Managing the Transected Airway by Georgie Harris
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The management of the transected airway is frightening because it is a rare airway emergency and one that does not fit the usual plan A,B,C airway management algorithms. An approach is presented which considers two principal anatomical distinctions for injuries both above and below the cricoid cartilage. Secondly, the mechanism of injury is classified according to whether it is either penetrating or blunt trauma. Finally the airway management urgency is described according to either an immediate or semi-urgent approach being required. These three approaches, the location of the injury relative to the cricoid, the mechanism of the injury and thirdly, the urgency of the airway intervention required are then applied together to provide a guide to management of the transected airway.
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Managing the Transected Airway by Georgie Harris
- 1. Photo by wwarby - Creative Commons Attribution License https://www.flickr.com/photos/26782864@N00 Created with Haiku Deck
- 4. WHERE is the injury?
- 5. WHERE IS THE INJURY?
- 9. BLUNT
- 12. PENETRATING
- 15. WHEN do I secure the airway?
- 16. NOW
- 17. NOW NOW
- 18. TRACHE TRACHE TRACHE TRACHE ABOVE CRICOID BELOW CRICOID BLUNT PENETRATING
- 19. SOON
- 20. Secure the airway in least traumatic fashion Prepare for tracheostomy Use smallest tube possible Avoid Cricothyroidotomy Avoid muscle relaxants Avoid BM ventilation Prepare for tracheostomy
- 22. WHERE WHAT WHEN
- 23. ABOVE CRICOID BELOW CRICOID BLUNT PENETRATING Risk of trachea descending in to mediastinum WHERE
- 24. ABOVE CRICOID BELOW CRICOID BLUNT PENETRATING Symptoms ≠ severity Avoid cricothyroidotomy High velocity can be devastating Intubate through wound? W H A T
- 25. WHEN SoonNow
- 26. QUESTIONS?
Editor's Notes
- The transected larynx…..its one of those heart pumping, adrenaline rush scenarios that everyone wants to hear about……..its an injury that goes straight to the most important thing in maintaining life – airway. The transected larynx is a clinical scenario that you may only see once or twice in your career. It is a situation that won’t necessarily fit your usual airway algorithyms… So..it is important that you take the time, mentally prepare and visualise what you would do if you you ever found yourself looking after this patient. As with all rare clinical situations, experience is limited…… and there are no right answers. Each of you, with your different skill sets will have different techniques for manageing the airway. But no matter what your background, no matter what your skill set….I think there are three critical question that we need to ask ourselves before we decide on our management plan……
- Where is the injury? Understanding the 3D anatomy of the larynx and especially the muscular attachements is crucial in understanding the consequences of the injury and what will happen when you start to manipulate the transected larynx What was the mechanism – Is it a blunt injury or penetrating injury and I’ll discuss exactly what is important about each of these. When do you need to secure the airway – How unstable the patient is, how urgent the aware dramatically limits the options for your management and your need to have mentally prepared for this situation.
- First question….So where anatomically is the injury
- Knowledge of the relevant anatomy is essential….. not only for understanding what is likely to have been injured…. but also to be able to appreciate where the dangers may lie when the airway needs to be secured. If you look at this picture, you can appreciate that the larynx is really suspended from the hyoid bone. There are no bony articulations to stablilse it, only the thyrohyoid membrane and muscle attachments to the thryoid and cricoid cartilages. And then below those laryngeal cartilages hangs the trachea…..connected to the cricoid by one thing….the cricotracheal ligament. HIGHLIGHT HYOID AND TRACHEA…..
- In terms of where the injury is, I think cricoid is key. We need to ask ourselves, is it above the cricoid or below. because below the cricoid, there are no muscle attachments, only the elastic recoil of the tracheal tissues that wants to pull the trachea back into the chest. Now despite it begin a complete ring a fracture of the cricoid isn’t that common….but if it fractured, then almost 50% of these patients will have asome degree of cricrotracheal seperation……and this carries a high mortality But the strange thing about CT seperation….a small percent do survive ….. In fact it is not uncommon to make the diagnosis hours/days and even weeks for a injury….So there is some robustness of the peritracheal fascia – it forms a neotrachea if you like and enables ventilation to continue. But what about a transection above the cricoid…above the thyroid ..will this too sink into the mediastinum if the larynx is transected and to really understand this, you need to look more at the muscle attachments.
- This is the one strap muscle that may help but too be honest, its pretty small in most people. You have the intrinsic muscles of the larynx such as the cricothyroid muscles – But more importantly, you have the inferior pharyngeal constrictor muscle….the largest of the three constrictors. 2 parts – thyropharyngeal part - lower part (whose attachements have been cut tin this picture to better see the cricoid known as the cricopharyngeus or the upper eosophageal sphincter. So hopefully you are beginning to realise, that it you get a transection above the level of the cricoid, the larynx isn’t going to just disapper.
