Neck injuries can create some of the greatest challenges to airway management. All agree that any patient with acute respiratory distress, airway compromise from blood or secretions, massive subcutaneous emphysema, tracheal shift, or severe alteration in mental status must have early airway intervention. Controversy arises when presented with patients who have significant injury mechanisms without any immediate evidence of vascular injury or airway compromise. There are no published data that definitively outline the optimal approach in such patients. It is important to realize how quickly blood or air dissecting into fascial compartments can distort normal anatomy. Once this occurs, airway management becomes difficult, if not impossible. The risk of performing an unnecessary intubation is minimal compared to the potential morbidity of a difficult intubation with respiratory distress and a distorted airway. It is particularly important to establish a definitive airway before a patient leaves the monitored setting of the Emergency Department for diagnostic studies. In most cases, orotracheal intubation with rapid sequence induction can be used.

If unsuccessful, the cricothyroidotomy is generally the next procedure of choice in adults. When performing a cricothyroidotomy care must be taken to avoid dislodging a contained hematoma. The integrity of the larynx should be evaluated prior to any intubation attempts, particularly in cases of blunt trauma. Intubation of a patient with a fractured larynx may result in complete transection or create a false passage, necessitating a tracheostomy. Occasionally, a tracheostomy site will be created by the injury itself. An existing tracheostomy may be intubated as a lifesaving means of securing the airway.4 In all cases of blunt neck trauma, or in penetrating trauma in which a cervical spine fracture is suspected, immobilize the cervical spine in the neutral position.

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