Airway management in penetrating neck trauma at a Canadian tertiary trauma centre

Abstract

Objectives: The optimal approach to airway management in penetrating neck injuries (PNIs) remains controversial. The primary objective of this study was to review the method of endotracheal intubation in PNI at a Canadian tertiary trauma centre. Secondarily, we sought to determine the incidence of PNI in our trauma population and to describe the epidemiologic elements of this population. Methods: We conducted a review of patients with PNIs who were enrolled in the Nova Scotia Trauma Registry database. We included all patients 16 years of age or under who presented between April 1, 1994 and March 31, 2005 with penetrating injuries of the neck and an Injury Severity Score (ISS) of 9 or less or who underwent Trauma Team activation at our Tertiary Trauma Centre (regardless of ISS) and/or who were identified upon admission as a “major” trauma case. The variables of interest were patient age and sex, injury mechanism, injury location, place of intubation and method of intubation. Results: There were 19 people who met inclusion criteria and they were enrolled in our study. The injury mechanisms involved knife (n = 13) or gunshot (n = 5) wounds (one patient's injuries were categorized as “other”). Three patients (15.8%) were not intubated. The remaining 16 patients were intubated during prehospital care (n = 5), in the emergency department (n = 6) or in the operating room (n = 5). Of these, 8 patients (42.1%) underwent awake intubation and 8 (42.1%) underwent rapid sequence intubation. Conclusion: There is clear variability of airway management in PNI. We believe that such patients represent a heterogeneous group where the attending physician must have a conservative yet varied approach to airway management based on the individual clinical scenario.

Airway management of an open penetrating neck injury

“…[1][2][3] PNI can result from stab wounds, gunshots, or, less commonly, trauma due to other sharp objects, such as glass. In the United States, PNI comprises about 1% of all trauma patients.…”

“…4 A single-centre review suggests that PNIs are less common in Canadian major trauma centres (about 0.5%), which may reflect the comparatively lower rate of violent crime. 3 In a systematic review involving over 2,400 patients with PNI, McConnell and Trunkey reported that the vital structures involved in such injuries included the trachea (10%), esophagus (9.6%), internal jugular veins (9%), and carotid arteries (6.7%). 5 Overall mortality in patients with PNI ranges from 3 to 10%.…”

“…A much smaller review performed at a Canadian tertiary trauma centre revealed variability in airway management in PNI. 3 Of 19 patients with PNI, 16 required intubation, with RSI and awake fibre-optic bronchoscopy each being used in eight instances. This would support others' assertion that the optimal airway technique in patients with PNI varies according to clinical presentation, technical skills, and hospital resources.…”

“…This would support others' assertion that the optimal airway technique in patients with PNI varies according to clinical presentation, technical skills, and hospital resources. 3 The option of awake fibre-optic intubation is appealing in that it maintains spontaneous respiration in a setting where the precise nature of the airway injury is undetermined and allows for the careful examination of the injury during intubation. This technique is limited by the patient's level of cooperation and ability to tolerate the procedure.…”

Diagnostic Peritoneal Lavage – A Lost Art? A Retrospective Observational Study at a Canadian Tertiary Trauma Centre

“…Nova Scotia has a provincewide population based trauma system which includes one adult (≥ 16 years) tertiary trauma centre (the study site) similar to a level I American trauma centre in many ways and the registry has been successfully used in other peer reviewed published research. 18,20,23 This project employed secondary analysis of an existing database, and involved no patient contact, treatment or chart reviews. Simple descriptive statistics were utilized to describe trends in the use of DPL, CT and FAST as diagnostics tools to evaluate these patients.…”