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A 25-year-old man drives into an unseen wire while he is snowmobiling. The wire strikes his anterior neck and throws him from his snowmobile. Paramedics failed to place an endotracheal tube (ETT) in the field and he arrives in the emergency department (ED) immobilized on a long spine board, with a cervical collar in place. He is unconscious, unresponsive to painful stimuli, and with stridor. Initial vital signs include a heart rate of 120 beats per minute (bpm), a blood pressure of 160/90 mm Hg, a respiratory rate of 24 breaths per minute, and an oxygen saturation of 93% on room air. A non-rebreather oxygen mask is applied, and his oxygen saturation increases to 97%.
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Palpation demonstrates no obvious subcutaneous air, but there is a large abrasion across the anterior and lateral areas of the neck (Figure 19-1). Palpation of the larynx demonstrates crepitus and slight anatomic distortion. Plans begin immediately to protect and secure the airway.
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19.2.1 What Are the Important Considerations in Evaluating This Patient?
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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 Aggressive initial management and a high index of suspicion for associated injuries are key steps in the successful management of patients with this type of injury.
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A young patient with no significant medical history should have adequate cardiorespiratory reserve. His initial oxygen saturation is concerning, but it improves with supplemental oxygen. His depressed level of consciousness could be due to a number of factors, and anoxic injury to the brain or spinal cord must be a consideration. His normotension, elevated pulse rate, and use of accessory muscles of respiration would suggest that his cervical cord is essentially intact. Despite two small studies which suggest that laryngotracheal injury is compatible with a normal cervical spine,2,3 the airway practitioner must assume that this patient has a cervical spine fracture until proven otherwise.4
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Other associated injuries can occur with this type of clothesline injury. These include facial laceration, laceration of the esophagus, and injury to the recurrent laryngeal nerve.5 It is imperative to thoroughly evaluate the patient after first ensuring airway, breathing, and circulation.
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19.2.2 What Are the Airway Priorities in This Patient?
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Considerations in this patient include laryngeal fracture, tracheal disruption, and a hematoma which could impinge on the airway; all of these may be difficult to detect.6 Blunt anterior neck trauma can influence all four choices of initial airway management in this patient: bag-mask-ventilation, use of ...