Emergency airway management in penetrating neck injury

Study objectives: Airway management in the context of penetrating neck inju ry is a challenging scenario. Management decisionmaking has not been well s tudied and the initial airway approach remains controversial. We examined v arious initial emergency airway techniques and their success in the setting of penetrating neck trauma. Methods: A retrospective study was conducted of emergency department intuba tions in penetrating neck injury from January 1, 1993, to December 31, 1996 , at a Level I trauma center. Cases of out-of-hospital traumatic arrest or out-of-hospital intubation were excluded. Successful airway management was defined as endotracheal tube placement confirmed by clinical evaluation, pu lse oximetry, chest radiography, and end-tidal CO2 detection. Results: During the study period, 748 consecutive patients with penetrating neck injury were evaluated in the ED. Of these, 82 (11%) were deemed to re quire immediate airway management. Twenty-four of the 82 were excluded beca use of out-of-hospital traumatic arrest or out-of-hospital intubation, resu lting in a study population of 58 patients. Of these 58 patients, 39 had in itial rapid sequence intubation using succinylcholine with a 100% success r ate. Five comatose patients had successful orotracheal intubation without p aralysis, and 2 patients underwent successful emergency tracheostomy The re maining 12 patients had initial fiberoptic intubation by otolaryngology cli nicians, which was unsuccessful in 3 patients. All 3 of these patients were subsequently successfully orotracheally intubated using the rapid sequence intubation technique. Therefore, oral endotracheal intubation was the defi nitive method of airway management in 47 (81%) of the 58 patients and was s uccessful in all cases. Conclusion: Rapid sequence intubation was the most commonly performed initi al technique by emergency physicians and was safe and effective in all case s attempted. Furthermore, rapid sequence intubation methodology resulted in successful intubation of the fiberoptic intubation failures. Physicians wi th airway expertise should consider using rapid sequence intubation as an i nitial airway technique in managing patients with penetrating neck injury w ho require airway control.