Airway Injuries in the Professional Ice Hockey Player

Sports-related injuries can be severe, resulting in death or significant disability.1 Blunt upper airway injuries in the athlete are rare;2,3 however, when they occur, they can be associated with high mortality.4 Airway injuries in ice hockey players are even more uncommon. The National Hockey League (NHL) Sports Injury Monitoring System registry, a database of all injuries occurring in the NHL, reports no airway injuries other than the three presented in this article over the last 10 years. When encountered, these injuries require prompt recognition, appropriate care, and transport to a definitive care facility to prevent catastrophe. Injuries to the upper airway in hockey players can occur secondary to receiving a direct blow to the neck from a puck, stick, skate, elbow, punch, or goalpost. There are currently no reports of upper airway injuries in ice hockey players in the literature; however, we have seen several of these injuries over the years in both professional and amateur athletes. Catastrophic injuries in hockey players have been described in the literature. These injuries are secondary to players being struck from behind or falling and hitting the crown of their head on the boards.5 Here we report 3 cases of airway injuries in professional ice hockey players in the NHL to give an overview of the spectrum of injuries and their management. We then outline an approach to the required preparedness for airway trauma in hockey players, the diagnosis of these injuries, the on-scene and prehospital management of these patients, and the anticipated complications. This article is designed to aid not only physicians and trainers treating professional ice hockey players, but also those treating semi- and nonprofessional ice hockey players as well as those treating athletes with the potential for blunt upper airway injury in any other sport. Given the possibility that the players could be identified by the nature of the public profile of these injuries, the players in all 3 cases gave their written consent to have their cases published. CASE REPORTS Case 1: Mild Injury A 30-year-old defenseman was hit in the right anterior neck with an elbow during an NHL game. He had a previous history of laryngeal trauma with a resulting paralyzed right vocal cord, which was treated with placement of a silastic implant. Following the injury, the player was examined in the treatment room at the arena. He had mild local edema and tenderness to the laryngeal area. No stridor was present; however, the player noted that his voice was different than prior to this hit. The next morning he was seen in the voice laboratory, where he underwent videolaryngoscopy. On examination, he had soft tissue ecchymosis to the right hemilarynx. There was no evidence of significant stenosis to the upper airway; however, his voice remained hoarse. He went back to playing professional hockey after 2 weeks with no sequelae from his injury. The current plan is for surgical correction of his laryngeal anatomic defects (medialization of his right true vocal cord) following his career. Surgical correction is delayed to avoid the risk of airway compromise and dyspnea on exertion that can occur following surgery. Case 2: Moderate Injury A 32-year-old left winger received a puck to the neck during the second period of an NHL game. Immediately postinjury, he fell to the ice; however, was able to get up and skate to the bench. Upon standing, he immediately clutched his throat with both hands (Fig. 1). In the treatment room, he had a diffusely swollen and tender neck as well as a raised ecchymotic area over the central larynx. His voice was clearly hoarse. There was no stridor or tracheal deviation. The patient was transported to the hospital, where he immediately underwent intravenous contrast enhanced computed tomography (CT-angiogram) of the neck. CT showed a comminuted fracture of the thyroid cartilage (Fig. 2) with soft tissue swelling and air outside the airway lumen. The cricoid cartilage was normal. There was also airway compromise due to submucosal edema. The patient was directly transported to the intensive care unit.FIGURE 1: Player grasping neck immediately postinjury.FIGURE 2: CT scan of the Neck. A, Fracture of thyroid cartilage.Clinical deterioration occurred en route to and in the intensive care unit. The patient was maintaining a patent airway; however, there was increasing hoarseness and stridor. It was therefore decided to perform an urgent endotracheal intubation for airway protection. In preparation for intubation (in a patient with impending airway obstruction), a multidisciplinary team was quickly mobilized to assure successful, seamless, definitive airway placement. An anesthesiologist, thoracic surgeon, ENT surgeon, and respiratory therapist were all present at the bedside. A fiberoptic bronchoscope, difficult airway kit, and ventilator were set up in the patient's room, as well as a tracheostomy/cricothyrotomy kit (with scalpel blades mounted). The patient was intubated by the anesthesiologist using a rapid sequence intubation protocol (propofol