Hi Minh,

The only thing to make clear about laryngeal fractures is a needle/surgical cric is not necessarily going to get you out of trouble. In fact the go to surgical airway is a tracheostomy in laryngeal fractures, an infinitely more difficult skill then the surgical cric we all talk about as our get of jail free card. Its interesting how difficult airway algorithms finish at surgical cricothyroidotomy but that is likely to fail in a laryngeal fracture. My choice would be an awake flexible fibreoptic intubation, however, this is a very challenging case. Anatomy in fractures is complex and difficult to negotiate distally. Just because you can view the glottic opening with a VL doesn’t mean the tube will pass as often the anatomical disruption is distal and hence my preference for flexible scope. The blood makes this case even more difficult and you need an anaesthetist at the top of their game. Use of the berman airway will make life easier and get you to the larynx and certainly reduce the amount of blood in your visual field. But a high expectation of failure should be maintained! Plan for failure, ENT surgeon would be my preference but not always logistically available. My plan B here (given my experience with tracheostomies on ICU) would be a 14g cannula well below the cricoid ideally between 2-3 tracheal rings. Use for oxygenation and then used for wire placement and seldinger technique for single dilator tracheostomy. Must emphasise my plan B is not ideal and an experienced surgeon is my preference. If all else fails do your best with scalpel, finger and bougie. Get lots of adrenaline into the subcutaneous tissues to help with the bleeding. To be honest a breathing patient with an upper airway injury (or more commonly experienced ludwig’s angina/FB in the airway/epiglotitis etc) is your friend so don’t paralyse them and force an uncontrolled action in the face of challenging anatomy. All of the above interventions can be done awake with local, and maybe sedation whether that be ketamine or sevoflurane (for skilled hands only).

Keep up the good work Minh!

Pete