2017-18 HSC Section 3 Green Book

Airway management in pediatric blunt neck trauma

D. Chatterjee et al.

injury to a complete airway transection, or creating a false passage (7). It is certainly possible that our patient developed a complete laryngotracheal separation follow- ing the endotracheal intubation at the scene of injury. The decision to perform RSI in these patients must be weighed against the possibility of causing greater harm. On arrival at the ED, a detailed trauma evaluation must be performed and cervical spine immobilization must be maintained until cervical spine injuries are ruled out (Figure 6). If the patient’s airway has already been secured, the position of the ETT or tracheostomy tube must be confirmed by flexible fiberoptic tracheoscopy and bronchoscopy. For patients with an unsecured air- way, the initial airway management depends on the clin- ical presentation. If the patient’s airway is stable, a detailed history and physical examination must be com- pleted. Flexible fiberoptic laryngoscopy may be per- formed at the bedside to assess the patency of the airway, extent of injuries, and vocal cord mobility (7). In the presence of minor endolaryngeal edema or hema- toma without any evidence of airway compromise, the patient may be managed conservatively with humidified air, close observation in a monitored setting, and serial endoscopies at the bedside. Administration of systemic corticosteroids may be considered to reduce airway edema. The patient may be discharged home if there is no evidence of progression after 24 – 48 h (7). Laryngotracheal injuries are commonly associated with injuries to the cervical spine, esophagus, and vascu- lar structures in the neck. Chest and neck radiographs must be obtained to rule out the presence of cervical spine fractures, subcutaneous emphysema, pneumothorax, or pneumomediastinum. CT scan of the neck provides valuable information regarding the anatomy of the endolarynx and the presence of laryngeal cartilage frac- tures, cervical spine fractures, and vascular injuries. In patients with a stable airway, indications for CT scan of the neck include substantial edema or soft tissue injury and patients who do not tolerate a flexible fiberoptic laryngoscopy (8). The initial airway management of a child with an unstable airway in acute respiratory distress remains controversial (6 – 8). Proposed techniques to secure the airway includes endotracheal intubation via direct laryngoscopy or under fiberoptic guidance and elec- tive tracheostomy. Direct laryngoscopy and orotra- cheal intubation under direct visualization by an experienced physician, using a smaller ETT has been described as a safe and effective technique (3). How- ever, as mentioned previously, this technique runs the risk of aggravating an existing injury (7). In addition, performing a tracheostomy at the bedside under local anesthesia in children is nearly impossible. If the

ENT surgeon and operating room are immediately available, the airway must be secured after induction of general anesthesia, under direct vision with a rigid bronchoscope (7). If the ENT surgeon and operating room are not immediately available, the most experi- enced clinician in the ED may attempt fiberoptic tra- cheoscopy and intubation under direct vision. An emergent needle cricothyroidotomy or tracheostomy at the bedside should be reserved as a last ditch effort to secure the airway. Clear and continuous lines of communication between the surgeon and anesthesiologist are critical throughout the procedure. During induction, the ENT surgeon must be present in the operating room with a rigid broncho- scope setup. After induction, the patient is kept breath- ing spontaneously and the administration of muscle relaxants must be avoided. General anesthesia is main- tained with either inhalational agents or intravenous anesthetic drugs such as propofol and remifentanil infu- sions. In addition to standard ASA monitors (pulse oximetry, electrocardiogram, blood pressure monitor- ing, and capnography), adequate intravenous access must be secured. Direct laryngoscopy and topical anes- thesia of the airway may be considered to ensure ade- quate depth of anesthesia. The ENT surgeon performs rigid bronchoscopy and advances the bronchoscope into the distal trachea under direct vision. A tracheostomy is then performed over the bronchoscope. A panen- doscopy that includes microlaryngoscopy, bronchoscopy, and esophagoscopy must be performed to rule out associated injuries. Pediatric laryngotracheal injuries from blunt neck trauma are extremely rare, but can be potentially catastrophic. Presenting symptoms are varied and a high index of clinical suspicion is required for early diagnosis. Airway management of children with laryn- gotracheal injuries remains controversial. The decision to perform RSI depends on the experience of the pre- hospital providers and has to be weighed against the possibility of aggravating the injury. If the patient’s airway is stable, a detailed history and physical examination must be performed, followed by a flexible fiberoptic laryngoscopy at the bedside to evaluate the extent of injuries. Conservative management includes administration of humidified air and systemic corticos- teroids, close observation in a monitored setting, and serial endoscopies at the bedside. If the patient’s clini- Intraoperative anesthetic management Conclusions

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

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