Original Contributions
Emergency airway management in penetrating neck injury

Presented at the annual meeting of the Society for Airway Management, Newport Beach, CA, September 1997.
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Abstract

Study objectives: Airway management in the context of penetrating neck injury is a challenging scenario. Management decisionmaking has not been well studied and the initial airway approach remains controversial. We examined various initial emergency airway techniques and their success in the setting of penetrating neck trauma. Methods: A retrospective study was conducted of emergency department intubations in penetrating neck injury from January 1, 1993, to December 31, 1996, at a Level I trauma center. Cases of out-of-hospital traumatic arrest or out-of-hospital intubation were excluded. Successful airway management was defined as endotracheal tube placement confirmed by clinical evaluation, pulse oximetry, chest radiography, and end-tidal CO2 detection. Results: During the study period, 748 consecutive patients with penetrating neck injury were evaluated in the ED. Of these, 82 (11%) were deemed to require immediate airway management. Twenty-four of the 82 were excluded because of out-of-hospital traumatic arrest or out-of-hospital intubation, resulting in a study population of 58 patients. Of these 58 patients, 39 had initial rapid sequence intubation using succinylcholine with a 100% success rate. Five comatose patients had successful orotracheal intubation without paralysis, and 2 patients underwent successful emergency tracheostomy. The remaining 12 patients had initial fiberoptic intubation by otolaryngology clinicians, which was unsuccessful in 3 patients. All 3 of these patients were subsequently successfully orotracheally intubated using the rapid sequence intubation technique. Therefore, oral endotracheal intubation was the definitive method of airway management in 47 (81%) of the 58 patients and was successful in all cases. Conclusion: Rapid sequence intubation was the most commonly performed initial technique by emergency physicians and was safe and effective in all cases attempted. Furthermore, rapid sequence intubation methodology resulted in successful intubation of the fiberoptic intubation failures. Physicians with airway expertise should consider using rapid sequence intubation as an initial airway technique in managing patients with penetrating neck injury who require airway control. [Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med . March 2000;35:221-225.]

Section snippets

INTRODUCTION

Airway management is of paramount importance in resuscitation and thus an essential skill for the emergency medicine specialist. Penetrating neck injuries are among the most difficult airway cases to manage, but a recent literature search of airway management in the setting of penetrating neck injury revealed only 3 studies specifically addressing this topic since 19691, 2, 3 and only 1 in the emergency medicine literature.2 Penetrating neck trauma is an uncommon, challenging injury that is

MATERIALS AND METHODS

A retrospective study of ED intubations in penetrating neck trauma was conducted from January 1, 1993, to December 31, 1996, at Los Angeles County–University of Southern California Medical Center, a Level I trauma center. The setting was a large inner-city hospital with an annual ED census of 151,000 patients including more than 3,000 major trauma admissions yearly with a large proportion of penetrating injuries. A large residency training program in emergency medicine exists within our

RESULTS

During the 4-year study period, a total of 748 penetrating neck injuries were evaluated in the ED. Of these injuries, 82 (11%) required immediate emergency airway management. One out-of-hospital intubation and 23 traumatic arrests were excluded by the above criteria resulting in a study population of 58 patients.

Fifty-five patients were male and 3 were female; the average patient age was 31 years (range 15 to 77 years). Mechanisms of injury included gunshot wound in 45 (78%), stab wound in 12

DISCUSSION

Penetrating neck injury is uncommon and is coupled with its inherent management challenges. Although many articles and studies have been written on penetrating neck injury, surprisingly few address airway management; this article is the second emergency medicine study addressing this important topic.

In 1969, Ginsberg and Freinkel3 briefly described their experience with 35 cases managed by anesthesiologists in South Africa. They outlined the hazards of anesthesia in this group of patients and

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Address for reprints: Diku Mandavia, MD, FRCPC, Department of Emergency Medicine, Room 1011, General Hospital, Los Angeles County–University of Southern California Medical Center, 1200 North State Street, Los Angeles, CA 90033; 323-226-6692,fax 323-226-6454;,E-mail [email protected] .

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