Difficult airway management in a patient with traumatic asphyxia.

Abstract

as a backup. Initially, topical airway anesthesia (10% lidoCaine hydrochloride spray) and intravenous sedation (midazolam 3 mg) were given, and an awake tracheal intubation was attempted using direct laryngoscopy. The patient became more agitated, and his airway became obstructed. Attempted bag-valve-mask ventilation was unsuccessful. The surgical team, who had already prepared the anterior aspect of the neck with betadine solution, was informed that an emergency cricothyroidotomy may be required. Thiopental (125 mg) and succinylcholine (120 mg) were administered. After induction, bag-valve-mask ventilation with oropharyngeal airway could be performed, but orotracheal intubation, attempted by a trauma anesthesia and critical care fellow, remained impossible because of severe pharyngeal and laryngeal edema. Cricothyroidotomy was performed immediately after this single attempt to tracheal intubation. Systemic blood pressure and heart rate did not change during airway management and subsequent positive pressure ventilation, and arterial blood analysis, performed shortly after endotracheal intubation with the patient receiving 100% oxygen, revealed a pH, of 7.24, Pace, 24 mm Hg, Pao, 320 mm Hg, and HCO, 15.8 mEq/L. Roentgenograms revealed a widened mediastinum, bilateral pleural effusions, and a 3-cm pubic diastasis. Bilateral tube thoracostomy was performed, and 300 mL of blood was drained. Approximately 45 min after arrival, the patient was transported to the operating room, where general anesthesia was maintained with 0,, N,O, and fentanyl, and an external pelvic fixator was applied. A diagnostic supraumbilical peritoneal lavage was negative. However, because of systemic hypotension @O/40 mm Hg) and a decreasing hemoglobin level (10.5 g/dL to 8.0 g/dL), he was resuscitated with 2 L lactated Ringer’s solution, 8 units of packed red blood cells,