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A 25-year-old male drives into an unseen wire while he is snowmobiling. The wire strikes his anterior neck and throws him from his snowmobile. Paramedics are unsuccessful in placing an endotracheal tube (ETT) in the field. He arrives in the emergency department (ED) immobilized on a long spine board and with a cervical collar in place. He is unconscious, unresponsive to painful stimuli, and stridulous. Initial vital signs include a heart rate of 120 beats per minute, a blood pressure of 160/90 mmHg, a respiratory rate of 24 breaths per minute, and an oxygen saturation of 93% on room air. A non-rebreather oxygen mask is applied at a flush-flow rate, and his oxygen saturation increases to 97%.

Palpation demonstrates no obvious subcutaneous air, but there is a large abrasion across the anterior and lateral areas of the neck (Figure 23.1). Palpation of the larynx demonstrates crepitus and slight anatomic distortion. Plans begin immediately to further protect and secure the airway.


This “clothesline injury” patient has a large abrasion across the anterior and lateral areas of the neck.


What Are the Important Considerations in Evaluating This Patient?

Upon arrival at the ED, the team should follow a protocol that is consistent with the guidelines of the Subcommittee of Advanced Trauma Life Support® of the American College of Surgeons Committee on Trauma.1–3 Careful but rapid airway assessment coupled with a high index of suspicion for associated injuries is a necessary step in the successful management of patients with this type of injury. The primary survey identifies an immediate airway concern, so airway management plans should immediately commence.

A young patient with no significant medical history should have adequate cardiorespiratory reserve if there are no concurrent traumatic injuries. His initial oxygen saturation is concerning, which prompts the addition of supplemental oxygen. His depressed level of consciousness could be due to a number of factors, including brain injury, and he might also have sustained a spinal cord injury. Head-injured patients have approximately 7% risk of an associated cervical spine fracture; the incidence of cervical spine fracture related to isolated blunt anterior neck trauma is difficult to adequately characterize, as it is such an infrequent event.4–9 The airway practitioner must assume that this patient has a cervical spine fracture until proven otherwise.2,10

Other associated injuries can occur with this type of “clothesline injury.” These include facial lacerations, vascular injuries, laceration of the trachea and/or esophagus,11 and injury to the recurrent laryngeal nerve.12 These injuries can present significant hazards to intubation. Vascular injuries and lacerations can result in hematoma formation that can impair visualization of the airway. Subcutaneous and submucosal emphysema can also impair visualization of the ...

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