SAQ 427 – Anaesthetics – blunt airway trauma with stridor
Model Answer
Anaesthetics – blunt airway trauma with stridor.
a. Equipment
- Direct and video laryngoscopes with appropriate blades.
- Bougie and cuffed endotracheal tubes.
- Supraglottic airway such as LMA.
- Front-of-neck access kit, including scalpel, bougie, forceps, and size 6 cuffed tube.
- Flexible fibreoptic scope with an experienced anaesthetist or airway operator.
b. Airway strategies
| Strategy | Pros | Cons |
|---|---|---|
| Awake fibreoptic intubation in theatre with ENT/surgical airway backup | Avoids losing spontaneous ventilation and allows controlled assessment. | Requires expert operator and may introduce delay while the airway may deteriorate. |
| Rapid sequence intubation with surgical airway backup | Familiar and fast if successful. | Loss of tone may worsen obstruction and create a cannot-intubate/cannot-oxygenate scenario. |
| Primary surgical airway | Bypasses supraglottic obstruction and provides a cuffed airway. | Invasive, difficult in distorted anatomy, and may fail if expertise is limited. |
| Inhalational induction or awake ED approach | May preserve spontaneous ventilation in selected settings. | Requires appropriate staff, setting, and backup; may be poorly tolerated. |
c. Preferred initial approach
- Keep him sitting upright, avoid distress, and explain the plan.
- Call senior anaesthesia and ENT; prepare RSI and front-of-neck access backup.
- Topicalise the airway, for example co-phenylcaine nasal spray or nebulised 2% lignocaine; small titrated ketamine 10-30 mg IV can be considered if needed.
- Pass a fibreoptic scope with an endotracheal tube preloaded and visualise the cords/airway injury.
- Advance and confirm the tube, then sedate/paralyse as required and secure the tube.
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