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Airway Management in a Patient With Tracheal Disruption due to Penetrating Neck Trauma With Hollow Point Ammunition: A Case Report

Johnson, Angela, M., MD*; Hill, James, L., MD*; Zagorski, Dave, J., CAA*; McClain, Joseph, M., MD; Maronian, Nicole, C., MD

doi: 10.1213/XAA.0000000000000675
Case Reports

Rapid sequence induction and intubation was performed for a patient in respiratory distress after a gunshot wound to the neck. Resistance was noted distal to vocal cords. With a bronchoscope unavailable, the endotracheal tube was advanced with a corkscrew maneuver. Subcutaneous emphysema had developed. The endotracheal tube was advanced into the right mainstem with adequate ventilation. Imaging illustrated tracheoesophageal injury. The patient was emergently explored. An intraluminal bullet was removed, lateral wall tracheal defect was repaired, and a tracheostomy was placed. The intubating provider should secure the airway by the method they are most comfortable, have high suspicion of airway injury, and prepare to manage airway disruption.

From the *Department of Anesthesia and Perioperative Medicine

Trauma Division, Department of General Surgery

Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

Accepted for publication September 19, 2017.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Angela M. Johnson, MD, Department of Anesthesia and Perioperative Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106. Address e-mail to

Penetrating neck injuries represent 0.4% to 10% of penetrating trauma in the civilian population and carry an up to 11% mortality rate.1,2 Mortality from bullet injuries to the neck can be further broken down to 1.2% to 2.2% for a low-velocity single bullet and >50% for a high-velocity single bullet.1 Laryngeal trauma specifically occurs between 1/5000 and 1/30,000 emergency department visits. Mortality rates are reported between 2% and 30% with >50% of deaths occurring within an hour of injury.3,4 Seventy-four percent of penetrating trauma injuries occur in the cervical trachea.4

Initial management of all trauma patients should follow “Advanced Trauma Life Support” as put forth by the American College of Surgeons Committee on Trauma. Most penetrating neck trauma algorithms suggest immediate operative exploration for those patients with hemodynamic instability and shock, hemorrhage, airway compromise, hematemesis, expanding or pulsatile hematoma, and massive subcutaneous emphysema or air bubbling through the wound.1,5 For penetrating injuries to zone II in the stable patient, imaging with computed tomography angiogram may be performed with more invasive procedures including exploration, bronchoscopy, and esophagoscopy based on imaging results.5

Numerous algorithms exist for the evaluation and management of patients with penetrating neck wounds; however, there is a paucity of data or algorithms for airway management in this patient population and for tracheal disruption in particular.1,2,4,6–12 Most available data on tracheal disruption include case reports, pediatric patients, and often a blunt mechanism. We present airway management in a patient with tracheal disruption due to penetrating neck trauma with 45 ACP hollow point ammunition.

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Written authorization was obtained from the patient before publication of this case.

Figure 1

Figure 1

The patient is a 21-year-old man who presented to the trauma bay via ambulance with a zone 2 gunshot wound to the left neck. Upon arrival, he was vocalizing and spitting up blood. His respiratory status worsened, and ventilatory support was initiated with mask ventilation. Air was noticed to be escaping from the bullet wound on the left neck. Rapid sequence induction was undertaken. A grade 1 view of vocal cords was seen with a Macintosh 3 blade, and an 8.0 endotracheal tube (ETT) was passed through the cords where resistance was noted. With all available bronchoscopes being utilized in the emergency department, none was quickly available in the trauma bay. The ETT was withdrawn, and a 7.0 ETT again met resistance past the cords. This ETT was advanced with a corkscrew maneuver. Subcutaneous emphysema developed shortly after intubation with air escaping from the bullet wound. Tracheal obstruction and injury were entertained, and the tube was advanced into right mainstem with the intent of advancing the cuff more distal to the suspected site of injury. Ventilation remained stable and adequate. Placement was confirmed via chest x-ray in the trauma bay. Subsequent computed tomography imaging illustrated diffuse subcutaneous emphysema with possible tracheoesophageal injury. The patient was taken emergently to the operating room with otolaryngology for neck exploration that revealed a right lateral wall tracheal defect just inferior to the seventh tracheal ring (Figure 1A). An airway foreign body related to the bullet was encountered at the site and removed (Figure 1B). The posterior tracheal wall was intact. A tracheostomy was placed at tracheal ring 5 and secured with an inferiorly based Bjork flap, and the defect was repaired. The patient was transferred to the trauma intensive care unit postoperatively. He was liberated from the ventilator on postoperative day 6. His tracheostomy tube was decannulated on postoperative day 14. He was discharged to a rehabilitation facility on postoperative day 21.

