A safe and easy way of securing airway in a patient with cut injury throat

Sir, Deep cut injury over the neck is a life-threatening emergency due to bleeding, aspiration of blood, sympathetic stimulation, air embolism, airway obstruction, and injury to major nerves and vessels. Securing a patent airway for adequate ventilation remains the greatest challenge for the anesthesiologist in such cases. We are reporting a case of a 24 year-old-male patient who presented with a self-inflicted open cut injury in the front of their neck and was posted for emergency wound exploration and repair. He was conscious, had no tachypnoea or stridor, heart rate was 62/min, blood pressure 120/70 mmHg with 100% saturation. On examination the thyroid cartilage could be identified outside the wound with expiratory air coming out of the open laryngeal inlet (Fig. 1a). Two wide-bore intravenous (IV) cannula were inserted and the patient was taken into the operating room and standard preinduction monitors were attached. 2 ml of 2% lignocaine was then instilled into the airway through the open wound and with the neck in extension trachea was intubated while the patient was awake with a lubricated 6.5 mm armored endotracheal tube (ETT), (Fig. 1b). After confirmation of tracheal intubation with bilateral chest movements and appearance of regular end-tidal carbon dioxide waveforms, the patient was induced with fentanyl 2 mcg/kg, midazolam 2 mg and propofol 2 mg/kg, neuromuscular blockade was provided with vecuronium 0.1 mg/kg. Anesthesia was maintained using 1.0 l/min flows of 50% oxygen: air mixture with sevoflurane 0.7–1.2 minimum alveolar concentration. ETT was secured using sutures and low tracheostomy was done by the surgeon using a 7.5 mm cuffed tracheostomy tube and ETT was removed. Dexamethasone 0.1 mg/kg was given to reduce tissue edema. Intraoperative bronchoscopy via oral route revealed a detached epiglottis from its attachment and an injured thyrohyoid membrane. Surgery was uneventful and the patient was shifted to the surgical intensive care unit in T piece after reversal of neuromuscular blockade.Figure 1: a) Cut injury infront of neck exposing thyroid cartilage. b) Intubation through injured laryngeal opening in the wound.In cut throat injuries death occurs mainly due to asphyxia and hemorrhage [1]. Cut injury to the neck involving larynx or trachea creates a unique airway challenge in mask ventilation as it can lead to considerable amount of air leak through the wound and could lead to surgical emphysema [2]. Laryngoscopy can be difficult because of blood, edema, and altered anatomy of the laryngopharynx making direct laryngoscopy challenging. Cricoid pressure in rapid sequence induction can further distort the airway anatomy [2]. Flexion of the neck can obstruct breathing via an open wound. Tracheostomy under local anesthesia is ideal for maintaining the airway. Intravenous induction is risky if the patient becomes apneic before the airway is secured [3]. Awake fibreoptic intubation in such cases can be difficult even in expert hands [3]. Distorted anatomy in laryngotracheal injury outweighs front-of-neck access via cricothyroidotomy as an approach for airway management [4]. A multidisciplinary team comprising of anesthesiologists, head and neck, plastic, and vascular surgeons are essential in the management of such patients for an optimal outcome. It is concluded that in patients with cut injury throat with an open airway, immediately securing the airway through the cut injury keeping the patient awake and spontaneously breathing is the safest and easiest technique. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.