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TraumaAirwayManagement
CherylLynnHorton,MDCalvinA.BrownIII,MDAliS.Raja,MD,MBA,MPH
JEmergMed.201446(6):814820.

Abstract
Background.Airwaymanagementinatraumapatientcanbeparticularlychallengingwhenbothadifficultairwayandtheneed
forrapidactioncollide.Theprovidermustevaluatethetraumapatientforairwaydifficulty,developanairwaymanagementplan,
andbewillingtoactquicklywithincompleteinformation.
Discussion.Thoroughknowledgeofairwaymanagementalgorithmswillassisttheemergencyphysicianinprovidingoptimal
careandofferarapidandeffectivetreatmentplan.
Conclusions.Usingacasebasedapproach,thisarticlereviewsinitialtraumaairwaymanagementstrategiesalongwiththe
rationaleforevidencebasedtreatments.

CaseReport
A34yearoldmanpresentedtotheemergencydepartment(ED)ofaLevelItraumacenterviaemergencymedicalservices
(EMS)afteramotorvehiclecollision.Hewastheunrestraineddriverinahighspeedsinglecaraccidentwithsignificantfrontend
damageandaprolongedextricationperiod.Witnessesreportedthathewasswervingforapproximatelyhalfamilebeforehe
eventuallyranoffoftheroadandstruckatree.UponEMSarrival,theynotedthathewasconfusedandexhibitedrepetitive
speech.Prehospitalvitalsrevealedabloodpressureof110/89mmHg,apulseof112beats/min(bpm),arespiratoryrateof18
breaths/min,andanoxygensaturationof97%onroomair.Hehadsustainedobvioushead,face,andchestinjuries.Hewas
placedinacervicalcollar,extricated,andbroughttotheEDonabackboard.
ImmediatelyuponarrivaltotheED,hisprimarysurveywasnotableforincoherentspeechandahoarsevoice.Hehaddecreased
breathsoundsontheright,2+symmetricpulsesthroughout,andvisiblerightchestwallecchymosis.HisinitialEDvitalssigns
revealedabloodpressureof95/70mmHg,apulseof115bpm,atemperatureof37.2C,andanoxygensaturationof96%on
roomair.HisGlasgowComaScale(GCS)scorewas11,ashewasonlyopeninghiseyestovocalcommandsandspeaking
incoherently,yetwasmovingallofhisextremitiesinresponsetopainfulstimuli.Anextendedfocusedabdominalsonographyfor
trauma(EFAST)examinationwasonlypositiveforfreefluidinMorrison'spouchanddemonstratednormallungsliding
bilaterally.Twolargeboreperipherallineswereestablishedandacardiacmonitorwasapplied.
Hissecondarysurveywasnotableforalarge15cmlacerationextendingfromhisforeheadtohisoccipitalscalp,withactive
bleedingandamoderateamountofbloodonthebackboard.Hispupilswereequalandreactive.Uponremovalofthecervical
collar,hewasnotedtohaveecchymosiswithmildedemaofhisanteriorneck,aswellassubcutaneousemphysemathat
extendeddowntohisnipplelineontheright.Histracheawasmidlinebutseemedtendertopalpation.Nostridorwasaudible,
buthehaddecreasedbreathsoundsontherightandwastenderonhisrightchestwallandinhisrightupperabdominal
quadrant.Theremainderofhisexaminationwasunremarkableandhecontinuedtobeabletomoveallfourextremitiesin
responsetopain.Hisvitalsignswererecheckedandfoundtobeunchanged.
Aportablechestxraystudywasnotableforanopacityintherightmiddlelobe,concerningforapulmonarycontusionbutdidnot
showapneumothoraxorpleuraleffusion.Hispelvisxraystudywasnormal.Givenhisinjuries,theemergencyphysicianand
traumasurgeondecidedthatheshouldhavehisairwayprotectedbeforegoingtocomputedtomography(CT)forevaluationof
hissuspectedneurologic,thoracic,andintraabdominalinjuries.

