Emergency Cricothyrotomy in a 51-Year-Old Woman with Traumatic Airway Obstruction After a High-Speed Collision

Introduction

The assessment of airway patency is an initial step in the evaluation of a trauma patient and can represent a challenging clinical scenario. Numerous factors, including fractures, hemorrhage, and anatomical anomalies, can further complicate this task. Consequently, standard airway measures can prove difficult to employ [1]. Furthermore, delayed endotracheal intubations in this population are associated with a significantly higher mortality rate; thus, the ability to secure a definitive airway in a rapidly deteriorating patient is of the utmost importance [2].

More than 30% of intubations in emergency departments are in the setting of trauma, with endotracheal intubation being the most common method of securing the airway [3]. Compromised airways can present secondary to a loss of support from oral structures and can be further exacerbated by a cervical spine collar in trauma patients [4]. In particular, the incidence of maxillofacial fractures has been reported to be approximately 1000 patients per year at a major trauma center in Austria and occurs at a 2: 1 ratio of male to female patients [5]. Maxillofacial fractures can cause posterior displacement of fractured segments and complicate the process of securing the airway [4]. Recognizing patterns of maxillofacial trauma etiologies can facilitate preparation for a difficult airway.

In cases involving maxillofacial trauma, the rate of unsuccessful endotracheal intubation has been reported to be up to 12% [6,7]. Sakles et al noted that intubation success rates were affected by nearly 10% when trauma patients with facial or neck injuries presented with airway contamination, as compared with trauma patients without blood or vomitus [8]. Additionally, thyroid abnormalities or anatomic anomalies that result from head and neck cancer can obscure normal structures and consequently affect emergency airway management [9].

In the event of failed endotracheal intubation, a cricothyrotomy can be performed [10]. A scenario that can require cricothyrotomy is oral or maxillofacial trauma [11]. Proper identification of the standard landmarks is essential to performing this procedure, which can be complicated by anatomical distortion of the ventral neck region [1]. As opposed to the standard cricothyrotomy procedure as highlighted by Schellenberg et al [12] (Figure 1), airway management in acute traumas is dictated by individual presentations. This report describes a uniquely difficult emergency cricothyrotomy in a decompensating trauma patient with complex facial fractures and a large neck mass causing significant anatomical distortion.

Case Report

A 51-year-old unrestrained female driver was involved in a high-speed rollover collision. The patient was ejected out of the front windshield, sustaining head and facial injuries. She was found in the field by first responders and emergency medical services (EMS) personnel. Following initial evaluation and prehospital stabilization by the ground EMS crew, the patient was transported by aeromedical services to a regional trauma center.

The patient’s Glasgow Coma Scale (GCS) score was reported to be 13 (E4V4M5) on initial evaluation and gradually deteriorated to GCS score of 11 (E3V3M5) during the 45-min helicopter transportation. While en route, the patient maintained her airway with supplemental oxygen delivered via a non-re-breather mask at 15 L per min. Upon arrival to the trauma center, her GCS score was noted to be at 11 (E3V3M5), and her first set of vital signs included a blood pressure of 156/78 mm Hg, heart rate of 80 beats per min, respiratory rate of 20 breaths per min, core body temperature of 36.6°C (97.9°F), and oxygen saturation of 98% on 15-L non-rebreather mask. No past medical, surgical, or social history was obtained during the initial phase of trauma care.

While undergoing the primary survey and trauma resuscitation, the patient’s mental status acutely deteriorated and necessitated the need for establishment of a definitive airway. Rapid sequence endotracheal intubation was attempted by the emergency and anesthesia teams, using manual and video laryngoscopy techniques; however, appropriate visualization of anatomical landmarks was unsuccessful due to severe traumatic obfuscation of normal anatomy. An attempt at passing an Eschmann-style bougie tracheal tube introducer was also unsuccessful, secondary to significant airway edema, and the patient’s oxygen level rapidly desaturated to 70%. As a last resort, an emergency cricothyrotomy was considered. During the procedure, the operator noted a distorted anatomy of the anterior neck, with a large left neck mass pushing the larynx away from the typical midline position toward the right side of the patient’s neck.

After applying a chloraprep swab to cleanse the neck, a 2-cm vertical incision using a number 11 blade was performed in the midline of the neck. The larynx was located with a finger sweep roughly 4 to 5 cm off the usual midline to the right of the incision site. The larynx was digitally pulled toward the center and held securely for the cricothyrotomy procedure. An incision was made in the cricothyroid membrane, and a bougie was inserted into the trachea. A number 6 cuffed endotracheal tube was guided into the trachea using the inserted bougie and was secured 2 cm above the carina, and the endotracheal cuff was subsequently inflated. The procedure was completed rapidly, without any incidence of bradycardia or further hypoxia, and with minimal tissue trauma and bleeding at the site of the incision.

Following the cricothyrotomy, the primary and secondary surveys were completed by the trauma team, and the patient underwent a series of imaging, including bedside extended focused assessment with sonography in trauma, chest, and pelvic X-rays, and computed tomography scans of the head, maxillofacial, neck, chest, abdomen, and pelvis, accompanied by the cervical, thoracic, and lumbar spine. Standard trauma laboratory panels were performed, including a complete blood count, type and cross, basic metabolic panel, urine analysis, urine drug screening, and ethanol level. Major findings on the imaging studies included significant bilateral subcutaneous air in the facial soft tissue and extensive right scalp injury, right medial orbital wall fracture, right periorbital and retro-orbital air, moderate bibasilar lung contusions, and large bilateral thyroid masses up to 8 cm in the left displacing the trachea to the right (Figure 2A–2C). After the initial stabilization, the patient was admitted to the hospital and underwent surgical conversion of the cricothyrotomy to a tracheostomy the following day. During the course of her hospital stay, she was cared for by various medical specialty services.

