2017-18 HSC Section 3 Green Book

Airway management in pediatric blunt neck trauma

D. Chatterjee et al.

geal fractures. However, the narrower lumen of the pedi- atric airway and loose attachment of mucosa to underly- ing laryngeal cartilages in children increases the risk of soft tissue damage, edema, and hematoma formation resulting in airway obstruction (5 – 8).

patients who are relatively asymptomatic or stable on initial presentation may rapidly deteriorate and develop respiratory distress from airway obstruction.

Classification of laryngotracheal injuries

Based on the severity of the injury, laryngotracheal inju- ries are classified into five groups (Table 1). Schaefer et al. proposed a classification system that included four groups and Fuhrman et al. added a fifth group repre- senting complete laryngotracheal separation (11,12). Traditionally patients in groups I and II are managed conservatively, while surgical intervention is reserved for patients in groups III – V. The prehospital management of the patient at the scene of injury should follow ATLS guidelines and include a rapid primary survey followed by a more comprehensive secondary assessment. Necessary clinical skills and/or equipment for the evaluation and management of com- promised pediatric airways clearly depends on local practices and vary considerably from both country to country and regionally within any given country. Early consultation with suitably experienced clinicians at the closest pediatric trauma center is strongly recom- mended, but this is often not possible when the injury occurs in very remote locations. In the case described, the decision to intubate by the prehospital providers was clearly a difficult one. They immediately recognized the airway compromise, and had to weigh the possibility of aggravating the injury vs securing the airway for a prolonged transport on a heli- copter, where intubation would have been even more challenging. There is little evidence in the literature to guide this decision; and with the rarity of this injury, there is unlikely to be any in the future (13,14). Direct laryngoscopy and blindly advancing the ETT into the distal trachea runs the risk of aggravating an existing injury, converting a partial laryngotracheal Initial management

Mechanisms of injury

The mechanisms of laryngotracheal injuries from blunt neck trauma include (5 – 10): 1. Rapid deceleration of a motor vehicle, causing an unrestrained passenger to be thrown forward, usually with the head extended and the neck collides with the steering wheel or dashboard, crushing the laryngeal and/or tracheal cartilages against the cervical verte- brae. 2. Clothesline injuries to the neck while riding motorcy- cles, all-terrain vehicles, or snowmobiles when the rider strikes a stationary object such as a wire fence or tree limb. Clothesline injuries can also occur in high contact sports and martial arts. 3. Direct trauma to the neck from interpersonal violence (direct blows using fists, feet, or blunt weapons). 4. Strangulation from hanging, ligature suffocation, or manual choking. 5. Blunt chest trauma causing antero-posterior com- pression, resulting in sudden increase in transverse diameter of the chest, lateral traction on the trachea, and linear rupture. The etiology of blunt neck trauma in children is age dependent. In younger children, common etiologies include falls onto furniture or bicycle handlebars with the neck extended, causing compression of the larynx and trachea against the vertebral column (5 – 8). Among adolescents, the etiology is similar to adults and includes motor vehicle accidents, sports injuries, and clothesline injuries (5 – 8). Early diagnosis often requires a high index of clinical suspicion. A detailed history of the mechanism of injury along with a description and duration of symptoms must be obtained. Presenting symptoms are varied and range from mild dysphonia and hoarseness of voice to stridor and acute respiratory distress (5 – 8). Other symp- toms include dyspnea, dysphagia, anterior neck pain, hemoptysis, and cough. A targeted physical examination of the airway and neck should be performed looking for subcutaneous emphysema, edema, abrasion or ecchymo- sis in the neck, loss of laryngeal landmarks, and palpa- ble cartilage fractures. It is important to note that Clinical presentation

Table 1 Classification of laryngotracheal injuries

Group I

Minor endolaryngeal hematoma without detectable fracture Edema, hematoma, minor mucosal disruption without exposed cartilage Massive edema, mucosal tears, exposed cartilage, cord immobility As Group III, with more than two fracture lines or massive trauma to laryngeal mucosa

Group II

Group III

Group IV

Group V

Complete laryngotracheal separation

Reprinted with permission from Fuhrman et al. (12).

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

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