A 9-year-old boy wearing a helmet and chest protector is bucked from a bull, and strikes his anterior neck on the bull's horn. He arrives in the ED with normal vitals and no sign of trauma except for mild anterior swelling with subcutaneous emphysema on his neck; he has no open wounds, no respiratory distress, and no stridor but a quiet voice. Shortly after CT, he is noted to have increased swelling and, now has respiratory distress with an oxygen saturation of 88% on 12 liters of oxygen/minute via non-rebreather mask.
What would you do in this challenging case? I asked three colleagues that question, and here are their responses.
Laeben Lester, MD, Emergency Physician turned Anesthesia Resident at Johns Hopkins University
The first step is to recognize that this is a true airway emergency. The next step is to mobilize all available resources including ENT and trauma and general surgery. Simultaneously, we need to improve the patient's tenuous oxygenation using a jaw thrust, 100% oxygen via self-inflating bag (gently fluttering the valve if the patient is not generating enough inspiratory pressure), and possibly a nasal airway.
If a team member is available to review the CT scans, it might support or refute our concerns for laryngotracheal injury and identify other causes for hypoxemia. Then determine if the patient can be safely transported to the operating room. The airway itself involves the use of a “double setup” technique in which the patient is prepped and draped, and the person designated to perform the surgical airway is gowned and gloved before any attempt at intubation is made.
I would manage the case with fiberoptic intubation, but this takes longer, and few emergency physicians are skilled using this technique.
Justin Hazen, MD, Emergency Department Director, Dan C. Trigg Hospital, Tucumcari, NM
I would start with a portable chest x-ray to look for other explanations for the hypoxemia and subcutaneous air, such as a pneumothorax. Given that I am out in the middle of nowhere without backup, I would first prep both sides of the chest for needle decompression and the neck for a failed airway. Backup airways such as an LMA may be useless if there is edema of the airway. This patient will need a definitive airway before the long transfer out of my facility.
I would needle-decompress both sides of the chest if I were unable to determine one side using physical exam. Naturally, if I get a response from one side and vitals improve, I will wait on the second side. If there were no response, I would go for an awake intubation with our Glidescope. If I were unsuccessful, I would go to a surgical airway.
Brian Moore, MD, Director, Pediatric Emergency Medicine Fellowship, University of New Mexico, Albuquerque
One of the most important issues in airway management is anticipating a difficult airway. I would anticipate this airway to have a high probability of being difficult to manage. One of the advantages of working in a tertiary care children's hospital and trauma center is the availability of subspecialty backup. Before trying to secure a definitive airway, I would call for our airway team, including an ENT surgeon.
For managing the airway, I would consider intubation without neuromuscular blockade. Propofol would be a good sedation option; it's fast-acting, and wears off quickly. If I did use a paralytic agent, this may be one of the very few times I would consider using succinylcholine due to its rapid offset. Having multiple backup options readily available at the bedside, including an LMA and a pediatric bougie, would be important. Ideally, this child should be intubated with a fiberoptic scope, and may need a surgical airway if he could not be managed with the other tools I mentioned.
Patients like this boy are scary to manage because they represent potential difficulty in all four airway pathways: intubation, bag-valve-mask ventilation, extraglottic airway, and surgical airway. And the patient is already on a steep portion of the oxygen desaturation curve. In fact, this patient is in the “no reserve” category in which you may have only a few seconds to manage the airway. Even though we all recognize that this patient needs a definitive airway quickly, definitely before transport, rushing in could be disastrous. It is also imperative to rule out other simpler causes of hypoxemia.
I agree that we must attempt this airway awake. While RSI may turn out to be very straightforward, it also may be a clean kill. Gathering help is critical, if help is available. If I were able to palpate neck structures, I would consider an awake surgical cricothyrotomy using local infiltration of lidocaine with epinephrine and small intravenous doses of fentanyl to take the edge off. Fortunately, this child is of an age where I feel comfortable using a surgical airway because needle jet ventilation could be problematic with a tracheal injury.
If landmarks were obscured or the child was too young for a surgical airway, I would go with awake laryngoscopy using generous topical and nebulized lidocaine and small intravenous doses of ketamine with propofol. A double setup is well advised. I would try to avoid positive pressure before intubation to avoid massive subcutaneous airway that could obscure landmarks for a surgical airway. If I were unable to visualize with laryngoscopy and the saturations were dropping, I would still put in an extraglottic airway as a temporizing measure for the subsequent cricothyrotomy, keeping my positive pressure very gentle.
This was a real case from the Land of Enchantment, where placing your child on top of a thousand-pound animal is good sport, but driving them to the rodeo without a seatbelt might land you in jail. The actual patient had a large pneumothorax and a laryngeal injury on CT. The patient was taken emergently to the OR by the trauma and ENT services, where a chest tube improved the saturations and allowed a controlled, uncomplicated intubation with double setup.