Airway Management in Penetrating Trauma

Abstract

Airway management in patients with penetrating trauma can be one of the more challenging situations you will face. This is particularly true with penetrating neck and facial injuries, which have the potential to wreak havoc when you attempt to establish an airway: blood, edema, debris, and, in rare cases, complete laryngotracheal transection. Airway management in such cases may involve direct laryngoscopy, video-assisted laryngoscopy, fiber-optic intubation, the use of supraglottic devices, cricothyrotomy, tracheostomy, or direct intubation through a neck wound. Conversely, impressive neck lacerations may pose no immediate airway problem but distract you from life-threatening injuries in the thorax or abdomen: one-third of patients with penetrating neck injuries have moderate to severe injuries elsewhere. Facing a patient with penetrating injuries, you must be skilled at evaluating the airway, be able to quickly determine the need for a definitive airway, and be familiar with the various techniques to do so. While some centers may have 24-h anesthesia support, there will be times when you are the most capable physician at establishing an airway, surgical or otherwise. Even when a skilled anesthesiologist is present, you, the surgeon, must decide what type of airway is most appropriate. Will oral intubation worsen a potential laryngotracheal injury? Will it be ineffective? Would fiber-optic intubation or a surgical airway make the most sense? In this chapter, we will review the pearls and pitfalls of airway management in penetrating trauma: who needs immediate intubation, how to do it, and what situations dictate a more creative means of establishing an airway.