Review Question - QID 107575

This patient has likely sustained significant trauma to his neck, resulting in bleeding into the airway, as evidenced by the rapid filling with blood and inability to speak. In trauma patients who are not in cardiac arrest, it is critical to first establish an airway. In this patient, in whom endotracheal intubation failed, the next step is cricothyroidotomy.

The most common way to establish a definitive airway is endotracheal intubation; however, endotracheal intubation may be more difficult when there is little to no room for the tube to pass or visualization of the airway is impaired. Examples are airway edema, facial or neck trauma, and significant bleeding into the airway. If endotracheal intubation fails, the preferred method of establishing an emergency airway is cricothyroidotomy, in which an incision is made in the cricothyroid membrane.

Hardcastle et al. performed an observational study of airway management in the trauma unit. In their study of 57 patients requiring airway management, they found that only 2 required cricothyroidotomy due to an inability to intubate, indicating that this procedure is rarely required.

Davidson et al. studied the use of percutaneous tracheostomy (PT) rather than cricothyroidotomy for the long-term management of airways in the critical care setting. They found that PT was a safe and effective means of airway management that may serve as a useful adjunct in the future.

Illustration A shows the thyroid cartilage, the cricoid cartilage, and the cricothyroid membrane through which the incision is made during cricothyroidotomy.

Incorrect Answers:
Answer 1: Endotracheal intubation may be impossible in the case of severe oral and laryngeal trauma, in which case cricothyroidotomy would be necessary to secure the airway.
Answer 3: Nasogastric tube is incorrect because it is first necessary to establish an airway before investigating sources of bleeding.
Answer 4: CPAP is incorrect because it is critical to establish a definitive airway in this patient prior to initiating positive pressure ventilation.
Answer 5: Cardiopulmonary resuscitation is incorrect because this patient is not in cardiac arrest.