Direct Airway Injuries
Direct airway damage can occur anywhere between the nasopharynx and the bronchi; sometimes more than one site may be involved, resulting in persistent airway dysfunction.
Intubation is achievable in mandibular fracture. Mask ventilation may be made more difficult by maxillofacial or mandibular injuries.
Partial or complete airway obstruction in the acute stage of air way trauma may be caused by
- Soft tissue edema of the pharynx and peripharyngeal hematoma
- Blood or debris in the oropharyngeal cavity
- Teeth or foreign bodies in the pharynx may be aspirated into the airway.
These may occur or be recognized only during attempts at tracheal intubation. Suctioning the airway, to clear clot, debris and any foreign body must be done first. Fracture-induced encroachment on the airway or limitation of mandibular movement, pain, and trismus may limit mouth opening. Fentanyl in titrated doses of up to 2 to 4 μg/kg over a period of 10 to 20 minutes may produce an improvement in the patient's ability to open the mouth if mechanical limitation is not present.
Patients who present with airway compromise may be intubated using laryngoscopy; the decision about the use of anesthetics and muscle relaxants is based on the results of airway evaluation.
Airway obstruction later during the first several hours
- Hematoma or edema in the face, tongue, or neck which expands during the first several hours after injury and ultimately occludes the airway.
- Penetrating facial injuries (Figure 5:1) or multiple traumas, as a result of progressive inflammation or edema resulting from liberal administration of fluids.
Prophylactic intubation of the trachea or close and repeated examination of the upper airway may avert airway compromise before it occurs.
Surgical airway (tracheostomy) is indicated when there is airway compromise, bleeding into the oropharynx, when direct laryngoscopy has failed or is considered impossible, when the jaws will be wired. Wire cutter should be available at the patient side.
Injury to the cervical air passages can result from blunt or penetrating trauma. Clinical signs such as escape of air, hemoptysis, and coughing are present in almost all patients with penetrating injuries. In contrast, major blunt laryngotracheal damage may be missed, either because the patient is asymptomatic or unresponsive, or because suggestive signs and symptoms are missed in the initial evaluation. The typical presentation includes hoarseness, muffled voice, dyspnea, stridor, dysphagia, cervical pain and tenderness, ecchymosis, and flattening of the thyroid cartilage. Whether the trauma is blunt or penetrating, attempts at blind tracheal intubation may produce further trauma to the larynx and complete airway obstruction if the endotracheal tube enters a false passage or disrupts the continuity of an already tenuous airway. Thus, an airway should be established surgically (tracheostomy). The tracheas of some patients with penetrating airway injuries, especially stab wounds, may be intubated through the airway defect without the need for anesthetics or laryngoscope.