AIRWAY TRAUMA

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AIRWAY TRAUMA ITS EMERGENCY MANAGEMENT

• MODERATOR PROF. RAJESHWARI
• PRESENTORS DR. CHITRA
• DR. GURURAJ

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
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TOPICS

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

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ANATOMY
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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

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PEDIATRIC AIRWAY

• Cricoid shielded by mandible
• Cartilage pliable
• More susceptible to edema hematoma

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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

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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

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CLASSIFICATION

• According to site of injury
• Supraglottic
• Transglottic
• Cricoid
• Tracheal

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CONTD

• According to the mechanism of injury
• Blunt trauma
• Penetrating trauma
• Superficial
• deep

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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

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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

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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

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MECHANISM OF BLUNT TRAUMA

• Motor vehicle accidents , clothesline injury ,
  strangulation injuries
• Frontal impact MVA ? victims 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

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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

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CONTD.

• Cricoid injury
• Recurrent laryngeal nerve injury
• Laryngotracheal disruption
• Tear of trachea or bronchi
• Concurrent cervical spine injuries , oesophageal
  injuries , pneumothorax , blunt thoracic trauma

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MORTALITY RATES

• Thyroid cartilage injuries 11
• Tracheal injuries 25
• Cricoid injuries 43
• Intrathoracic tracheal injuries or bronchial
  injuries higher mortality rates

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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

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CONTD

• Cervical spine
• Cervical nerve roots
• Spinal cord

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ZONE 2 INJURIES

• 82
• At risk structures
• Carotid artery , vertebral artery , jugular vein
• Pharynx
• Larynx
• Trachea
• Oesophagus
• Cervical spine

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CONTD.

• One third patients with zone 2 injuries require
  emergency airway management
• Airway compromise occurs due to
• Laryngeal injury
• Hematoma
• Subcutaneous emphysema

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ZONE 3 INJURIES

• 15
• At risk structures
• Salivary glands
• Oesophagus
• Trachea
• Cervical spine
• Carotid artery , jugular vein , 9 12 cranial
  nerves

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ASSOCIATED INJURIES

• Vascular injuries 25 40
• Injury to pharnyx , oesophagus 5 15
• Mortality
• 20 in penetrating trauma
• 40 in blunt trauma

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THERMAL INJURY

• Facial perioral swelling ? pharyngeal
  obstruction
• Thermal injury to upper airway ? laryngeal
  obstruction
• Chemical injury to lung ? impaired gas exchange

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• 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

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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

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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

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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

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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

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ASSOCIATED FACTORS

• Aspiration risk
• Intraocular injury
• Intracranial injury
• Thoracic trauma

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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

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PREVENTION

• Metoclopramide
• H 2 blockers
• Sodium citrate
• NG tube aspiration
• Cricoid pressure
• Secure airway

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INTRACRANIAL INTRAOCULAR INJURIES

• Direct trauma to the brain
• Secondary brain injury hypoxia, hypotension
• Injury to the globe

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THORACIC TRAUMA

• Blunt thoracic trauma - higher mortality than
  penetrating thoracic trauma
• Rib fracture
• Flail segments
• Chest wall contusion
• Pulmonary contusion

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CONTD

• Hemothorax
• Pnemothorax
• Pneumomediastinum
• Interstitial emphysema
• Bronchial tear
• Intrapulmonary bleed
• Air emboli

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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

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