2017-18 HSC Section 3 Green Book

Airway management in pediatric blunt neck trauma

D. Chatterjee et al.

50 km away. The paramedics were concerned about air- way swelling and elected to intubate the patient at the scene. While maintaining cervical in-line stabilization, a direct laryngoscopy was performed after rapid sequence induction (RSI) with midazolam, fentanyl, and rocuro- nium. After direct visualization of the vocal cords, the patient was intubated with a 6.0-cuffed endotracheal tube (ETT). The paramedics also visualized a ‘tracheal defect’ during laryngoscopy. After intubation, the patient’s oxygen saturations remained in the 80 – 85% range, despite intermittent positive pressure ventilation with 100% oxygen. He remained hemodynamically stable throughout the transport. Upon arrival at the rural hospital, blood was noted in the ETT and attempts at suctioning the ETT past its end were unsuccessful. Under very challenging circum- stances using fiberoptic guidance, the ETT was advanced through cervical soft tissue and into the distal trachea. Bilateral chest tubes were inserted for bilateral pneumothoraces. Suspecting laryngotracheal injury, the patient was transferred to the operating room for an urgent tracheostomy. A low tracheostomy was per- formed via an incision just above the sternal notch, through which a cuffed 5.0 Shiley tracheostomy tube was inserted. A computerized tomographic (CT) scan of the neck revealed complete tracheal transection and extensive subcutaneous air in the anterior neck and retropharyngeal spaces (Figure 1). In addition, an unstable fracture and subluxation of the C2 – C3 verte- brae was also noted. The patient was transferred to our hospital for further management. Upon arrival at our hospital, the position of the tra- cheostomy was confirmed by flexible fiberoptic bron- choscopy in the emergency department (ED). To further delineate the extent of cervical spinal cord injury, a magnetic resonance imaging (MRI) of the cervical spine was performed, which revealed evidence of spinal cord edema, narrowing of the spinal canal, and cord impingement (Figure 2). The patient was then transported to the operating room for further evaluation and management. General anesthesia was maintained with sevoflurane and intermittent boluses of fentanyl. ENT direct laryngoscopy revealed normal upper airway anatomy. However upon advancing the flexible bronchoscope beyond the vocal cords, com- plete separation of the trachea below the cricoid carti- lage was noted (Figure 3). Flexible esophagoscopy did not reveal any esophageal injuries. A closed reduction of the cervical spine fracture was attempted. However, satisfactory alignment of the cervical spine was not achieved and the orthopedic surgeon was hesitant to proceed in the absence of neurophysiologic monitor- ing. After halo vest immobilization, the patient was

transferred to the intensive care unit (ICU) for moni- toring. The following day, a closed reduction of the cervical spine fracture was attempted under neurophysiologic monitoring and only a minimal improvement in C2 – C3 alignment was achieved. The orthopedic surgeon expressed the need to proceed with an open posterior cervical spinal fusion and instrumentation in the prone position. After discussions between the anesthesiologist, ENT surgeon, and orthopedic surgeon, a decision was made to perform open neck exploration first before turning the patient prone. Open neck exploration con- firmed complete laryngotracheal separation between the first and second tracheal rings with the proximal and distal segments separated by approximately 6 cm (Figures 4 and 5). An open tracheoplasty was then per- formed with end-to-end anastomosis and the distal tra- cheostomy stoma was matured. A nasal ETT was positioned just above the tracheostomy stoma to allow rapidly securing the airway, should the trachesotomy tube be dislodged, and to function as a stent for the repaired section of airway. Subsequently, the patient was transferred back to the ICU for monitoring. On postoperative day 5, the patient underwent an uneventful open posterior cervical spinal fusion and instrumentation in the prone position under neurophysi- ologic monitoring. After 7 days of stenting, the nasal Figure 1 Sagittal reformat CT image of the neck and cervical spine showing fracture of C2 – C3 with anterior tilting of the dens and splay- ing of the spinous processes (large white arrow). There is large amount of subcutaneous air in the anterior neck (small white arrow) and retropharyngeal spaces. Complete tracheal transection (white asterisk) is noted with a tracheostomy tube (white x) in the distal trachea.

© 2015 John Wiley & Sons Ltd Pediatric Anesthesia 26 (2016) 132–138

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