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Airway management remains the first priority in all trauma resuscitation. Penetrating injuries to the neck are typically classified by location. Zone I extends from the inferior border of the cricoid cartilage to the clavicles. Zone II extends from the cricoid cartilage to the angle of the mandible. Zone III extends from the angle of the mandible to the base of the skull. Mortality risk is highest with zone I injuries as they typically involve major vessels, lungs, trachea, and esophagus.13 Surgical exposure is most challenging in zones I and III. Zone II injuries are the most frequent and have the least mortality as they present the best surgical exposure for identification and repair of injuries.1

Airway injury should always be suspected in those with penetrating trauma to the neck. Those with gunshot wounds from hollow point bullets are especially susceptible. The energy transfer seen with impact with a hollow point bullet is 1723 and 1477 J, much higher than that seen with 9 mm × 19 mm or 7.62 mm × 39 mm bullets.14 In addition, hollow point bullets create a cone-shaped cavity that starts at the impact surface with a maximal diameter of 16 cm occurring at a depth of 15 cm. Forty-five millimeter bullets have a much narrower cavity that reaches a maximum diameter of only 4 cm, with 7.62 mm × 39 mm and 9 mm × 19 mm bullets reaching a maximum diameter of 10 and 5 cm, respectively.14 The hollow point projectile is fully expanded after 5 cm of penetration, but often is already at maximum expansion after only a few millimeters of penetration.15 The ability to expand, high-energy transfer, and large cavity creation make them capable of causing a great deal of damage, especially when applied to important airway and vascular structures in the neck.

Challenges specific to airway management in penetrating neck injury include direct airway penetration, airway obstruction, distorted tissue planes or anatomy, hematoma formation, cervical and spinal cord injury, gastric contents, or excessive blood.7 Controversy exists over the use of paralytic agents as this can cause complete airway obstruction with loss of tone in supporting airway structures.7

Most authors agree that blind nasal intubation should not be utilized as this could create a false passageway or worsen airway obstruction or disruption although mixed opinions exist in the literature.1,11 Four awake blind nasal intubations were attempted in a retrospective study with 25% (1 patient) dying from loss of airway. The authors only suggest blind nasal intubation when no other means to secure an airway exists.6 A retrospective review of penetrating neck trauma patients from 1993 to 2001 at Denver Health Medical Center identified 40 patients who received prehospital blind nasotracheal intubation for airway management. Success rate is reported at 90% with a mortality rate of 5% not related to airway management technique. Mortality was not statistically different from that of rapid sequence induction and intubation (RSI) in the emergency department. The authors suggest prehospital blind nasal intubation as a safe alternative to airway management; however, data are limited and retrospective; so this must be taken into consideration.11