for sedation and succinylcholine for neuromuscular blockade) in an uneventful manner. The next morning, operative exploration of the fracture was undertaken. The laryngeal fracture was minimally displaced (Fig. 3) and was able to be reduced without internal fixation and plating. A tracheal stent was inserted, and a tracheostomy was performed. Postoperatively, the patient did very well. The tracheostomy was downsized gradually and was removed on postoperative day 6. The patient left the hospital on postoperative day 8. The patient was back skating within 1 month of injury, was able to return to full intensity activity, and resumed his NHL career.FIGURE 3: Thyroid cartilage fracture (operative photo). A, Linear fracture through thyroid cartilage. B, Perichondrium incised and retracted.Case 3: Severe Injury A 28-year-old professional hockey player was struck with a puck over the larynx during an NHL game while attempting to block a slapshot. Immediately after injury, he fell to the ice and was helped up by teammates. He was escorted to the bench while clutching his throat and collapsed as he stepped off the ice. The patient had severe airway compromise and was transported emergently to hospital using a manual jaw thrust in the ambulance to maintain a patent airway. On physical examination, he had massive subcutaneous emphysema over the neck and chest as well as profuse hemoptysis. The patient was transported directly from the ambulance to an alerted operating room, where he was intubated by the anesthesiologist on the operating table. Exploration of the neck was undertaken, and there was an obvious deformity of the larynx and cricoid cartilage. A tracheostomy was performed to secure a definitive airway. In the intensive care unit, a right-sided pneumothorax was identified on chest x-ray, and a tube thoracostomy was performed. The next morning, a CT scan of the neck was performed, which revealed fractures of both the thyroid and the cricoid cartilages (Fig. 4). The following day, the patient was taken to the operating room for open reduction internal fixation of both thyroid and cricoid cartilages as well as placement of a tracheal stent. The patient was discharged home on posttrauma day 11 with the tracheostomy in place. The tracheostomy was removed 8 weeks after injury, and the patient started skating 16 weeks later. Due to shortness of breath on exertion as a result of subglottic narrowing at the cricoid level, the patient was not able to return to playing hockey at the professional level.FIGURE 4: CT scan of the neck. A, Subcutaneous emphysema. B, Fracture of cricoid cartilage. C, Mucosal flap narrowing airway lumen.Blunt Upper Airway Injuries Blunt upper airway injuries secondary to direct blows to the neck most commonly injure the cartilages of the larynx.6 This can cause airway compromise or difficulties in ventilation secondary to impingement of fractured cartilage segments in the airway lumen, cartilage dislocation, laceration, or avulsion of any part of the laryngo-tracheal complex. Luminal compromise can also occur secondary to blood, edema, and air accumulation in the supraglottic and subglottic submucosa.7 Subcutaneous emphysema can also cause airway compromise secondary to epiglottic emphysema and narrowing of the supraglottic airway. Foreign body obstruction of the airway can also occur in hockey. Foreign bodies of concern in ice hockey players include teeth, mouthguards, and chewing gum. There are many injuries that have been shown to be associated with blunt airway trauma in the civilian population. These include injuries to the cervical spine, esophagus, major vascular structures in the neck (carotid arteries and jugular veins), and nerves. Cervical spine injuries can be associated with upper airway trauma, and it is crucial to rule out cervical spine injuries in the hockey player with a suspected upper airway injury. MANAGEMENT OF HOCKEY-RELATED AIRWAY INJURIES Preparedness National Hockey League teams are required to have a physician present at all games. These physicians are encouraged to have training and certification in airway techniques by a professional organization such as the Advanced Trauma Life Support (ATLS)8 course for physicians run by the American College of Surgeons. ATLS teaches basic trauma principles and allows physicians to feel comfortable with the acute management of injured patients. It is a valuable course for any physician caring for an athletic team. Team physicians and trainers who do not care for trauma patients on a regular basis should practice on-ice and off-ice assessments of injured patient, as well as the transport of these patients from the ice surface to the treatment room or ambulance. Transport training must include cervical spine immobilization precautions should this be necessary during a game or practice session. The use of players to assist with transport has been invaluable. Due to the fact that they are on skates, they can transport injured players to the treatment room more quickly and with more stability than trainers and physicians wearing shoes. Proximity of the emergency clinic to the ice surface is an important