If you were faced with a stab wound to the neck and had to act fast, would you have a well-thought out plan that you are comfortable with? In this EM Cases Best Case Ever podcast we discuss the do’s and don’ts of penetrating upper airway injury awake intubation with airway expert George Kovacs….
Don’ts in Penetrating Upper Airway Injury Awake Intubation
Don’t wait to intubate a patient with a potential penetrating upper airway injury. The neck is a closed space. If you suspect that the patient with a penetrating neck injury has an airway that is obstructed, distorted or disrupted, they’re good until they’re dead. In other words, deterioration will be rapid and a panic situation will ensue.
Don’t choose RSI only because that’s what you’re most comfortable with. There are some situations where awake intubation, which most of us are not as familiar with, is preferred. If you aren’t’ familiar with awake intubation, practice with simulation.
If you do an RSI, don’t do anything blind because you can disrupt the upper airway further.
Don’t use positive pressure ventilation (no bagging, no supraglottic device) to avoid worsening subcutaneous emphysema.
Sowers N, Kovacs G. Use of a Flexible Intubating Scope in Combination with a Channeled Video Laryngoscope for Managing a Difficult Airway in the Emergency Department. J Emerg Med. 2016;50(2):315-9. Full pdf
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.