Management of the Traumatized Airway

CLINICAL CONCEPTS AND COMMENTARY Jerrold H. Levy, M.D., F.A.H.A., F.C.C.M., Editor Management of the Traumatized Airway Uday Jain, M.D., Ph.D., Maureen McCunn, M.D., M.I.P.P., Charles E. Smith, M.D., Jean-Francois Pittet, M.D. IRWAY injury is a major cause of early death in Anatomy of Trauma to the Airway 1,2 A trauma. The incidence of traumatic airway injuries is Airway injuries can be divided into three types: maxillofa- 3,4 low, although it is recently increasing. In contrast, mortal- cial, neck, and laryngeal injury. ity due to traumatic airway injuries is high, in part, because of associated injuries to other organs, which are present in Maxillofacial Trauma about one half of the cases of blunt or penetrating airway Blunt or penetrating trauma to the face can affect the max- 1,2 trauma. Patients with a significant injury severity (scored illary/mandibular or mid-facial region and extend intra- 5 on a scale of 0 to 75, which accounts for the most severely cranially12–14 (table 1). Maxillofacial trauma can result in traumatized body systems) have a higher predicted mortality. life-threatening airway and hemorrhage problems and lead In a retrospective review of 12,187 civilian patients treated to significant ocular, nasal, and jaw dysfunction. Bleeding at a regional trauma center in Toronto from 1989 to 2005, may complicate airway management. Swallowing of blood 36 patients (0.3%) had blunt airway trauma (injury sever- clears the airway and is facilitated with the patient in the sit- ity score, 33; mortality, 36%) and 68 patients (0.6%) had ting position. However, gastric distension from swallowing penetrating airway trauma (injury severity score, 24; mortal- of blood may increase the likelihood of regurgitation and ity, 16%).1 Among 24 deaths, airway injury was the primary aspiration. Venous bleeding can be controlled by packing cause in 10 patients. Twelve patients had thoracic airway and fracture reduction. Patients may not be able to control injury, 9 of whom died. In another study including 44,684 their own airway due to brisk arterial hemorrhage. Arterial trauma patients from Texas between 1996 and 2003,2 bleeding may require angiographic embolization or may be there were 19 patients (12 died) with blunt trauma and resolved with surgical intervention. 52 patients (7 expired) with penetrating laryngeal–tracheal In bilateral (bucket handle) or comminuted parasymphy- trauma. Traumatic airway injury is rare (incidence < 1%); seal mandibular fractures, the tongue is no longer anchored thus, assessment and management are not well characterized anteriorly. This leads to posterior displacement of tongue because physicians rarely treat such cases. and periglottic soft tissue, causing airway obstruction. How- Previous reviews of trauma care have addressed air- ever, this airway obstruction can be reduced by upright posi- way management, usually without a detailed discussion of tioning, although a known or suspected spinal cord injury management of patients with a traumatized airway.1,2,6–11 could be worsened with upright positioning. Finally, a con- This clinical commentary will thus review the approach to dylar fracture fragment might be displaced through the roof patients with airway trauma, particularly with injuries to the of the glenoid fossa to the middle cranial fossa, thus prevent- facial compartments (i.e., maxillary and mandibular regions) ing mouth opening. and to the neck and glottis region. Care of patients with Mid-facial injury can cause unilateral or bilateral Le Fort lower airway trauma, which represents thoracic trauma, will I, II, and III, and associated fractures (fig. 1). Le Fort II and not be addressed in this review. III fractures may be associated with a fractured skull base and This article is featured in “This Month in Anesthesiology,” page 1A. Figures 1 to 3 were enhanced by Annemarie B. Johnson, C.M.I., Medi- cal Illustrator, Vivo Visuals, Winston-Salem, North Carolina. Submitted for publication September 18, 2014. Accepted for publication August 6, 2015. From the Department of Anesthesiology, Alameda Health System, Oakland, California (U.J.); Divisions of Trauma Anesthesiology and Surgical Critical Care, Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland (M.M.); Department of Anesthesiology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio (C.E.S.); and Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama (J.-F.P.). Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2016; 124:199–206 Anesthesiology, V 124 • No 1 199 January 2016 Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/Journals/JASA/934773/<zdoi;10.1097/ALN.0000000000000903> on 09/26/2016 Management of the Traumatized Airway Table 1. Selected Findings in Maxillofacial Trauma cause laryngeal edema, apnea due to loss of diaphragmatic innervation, and neurogenic shock due to decreased sym- Type of injury Findings pathetic tone. This complicates the management of the Dentoalveolar Avulsed and/or fractured teeth, tongue lac- associated airway trauma. C-spine injury may occur in erations, soft tissue swelling, oropharyn- conjunction with face, neck, and head trauma, especially geal hemorrhage Temporomandibular Limitation of mouth opening (trismus vs. in patients with blunt trauma and Glasgow Coma Scale mechanical obstruction). Open lock score ≤ 8. Finally, a digestive tract injury should be sus- anterior dislocation of condyle with pected in the presence of dysphagia, retropharyngeal air, drooling and difficulty swallowing, or pneumomediastinum.17 mandibular malalignment, edema, oropharyngeal bleeding Laryngeal Trauma Mid-face Skull base fractures, leakage of cerebrospinal fluid from the nose, epistaxis, soft The signs, symptoms, and bronchoscopic and computed 22 tissue swelling, oropharyngeal hemor- tomographic (CT) findings of laryngotracheal trauma are rhage, separation of maxillary alveolus presented in table 3. Signs and symptoms may not corre- and palate, or separation of the entire late with the severity of injury. Associated injuries include maxilla from the rest of the face those to skull base, cranium, neck, C-spine, esophagus, and Zygomatic and Retrobulbar hemorrhage, visual dis- orbital fractures turbance, and vision loss. Traumatic pharynx. Cervicothoracic vascular injuries are present in one 2 mydriasis. Increased intraocular pressure quarter of the patients. Blunt trauma to the larynx usually involves the trachea. Some patients with blunt injury Modified from the study by DeAngelis et al.15 to the anterior neck may initially appear to have a normal airway but may develop airway compromise over several leakage of cerebrospinal fluid (CSF). The cribriform plate and hours due to an increase in laryngeal disruption, edema, sphenoid sinus may be damaged in patients with nasoorbito- and hematoma. Time from injury—to include prehospital ethmoid fractures, Le Fort II and III fractures, or panfacial transport—as opposed to time since admission should be a fractures. Mid-face fractures are generally associated with consideration in the decision to intubate or to observe the head and cervical spine (C-spine) injuries, whereas zygomatic patient. Other patients may have self-limiting injuries, not and orbital fractures are associated with eye injury.15 requiring tracheal intubation or laryngeal surgery.22 Tracheal Basilar skull fractures may involve the temporal, occipital, compromise by compression or direct injury should be sus- sphenoid, and ethmoid bones. They may lead to “raccoon pected if there is airway obstruction, stridor, or trauma to the eyes,” i.e., periorbital ecchymosis; Battle’s sign, i.e., retroau- neck, sternum, or clavicle.8–11,23 ricular ecchymosis; CSF rhinorrhea; and cranial nerve palsy. Laryngeal–tracheal separation may occur. Insertion of an endotracheal tube (ETT) may also cause separation of Neck Trauma a trachea tenuously held to the larynx. Sudden deceleration Penetrating and blunt neck trauma may involve almost every causing flexion–extension of the neck can lead to shearing, major vital structure including respiratory, vascular, diges- primarily at the cricoid and carina as they are anchored to tive, endocrine, and neurologic organs.17 Findings consistent adjacent structures (fig. 3). Blunt trauma may crush the tra- with major injury to the neck are listed in table 2. After pen- chea against the vertebral bodies, transecting tracheal rings etrating trauma, arterial injury was reported in 12 to 13% and the cricoid cartilage, causing a “clothesline” injury. A of the cases, whereas the incidence of venous injury was transected cervical trachea may retract into the mediastinum found in 18 to 20% of the patients. Early deaths are gener- and will need to be surgically extracted. Other causes of ally caused by asphyxia from airway compromise or arterial blunt airway trauma are steering wheel or bicycle handlebar hypotension from hemorrhagic shock.18 injury and hanging. Finally, an increased intrathoracic pres- Dividing the neck into three zones (fig. 2) helps with sure due to chest compression against a closed glottis can tear the differential diagnosis of penetrating injuries and deter- the posterior membranous trachea.

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