|Year : 2014 | Volume
| Issue : 1 | Page : 22-24
Endotracheal intubation in the prone position, in a patient with a high-velocity missile injury to the abdomen and thorax
Oyebola Olubodun Adekola1, Ibironke Desalu1, MO Obietan2, GK Oguntuase2, OO Olusoji3
1 Department of Anaesthesia and Intensive Care Unit, College of Medicine University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Anaesthesia and Intensive Care Unit, Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Surgery, Cardiothoracic Unit, Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||21-Jul-2014|
Oyebola Olubodun Adekola
Department of Anaesthesia and Intensive Care Unit, College of Medicine University of Lagos, Lagos University Teaching Hospital, Lagos
Source of Support: None, Conflict of Interest: None
The airway management in prone position secondary to penetrating posterior thoracic injury is challenging to the anesthetist. We described a successful endotracheal intubation under direct laryngoscopy at first attempt in the prone position in a 25-year-old male with a 6-foot hollow metal impacted in the right posterolateral thorax.
Keywords: Endotracheal intubation, posterior thoracic injury, prone position
|How to cite this article:|
Adekola OO, Desalu I, Obietan M O, Oguntuase G K, Olusoji O O. Endotracheal intubation in the prone position, in a patient with a high-velocity missile injury to the abdomen and thorax. J Clin Sci 2014;11:22-4
|How to cite this URL:|
Adekola OO, Desalu I, Obietan M O, Oguntuase G K, Olusoji O O. Endotracheal intubation in the prone position, in a patient with a high-velocity missile injury to the abdomen and thorax. J Clin Sci [serial online] 2014 [cited 2019 Sep 22];11:22-4. Available from: http://www.jcsjournal.org/text.asp?2014/11/1/22/137248
| Introduction|| |
The airway management of the patients after penetrating posterior cervical or thoracic injury is a major concern to the anesthetist, as it may require induction and intubation in the prone position. Airway management in the prone position is not routinely practiced, it may however be the only option in emergency posterior thoracic injuries. , The available options for securing the airway in the prone position includes awake fiber optic intubation,  endotracheal intubation under direct laryngoscopy,  and the insertion of a laryngeal mask airway (LMA). ,, Awake fiber optic intubation is considered the gold standard in intubation in patients with posterior thoracic or cervical injury.  It, however, requires extensive training, acquisition of appropriate skill, and patients cooperation; all of which might be difficult to accomplish in emergency situations. 
Endotracheal intubation under direct laryngoscopy in the prone position is not a routine technique of securing the airway in our institution. Only one study described endotracheal intubation under direct laryngoscopy after a failed awake fiber optic.  Other airway devices previously used to secure the airway in individuals with penetrating posterior cervical, or thoracic injuries include classical laryngeal mask airway (CLMA), intubating laryngeal mask airway (ILMA), and fiber optic. ,,
| Case Report|| |
A 25-year-old male, bakery worker sustained a penetrating injury from a 6-feet bakery oven pole following an explosion of the oven [Figure 1], a patient with a 6-feet hollow cylindrical metal impacted on the right posterolateral aspect of the thorax.
|Figure 1: Patient with 6-foot hollow cylindrical metal impacted on the right posterolateral aspect of the thorax|
Click here to view
He complained of chest pain, dyspnea, and inability to move the right lower limb for 5 hours from the injury time. He was conscious, breathing spontaneously, and voluntarily avoiding any movement. He had reduced sensation and motor power in the right lower limb.
On initial examination, the patient was in the prone position, pale and in painful distress. A 6-feet long hollow metallic rod protruded from the posterior axillary line, at the level of T10 running on an oblique course exiting at the left thoracoabdominal region, 4 cm from the midline. There was associated third degree burns wound at both the entry and exit port with cloth fibers dragged into the wound. The respiratory rate was 28 breaths/minutes, he was dyspneic, and there were dull percussion notes on the right posterolateral hemithorax with markedly reduced air entry in the right middle and lower lung zones. The abdomen was not accessible on account of prone position.
He was initially administered with oxygen via Hudson face mask and intravenous fluid (0.9% normal saline). The metallic rod was reduced to 2 feet by the engineering department [Figure 2]. He was subsequently transferred for chest radiographs and computerized tomography (CT) scan. The chest radiograph revealed a cylindrical metal impacted on the right side of the chest, with minimal pleural effusion. The CT revealed a 2-3-foot hollow rod. A complete blood count showed low Hb, necessitating transfusion with two pints of whole blood. After the CT scan, a decision was made for the patient to undergo an emergency thoracotomy and exploratory laparotomy.
Preparation was made for a difficult airway with different laryngoscopes blade designs sizes, endotracheal tubes of different sizes, and size 3 and 4 LMA devices. Monitors were attached and baseline vital signs were measured. The patient laid prone on the operating table with the head turned to the right. The patient was informed about the procedure. A resident anesthetist stood on the left side of the table to assist and support the patient's head during induction. The attending anesthetist stood at the head of the operating table, and stooped forward with the head toward the patient's head. IV midazolam 2 mg was administered for anxiolysis, and IV ranitidine 50 mg and metoclopramide 10 mg were given for acid prophylaxis. The anesthetist placed the right hand underneath the patient's head and elevated it slightly, and the face mask was applied and oxygen (100%) was administered for 5 minutes. Anesthesia was induced in the prone position with IV propofol 100 mg and IV suxamethonium 100 mg. The patients head was then elevated by the anesthetist using the right index finger around the upper molars while at the same time using the left hand to elevate and slightly extend the head dorsally. A size 3 Macintosh laryngoscope blade was cautiously applied with the left hand until the right part of the tongue was pressed down and no longer visible. The epiglottis was localized, the laryngoscope adjusted, and the glottis inspected. Endotracheal intubation was performed with a size 8 mm endotracheal tube, bilateral air entry was confirmed and the tube was secured [Figure 3]. A 25-year-old male patient was successfully intubated via direct laryngoscopy in the prone position.