Ryder Trauma Center in Miami, Florida, prospectively reviewed 1006 trauma intubations from April 1996 to March 1998 and found that only 3 cases of failed intubation resulting in surgical airway were in penetrating neck injury.1 Since this discovery, they revamped their penetrating neck injury airway algorithm and performed all airway management under direct visualization with direct laryngoscopy and/or fiberoptic bronchoscope with suction capability. The authors note that awake fiberoptic intubation is the safest method although not always possible due to patient cooperation, visualization, and procedural time. In patients without a suspected difficult airway, a rapid sequence fiberoptic may be performed with rapid sequence induction, direct laryngoscopy, and bronchoscopic intubation to evaluate for injury. While not found in every emergency department, this allows for optimal placement of the ETT balloon distal to the injury. Standard RSI is chosen for patients with favorable airway anatomy, minimal risk for airway injury, and high risk for bleeding with stimulation from awake laryngoscopy or bronchoscopy. Awake orotracheal intubation is pursued in moribund and apneic patients or those with massive upper airway bleeding obscuring bronchoscopic views. If these 4 management techniques are unsuccessful, a surgical airway is obtained. Surgical airway is also indicated in those with laryngeal injury or proximal tracheal injury.2 Cricothyroidotomy is not recommended if the location of an airway injury is unknown as this may result in complete airway obstruction.1 Airway management techniques should be instituted once the trachea, cricothyroid membrane, and availability of personnel to perform a surgical airway have been identified.6

An observational, retrospective study at a tertiary trauma center in Canada identified 19 cases of penetrating neck trauma from April 1994 to March 2005. Forty-two percent of patients underwent awake and rapid sequence intubations without adverse airway-related outcomes.2 A retrospective study by Parkland Memorial Hospital identified 107 patients requiring intubation with penetrating neck injuries. Eighty-three percent of patients underwent direct laryngoscopy with RSI, 7% underwent awake fiberoptic bronchoscopy, and 6% had initial surgical airway management. Success rates were 100% for primary surgical and fiberoptic bronchoscopy and 98% with direct laryngoscopy.6 A retrospective study of emergency department intubations also elucidated RSI to be airway management of choice and successful in penetrating neck injuries among emergency room physicians with 39 of 58 patients successfully intubated with RSI. Three of 12 patients had awake fiberoptic attempts that were unable to secure an airway; these 3 patients were successfully intubated via RSI.7

Figure 2

Figure 2

Our case presented difficulty passing an ETT during RSI in a patient with zone II penetrating trauma. Due to equipment constraints, bronchoscopy was not readily available allowing for examination of the trachea and identification of the tracheal injury. Ventilating the patient via bag mask or laryngeal mask airway while awaiting bronchoscope availability could be fraught with the risks of aspiration. In addition, our patient developed hemoptysis before intubation with air escaping from the wound in his neck. Visualization with a bronchoscope would likely be limited, and ventilation without right mainstem intubation would likely not have been successful. Downsizing the ETT further may have allowed for intubation without resistance. Additional consideration could be given to intubation with a bougie and subsequently passing an ETT over the bougie. Both options of downsizing the ETT and intubating over a bougie still present with risks of worsening tracheal injury or creating a false passage. We have proposed an algorithm for airway management in patients with penetrating neck trauma (Figure 2); however, the intubating provider should secure the airway by the method they are most comfortable, have a high suspicion of underlying airway injury, and be prepared to manage any airway disruption.

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No airway management has been found to be superior to another in penetrating neck trauma; however, RSI appears to be the most commonly used and is done so successfully. In addition, management will be impacted by patient cooperation, injury, and visualization. Blood, gastric contents, and mucous may interfere with bronchoscopic visualization and can impede the ability to apply topical anesthetic in the oropharynx and larynx.6

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Name: Angela M. Johnson, MD.

Contribution: This author helped conceive the work, and write and revise the manuscript.

Name: Dave J. Zagorski, CAA.

Contribution: This author helped in care for the patient and revise the manuscript.

Name: James L. Hill, MD.

Contribution: This author helped care for the patient, conceive the work, and write and revise the manuscript.

Name: Joseph M. McClain, MD.

Contribution: This author helped care for the patient and revise the manuscript.

Name: Nicole C. Maronian, MD.

Contribution: This author helped care for the patient and revise the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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