feature in facility design. Each arena must have an ambulance and emergency medical technician or paramedic dedicated to the transfer of the injured player to the hospital. Proper equipment is crucial in terms of managing the acute airway during a sporting event. Equipment should be simple, organized, and portable. An example of the airway kit we use is shown in Figure 5, and a list of important components is outlined in Table 1. Aside from the equipment described in Table 1, supplemental oxygen, a Bag-Valve-Mask device, and an adequate suction device (Fig. 6) are crucial to managing airway injuries and should be present on scene.FIGURE 5: Portable emergency airway kit. Table 1 describes contents of kit.FIGURE 6: Airway injury equipment. Equipment includes airway kit, supplemental oxygen, suction device, and bag-valve-mask device.TABLE 1: Airway Management KitDiagnosis Clinical presentation of airway injury in hockey has a wide spectrum. The player may present with acute, ominous complete, or near-complete airway obstruction with asphyxiation or with no signs or symptoms. Players may also complain of neck tightness, air hunger, high-pitched or low-pitched voice, hoarseness, pain, tenderness, or dysphagia. Immediately postinjury, patients with airway trauma typically grab their neck with both hands (Fig. 1). This is the universal sign of choking. Physical findings may include neck swelling, hematoma, tenderness, subcutaneous emphysema, hoarseness, stridor, shortness of breath, respiratory distress, hemoptysis, visible hypoxemia (blueish mucous membranes and skin), syncope, and cardiopulmonary arrest.9,10 However, most patients will have no detectable physical signs of injury.7 On-Scene Initial Assessment and Management The initial on-ice management for players with suspected airway injuries should follow ATLS principles. If the mechanism requires cervical spine immobilization, this should be carried out using a rigid cervical collar. However, in most circumstances, these injuries will occur through a direct anterior blow to the cervical airway by a puck, stick, or punch, and cervical spine immobilization is unnecessary. Patients with significant luminal compromise will usually prefer to be in the upright, or sniffing, position in an attempt to maintain patency of their own airway. These patients should not be encouraged or instructed to lie flat on their backs as this may worsen luminal obstruction. In the rare case where cervical spine injury is suspected and the patient has a significant airway injury and cannot breathe, the airway injury should take precedence over the cervical spine. However, in most circumstances, both cervical spine protection and airway patency can be addressed and maintained simultaneously. Patients having had a significant mechanism of injury who appear to have insignificant injuries as assessed by lack of symptoms or mild symptoms should still be transported to the hospital to undergo radiologic evaluation of the airway. As mentioned, most patients with airway injury will not have any specific signs or symptoms of injury. A missed injury involving the airway can lead to catastrophic results, and we therefore recommend a vigorous approach to ruling out as opposed to ruling in an injury to the airway. Luminal obstruction from submucosal edema and hematoma can be delayed, and therefore, all patients should be evaluated in the hospital. Most patients with airway injury can be urgently transported to the hospital without on-scene endotracheal intubation. A chin lift or jaw thrust can often be used to maintain the airway patent in a player with airway compromise during transport to the hospital. The chin-lift maneuver (Fig. 7) consists of placing 2 fingers of 1 hand under the patient's chin and the other hand on the patient's head, and hyperextending the neck. This maneuver is contraindicated in patients with suspicion of cervical spine injury. A jaw thrust (Fig. 8) consists of the physician kneeling behind the head of the patient, placing the first 2 fingers behind the angle of the mandible on both sides of the jaw, and lifting the mandible upward. The head need not be tilted backward. This technique can be used safely while employing cervical spine precautions in an injured athlete with a possible cervical spine injury. Both maneuvers elevate the hyoid bone and maintain the airway patent by pulling the muscles away from the airway lumen. They also play a role in reducing airway fractures.FIGURE 7: Head-tilt, chin-lift maneuver.FIGURE 8: Modified jaw-thrust maneuver.No sedation or narcotics should be administered to the nonintubated patient with potential airway compromise in the prehospital setting. Sedation should be deferred until the patient is in an appropriate setting where definitive airway control can be achieved. Patients with airway injury require a definitive airway until their injury can be worked up in an appropriate setting. ATLS defines a definitive airway as “a tube in the trachea with the cuff inflated.”8 Endotracheal intubation is usually possible in patients with airway injury; however, it is not straightforward and should be performed