Discussion
InitialEvaluationandIntervention

Airwaymanagementinthetraumapatientcanbechallengingand,forsomepatients,theneedtoacturgentlyanddecisivelycan
bethedifferencebetweensurvivalanddeath.Tenuoushemodynamics,cervicalimmobility,anddirectairwaytraumaoften
complicatedecisionmaking.Typicalintubationmethodscanbedifficultorimpossibleinpatientswithrapidoropharyngeal
hemorrhage,reducedoralaccess,orlaryngotrachealinjuries.
Althoughsomedecisionsarespecifictotraumaintubations,soundairwaymanagementprinciplesthatarecommontoall
intubationsstillconstituteafoundationforsuccess.Decidingtointubateisthefirststep.Althoughthisisintuitiveformany
patients,theneedforintubationmightnotbeinitiallyobviousinsomepatients.Therearethreemainindicationsforemergency
intubationthatcanbeuncoveredbyaskingthefollowingquestions:1)Isthereafailuretomaintainorprotecttheairway?2)Is
thereafailureofoxygenationorventilation?or3)Isthereaneedforintubationbasedontheanticipatedclinicalcourse?.
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thereafailureofoxygenationorventilation?or3)Isthereaneedforintubationbasedontheanticipatedclinicalcourse?. [1]
Afailuretomaintainone'sairwayisnotalwaysclinicallyobvious.Oneapproachistocalculatethepatient'sGCSscore.AGCS
score8intheabsenceofareversiblecauseisaclinicalcomaandthesepatientsgenerallyrequireintubation. [24]Most
patientswithaGCSscore12willhavesustainedsignificantbraininjuryandoftenwillalsorequireintubation.Theinabilityto
protectone'sairwaycanbesubtle,butintraumapatientsthisusuallyoccursinthesettingofdepressedmentalstatuscausedby
headtrauma,hypovolemicshock,oringestionofdrugsoralcohol.Clinicianscantestforairwayprotectionbyevaluating
phonationandapatient'sabilitytoswallowandhandlesecretions.Thegagreflexshouldneverbeassessedinacriticallyinjured,
immobilizedtraumapatient,asdoingsocanprovokevomitingandworsenthesituation.Inaddition,thisreflexisweakinupto
25%ofthenormaladultpopulationanditsabsencedoesnotnecessarilyindicatetheneedforintubation. [2]Failureto
appropriatelyoxygenateandventilatecanbeassessedclinicallybyevaluatingapatient'srespiratoryeffort,oxygensaturation,
andoverallsenseofthepatient'sinjuries.Theanticipatedclinicalcoursehelpstoguidethedecisiontointubateinpatientswho
donothaveanimmediateproblemwithairwayprotection,ventilatoryeffort,oroxygenation.Itisbettertoerronthesideof
intubatingearlyandsecuringapotentiallythreatenedairwaythanobservingthepatientwithafalsesenseofsecurityoriginating
frommomentarilyadequateoxygenationandventilation.Inaddition,thepatient'strajectorymayincludeinevitableintubation,
andtheopportunitytointubateearlyallowsamorecontrolledandplannedapproach.Forexample,ablunttraumapatientwith
anopenfemurfracture,intractablepain,andagitationmayhaveanindicationforintubationinordertohumanelyandsafely
performathoroughtraumaandradiologicevaluation,evenintheabsenceofoxygenationdifficultiesordirectairwaytrauma.
Supplementaloxygenationshouldbestartedimmediatelyforanyhypoxictraumapatient,especiallythosewithsuspectedbrain
injury. [5]Nasalcannulaoxygenationmaysufficeforthosewithamildoxygendebtbut,generally,facemaskoxygenationwitha
reservoirat15L/minflowisused.Ifintubationisplanned,preoxygenationshouldbestartedbyhavingthepatienttakefulltidal
volumebreathsofhighconcentrationoxygenfor23minutes. [6]Forpatientspredictedtodesaturaterapidly,nasalcannula
oxygenshouldbeleftinplaceduringtheapneicphaseofintubation,asthiscansignificantlyprolongtheperiodofsafeapnea.
[7,8]

