Introduction

Upper Airway injuries after penetrating trauma of neck can have dire consequences. Patient may present as dyspnea, hoarsenes of voice, pain or subcutaneous emphysema.^[1,2] These are usually managed conservatively or tracheostomy is done.^[3] Other option is endotracheal intubation under general anaesthesia using direct laryngoscopy (DL) or fibreoptic bronchoscopy (FOB). Fibreoptic bronchoscopy can be used for assessment of airway injury as well as for securing the airway. Endotracheal intubation under DL has risk of further damaging the upper airway injury. So tracheostomy under local anaesthesia is the safest option but in child and uncooperative patients general anaesthesia has to be given.^[4] We report a case of a child with penetrating trauma of neck, which was taken up for emergency tracheostomy in view of respiratory distress.

Case Report

An eight year old female child, weighing 30kgs sustained penetrating neck injury while playing with the chain of a cart. Patient came in emergency department with complain of respiratory distress, stridor and subcutaneous emphysema from eyes to upper chest region. Surgeons decided to do emergency tracheostomy immediately, in view of suspected tracheal injury without waiting for any investigations. On examination, patient was tachypnoec with respiratory rate of 30/min, heart rate 140/min, bilateral crepts were present in the chest with decreased air entry, subcutaneous emphysema was present from eyes upto upper chest region. All routine monitors were attached. Induction was done using 40mgs of inj. propofol and 40mgs of inj. ketamine to maintain spontaneous respiration. No muscle relaxant was used. Maintainance of anaesthesia was done using oxygen and sevoflurane. Tracheostomy was performed under general anaesthesia, while patient breathing spontaneously on mask. Pediatric tracheostomy tube was not available in emergency operation theatre, so endotracheal tube of internal diameter 5.5mm introduced and distal end was cut short [Figure 2]. After procedure, sevoflurane was discontinued. Patient became conscious and oriented. She was sent in the ward while breathing spontaneously on tracheostomy tube. Later NCCT of neck and thorax of patient was done, which showed mild right sided pneumothorax, pneumomediastinum, subcutaneous emphysema in the bilateral lateral wall of the chest and tracheostomy tube in situ in the trachea [Figure 3,4]. Pediatrician advised conservative management of the pneumothorax. Patient was discharged home after a week in stable condition after removing endotracheal tube by fenestration and plugging.

Discussion

Penetrating injury to the neck can be fatal due to presence of larynx, trachea, major blood vessels, nerves and pleura.^[5] If patient is hemodynamicaly unstable or respiratory distress is present, immediate surgical exploration and securing of airway is needed. Endotracheal intubation can also lead to complete disruption of trachea. Awake fibreoptic intubation is safer but it requires patient co-operation, time and usually not available in emergencty operation theatre.^[6] Also our patient was in respiratory distress, requiring immediate intervention. We planned general anesthesia without endotracheal intubation while the patient breathing spontaneously on mask. Muscle relaxant was not given to avoid collapse of injured airway and further spreading of emphysema. Patient improved after tracheostomy. However postoperative computed tomography scan showed no airway injury, with mild right sided pneumothorax and tracheostomy tube in situ. Pneumothorax was missed on clinical examination probably due to presence of subcutaneous emphysema. Conservative management of pneumothorax was done as advised by pediatrician. Fortunately positive pressure ventilation was not done which might have lead to tension pneumothorax. Patient was discharged home after a week in stable condition after removing endotracheal tube by fenestration and plugging.

Conclusion

Managing traumatised airway is quite challenging for anaesthetists. Mild pneumothorax in presence of subcutaneous emphysema, without chest x-ray or computed tomography may go unnoticed. So securing airway, while patient is breathing spontaneously is the safest technique.