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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 103-104
 

Ketamine and lignocaine in airway trauma: Boon for anesthesiologists


1 Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India

Date of Submission07-Jul-2020
Date of Decision01-Aug-2020
Date of Acceptance16-Aug-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Sunit Kumar Gupta
Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_104_20

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How to cite this article:
Sethi P, Kumar R, Gupta SK, Sharma A. Ketamine and lignocaine in airway trauma: Boon for anesthesiologists. Indian Anaesth Forum 2021;22:103-4

How to cite this URL:
Sethi P, Kumar R, Gupta SK, Sharma A. Ketamine and lignocaine in airway trauma: Boon for anesthesiologists. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:103-4. Available from: http://www.theiaforum.org/text.asp?2021/22/1/103/309739




Sir,

Road traffic accident (RTA) is a modern-day epidemic which involves multiple challenges for anesthesiologists. A 40-year-old male was admitted to our emergency department with a history of RTA, and he was conscious, alert, and hemodynamically stable, with a respiratory rate of 20 and 97% saturation on room air. The patient had a bilateral tibial fracture, and focused assessment with sonography for trauma scan was negative. There was mild subcutaneous emphysema with bruise all over the neck. Immediate computed tomography (CT) head and neck was done, which revealed CT head as normal but neck showed completely dissected anterior and lateral tracheal walls with lacerated posterior tracheal wall.

Hence, emergency tracheal repair was planned. A comprehensive plan for anesthesia and surgery was discussed among anesthesiologists and surgeons. It was a difficult airway emergency in which direct laryngoscopy and intubation and fiber-optic bronchoscope by railroading of tube and manipulation could have completely dissected trachea and lead to complete loss of airway [Figure 1]. Hence, we planned to proceed for primary tracheal repair under local anesthesia (LA) with monitored anesthesia care. Glycopyrrolate 0.2 mg, ranitidine 50 mg, and metoclopramide 10 mg were given intravenous (IV) as prophylaxis to prevent secretions and to decrease the risk of acid aspiration, respectively. As the patient came to the emergency department during morning hours and had dinner at night, so he was adequately fasted. The patient was counseled, and nebulization with 50 mg ketamine and 4 ml of 4% lignocaine was done to anesthetize tracheal mucosa. Using only lignocaine could be an option, but the achievement of complete anesthesia for tracheal repair was doubtful. Hence, we used a combination of ketamine and lignocaine. Airway blocks such as superior nerve block and recurrent laryngeal nerve block were not possible in our case due to transaction of trachea along with gross swelling over the area. Surgeons infiltrated 2% lignocaine over the incision site and started the procedure. It was uneventful, and the patient was stable and comfortable throughout the surgery duration of 45 min. Postoperatively, the patient was shifted to the recovery room for further monitoring.
Figure 1: Chest X-ray posterior-anterior view showing surgical emphysema

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Airway injuries are a challenge to anesthesiologists and require careful planning and knowledge of the airway tract. Mercer et al.[1] described the management of blunt tracheal trauma as either repair under LA or awake fiber-optic and direct laryngoscopy for intubation to secure the airway. Repair under LA was considered as safest. Direct laryngoscopy or fiber-optic intubation might increase the tear during railroading of tube. Elkoundi et al.[2] also reported ketamine nebulization for awake fiber-optic intubation. We had the only option of LA for tracheal repair so nebulized airway with lidocaine and ketamine. Probably, only lignocaine can be used, but we needed a deeper anesthesia with analgesia, so ketamine was added. The effectiveness of ketamine nebulization could be due to peripheral analgesic effects and attenuation of local inflammation. Literature has proved the effectiveness of ketamine in neuropathic and cancer pain.[3] IV ketamine was our plan B, but our patient was comfortable and co-operative throughout the procedure. We want to emphasize our short communication that nebulized ketamine can be an effective and viable option for airway trauma.

Ketamine with lignocaine can be lifesaving for patients and boon for anesthesiologists in the management of difficult airway scenarios. Further studies should be done to evaluate its efficacy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mercer SJ, Jones CP, Bridge M, Clitheroe E, Morton B, Groom P. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. Br J Anaesth 2016;117 Suppl 1:149-59.  Back to cited text no. 1
    
2.
Elkoundi A, Bensghir M, Lalaoui SJ. Nebulized ketamine for successful management of difficult airway. J Clin Anesth 2017;41:71-2.  Back to cited text no. 2
    
3.
Wood RM. Ketamine for pain in hospice patients. Int J Pharm Compd 2000;4:253-4.  Back to cited text no. 3
    


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