IntubationoftheTraumaPatient

Oncethedecisiontointubateatraumapatienthasbeenmade,choosingthebestmethodisparamountandbasedonthe
predictedtimeline,clinicalscenario,andavailableequipment.Forallpatients,adifficultairway(DA)assessmentisnecessary
beforerapidsequenceintubation(RSI)withneuromuscularblockade.ThereareanumberofDAassessmentmnemonicsthatare
easytorememberandcanbeappliedquicklytomostpatientsatthebedside. [1]Theyevaluateforpotentialdifficultywithdirect
laryngoscopy,rescuebagandmaskventilation,useofanextraglotticdevice,andperformanceofasurgicalairway.Theacronym
LEMON(Figure1)assessesfordifficultywithdirectlaryngoscopyandhasbeenvalidatedinoneEDstudy(Figure2)ismadeup
ofawellvalidatedsetofpatientcharacteristicsknowntoresultindifficultmaskventilation.Theseshouldberecognizedearly,as
meticulousbaggingtechniquewillbenecessarytoeffectivelyventilatepatientswithredflagsontheirMOANSevaluation. [1,10]

Figure1.

LEMONfordifficultdirectlaryngoscopyassessment.

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Figure2.

MOANSfordifficultmaskventilationassessment.
Forpatientswithoutobviousdifficultairwayattributes,RSIisgenerallybelievedtobethesafestandmostreliablewayto
intubateapatient.Withcompletesedationandparalysis,RSIalsoprovidesthegreatestchanceforasuccessfulintubation. [11]
Whenadifficultintubationisanticipated,analgorithmicapproachshouldbeusedandisdictatedbyapatient'shemodynamic
stabilityandtheurgencyoftheintubation(Figure3).Firstandforemost,ifadifficulttraumaairwayisanticipatedandtimeallows
forit,theemergencyphysicianshouldstronglyconsidercallinganesthesiaorsurgicalcolleaguestothebedside,especiallyif
advancedfiberoptictechniquesorcricothyrotomywillpotentiallyberequired.Insomeurgentscenarios,patientscanevenbe
movedtotheoperatingroom(OR)forintubation,whereinductionwithaninhalationalanestheticcanbeused.

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Figure3.

