Open wound of larynx and trachea
ICD-10 S11.0 is a billable code used to indicate a diagnosis of open wound of larynx and trachea.
An open wound of the larynx and trachea refers to a traumatic injury that disrupts the integrity of the laryngeal and tracheal structures, often resulting from penetrating trauma, such as stab wounds, gunshot wounds, or blunt force trauma that causes laceration. These injuries can lead to significant airway compromise, bleeding, and potential aspiration of foreign materials. Clinical presentation may include stridor, dyspnea, hemoptysis, and subcutaneous emphysema. Immediate assessment is crucial, often involving imaging studies such as CT scans to evaluate the extent of the injury and any associated damage to surrounding structures. Management typically requires surgical intervention to repair the wound, secure the airway, and prevent complications such as infection or airway obstruction. The prognosis depends on the severity of the injury and the timeliness of intervention.
Documentation must include a detailed account of the injury mechanism, initial assessment findings, and any immediate interventions performed.
Trauma cases involving stabbings or gunshot wounds to the neck, presenting with respiratory distress.
Ensure that airway management techniques used in the emergency setting are documented, as they may influence coding.
Operative reports must detail the surgical approach, techniques used for repair, and any complications encountered during the procedure.
Surgical repair of laryngeal or tracheal lacerations following trauma.
Document any additional procedures performed, such as tracheostomy or airway stabilization.
Used in cases of airway compromise due to open wounds.
Document the indication for intubation and any complications.
Emergency medicine providers must ensure clear documentation of the airway management process.
Performed when there is severe airway obstruction.
Operative report must detail the procedure and any complications.
Surgical documentation should include the reason for the tracheostomy and any follow-up care.
S11.0 is used for open wounds of the larynx and trachea, while S11.1 is for closed wounds. Accurate documentation of the injury type is essential for correct coding.
