Trauma Airway Management

ATLS Guidelines for a definitive airway:

• Need to ventilate / oxygenate: Apnea, respiratory failure, Massive blood loss, severe head injury (GCS < /= 8)

• Protect the airway: Severe Maxillofacial fractures, risk for obstruction / aspiration, unconsiousness

• RSI followed by direct laryngoscopy (DL) is the most commonly used method for securing the airway in trauma patients

Key Steps:

• Difficult Airway Algorithm

• Preoxygenation, RSI, CP, manual in-line cervical stabilization

• Confirm with end-tidal CO2, CXR, direct visualization, or physical exam (lung sounds with absent gastric sounds, fogging in tube, adequate pulse ox)

• Intubation Equipment List

RSI: Anesthetic Agents / NMBDs

• Induction Agents: 

  1. Propofol (hypotension risk)

  2. Etomidate (less hemodynamic changes, but potential adrenal supprssion)

  3. Ketamine (tachycardia, hypertension risk but can be useful in a trauma setting, to include head injury)

• Paralytics: 

  1. Succinylcholine (depolarizing); most reliable, fast onset;

     • Dose: at least 0.6 mg/kg; 1-1.5 mg/kg used (faster onset, longer paralysis)

     • CI with electrical burns, 48 hrs following acute burns (thermal/ chemical) or paralysis

     • Relative CI with suspected severe hyperkalemia (rhabdo, renal failure)

     • No CI for head injury or increased ICP

  2. Rocurionium (non depolarizing)

     • Dose: 0.9 to 1.2 mg/kg

     • Reversal: Sugammadex (16 mg/kg)

Oxygenation and Cricoid Pressure

• Preoxygenate with face mask or BVM in trauma when possible, especially in patients with TBI (oxygenation outweighs risks of aspiration)

• Use small ventilations to decrease risk of gastric insufflation

• CP is often used for RSI; remove if it impedes intubation, BVM ventilation, or insertion of a supraglottic airway

Cervical Spine Immobilization

• Awake intubation is best but can rarely be performed in trauma patients d/t other issues

• MILS is needed during intubation as C-collars do not reliably immobilize the neck

• Remove anterior portion of collar

Airway Assistance

• Video Laryngoscopy (VL): blood / body fluids can obstruct view, limited mouth opening is a potential constraint

• Bougie: Coude tip catheter for airway exchange, rigidity can cause injury

• Aintree Cath: hollow introducer which allows for ventilation during exchange

• Supraglottic Airway: 

• LMA/LTA Exchange Options

  1. Remove LMA then insert ETT via DL

     • use if airway does not appear difficult

  2. Remove LMA then insert ETT via VL

     • body fluids can obstruct VL view

  3. LMA as conduit for intubation or airway exchange

     • Depends on LMA type and ETT tube size

     • Bougie can facilitate exchange for a difficult airway

• Flexible Bronchoscopy: 

  2. • Awake - limited to cooperative patients

     • Can achieve visualization and diagnose airway injury

     • Limited by blood / secretions during visualization

The Surgical Airway

• Cricothyroidectomy - open technique is the fastest method for obtaining a surgical airway by surgically inexperienced individuals

• Tracheostomy - best in a controlled setting, may have fewer long-term complications

Penetrating Neck Injury

• No agreed upon method, advise against blind intubation methods (nasotracheal)

• Awake fiberoptic bronchoscopy should be considered in cooperative patients

• RSI fiberoptic bronchoscopy can be used in  uncooperative patients to assess for injury / blood below the cords (however blood / body fluids can affect view)

• Awake orotracheal intubation via DL is the fastest approach in cases of apnea or massive upper airway bleeding

• Surgical airway set up should be on standby and used if above methods fail

• Intubation can occur through an open wound in the skin directly communicating with the airway