Thedifficultairwayalgorithm.BNTI=blindnasotrachealintubationBVM=bagvalvemaskEGD=extraglotticdeviceILMA=
intubatinglaryngealmaskairwayPIM=postintubationmanagementRSI=rapidsequenceintubation.(FromWallsR,Murphy
M.Manualofemergencyairwaymanagement.4thed.LippincottWilliams&Wilkins2012.Reprintedwithpermission.)
Next,theemergencyphysicianshouldassessthepatient'srateofairwayorclinicaldeterioration.Iftheneedforintubationis
immediateandafullairwayassessmentortheluxuryofextrastaff,equipment,andmanagementplanningarenotpossible,then
theprovideris"forcedtoact."Inthissituation,one"bestattempt"bythemostexperiencedoperator,withthebestdevice,using
RSI,isappropriateknowingthatthereisimmediaterecoursetoasurgicalairwayshouldthatoneattemptfail. [1]
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Fordifficultintubationsinwhichthereistimetoplan,butthenatureoftheairwaycomplexitiesmakechancesofsuccessful
laryngoscopyorrescueventilationunlikely,thenan"awake"intubationattemptoranawakeevaluationoftheairwayshouldbe
performed.Anawakeintubationinvolvesadministrationoftopicalanesthesia,possiblyaugmentedbyjudicioususeofasedative
agenttopermitanawakeevaluationoftheairwaywitheitheraconventionallaryngoscope,videolaryngoscope,orflexible
fiberopticbronchoscope.Apatientmustbecooperativeandabletotoleratethisexaminationforittobesuccessful.Awake
laryngoscopyallowstheoperatorstodooneofthreethings:1)intubatethepatient,2)visualizethecordsanddeterminethat
intubationispossibleandthepatientcanbeintubatedwithRSI,or3)determinethatoralintubationisimpossibleandan
alternativeapproachisnecessary.
Allpatientswhohavebeensubjectedtosignificantblunttraumashouldbeassumedtohaveacervicalspineinjuryuntilithas
beenexcluded.Motorvehiclecollisionsarethegreatestcauseofspinalinjury,accountingforapproximately50%,followedby
falls,athleticinjury,andinterpersonalviolence. [12]Patientswithsuspectedorprovencervicalspineinjuryshouldbeintubated
withthehelpofasecondproviderperforminginlinecervicalspinestabilization.AlthoughthereisnocredibleevidencethatRSI
anddirectlaryngoscopyresultinclinicallysignificantcervicalspinemovement,somedevicesarethoughttobebetterforpatients
athighriskforcervicalspineinjury. [1315]Opticallyandvideoenhanceddeviceswithcurvedarchitecture,suchastheAirtraqand
GlideScopevideolaryngoscopes,haveproventobesuccessfulintraumapatientsandmayreducecervicalspinemovement
comparedwithdirectlaryngoscopy. [16,17]Forconventionallaryngoscopy,theanteriorportionofthecollarshouldbeopenedwhile
anassistantholdsthecervicalspine.Ifthecervicalcollarisleftfullyengaged,theremaybelimitationstomouthopeningthat
canmakeintubationmoredifficult,andthereisnoevidencethatthisreducescervicalspinemovement. [14,18,19]
Medicationchoiceandthetimingofadministrationisanimportantaspectofasuccessfulintubation.Althoughpretreatment
medicationshaveneverbeenproventoresultinimprovedoutcomes,therearetheoreticalandcommonsensereasonswhythese
agents,inselectedpatientswithoutcontraindications,wouldbebeneficial.Forheadinjuredpatients,lidocaine(1.5mg/kg)and
fentanyl(23mg/kg)administered35minbeforetheinductionagent,canbeusedinanattempttominimizetherisein
intracranialpressure(ICP)thataccompanieslaryngealmanipulation.Themechanismbywhichlidocaineworksispoorly
understoodbutitisthoughttoattenuateadirect,neurallymediatedreflexafterlaryngoscopy,whilefentanylhasbeenshown,in
adosedependentfashion,tobluntthereflexsympatheticresponsetolaryngoscopy,furtherattenuatingspikesinheartrateand
bloodpressurethatcanbeseenwithlaryngealmanipulation. [1,20]
Etomidateandketaminearethemostcommonlyusedinductionagentsfortraumapatientsrequiringintubation.Etomidate(0.3
mg/kg)hasbeneficialhemodynamicstabilityduringRSIandcausesvirtuallynochangeinmeanarterialbloodpressureinnormal
andhypovolemicpatients. [21]Inpatientswithfrankshock,however,thedoseshouldbereducedto0.15mg/kgandinmorbidly
obesepatients,dosingshouldbebasedonleanbodyweight,aslargedoses(twotothreetimestheinductiondose)cancause
hypotension. [22]EtomidateappearstohavesomecerebralprotectiveeffectandcansignificantlylowerICPwithoutadverse
effectsonperfusionpressure. [23]Studiesshowthatthereistransientadrenalsuppressionafterasingledoseofetomidate,
althoughthesignificanceofthisintraumapatientsisunknownandcurrentliteratureevaluatingetomidateandtraumapatients
suffersfromirrecoverabledesignandanalysisflaws. [24,25]However,resultsfromarecentrandomizedstudycomparingketamine
andetomidateincriticalillnessshownodifferenceinpatientmortality. [26]Nevertheless,ketamineat1.5mg/kgisareasonable
alternativetoetomidate.Itexhibitscardiovascularstabilityandmaintainsprotectiveairwayreflexesandcanbeusedtofacilitate
airwayevaluationsorawakeintubations.Bronchorrheamaybeattentuatedwithadryingagentsuchasglycopyrrolateoratropine.
[27]Inpatientswithseverehemodynamiccompromise,thedoseshouldbereducedto1mg/kg.Inpatientswithrefractoryshock,
ketaminedepressesmyocardialcontractilityandmustbeusedwithcaution. [28,29]
SuccinylcholineistheparalyticofchoiceforRSIofthepolytraumapatient.Competitiveneuromuscularblockingagentslike
rocuronium(1.0mg/kg)achieveintubatingconditionsnearlyasrapidlyassuccinylcholineandshouldbeusedifacontraindication
tosuccinylcholineexists,however,thedurationofparalysisisapproximately45min. [3032]Forthisreason,succinylcholine,with
itsrapidonsetandshorterdurationofaction,remainsthedrugofchoiceforemergencyintubationoftraumapatients.
Overallresuscitationfromthehypovolemicstatemustoccurinparallelwithpreparationforintubation.Crystalloidscanbeinfused
asthefirst2Loffluidduringresuscitationbutshouldbereplacedwithbloodifshockisongoingorworsening.Inanunstable
multipletraumapatient,iftheneedforintubationisnotimminent,volumeresuscitationshouldtakeprecedenceinorderto
improvehemodynamicsandallowmorepharmacologicoptionsduringRSI.

