How to manage a trauma patient with a transected trachea above the thyroid cartilage?

Management of Transected Trachea Above Thyroid Cartilage

In a trauma patient with a transected trachea above the thyroid cartilage, immediately secure the airway by directly intubating through the traumatic defect in the trachea at the bedside, bypassing the upper airway entirely. This is a life-threatening emergency requiring immediate action to prevent death from hypoxia.

Immediate Airway Management Algorithm

Step 1: Direct Intubation Through the Tracheal Defect

• Immediately identify and expose the tracheal transection site by opening the wound if not already exposed 1
• Insert a cuffed endotracheal tube (6.0-7.0 mm internal diameter) directly into the distal tracheal segment through the traumatic defect 1
• Verify correct placement with waveform capnography immediately 1, 2
• Use a smaller tube if needed to facilitate passage through potentially edematous or distorted anatomy 1

Step 2: Simultaneous Resuscitation

• Administer 100% supplemental oxygen immediately 1, 3
• Position the patient head-up if hemodynamically stable to reduce venous congestion and bleeding 1
• Call for immediate surgical and anesthesia backup 1

Step 3: If Direct Intubation Through Defect Fails

• Do not attempt conventional oral intubation as the transection above the thyroid cartilage means the upper airway is disconnected from the distal trachea 2, 3
• If the tracheal defect cannot be accessed or intubated directly, perform emergency surgical cricothyroidotomy only if the cricothyroid membrane is intact and below the level of injury 1, 2
• Use the scalpel-bougie-tube technique: horizontal incision through cricothyroid membrane, caudal traction on cricoid cartilage, bougie insertion, then cuffed tube over bougie 2

Critical Anatomical Considerations

A transection above the thyroid cartilage is anatomically above the cricothyroid membrane, making this injury particularly challenging 4, 5:

• The cricothyroid membrane lies between the inferior border of the thyroid cartilage and superior border of the cricoid cartilage 4, 5
• If the injury is truly above the thyroid cartilage, the cricothyroid membrane may still be intact and accessible for emergency access if direct intubation through the defect fails 2
• The trachea extends 6.9-8.2 cm from cricoid cartilage to sternal notch, with approximately 11 tracheal rings 5

Equipment Required at Bedside

Have immediately available 1, 2:

• Multiple cuffed endotracheal tubes (sizes 5.0-7.0 mm internal diameter)
• Scalpel with number 10 blade
• Bougie
• Tracheal hook for retraction
• Suction
• Capnography capability

Common Pitfalls to Avoid

• Do not delay definitive airway management by attempting multiple failed conventional intubation attempts, as this worsens outcomes and risks complete airway loss 1, 3
• Do not assume you can intubate from above when there is complete tracheal transection—the upper and lower airway segments are disconnected 2, 3
• Ongoing bleeding is not a contraindication to performing emergency airway access 1, 3
• Do not use needle cricothyroidotomy as it has high failure rates and cannot provide adequate ventilation in this scenario 2
• Stridor is a late sign; intervene immediately based on mechanism of injury, not waiting for signs of complete obstruction 1, 3

Post-Intubation Management

Once the airway is secured 1, 2:

• Confirm tube position with waveform capnography
• Ventilate with low-pressure source initially to avoid barotrauma
• Verify bilateral breath sounds and chest rise
• Secure the tube meticulously to prevent dislodgement
• Transfer immediately to operating room for definitive surgical repair
• Consider smaller tube size (6.0 mm) to reduce risk of further tracheal injury during placement 1