1. AIRWAY TRAUMA & ITS EMERGENCY MANAGEMENT
MODERATOR : PROF. RAJESHWARI
PRESENTORS : DR. CHITRA
DR. GURURAJ

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

14. 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

15. 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

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

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

18. 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

19. CONTD…
Cervical spine
Cervical nerve roots
Spinal cord

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

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

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

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

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

25. 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

26. 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

27. 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

28. 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%

29. 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

30. ASSOCIATED FACTORS Aspiration risk Intraocular injury
Intracranial injury
Thoracic trauma

31. 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

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

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

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

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

36. 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