TracheobronchialInjuries
Althoughtraumatictracheobronchialinjuriesarerare,theyshouldbesuspectedinpatientswithbluntorpenetratinginjurytothe
neckorchest,especiallywithexternalevidenceofinjury,includingpain,ecchymosis,swelling,orsofttissuecrepitus.The
incidenceoftraumatictracheobronchialinjuriesisestimatedtobe0.5%2%ofpatientswithblunttraumapatientsand3%8%of
penetratingcervicaltraumapatients. [33,34]Patientswithcompletetraumatictracheobronchialtransectionshaveahighmortality
rateandoftendiebeforemakingittotheED.Inonestudy,78%ofpatientsdiedinthefieldand21%ofpatientsdiedwithin2h
ofhospitalarrival. [35]Kirshetal.haveproposedseveralmechanismsfortheseinjuries,includingaforcedcompressionofthe
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chesttearingthecarinafromthebronchus,ashearforcefromadecelerationinjurycausingthefreelymobilelungstotearfrom
thebronchusortrachea,andcompressionofthechestagainstaclosedglottiscausingateartothemembranoustrachea. [36,37]
Patientsoftenpresentwithdyspneaorrespiratorydistress(76%100%)andhoarsenessordysphonia(46%). [3840]Commons
signsoftracheobronchialinjuriesarepneumothoax(20%50%),subcutaneousemphysema(35%85%),andhemoptysis(14%
25%). [41]AlthoughCTscansdetectroughly90%ofinjuries,bronchoscopyisthegoldstandardfordiagnosis.Injuryseverityand
treatmentoptionscanalsobedeterminedusingbronchoscopyaswell. [41]
Patientswhomakeittothehospitalwithatracheobronchialinjuryarealivebecausetheyhaveeitheraminorinjurynotlikelyto
belifethreateningorapartialtransection.Iftheyhavethelatter,actionsbytheemergencyphysiciancanbeeitherheroicor
quicklyresultindeath.Paramountinmanagingsuspectedpartialtrachealtransectionsistoavoidconvertingtheinjurytoa
completetransection.Positivepressureventilationoranunguidedplacementofalargeboretrachealtubecancompleteapartial
trachealtransection.Inthesepatients,successfultrachealintubationisbestaccomplishedintheOR,withinhalational
anesthestics,askilledfiberopticintubatorandasmalltrachealtubeplaceddistaltotheleveloftheinjury.Iftheairwaymustbe
managedbeforetheOR,thenanawaketechniqueshouldbedonewithtopicalanesthesiaandsedation,asneeded,tocomplete
theprocedure.Thisismosteasilydoneinstable,cooperativepatients,however,theemergencyphysicianmustbereadytodeal
withagitationandairwaycollapseshouldtheyoccurduringtheawakeattempt.Inthesesituations,preparationforanimmediate
tracheostomyorcricothyrotomymustbedoneconcurrentlywiththeintubationattempt.Itisimportanttorecognizethat
cricothrotomyisunlikelytobesuccessful,asthetracheallacerationisoftendistaltothetracheostomytube.Athin,flexible
fiberopticintubatingbronchoscopewitha6.0or6.5trachealtubeisthebestoptionwithearlyrecoursetoasurgicalairway
shouldtheintubationfailandthepatientrapidlydeteriorates.
Definitivemanagementofatracheobronchialinjuryislargelydictatedbythelocationandseverityoftheinjury.Historically,
surgicalrepairwasthetreatmentofchoice,butrecently,removablestentshavebeenusedtomanagelargetears.Conservative
managementispossibleifthelacerationislocatedintheupperormiddleportionofthetracheaandanendotrachealtubeor
tracheostomytubecanbeplaceddistaltothelevelofthetracheallaceration. [42]
AdditionalEDManagement,Summary,andPrognosis

