Initial evaluation and management of upper airway injuries in trauma patients

To examine and compare the mechanism of injury, diagnostic findings, initial methods of airway management, and outcome of patients who had upper airway injuries.

A retrospective review of hospital records.

A large metropolitan, university-affiliated trauma center.

Forty-six cases of upper airway injuries admitted between 1984 and 1988.

Diagnostic methods included clinical examination, cervical and thoracic radiographs, bronchoscopy and computerized tomographic (CT) scan. Therapeutic interventions ranged from conservative management with or without endotracheal intubation to operative reconstruction.

Mechanism of injury was knife stab wound in 9 cases, gunshot wound in 17 cases, and blunt trauma in 20 cases. Location was the larynx in 13 cases, trachea in 24 cases, cricoid cartilage in 5 cases, and multiple sites in 4 cases. Diagnostic findings varied considerably according to the mechanism of injury, but radiographic evidence of soft tissue air and wounds opening into the airway were common findings. CT scan and bronchoscopy also were useful diagnostic tools. Overall mortality was 24%, which did not vary according to patient age or mechanism of injury. The airway injury itself was a primary or contributory cause of death in four cases, two of which were tracheal injuries and two injuries at the cricotracheal junction.

In any patient with possible upper airway injury, plain radiographs of the chest and neck should be obtained to aid in the diagnosis. Elective intubation should be attempted only with a surgical team present and prepared for emergency tracheotomy. Fiber-optic bronchoscopy could be a valuable aid for both intubation and evaluation in such cases.