- The second question to consider is what was the mechanism of injury….was it blunt or penetrating
- When you think about where the larynx is actually situated, it is really is very well protected. Sternomastoid muscles laterally, sternum below and the mandible above…in fact in the flexed position…..it is pretty damn hard to get to the larynx. So to actually get blunt injury to the larynx you need either…….extension of the neck…..in MVA its often being hit from behind, the head goes back and the neck is crushed against the steering wheel. Or you need a thin object that can get under the mandible such as a wire fence that you didn’t see as you are riding on your motorbike
- Or as in this guys case – strangulation from a scarf that got caught in his go cart wheel. The thing about blunt trauma is that it can be very deceptive. In this particular case…..this guy was stable throughout his ED presentation. Haemodynamically stable with RR of 15 and sats 100% on o2 mask. IN fact it wasn’t until they took his collar off that they noticed some crepitus and neck insufflation with exhalation. HE was also completely aphonic. Almost 2 hours after his injury and on subsequent review of his imaging, he was diagnosed with a 6cm complete cricotracheal seperation and he was taken to theatre.
- The thing to remember about blunt neck injuries is that symptoms do NOT equal severity. Delayed diagnosis of cricotracheal seperation is not uncommon so have a high index of suspicion in these pateints. The other point I also want to make is that in these patients, cricothyroidotomies are contraindicated. If the pt has had blunt trauma to the neck, and you suspect a a laryngeal injury, you don’t want to be pushing anthing through the small window of the cricothyroid membrane and possibly making the injury worse….you need to do a tracheostomy
- Penetrating injuries in comparison are clinically a little different. To start with, they are a bit more obvious and in these sort of injuries you do have a higher incidence of vascular and esophageal injury.
- But they too can be deceiving. The small skin wound can be just the tip of the iceberg and the precise trajectory difficult to estimate. This patient had an expanding haematoma due to carotid artery injury. Which was subsequently treated endovascularly trajectory is important but so too is the the kinetic energy of the penetrating object
- Because when it comes to damage from these penetrating objects, kinetic energy is what determines damage and it is the velocity or speed rather than the mass that is more important… Now I’m sure you guys are all over this, but I find it really interesting. As the object moves into the tissue, the transmitted energy causes acute tissue distension and creates a temporary cavity. Now this only lasts milliseonds but it can cause major damage due to the resulting shock wave …..and the if temporary cavity exceeds the elastic limit of the laryngeal tissue, the larynx bursts. So a small projectile, if travelling fast enough, can have devastating results.
- Finally the third question – when do I need to secure the airway? This is important because if its….urgent…..you don’t have time to get extra help, send out a tweet…although Minh le con would probably get back to you within a few minutes….. If the airway needs to be secured straight away, it limits your options. So you need to know your skill set …..you need to have mentally prepared to urgently secure the transected larynx…..because when this pt
- So when this patient comes through your door…….Their airway is going to be compromised and you need to do something now.
- Early airway management of these patients is a contentious issue and many people have very definite ideas about what is the right thing to do. I don’t agree that there is any one right way….each situation will be different…and it depends on your skill set. So knowing my skill set, These would be my options…..
- These would be my options! Not really, obviously if the trachea is on show intubating through the wound while securing the trachea is easiest……but you need to be prepared…you need to have decided what you would do and mentally rehersed exactly what you would do. Now I know my skill set and I know….I don’t intubate every day like you guys but generally speaking I know I could definitely do a trache within a minute or two and for patients with a potentially transected larynx, it is going to be the safest option for them
- But what about the stable patient….If the airway doesn’t immediately need to be secured then you have more options…… you have more time…… Call for help and expand the collective skill set Move the patient to theatre where a trache is going to be much easier……and you would have more options from an anaesthetic point of view.
- Now I’m not going to stand up here and talk to you about various airways and the best devices and drugs to use but I did want to go over a few general things I think are important Ultimate goal is the secure the airway in the least traumatic fashion For many of you, doing a trache is daunting and orotracheal intubation may be the quickest and you may feel the safest……..but you need to use the least amount of manipulation and be ready to go straight to a trache if you can’t secure airway orally. By using a smaller tube, you reduce your manipulation of the airway. Avoid Crics, mainly with any blunt injury, due to the risk of making a partcial seperation into a complete cricotracheal seperation Avoid positive ventilation – now this may not be possible but you need to be aware that increasing surgical emphysema may further distort your airway Muscle relaxants – I know this has been used succesfully in these situations but I personally think that keeping a patient spontaneously breathing is best
- Now I just wanted to show this photo because to me…..this photo is actually the scariest out all the ones I’ve shown today. Nows its obviously blunt trauma….so a tracheostomy is probably going to be in order But look at where the ecchymosis is…..lower neck. So I’m mentally preparing myself for the fact that if I start doing a tracheostomy on him, his trachea might be so injured that I need to move down into the mediastinum…..so I’m no mentally preparing to crack his chest and do a sternotomy Now I don’t know if its possible…..and I’d be interested in anyone who has ever seen this…..but if that is going pear shaped…..should I have called for VV ecmo earlier……
- So if we go back to our three questions……
- Where is the injury – if its below cricoid, remember that there is minimal support for the trachea and you risk the trachea descending into the mediastinum unless you are very very careful
- What was the mechanism – have a high index of suspicion for cricotracheal seperation, even if they are stable and beware the small penetrating injury that had a high velocity
- Soon is more about logistics and remember those guidleines. If its urgent, your options are limited. Know your skill set and be mentally preprared.