by the most experienced person in airway management available. Neuromuscular blockade should never be used in patients with airway injury (in an uncontrolled setting), as a catastrophic event would be a patient who could not be intubated following paralytic administration and could no longer be ventilated due to relaxation of airway muscle tone. This situation would necessitate an urgent surgical airway. For patients who require a surgical airway, various techniques can be employed. The choice of technique should be based not only on the specific patient, but also on the physician's familiarity with the technique and comfort level. A basic surgical airway kit is outlined in Figure 9. This kit consists of a cuffed tracheostomy tube, a tracheal spreader, a curved hemostat, Metzenbaum scissors, and a mounted scalpel. This kit can be used to perform an open emergency cricothyrotomy. Other important airway techniques include the use of commercially available percutaneous cricothyrotomy kits (Melker Cricothyrotomy Catheter Kit, Cook Medical Canada), needle jet insufflation, retrograde intubation, bronchoscopy guided orotracheal and nasotracheal intubation, light-wand intubation, and blind bougie intubation.11-15 The Melker Cricothyrotomy Kit (Fig. 10) is easy to learn and use and is probably the best available kit for use by physicians inexperienced with cricothyrotomy/tracheostomy in an emergency setting. However, one must always be suspicious of a cricoid cartilage fracture, which would necessitate a surgical tracheostomy, as opposed to a cricothyrotomy (injury occurring below cricothyroid membrane-site of cricothyrotomy; see case 3).FIGURE 9: Emergency surgical airway kit.FIGURE 10: Melker Percutaneous Cricothyrotomy (Cook Canada) management algorithm.We have found the straightforward jaw thrust to be the simplest, most user-friendly, and most effective method of airway maintenance in the prehospital setting. In a patient who is moving air reasonably well, the ideal treatment strategy is not to attempt definitive airway techniques at the rink but rather to transport players as quickly as possible to a definitive care center for controlled intubation by experienced personnel. An algorithm for the management of airway injuries in ice hockey players is presented in Figure 11.FIGURE 11: Management algorithm.Transport to Definitive Care Center The decision to transport an injured athlete to the hospital or to let the player continue playing is a difficult one.16 When dealing with potential airway injuries, it is important to have a high index of suspicion, and the onus is on the physician to rule out an injury rather than to rule one in. We therefore believe that it is prudent to transport all players with potential airway injury to the hospital as soon as possible for diagnostic evaluation. It is much preferred to send a patient home from the hospital after an elective negative workup for airway injury than to deal with delayed airway compromise secondary to submucosal edema or hematoma in what may transpire as an urgent and possibly deadly situation. Transport of patients with airway injury should ideally be by ambulance with a physician skilled in airway management present. Patients should not be transported to the nearest hospital unless they have significant hemodynamic or respiratory compromise. Patients should be transported directly to a tertiary care center for evaluation and appropriate management. Direct transport of injured patients to tertiary centers has been repeatedly shown in the literature to improve outcomes in severely injured patient populations.17-19 Definitive Care Definitive care of blunt airway injuries is a large topic and is beyond the scope of this article. Following initial stabilization of airway injuries with a cuffed tube in the trachea, patients should be managed by physicians and surgeons who are familiar with the management of these injuries. All patients should be observed in an intensive care unit setting until airway luminal narrowing is ruled out. Definitive care requires a multidisciplinary team approach and may include any or all of the following specialists: trauma surgeons, thoracic surgeons, anesthesiologists, otolaryngologists, intensive care physicians, respiratory and Injuries and Injuries that have been shown to be associated with blunt tracheal injury include injury, major vascular injury, injury, laryngeal injury, thyroid injury, fracture, injury, and Severe blunt airway injury can result in injury or death secondary to In patients injury to the airway, include hoarseness, tracheal vocal and vocal or In the of severe airway injury with of or associated injuries, return to such as professional hockey is Injuries to the airway are rare in however, when they do occur, they require a prompt and appropriate diagnostic and treatment All potential injuries should be evaluated and treated in an appropriate center by experienced in difficult airway A high index of suspicion is necessary to prevent in an area of the body that for We would to and for their with the and for this article. 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