We cannot be lulled into relying totally on imaging studies that might jeopardize the patient’s well-being, he emphasized, but rather still consider penetrating injuries of the neck to be a surgical condition.
Explore This IssueDecember 2009
He emphasized situations in which mandatory surgical exploration may be safer for patients, including geographically isolated facilities, insufficient diagnostic imaging capabilities, inadequately trained radiologists, unreliable or outdated equipment, poor transportation capability to a higher-level treatment center, patient or family transportation refusal, and local or regional military or paramilitary conflicts where transporting a patient to a higher-level facility would be dangerous.
Opening the Airway
Another lesson drawn from the battlefield is the critical role otolaryngologists play as first responders to a trauma injury in establishing the airway. According to Manuel Lopez, MD, of the Facial Plastic and Reconstructive Surgery Service in the Department of Otolaryngology-Head and Neck Surgery at Lackland Air Force Base in San Antonio, TX, establishing the airway in a trauma injury is the essential first role that otolaryngologists play in a triage situation, such as a mass casualty situation such as Hurrican Katrina or 9-11. Only after the airway is secure should the otolaryngologist do a secondary examination of the entire head and neck for injuries.
Speaking on the different techniques currently available to open the airway, Robert M. Kellman, MD, Professor and Chair of Otolaryngology and Communication Sciences at SUNY-Upstate Medical University in Syracuse, NY, emphasized that otolaryngologists are the specialists, bar none, who are called in as the backup specialists for any difficulties opening the airway. There is no other specialty that competes with us as the backup person to handle the airway, he said.
As an otolaryngologist with many years of experience managing airway problems in trauma patients off the battlefield, Dr. Kellman emphasized that otolaryngologists need to be familiar with available techniques to permit expedient use of the least morbid technique. Among the techniques that are becoming more widely used are techniques for nasotracheal intubation (eg, using flexible fiberoptic incubation using a fiberoptic bronchoscope) and orotracheal intubation (eg, using a lighted stylet or rigid fiberoptic laryngoscope).
These newer technologies are designed primarily as techniques that allow you to avoid having to get to the final step in the pathway, said Dr. Kellman, which is the need to open the airway by performing either a cricothyroidotomy or tracheotomy.
According to Dr. Kellman, the most important issue in a trauma injury is to avoid injury to the cervical spine. He said that intubation approaches using the fiberoptic instruments or lighted stylet probably are the least likely to result in neck movement that may lead to spinal cord injury.