A 30-year-old male arrives by Emergency Medical Services (EMS) helicopter with a tree branch impaled in his neck (see Figure 24–1). It is apparent that substantial force was involved in this impaling injury.

He is a healthy lumber-worker in a surrounding mountain area. The injury occurred 4 hours ago, the patient was extricated from the scene and the medics received report that there was a moderate amount of blood at the scene. Shockingly, he is intact neurologically with normal movement and sensation. His airway was intact in-flight but the medics are now reporting some increased hoarseness and confusion. They were with him for 2 hours and administered 4 mg of midazolam and 200 mcg of fentanyl. He kept pulling off his oxygen so they left it off even though his oxygen saturation was 94% with the oxygen by non-rebreather face mask. They are concerned that he seems to be getting more agitated. The patient denied past medical history, medications, or allergies.

The patient is sitting semi-upright in restraints, slightly agitated and appearing very anxious. His vitals are: BP, 150/110; HR, 130 bpm; RR, 32 breaths per minute, and a pulse oximetry of 90% on room air. He is moderately cooperative for the examination but seems anxious and his voice is definitely hoarse. The neck wound is not pulsatile but there is oozing blood.

What Are the Important Considerations in Evaluating This Patient?

This patient has a suspected penetrating tracheal/esophageal injury as evidenced by his hoarse voice. He is also at significant risk for a cervical spine injury and has the potential for rapid deterioration to his airway and cardiovascular stability. The most important first step is to get control of the patient. Aggressive initial management is necessary in order to safely care for the patient, for both the team and the patient’s sake. Immediate chemical restraint is necessary.

The presence of this large impaling foreign body in his neck signals that intubation in the supine position is highly unlikely. Therefore, it is imperative to better evaluate this airway in order to strategize how to proceed with intubation. His hypertension is most likely due to anxiety from the injury. His tachycardia could be due to anxiety as well or blood loss and impending shock. He is a young patient who should have adequate cardiorespiratory reserves. His initial oxygen saturation is concerning but since he is thrashing around it is unknown how he might respond to supplemental oxygen. He has no other signs of trauma and associated injuries. Therefore, besides his wound, you should have no further complications.

What Are the Airway Priorities in This Patient?

While management of this airway should follow the American College of Surgeons ATLS standards, this airway needs very special attention.¹ Significant considerations for tracheal and cervical injuries are on the list. These potential injuries carry serious concern as blind intubation could completely transect the trachea or cause spinal injury. Should a blind technique be selected, it would only be immediately pre or post arrest as a last ditch effort.

Penetrating neck trauma has been a rare but significant cause of injury for centuries. Incidence of penetrating neck injury is closely related to violent crimes and military conflict. In the Unites States in 2013, penetrating neck injuries accounted for less than 2% of all reported injuries with very high fatality.² Penetrating neck wounds due to occupational exposures are still case reportable.

His MOANS (see section “Difficult BMV: MOANS” in Chapter 1) evaluation gives the practitioner the sense that there may well be some difficulty in bag-mask-ventilation. While the patient has a normal appearing face, is not obese, not elderly, without facial hair, and not edentulous, just a visual inspection of the foreign body location is concerning. The pressure generated by bag-mask-ventilation could potentially dislodge a clot or produce subcutaneous emphysema. Though it is not anticipated that mask seal will be an issue, opening the airway with a jaw thrust or chin lift might be impeded by the impaled foreign body. Flexing or extending this patient’s neck could possibly move his cervical spine should there be an unstable injury. The airway practitioner should be prepared for bag-mask-ventilation failure.

Chemical restraint should be initiated early and aggressively. Options include medications such as midazolam, haloperidol, olanzapine, and ketamine alone or in combination. There is a great deal of literature regarding the safety of chemical restraint.^3–6 The first paper to appear in the emergency medicine literature was in 1987 by Young.⁶ Many of the studies report that chemical restraint can cause hypoxemia especially when used in combination with other sedatives.⁷ The most recent studies are on the use of ketamine especially in the pre-hospital setting for agitated delerium.^8–11 However, this body of literature centers around either psychiatric conditions or acute drug intoxication, not around agitation due to injury and/or portending shock.

What Are the Considerations in Managing This Patient’s Airway?

This airway is not a crash airway but is definitely a difficult one. Difficulty should be anticipated with both bag-mask-ventilation and laryngoscopy. RODS (Restricted mouth opening, Obstruction [upper airway], Disrupted or distorted airway, Stiff lungs or cervical spine) is a mnemonic intended to identify successful use of an extraglottic device (see section “Difficult Use of an EGD: RODS” in Chapter 1). This patient has normal mouth opening, however, his hoarse voice may signal edema or distortion, and a potential impending cervical spine injury are strong indicators that a rescue technique using an extraglottic device (EGD) may not be successful. EGDs may not be successful, particularly if the geometry of the hypopharynx is distorted by the injury as EGD seat and seal are hindered.

Topical anesthesia coupled with pharmacologic control of the patient may permit the practitioner to perform indirect visualization of the airway with a video-laryngoscope or flexible endoscope (via the mouth or the nose). This may be of great benefit in planning the airway management strategy.

If time allows as in this patient, an awake intubation with a flexible bronchoscope should be performed. The most skilled and experienced practitioner should be at the helm. This may be anesthesia, the emergency physician, or the surgeon but reasonable skill with flexible endoscopic intubation is essential.

There is still a competing risk of cervical injury and vascular collapse due to clot dislodgment and serious consideration should be made to taking this patient to the operating room where a possible emergency tracheotomy and/or thoracotomy could be urgently performed to get control of both bleeding and the airway.

Depending on the evaluation, ECMO performed in the OR, but contemplated and activated in the ED may be considered if sudden loss of the airway is judged to lead to a situation that is impossible to rescue by BMV, EGD, direct or indirect laryngoscopy, or even a surgical airway.

What Are the Indications and Contraindications for Flexible Endoscopic Intubation?