortion, massive midface trauma, and inability to visualize the glottis because of heavy bleeding, edema, or anatomic disruption.
Cricothyrotomy can be difficult in a patient with anatomical distortion. The procedure is relatively contraindicated if an anterior neck hematoma exists or a laryngeal injury is suspected, but may be the only option in some patients with PNI. If the necessary resources and expertise are readily available, patients whose external landmarks are sufficiently distorted to make cricothyrotomy difficult or impossible are generally intubated awake using a flexible fiberoptic intubating scope. If the clinician suspects partial or complete laryngeal transection, a fiberoptic approach or a tracheostomy inferior to the injury may be necessary.
Percutaneous needle transtracheal or cricothyroid jet ventilation can provide oxygen to adult and pediatric patients while arrangements are made to establish a definitive airway. Clinicians must take care to avoid catheter misplacement or dislodgement, which can force air into the tissues and distort normal airway anatomy. There is no evidence to support the use of percutaneous oxygenation in patients with PNI, and the technique is best reserved for small children in whom formal cricothyroidotomy is difficult or impossible.

31. Airway Risks in Neck Trauma
“Clothesline” injury: motorcycle, bicycle, snowmobile vs. wire, tree limb
Can transect trachea: mis-alignment or loss of distal limb w/muscle relaxant
Zone I: Pneumothorax, hemothorax
Hypotension, high O2 requirement, decreased breath sounds
Hematomas that are initially hidden and later expand
Foreign body in neck
Airway deviation / obstruction

32. Decision Points Concern related to use of muscle relaxants
Theoretically, muscle relaxation can potentially convert a partially obstructed airway to a complete obstruction.
But… patient’s muscular tone can be more detrimental than helpful when trying to resolve the acute airway emergency.
Although extensively used in emergency practice, rapid sequence intubation remains controversial in those with the potential of distorted airway anatomy such as in patients with penetrating neck injuries. Theoretically, muscle relaxation can potentially convert a partially obstructed airway to a complete obstruction; however, endotracheal tube passage is greatly facilitated and the airway can be quickly and definitively secured.

33. Decision Points
Avoid techniques not performed under direct or fiberoptic visualization.
Blind placement of an ETT into a lacerated tracheal segment can create a false lumen outside the trachea or convert a partial tracheal laceration into a complete transection.
Be prepared for unexpected difficulty. Have available and ready:
two suction devices, a range of different sized ETTs, rescue airway devices, and a surgical airway kit (with a surgeon close!)
Bag mask ventilation to preoxygenate in preparation for RSI or to reoxygenate following a failed attempt at intubation may force air into injured tissue planes and distort airway anatomy. Although it is appropriate to perform BMV to oxygenate patients when necessary, ventilation should be done as gently as necessary, and with vigilance to ensure it is not creating more harm than benefit.
The best method to achieve definitive airway control in the setting of PNI may vary according to clinical circumstances, clinician skill, and hospital resources . Nevertheless, the following concepts generally apply.
We recommend a double set-up for patients with PNI in whom orotracheal intubation is attempted. Patients with neck trauma can deteriorate quickly and may have abnormalities that complicate ETT placement but are not apparent externally.

34. Summary Injury often occult, airway compromise insidious
Clothesline injury is highest risk blunt trauma
Consider early intubation for expanding hematoma, GSW, transection of platysma
RSI, DL usually successful for neck trauma w/o tracheal injury
Surgical airway preferred for tracheal injury with distorted anatomy

35. Questions?

36. “Learning is the only thing the mind never exhausts, never fears, and never regrets.”
Leonardo di ser Piero da Vinci (April 15, 1452 – May 2, 1519)