Introduction:
Mastery of the airway is a fundamental skill for all anesthesiologists. Pediatric airways present unique challenges and pediatric trauma can compound the complexity of pediatric airway management.
Case:
A 12 year old male was an unrestrained passenger in a motor vehicle crash. Initial GCS on the scene was a 3 and he was emergently intubated in the field. After arrival in the ED patient became hemodynamically unstable and was noted to have a large epidural hematoma, open, depressed skull fracture, multiple facial fractures, and spinal cord injuries.
Patient was taken emergently to the OR for right frontal craniectomy and other stabilizing procedures. During the operative course, there was significant difficulty with ventilation and oxygenation. CT images obtained prior to the OR demonstrated an ETT morphology with narrowing of the lumen toward the distal tip without complete occlusion or obvious obstruction. Efforts to pass a fiberoptic bronchoscope were unsuccessful. Video laryngoscopy was utilized without any obvious supraglottic swelling or obstruction. A bougie was gently inserted and was unable to pass the length of the ETT. Decreasing the volume of air in the balloon tip of the ETT with simultaneous relaxation of the cervical collar allowed increased ventilation and oxygenation and eventual tube exchange with a video laryngoscopy-assisted bougie exchange technique.
Discussion:
Here we present an unusual case of delayed ventilatory challenges in an intubated patient. The patient sustained significant traumatic injuries resulting in a challenging airway (facial and cervical injuries) and a neurologic status requiring intubation. Despite successful intubation, airway management became very challenging hours later.
CT imaging suggests a clear narrowing of the lumen in the coronal dimension with a patent distal end. Radiographic differentials include saber sheath trachea1,2 or a distended ETT balloon3; but neither of these conditions seems to fit given the lack of tracheal malformation, the absence of an obvious obstructing object distally, or any readily apparent compressive forces. Potentially, the ETT was defective with an intrinsic defect with a combination of an overdistended balloon with neck edema and external compression (tracheal collar) resulting in a net effect of lumen narrowing.
Ultimately, as anesthesiologists we must be prepared to manage challenging airways and despite having a ‘secure airway’, we must remain vigilant and consider defective equipment if standard troubleshooting efforts fail to correct issues.
