1. 35 yo male is seen in the trauma bay following a stab with an ice pick to his right neck lateral to midline.  Primary and secondary survey reveal the following pertinent information: He has mild shortness of breath, but he is still able to talk in complete sentences.  He states his last meal was more than 8 hours ago.  He has no stridor and his pOx is 97% on room air.  The stab wound is in Zone II and there is a spreading ecchymosis with some fullness in the left neck.  The trachea is mildly shifted to the left.  His cervical spine has been cleared by the trauma team.  The patient has a large neck with limited extension.  A CT scan with angiography is unavailable.  Your anesthesia colleague would like to discuss with you how you want to handle a potentially difficult airway.  In an organized fashion, how do you want to manage this airway?
   1. Currently, he is stable but he is in guarded condition.  Despite his sensation of mild shortness of breath, he is talking with complete sentences, protecting his airway, and has no stridor.  He currently is supine with his head elevated 45 degrees.  However, he likely has an expanding cervical hematoma from the stab wound and it is slowly pushing his trachea to the contralateral side.  
   2. You will need to assess his ability to open his mouth, Mallampati score, and neck range of motion.   You will also need to check his tracheal deviation and determine if it slowly expanding over time and does it coincide with his worsening of symptoms.
   3. Effective and professional communicating with your anesthesia colleagues is key as you determine if he can be sedated and paralyzed for oral intubation or if he should be fiberoptically intubated.  You will need to understand what type of intubation techniques your colleague can and cannot do.
   4. No matter what you decide to do, you should always be ready to do an urgent surgical airway whether it be a cricothyrotomy or a “slash” tracheostomy
2. 24 year old male is brought to the emergency room following a high-velocity round to his right face.  First responders immediately treated him at the scene and documented an initial GCS of 15.  He had some gurgling from his mouth/nose, became mildly confused, and was orally intubated for airway protection.  His right facial defect was packed with 2 rolls of Kerlix by EMT and estimated blood loss was 500 ml.  In the trauma bay his pertinent vitals are: HR 120, BP 90/60.  GCS is now 3T but enroute his sedation wore off and he was able to start pulling at his oral endotracheal tube until his sedation was redosed.  What are your next steps?
   1. As with any trauma you must proceed down the ATLS algorithm.  He indeed has a grotesque injury that you want to treat immediately but you must follow the A, B, Cs of the primary survey.  

A = airway – he is orally intubated and it is secure, thus his airway is protected
B = breathing – because he is orally intubated, he is currently being manually ventilated.  If it hasn’t been arranged, the team leader should call for a mechanical ventilator
C = circulation – he is tachycardic and hypotensive.  Given his 500 cc of blood loss and his right sided facial wound, he has lost significant amount of blood.  He will likely need at least 2 units of packed red blood cells along with appropriate (and warm) IV fluids.  But you need to make sure he has good vascular access – ideally 2 large bore IVs.  The Kerlix dressing is likely tamponading the bleeding for now.  Thus, it is recommended to take this dressing down in the operating room where you can surgically address the potential bleeding.  If he has significant bleeding (i.e. exsanguating from his wound), the algorithm may change where it is X,A,B,C, etc where X = stop the massive bleeding with tourniquets, direct pressure, etc. 
D = disability – he needs a brief neuro exam.  Because of his sedation, you cannot properly assess his GCS.  Examine his pupils for symmetry, size and reaction and look for any signs and symptoms of spinal cord injury.  You also cannot clinically clear his cervical spine based on the NEXUS criteria and he needs to be in a cervical collar – his C-spine status is important to remember when you take him to the operating room.
E = Exposure/environmental control – fully remove all clothing (1) to remove any fluids, contaminants, chemicals that could lead to adverse events and (2) to allow an adequate total body exam.  At the same time, you will need to make sure the patient avoids hypothermic conditions with warm and dry blankets and warmed IV fluids/blood products.

1. Secondary survey:

-you will need to obtain the pertinent history (AMPLE – Allergies, Medications currently used, Past illnesses/Pregnancy, Last meal, Events/environment related to the injury) and mechanisms/types of trauma inflicted on the patient.
-you should also do a complete head to toe exam of the patient to determine if there any other injuries or conditions that could worsen the patient’s mortality and morbidity and to ascertain there are no missed injuries.
-order any tests that are appropriate based on your secondary survey