Airway Management
For Neck Trauma
Alex Sigalovsky, CRNA
Objectives
Anatomy
Classifications
Mechanisms
Airway
Cases
Summary
Anatomy of Neck
A complex network of
muscles, vessels, and nerves –
all supported by fascial planes
Two primary classifications
utilized in description of neck
injuries:
Zones
Triangles
Leonardo da Vinci. Study of a Man with his Head Turned, c. 1495
Anatomy: Neck Contents
Musculoskeletal structures: vertebral bodies; cervical muscles,
tendons, and ligaments; clavicles; first and second ribs; and hyoid
bone.
Neural structures: spinal cord, cervical roots of phrenic nerve
and brachial plexus, recurrent laryngeal nerve, cranial nerves
(specifically IX-XII), and stellate ganglion.
Vascular structures: carotids, vertebral arteries, & vertebral vein,
brachiocephalic vein, and jugular veins.
Visceral structures: thoracic duct, esophagus and pharynx, and
larynx and trachea.
Glandular structures: thyroid, parathyroid, submandibular.
Fascia: superficial and deep cervical fascia.
Anatomy: Neck Zones
Anatomy: Neck Zones
Zone I: sternal notch – cricoid
cartilage
Proximal subclavian, vertebral,
carotids; lung apices, trachea,
esophagus, thoracic duct, glands
Zone II: cricoid – angle of mandible
Carotid, vertebrals, trachea, larynx,
esophagus, cord, vagus/ recurrent
laryngeal
Zone III: above angle of mandible
Pharynx, salivary glands, distal
carotid/ vertebrals, cranial nerves
Anatomy: Triangles
Anterior and posterior triangles of the neck : separated by the
sternocleidomastoid muscle (SCM):
Anterior triangle, defined:
Anteriorly – by midline
Posteriorly – by SCM
Superiorly – by mandible
Posterior triangle, defined:
Anteriorly – by SCM
Inferiorly – by the clavicle
Posteriorly – by the anterior
border of the trapezius muscle
Anatomy: Triangles
Anterior triangle structures:
Carotid artery
Internal jugular vein
Vagus nerve
Thyroid gland
Larynx
Trachea
Esophagus
Posterior triangle structures:
Subsclavian artery
Brachial plexus
Anatomy: Fascial Planes
Platysma:
superficial muscle that overlaps the
sternocleidomastoid
Covers anterior triangle completely
Covers anteroinferior aspect of
posterior triangle
Critical landmark in injury diagnosis
Deep Cervical Fascia:
Pretracheal portion communicates
with mediastinum
May lead to mediastinitis
Anatomy: Larynx
Four basic anatomic components of the larynx: a cartilaginous
skeleton, intrinsic and extrinsic muscles, and a mucosal lining.
Anatomy: Larynx
Cartilaginous skeleton, which houses
the vocal cords, is comprised of the
thyroid, cricoid, and paired arytenoid
cartilages.
These cartilages are connected to
other structures of the head and neck
through the extrinsic muscles.
The intrinsic muscles of the larynx
alter the position, shape and tension
of the vocal folds
Mechanism of Injury
Penetrating
Blunt
Stangulation
Neck Trauma: Penetrating
Penetrating: > 95%
Stab
Gun shot wounds (GSW)
Motor vehicle collisions
(MVC)
Clothesline / wire
Questions
Is the platysma penetrated?
Stable vs Unstable?