Initialmanagementstepsinourtraumapatientwerefocusedonfluidresuscitationandthecontrolofongoingbloodloss.The
scalplacerationwasstapledimmediatelytopreventanyadditionalbleedingand1unitofO+uncrossmatchedpackedredblood
cellswasadministeredtocorrectthepatient'srelativehypotensionduetohypovolemia.
ThedecisiontointubatethepatientbeforetransfertoCTwasmadebecausethepatienthadaGCSof11andhisprojected
clinicalcourseincludedapossibleoperativerepairofapresumedtrachealinjury.Inaddition,respiratoryfailureandhypoxiawere
likely,givenhispulmonarycontusionandongoingresuscitationrequirements.Althoughhewashypoxicandhypotensive,achest
tubethoracostomywasnotperformedbecausehisEFASTwasnegative.
TheanteriorneckwaspreparedwithBetadineaspartofadoublesetupincaseasurgicaltracheostomyhadbeenrequired.The
patientreceivedtopicalanesthesiawithnebulizedlidocaineandglycopyrrolatetominimizebronchorrhea,aswellasahalfdose
ofetomidate(0.5mg/kg).ThefiberopticbronchoscopewasloadedwithanendotrachealtubeandinsertedthroughaBerman
airway.Apartialtracheallacerationwasvisualizedapproximately4cmproximaltothecarina.Thefiberopticbronchoscopewas
insertedtothelevelofthecarinatoverifythatthetrachealdisruptionhadbeenpassed,anda6.0endotrachealtubewasgently
passedinordertominimizeanyfurthertrachealdisruption.Noairleakwasnotedafterinsufflationoftheendotrachealballoon
andthepatientwasthensedatedwithfentanylandmidazolam.
TheCTscanoftheheaddidnotshowanyacuteintracranialhemorrhageandtherewerenofracturesofthecraniumorcervical
spine.TheCTofthechestandabdomenshowedsubcutaneousairinthesofttissueoftheneckandupperchestinadditionto
pneumomediastinum.Amoderatesizedrightmiddlelobeopacityconsistentwithacontusion,andagrade2liverlaceration
withoutactiveextravasationwerealsoappreciated.Significantlaboratoryvaluesincludeahemoglobinof8.7g/dL,basedeficitof
18mEq/L,andalactateof4.1mmol/L.
Thepatientwasthentransferredtothesurgicalintensivecaseunitforfurtherresuscitationandmanagement.

Authors'Recommendations
Traumapatientswhoneedanairwayinterventionrequirerapidevaluationfordifficultairwayattributes,managementviaa
preplannedairwayalgorithm(includingrescuetechniquesintheeventoffailure),andawillingnesstoactquicklywithincomplete
information.Inmostcases,theneedtointerveneisapparent,however,certainsituationscanmisleadtheevaluatingphysician,
lullingthemintothemisperceptionthatanairwayis"stable."Manytraumapatientscaninitiallyappearsotheymaintainpatent
airwaysandbreathespontaneouslyuntiltheculminationoftheirinjuriescausethemtodeterioraterapidly.Softtissueswelling,
hematoma,orsubcutaneousaircancausedramaticandpotentiallylethalairwaydistortion,eventhoughexternalfindingsremain
unremarkable,untilthepatientsuddenlydecompensates.Theimperativewithanytraumatizedairwayisforearlyassessment
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anddecisiveaction.Likeotherdifficultairways,traumaintubationsrequireclarityofthought,sounddecisionmakingbasedon
acceptedmanagementalgorithms,useoffiberoptic,video,andsurgicaltechniqueswhencalledfor,andalowthresholdtoask
forspecialtyassistance.Delayorobservation,althoughinitiallyseemingprudent,canleadtocatastrophicairwaycompromise
andmakeairwaymanagementmuchmoredifficultthanifithadbeenundertakenearlier.

Conclusions
Ourpatientwasextubatedonhospitalday(HD)6.HewasmovedtoageneralsurgicalflooronHD8,butremainedhospitalized
for2weeksbeforebeingdischargedtoarehabilitationfacility.Afollowupbronchoscopyshowedawellhealedtracheawithout
stricture.
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