trauma- neck.subcut emphysema

(May-2001 Q10) A 17 yo trail bike rider was struck on the neck by a low branch and thrown from his bike. He presents to your casualty with a hoarse voice, stridor and subcutaneous emphysema of the neck. Discuss your plan to secure this patient's airway.

This patient has a history of neck trauma and impending respiratory distress. In view of the history of neck trauma and subcutaneous emphysema, the most important differential will be disruption of the tracheobronchial tree.

I would consult an ENT specialist with view of performing a surgical airway, as it is likely that any upper airway manipulation might be difficult in view of localized trauma, and the disruption might be distal to the glottis.

I would discuss with the patient regarding an awake tracheostomy under local anaesthesia. This would be done with supplemental O2 via facemask and standard college monitoring is in place.This may not be tolerated well by the patient, however sedation may be fraught with danger because he might have respiratory depression that would further compromise the airway.

maintain spont vent

Alternatives would be fibre optic assessment of the trachea but this is not ideal in this situation given that the patient is stridorous and less likely to cooperate with the procedure. Also, any trauma or bleeding from fibre optic intubation may further jeopardise the airway.

any ETT should be cuffed passed distal to the disruption

Tracheostomy -may be able to locate the distal end of the disruption but may still be proximal to the tracheobronchial disruption , may be difficult due to local tissue injury/bleeding/ edema, may not be aseptic.

After securing the airway, secondary survey looking for other causes of subcut emphysema/ other areas of injury

definitive imaging: neck XR/CT thorax