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

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?

A. Awake intubation with topical airway anesthesia.

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

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

D. Inhalational induction.

E. Awake tracheostomy under local anesthesia.

(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.

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?

A. Use sedative agents to alleviate patient anxiety.

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

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

D. Administer racemic epinephrine via aerosol.

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

(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.

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?

A. Direct laryngoscopy and intubation.

B. Placement of a laryngeal mask airway.

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

D. Awake intubation with a flexible bronchoscope.

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

(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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