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Chapter 57. Airway Management of the Patient with a Neck Hematoma

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Recognizing that no method of intubation can be guaranteed 100% complication free, which of the following approaches to securing the airway is LEAST safe in the patient with a neck hematoma?

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A. Awake intubation with topical airway anesthesia.

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B. Rapid sequence intubation with induction agent and muscle relaxant.

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C. Local or regional anesthesia for evacuation of hematoma and no intubation.

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D. Inhalational induction.

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E. Awake tracheostomy under local anesthesia.

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(B) Rapid sequence intubation with induction agent and muscle relaxant in a patient with a neck hematoma is the least safe. Even with awake intubation or an inhalational induction in the patient with a postsurgical neck hematoma, the risk of complete loss of the airway is always present during the procedure.

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In the patient with obstructing airway pathology such as a neck hematoma, which of the following is the LEAST safe option to help symptomatically temporize the patient while preparing for intubation?

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A. Use sedative agents to alleviate patient anxiety.

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B. If patient oxygenation permits, use Heliox to help the work of breathing.

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C. Have the patient in the sitting or semi-sitting position.

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D. Administer racemic epinephrine via aerosol.

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E. Give intravenous steroids to help counteract any inflammatory component.

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(A) While placing the patient in the sitting or semi-sitting position, administering Heliox, IV steroid, and nebulized epinephrine may be useful, great caution should be given in the use of sedative agents to alleviate patient anxiety.

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In the patient with obstructing airway pathology such as a neck hematoma, which of the following airway management techniques would be (at least relatively) contraindicated?

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A. Direct laryngoscopy and intubation.

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B. Placement of a laryngeal mask airway.

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C. Blind ETT passage through an intubating (Fastrach®) laryngeal mask airway.

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D. Awake intubation with a flexible bronchoscope.

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E. Bag-mask-ventilation with an oropharyngeal airway.

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(C) In the presence of altered or abnormal anatomy (neck hematoma), the use of a blind intubation technique (Fastrach intubation) is not recommended.

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