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Airway Management in Trauma Patients

  • Michal BarakEmail author
  • Yoav Leiser
  • Yoram Kluger
Chapter

Abstract

Establishing a definitive airway in a trauma patient is a primary essential of early management. Any flaw in airway management may lead to grave morbidity or mortality. Occasionally, the caregiver may encounter difficulties in intubating the patient for anatomical or technical reasons, especially if the trauma involves the face and neck regions. In addition, trauma patient is generally regarded as having a “full stomach” and often has not been cleared of a C-spine injury. These may complicate airway management furthermore. The time available to accomplish airway control is short, and the patient’s condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In order to improve airway management capability, the physician has to understand the complexity of the situation, be familiar with various airway devices and alternative ventilation techniques, and have experience in several emergency airway skills.

In this chapter we discuss airway evaluation, present several airway devices and techniques, and propose an approach that may assist the surgeon in airway management of the trauma patient.

Keywords

Airway management Mask ventilation Difficult intubation In-line stabilization 

References

  1. 1.
    Committee on Trauma; American College of Surgeons. Advanced trauma life support for doctors ATLS. 8th ed. Chicago: American College of Surgeons; 2008.Google Scholar
  2. 2.
    Langeron O, Birenbaum A, Amour J. Airway management in trauma. Minerva Anestesiol. 2009;75:307–11.PubMedGoogle Scholar
  3. 3.
    Walls RM. Management of the difficult airway in the trauma patient. Emerg Med Clin North Am. 1998;16:45–61.PubMedGoogle Scholar
  4. 4.
    Mayglothling J, Duane TM, Gibbs M, McCunn M, Legome E, Eastman AL, Whelan J, Shah KH, Eastern Association for the Surgery of Trauma. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S333–40.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Gätke MR, Wetterslev J, Danish Anaesthesia Database. A documented previous difficult tracheal intubation as a prognostic test for a subsequent difficult tracheal intubation in adults. Anaesthesia. 2009;64:1081–8.PubMedGoogle Scholar
  6. 6.
    Vannucci A, Cavallone LF. Bedside predictors of difficult intubation: a systematic review. Minerva Anestesiol. 2016;82:69–83.PubMedGoogle Scholar
  7. 7.
    Mallampati SR. Clinical sign to predict difficult tracheal intubation (hypothesis). Can Anaesth Soc J. 1983;30:316–7.PubMedGoogle Scholar
  8. 8.
    Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429–34.PubMedGoogle Scholar
  9. 9.
    Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth. 1994;41:372–83.PubMedGoogle Scholar
  10. 10.
    Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429–37.PubMedGoogle Scholar
  11. 11.
    Healy DW, LaHart EJ, Peoples EE, Jewell ES, Bettendorf RJ Jr, Ramachandran SK. A Comparison of the Mallampati evaluation in neutral or extended cervical spine positions: a retrospective observational study of >80 000 patients. Br J Anaesth. 2016;116:690–8.PubMedGoogle Scholar
  12. 12.
    Advanced Trauma Life Support Student Course Manual, 9th ed, Chicago, IL; American College of Surgeons, 2012. Chapter 2 pp 31–49.Google Scholar
  13. 13.
    Hamaekers AE, Henderson JJ. Equipment and strategies for emergency tracheal access in the adult patient. Anaesthesia. 2011;66:65–80.PubMedGoogle Scholar
  14. 14.
    Mace SE. Challenges and advances in intubation: rapid sequence intubation. Emerg Med Clin North Am. 2008;26:1043–68.PubMedGoogle Scholar
  15. 15.
    Algie CM, Mahar RK, Tan HB, Wilson G, Mahar PD, Wasiak J. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database Syst Rev. 2015;(11):CD011656.Google Scholar
  16. 16.
    Nemeth J, Maghraby N, Kazim S. Emergency airway management: the difficult airway. Emerg Med Clin North Am. 2012;30:401–20.PubMedGoogle Scholar
  17. 17.
    Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP, Wong DT. Canadian Airway Focus Group. The difficult airway with recommendations for management—part 1—difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth. 2013;60:1089–118.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A, American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251–70.PubMedGoogle Scholar
  19. 19.
    Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99:607–13.PubMedGoogle Scholar
  20. 20.
    Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal intubation in trauma patients: a 10-year experience at a major adult trauma referral center. Anesth Analg. 2009;109:866–72.PubMedGoogle Scholar
  21. 21.
    Lockey DJ, Healey B, Crewdson K, Chalk G, Weaver AE, Davies GE. Advanced airway management is necessary in prehospital trauma patients. Br J Anaesth. 2015;114:657–62.PubMedGoogle Scholar
  22. 22.
    Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O’Sullivan EP, Woodall NM, Ahmad I, Difficult Airway Society Intubation Guidelines Working Group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115:827–48.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology. 2011;114:34–41.PubMedGoogle Scholar
