From Prone to Prepared: Airway Management in a Patient With Penetrating Thoracic Trauma

Perioperative and critical care management following penetrating thoracic trauma represents a complex challenge. Those who survive the early trauma approach and reach the hospital alive often remain in critical condition, with cardiocirculatory complications and major pulmonary injuries. Additional difficulty arises from the presence of a weapon in situ, particularly in a dorsal location, which limits patient positioning, and the safe manipulation of both the weapon and the patient. We present the case of a 47-year-old man, who suffered a stabbing assault, resulting in a deep dorsal thoracic wound with the knife still in situ. The patient was initially treated by the pre-hospital team, where the weapon was stabilized with gauze pads and medical tape, and resuscitation was initiated. He was then transported to a regional hospital hemodynamically unstable, requiring further resuscitation with blood products. After stabilization, a computed tomography scan revealed bilateral hemopneumothoraces and the tip of the knife lodged in the lower lobe of the left lung. The hemopneumothoraces were drained and the patient was transported to our trauma center in the prone position, spontaneously breathing with the weapon in situ. The patient was proposed to undergo thoracic surgery, specifically an exploratory thoracotomy in the right lateral decubitus position. Airway approach plan A involved anesthetic induction in the prone position while maintaining spontaneous ventilation and placement of an AuraGain™ (Ambu, Denmark) laryngeal mask airway (LMA), followed by fiberoptic guided intubation through the device. Due to glottic edema and inability for glottic progression of the fibrescope, the AuraGain® LMA was replaced by an iGel® (Intersurgical, UK) LMA, and fiberoptic-guided intubation was successfully achieved. After surgery, the patient remained in the intensive care unit and was successfully extubated five days later. We acknowledge that alternative solutions could have been applied to this case, and we discuss some of them further in this text. This case highlights that, in such complex scenarios, clinical experience and comprehensive knowledge of various airway management devices are critical. Nevertheless, certain principles remain universal in difficult airway management, including the preservation of spontaneous ventilation and meticulous but flexible planning.