Other notable procedures performed during the hospital course included incision and drainage of an orbital abscess 5 days after admission. Three weeks later, the patient underwent endoscopy with gastrostomy tube placement, due to a failed swallow study. The patient was discharged to a subacute rehabilitation facility with tracheostomy management capabilities about a month after originally presenting to the trauma center, with a plan for outpatient follow-up for thyroid biopsy and assessment for thyroidectomy.

Discussion

Maxillofacial trauma and associated airway contamination represent significant barriers to successful endotracheal intubation [6,7]. This can be further complicated by non-traumatic anatomical anomalies, such as a large thyroid goiter, as highlighted in this case report (Figure 2A–2C). As such, airway management in trauma patients and the knowledge of appropriate contingencies are priorities and represent core skills in trauma care. This requires regular training to overcome difficult intubations and prevent complications, such as hypoxemia and aspiration. Particularly in acute trauma care, patient presentation dictates the airway management techniques that must be employed for the establishment of a safe and secure airway and demonstrates the importance of preparedness for various airway procedures [2]. In the setting of complex facial and neck trauma, airway compromise presents a challenging clinical scenario, given the increased potential for obscured visualization of the epiglottis and vocal cords [4]. Hemorrhage, gross deformities of the airway, burns, and angioedema can act to impede the passage of an endotracheal tube, even when appropriate structures are visualized [13]. Furthermore, organic etiologies, including goiter, oral cancer, and oropharyngeal cancer, can further complicate the traumatic presentation [9].

With advancements in modern airway management technologies, including video-assisted laryngoscopy, the need for performing emergency surgical airways has been reduced [14]. George et al outline 2 distinct factors that can contribute to decreased proficiency in performing the emergency cricothyrotomy [1]. First, the nature of the procedure is rare, and dedicated training with repetition should be encouraged for all medical providers who are involved in management of critical airways. Second, surgical and emergency physicians often use different techniques to establish a surgical airway, namely the Scalpel-Bougie-Tube (SBT) and the surgical cricothyrotomy technique [1]. While the techniques themselves did not have a difference in outcomes, providers may need to be consistent with the technique they use and to be familiar with the specific medical equipment available at the time of the procedure [1].

The important anatomical landmarks that must be identified to perform a surgical cricothyrotomy include the thyroid prominence, cricoid prominence, and cricothyroid membrane [13]. The SBT, typically preferred by surgeons, based on their widespread training in cases of emergency cricothyrotomy, involves making an initial vertical midline incision of 3 to 5 cm through the skin and subcutaneous tissues, palpating the cricothyroid membrane through the skin to confirm anatomy, making a horizontal incision, using a tracheal hook and dilator, and then placing a tracheostomy tube through the membrane [10]. Alternatively, the surgical cricothyrotomy technique, more often performed by emergency physicians, involves palpating the cricothyroid membrane, making a single horizontal stab incision through the skin, subcutaneous tissue, and cricothyroid membrane, and then inserting of the bougie into the incision to guide proper placement of the endotracheal tube [10]. A retrospective study comparing the surgical cricothyrotomy technique and SBT found no difference in success rates, complications, or mortality between the 2 techniques [1]; however, SBT can require less time to perform [15–17].

In cases in which the cricothyroid membrane cannot be manually located using traditional anatomic landmarks, the Difficult Airway Society recommends extending an 8- to 10-cm vertical incision to the anterior neck [13]. Fennessy et al further clarify these recommendations, demonstrating that an 8-cm incision commencing 3 cm above the suprasternal notch would include all cricothyroid membrane locations [18]. Similar to this case, the SBT technique has been documented in the literature as an effective method to secure a definitive airway in a complicated patient presenting with a large mass at the base of the tongue and left tonsillar area with pharyngeal displacement with failed rapid-sequence intubation [19].

Due to the rarity and critical nature of the emergency cricothyrotomy procedure, it is difficult to accurately document the overall complication rate; however, in a systematic review by Devore et al, the rate of early complications and late complications is estimated to be about 13% [11,20]. Early complications include injury to cartilaginous structures, failure to obtain an airway, hemorrhage, execution time delays, pneumothorax, and subcutaneous emphysema [11,20]. Late complications include airway stenosis, peristomal bleeding, dysphonia, aspiration pneumonia, peristomal infection, granulation tissue, dysphagia, and air leaks [11,20]. It is also probable that nearly all complications can be reduced with increased familiarity with the techniques and equipment used in performing emergency surgical airways [1,21,22].

Conclusions

An emergency cricothyrotomy complicated by a significantly distorted anatomy presents a major challenge for the trauma team. This report has highlighted the importance of airway evaluation in patients with acute trauma and has shown that cricothyrotomy is a life-saving procedure. Using a systematic approach with the use of a familiar technique and equipment by the operator can be beneficial in an atypical traumatic presentation.