Laryngotracheal Trauma

Airway trauma is an airway emergency best classified by the degree of life-threat:

Epidemiology and Risk Factors

Airway trauma is:

  • Rare
  • Usually fatal pre-hospital
  • Associated with:
    • Spine injury
    • Head injury
    • Facial injury

Pathophysiology

Pattern of injury affects the nature of injury:

  • In blunt trauma:
    • Laryngeal injury associated with direct blows
    • Tracheal injury associated with flexion/extension injury
      • Usually occurs at junction of cricoid and trachea
  • In penetrating trauma:
    • Vascular injury common
    • Cervical trachea

Aetiology

Causes include:

  • “Clothesline” injury:
    • Cyclists
    • Horse riding
  • Assault
    • Strangulation
    • Direct blows

Clinical Manifestations

  • May present with acute airway obstruction
  • Stridor common
  • ‘Classical triad’ of;
    • Hoarseness
    • Subcutaneous emphysema
    • Palpable fracture
  • Inability to lie flat

Diagnostic Approach and DDx

Investigations

Bedside:

  • Fibreoptic evaluation
    • Ease of intubation
    • Vocal cord dysfunction
    • Laryngeal integrity

Laboratory:

Imaging:

  • XR
    • Limited information compared to CT
    • Can be performed in the sitting patient
    • Can occur at the bedside
  • CT
    • Gold standard for characterisation of injury and location of abnormality

Other:

Management

  • Intubation required for:
    • Airway obstruction
    • Respiratory distress
    • Hoarseness
    • Mucosal or cartilage disruption on CT
  • Goal is to place a cuffed endotracheal tube in the distal trachea under direct vision

Resuscitation:

The following are absolutely contraindicated:

  • Positive pressure ventilation
    Will ↑↑ air leak and may ↑↑ subcutaneous emphysema.
  • Cricoid pressure
    Laryngotracheal separation.
  • Cricothyrotomy
    Blind technique that may result in laryngotracheal separation.
  • Percutaneous tracheostomy
    Force of dilation may further worsen trauma.
  • A
    There are three viable airway techniques, with the choice based upon available expertise and clinical urgency:
    • Awake surgical tracheostomy
      Longest duration, requires an ENT surgeon.
      • Gold standard
      • Requires compliant patient
    • AFOI
      Medium duration, requires a skilled awake intubator.
      • Maintains spontaneous ventilation and allows airway inspection
      • Requires a moderately compliant patient
      • Demands good topicalisation
    • Double set-up video laryngoscopy
      Quickest, requires two skilled airway clinicians.
      • Induction of anaesthesia results in no spontaneous ventilation
        No good retreat if intubation unsuccessful as PPV will likely be required.
      • Does not require topicalisation
      • View improved by muscle relaxation

Occasionally, gaping airway wounds can be intubated directly.

Specific therapy:

  • Pharmacological
  • Procedural
  • Physical

Supportive care:

Disposition:

Preventative:

Marginal and Ineffective Therapies

Anaesthetic Considerations

Complications

Prognosis

Key Studies

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.