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AIRWAY TRAUMA & ITS EMERGENCY MANAGEMENT

AIRWAY TRAUMA & ITS EMERGENCY MANAGEMENT. MODERATOR : PROF. RAJESHWARI PRESENTORS : DR. CHITRA DR. GURURAJ . www.anaesthesia.co.in anaesthesia.co.in@gmail.com. TOPICS. Airway anatomy Definition Incidence Classification Mechanisms Airway injuries Associated injuries

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AIRWAY TRAUMA & ITS EMERGENCY MANAGEMENT

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  1. AIRWAY TRAUMA & ITS EMERGENCY MANAGEMENT MODERATOR : PROF. RAJESHWARI PRESENTORS : DR. CHITRA DR. GURURAJ www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. TOPICS • Airway anatomy • Definition • Incidence • Classification • Mechanisms • Airway injuries • Associated injuries • Concerns

  3. ANATOMY

  4. 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

  5. PEDIATRIC AIRWAY • Cricoid shielded by mandible • Cartilage pliable • More susceptible to edema & hematoma

  6. 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

  7. 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

  8. CLASSIFICATION • According to site of injury : • Supraglottic • Transglottic • Cricoid • Tracheal

  9. CONTD… • According to the mechanism of injury : • Blunt trauma • Penetrating trauma • Superficial • deep

  10. 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

  11. 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

  12. 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

  13. MECHANISM OF BLUNT TRAUMA • Motor vehicle accidents , clothesline injury , strangulation injuries • Frontal impact MVA  victim’s 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

  14. 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

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

  16. MORTALITY RATES • Thyroid cartilage injuries – 11 % • Tracheal injuries – 25 % • Cricoid injuries – 43 % • Intrathoracic tracheal injuries or bronchial injuries – higher mortality rates

  17. 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

  18. CONTD… • Cervical spine • Cervical nerve roots • Spinal cord

  19. ZONE 2 INJURIES • 82 % • At risk structures : • Carotid artery , vertebral artery , jugular vein • Pharynx • Larynx • Trachea • Oesophagus • Cervical spine

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

  21. ZONE 3 INJURIES • 15 % • At risk structures : • Salivary glands • Oesophagus • Trachea • Cervical spine • Carotid artery , jugular vein , 9 – 12 cranial nerves

  22. ASSOCIATED INJURIES • Vascular injuries : 25 – 40 % • Injury to pharnyx , oesophagus : 5 – 15 % • Mortality • 20 % in penetrating trauma • 40 % in blunt trauma

  23. THERMAL INJURY • Facial & perioral swelling  pharyngeal obstruction • Thermal injury to upper airway  laryngeal obstruction • Chemical injury to lung  impaired gas exchange

  24. 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

  25. 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

  26. 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

  27. 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%

  28. 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

  29. ASSOCIATED FACTORS • Aspiration risk • Intraocular injury • Intracranial injury • Thoracic trauma

  30. 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

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

  32. INTRACRANIAL & INTRAOCULAR INJURIES • Direct trauma to the brain • Secondary brain injury : hypoxia, hypotension • Injury to the globe

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

  34. CONTD… • Hemothorax • Pnemothorax • Pneumomediastinum • Interstitial emphysema • Bronchial tear • Intrapulmonary bleed • Air emboli

  35. 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 www.anaesthesia.co.in anaesthesia.co.in@gmail.com

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