| Discussion|| |
This case review has demonstrated that endotracheal intubation under direct laryngoscopy is achievable under emergency situation in the presence of an experienced anesthetist. This observation has been previously documented by others.  During elective surgical procedures, endotracheal intubation is routinely performed in the supine position. In patients who sustained posterior cervical or thoracic injury, it is impossible for them to be positioned supine. In such circumstances, airway management can only be performed in the prone position. , The gold standard for securing airway in such circumstances is awake fiber optic,  which requires extensive training, acquisition of appropriate skill, and patients cooperation; all of which might be difficult to accomplish in emergency situations.  The options for securing the airway includes awake fiber optic, the LMA-Fastrach, LMA-CTrach (Laryngeal Mask, Mahe, Seychelles), and videoscope laryngoscope; , however, they were unavailable during this case presentation. The available airway techniques included endotracheal intubation under direct laryngoscope or insertion of a CLMA.
Lipp et al.,  in a case report of a male patient who had a large knife protruding from his back between the scapula and spinal column for the surgical revision, reported of a successfully performed endotracheal intubation in the prone position with the aid of a fiber optic device. In contrast, van Zundert et al.,  in another case report, tried ﬁber optic intubation in the prone position without success in a patient with a traumatic thoracic injury. The patient airway was secured successfully with endotracheal tube under direct laryngoscopy. In another case review, the ILMA was successfully used to secure the airway in a male adult who sustained posterior cervical injury with a native butcher's knife.  The ILMA was used because it facilitated both tracheal intubation and ventilation, and was available. Other researchers also intubated in the prone position with the aid of the CLMA. , All intubation were, however, performed during elective surgical procedures.
In our presentation, the ILMA was unavailable while the CLMA was not an immediate alternative of securing the airway as the surgical procedure was an emergency exploratory thoracotomy and laparotomy. As such, the patient was a full stomach who was at increased risk of regurgitation and aspiration of gastric content, he also required postoperative elective mechanical ventilation. The most appropriate airway technique available to us was endotracheal intubation under direct laryngoscopy. Surprisingly, during elective spine surgery, Baer et al.,  successfully secured the airway in 244 of 247 patients (98.8%) using endotracheal intubation under direct laryngoscopy in the prone position. They suggested that routine tracheal intubation in the prone position can be performed effectively by experienced anesthesiologists when indicated during elective surgical procedures, but this require continuous training and good support from the anesthesiology staff.
We have illustrated that successful securing of the airway in the prone position is possible with endotracheal intubation under direct laryngoscopy. Success at securing the airway under anesthesia in the prone position may depend on the airway skill and experience of the attending anesthetist and the availability of different airway devices. We therefore suggest that airway operators should use the airway technique or skill they are proficient in. Training in different airway skills should be offered to anesthetist in our institution on a regular basis. Endotracheal intubations on a model (mock airway instrumentations) should be performed not only in the standard (supine position) but also in the sitting, lateral, and/or prone positions. Different airway devices should also be available in our institutions. As the provision of appropriate airway devices and training will improve the airway skill of airway operator in our institution.
| Conclusion|| |
This case presentation has shown that endotracheal intubation under direct laryngoscopy during general anesthesia is possible and relatively easy to perform in the presence of an experienced anesthetist.
| References|| |
|1.||van Zundert A, Kuczkowski KM, Tijssen F, Weber E. Direct laryngoscopy and endotracheal intubation in the prone position following traumatic thoracic spine injury. J Anesth 2008;22:170-2. |
|2.||Prasad MK, Sinha AK, Bhadani UK, Chabra B, Rani K, Srivastava B. Management of difﬁcult airway in penetrating cervical spine injury. Indian J Anaesth 2010;54:59-61. |
|3.||Lipp M, Mihaljevic V, Jakob H, Mildenberger P, Rudig L, Dick W. Fiberoptic intubation in the prone position. Anesthesia in a thoraco-abdominal knife stab wound. Anaesthesist 1993;42:305-8. |
|4.||Samantaray A. Tracheal intubation in the prone position with an intubating laryngeal mask airway following posterior spine impaled knife injury. Saudi J Anaesth 2011;5:329-31. |
|5.||Brimacombe JR, Wenzel V, Keller C. The proseal laryngeal mask airway in prone patients: A retrospective audit of 245 patients. Anaesth Intensive Care 2007;35:222-5. |
|6.||Agrawal S, Sharma JP, Jindal P, Sharma UC, Rajan M. Airway management in prone position with an intubating Laryngeal Mask Airway. J Clin Anesth 2007;19:293-5. |
|7.||Ng A, Raitt AD, Smith G. Induction of anesthesia and inserting of a laryngeal mask airway in prone position for minor surgery. Anesth Analg 2002;94:1194-8. |
|8.||Kumar V, Lalitha K, Lone T. Use of classic laryngeal mask airway inserted in prone position for controlled ventilation: A feasibility study. Indian J Anaesth 2008;52:813-7. |
|9.||Baer K, Nyström B. Routine intubation in the prone position. Ups J Med Sci 2012;117:411-4. |
[Figure 1], [Figure 2], [Figure 3]