Neck Trauma: Blunt
Blunt:
MVC (especially
unrestrained)
Assault
Hanging
Clothesline accident
Sports injury
Much more rare
Symptoms may be minimal
or delayed
Causes 3-10% of all
cervical vascular injury
Neck Trauma: Strangulation
Strangulation:
Hanging
Clothesline accident
Severe hoarseness and stridor
signal impending airway
obstruction
Death from three mechanisms:
Injury to the spinal cord or
brain stem
Mechanical constriction of the
neck structures
Cardiac arrest
Evaluation
Evaluation
Evaluation
Anatomic zone
Structures at risk, ease of access,
hemorrhage control
Signs, symptoms: vascular,
laryngeal, tracheal disruption
Vascular: active bleed, expanding
hematoma, carotid bruit
Tracheal: stridor, bubbling bleed,
voice changes, dyspnea,
subcutaneous emphysema
Esophageal: dysphagia
Airway Management
Intubating because of Acutely Failed
Anatomy or Hemodynamic Instability
Can’t just wake the patient up
Once the decision to RSI has been made, the
patient is committed to a surgical airway if
other means to secure airway fail
Airway Management
Two difficult questions to answer:
When?
How?
Airway Management
Earlier intubation is easier intubation…
Signs & Symptoms:
respiratory distress
blood/ secretions
sub-Q air
tracheal shift
altered mental status1
Injury: Consider intubating asymptomatic
patient if expanding hematoma, GSW to
neck1,2
1Eggen
JT. J Emerg Med 1993:11(4):381-85.
2Walls
RM. J Emerg Med 1993:11(4):479-80.
Method of Securing Airway
If no indication of laryngeal injury:
Orotracheal intubation, RSI
Highest success rate, fewest complications3, 4
If suspected / obvious laryngeal injury:
If maintaining airway  Surgical airway in OR
Blunt laryngeal trauma  Awake fiberoptic5
Open laryngeal injury  Direct intubation of distal segment5
3Mandavia
4Shearer
5Walls
DP. Ann Emerg Med 2000;35(3):221-225.
VE. Ahesth Analg 1993;77(6):1135-1138.
RM. Emerg Med Clin North Am;16(1):45-61.
Open Tracheal Injury
Open Tracheal Injury
Open Tracheal Injury
Alternative Airway
Approaches
Cricothyrotomy:
Not if expanding
hematoma
Emergent option in
tracheal injury pt who is
not maintaining airway
Percutaneous Transtracheal Jet
Ventilation6
6Patel
RG. Chest 1999;116:
1689 – 1964.
Airway Risks in
Neck Trauma
“Clothesline” injury: motorcycle, bicycle, snowmobile vs.
wire, tree limb
Can transect trachea: mis-alignment or loss of distal limb
w/muscle relaxant
Zone I: Pneumothorax, hemothorax
Hypotension, high O2 requirement, decreased breath
sounds
Hematomas that are initially hidden and later expand
Foreign body in neck
Airway deviation / obstruction
Decision Points
Concern related to use of muscle
relaxants
Theoretically, muscle relaxation can
potentially convert a partially
obstructed airway to a complete
obstruction.
But… patient’s muscular tone can be
more detrimental than helpful when
trying to resolve the acute airway
emergency.
Decision Points
Avoid techniques not performed under direct or fiberoptic
visualization.
Blind placement of an ETT into a lacerated tracheal segment can
create a false lumen outside the trachea or convert a partial tracheal
laceration into a complete transection.
Be prepared for unexpected difficulty. Have available and ready:
two suction devices, a range of different sized ETTs, rescue airway
devices, and a surgical airway kit (with a surgeon close!)
Bag mask ventilation to preoxygenate in preparation for RSI or to
reoxygenate following a failed attempt at intubation may force air
into injured tissue planes and distort airway anatomy. Although it
is appropriate to perform BMV to oxygenate patients when
necessary, ventilation should be done as gently as necessary, and
with vigilance to ensure it is not creating more harm than benefit.
Summary
Injury often occult, airway compromise insidious
Clothesline injury is highest risk blunt trauma
Consider early intubation for expanding hematoma, GSW,
transection of platysma
RSI, DL usually successful for neck trauma w/o tracheal
injury
Surgical airway preferred for tracheal injury with distorted
anatomy
Questions?
“Learning is the only thing the mind never
exhausts, never fears, and never regrets.”
Leonardo di ser Piero da Vinci (April 15, 1452 – May 2, 1519)