  24. 24.
    Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database Syst Rev. 2016;11:CD011136.PubMedGoogle Scholar
  25. 25.
    Jones BM, Agrawal A, Schulte TE. Assessing the efficacy of video versus direct laryngoscopy through retrospective comparison of 436 emergency intubation cases. J Anesth. 2013;27:927–30.PubMedGoogle Scholar
  26. 26.
    Sakles JC, Mosier J, Chiu S, Cosentino M, Kalin L. A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Ann Emerg Med. 2012;60:739–48.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Serocki G, Bein B, Scholz J, Dörges V. Management of the predicted difficult airway: a comparison of conventional blade laryngoscopy with video-assisted blade laryngoscopy and the GlideScope. Eur J Anaesthesiol. 2010;27:24–30.PubMedGoogle Scholar
  28. 28.
    Schalk R, Byhahn C, Fausel F, Egner A, Oberndörfer D, Walcher F, Latasch L. Out-of-hospital airway management by paramedics and emergency physicians using laryngeal tubes. Resuscitation. 2010;81:323–6.PubMedGoogle Scholar
  29. 29.
    Ruetzler K, Roessler B, Potura L, Priemayr A, Robak O, Schuster E, Frass M. Performance and skill retention of intubation by paramedics using seven different airway devices—a manikin study. Resuscitation. 2011;82:593–7.PubMedGoogle Scholar
  30. 30.
    Goliasch G, Ruetzler A, Fischer H, Frass M, Sessler DI, Ruetzler K. Evaluation of advanced airway management in absolutely inexperienced hands: a randomized manikin trial. Eur J Emerg Med. 2013;20:310–4.PubMedGoogle Scholar
  31. 31.
    Grier G, Bredmose P, Davies G, Lockey D. Introduction and use of the ProSeal laryngeal mask airway as a rescue device in a pre-hospital trauma anaesthesia algorithm. Resuscitation. 2009;80:138–41.PubMedGoogle Scholar
  32. 32.
    Mabry RL, Frankfurt A. Advanced airway management in combat casualties by medics at the point of injury: a sub-group analysis of the reach study. J Spec Oper Med. 2011;11:16–9.PubMedGoogle Scholar
  33. 33.
    Adams BD, Cuniowski PA, Muck A, De Lorenzo RA. Registry of emergency airways arriving at combat hospitals. J Trauma. 2008;64:1548–54.PubMedGoogle Scholar
  34. 34.
    Wong DT, Yang JJ, Mak HY, Jagannathan N. Use of intubation introducers through a supraglottic airway to facilitate tracheal intubation: a brief review. Can J Anaesth. 2012;59:704–15.PubMedGoogle Scholar
  35. 35.
    Idris AH, Gabrielli A. Advances in airway management. Emerg Med Clin North Am. 2002;20:843–57.PubMedGoogle Scholar
  36. 36.
    Rabitsch W, Schellongowski P, Staudinger T, Hofbauer R, Dufek V, Eder B, Raab H, Thell R, Schuster E, Frass M. Comparison of a conventional tracheal airway with the Combitube in an urban emergency medical services system run by physicians. Resuscitation. 2003;57:27–32.PubMedGoogle Scholar
  37. 37.
    Davis DP, Valentine C, Ochs M, Vilke GM, Hoyt DB. The Combitube as a salvage airway device for paramedic rapid sequence intubation. Ann Emerg Med. 2003;42:697–704.PubMedGoogle Scholar
  38. 38.
    Vézina MC, Trépanier CA, Nicole PC, Lessard MR. Complications associated with the Esophageal-Tracheal Combitube in the pre-hospital setting. Can J Anaesth. 2007;54:124–8.PubMedGoogle Scholar
  39. 39.
    Dob DP, McLure HA, Soni N. Failed intubation and emergency percutaneous tracheostomy. Anaesthesia. 1998;53:72–4.PubMedGoogle Scholar
  40. 40.
    Helm M, Gries A, Mutzbauer T. Surgical approach in difficult airway management. Best Pract Res Clin Anaesthesiol. 2005;19:623–40.PubMedGoogle Scholar
  41. 41.
    Benkhadra M, Lenfant F, Nemetz W, Anderhuber F, Feigl G, Fasel J. A comparison of two emergency cricothyroidotomy kits in human cadavers. Anesth Analg. 2008;106:182–5.PubMedGoogle Scholar
  42. 42.
    Murphy C, Rooney SJ, Maharaj CH, Laffey JG, Harte BH. Comparison of three cuffed emergency percutaneous cricothyroidotomy devices to conventional surgical cricothyroidotomy in a porcine model. Br J Anaesth. 2011;106:57–64.PubMedGoogle Scholar
  43. 43.
    Dillon JK, Christensen B, Fairbanks T, Jurkovich G, Moe KS. The emergent surgical airway: cricothyrotomy vs. tracheotomy. Int J Oral Maxillofac Surg. 2013;42:204–8.PubMedGoogle Scholar
  44. 44.
    Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan. J Spec Oper Med. 2012;12:17–23.PubMedGoogle Scholar
  45. 45.
    Kearney PA, Griffen MM, Ochoa JB, Boulanger BR, Tseui BJ, Mentzer RM Jr. A single-center 8-year experience with percutaneous dilational tracheostomy. Ann Surg. 2000;231:701–9.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Yuen HW, Loy AH, Johari S. Urgent awake tracheotomy for impending airway obstruction. Otolaryngol Head Neck Surg. 2007;136:838–42.PubMedGoogle Scholar
  47. 47.
    Altman KW, Waltonen JD, Kern RC. Urgent surgical airway intervention: a 3 year county hospital experience. Laryngoscope. 2005;115:2101–4.PubMedGoogle Scholar
  48. 48.
    Gupta P, Modrykamien A. Fatal case of tension pneumothorax and subcutaneous emphysema after open surgical tracheostomy. J Intensive Care Med. 2014;29:298–301.PubMedGoogle Scholar
  49. 49.
    Cooper S. We need to cut the neck! Confronting psychological and moral distress during emergency cricothyrotomy. Narrat Inq Bioeth. 2013;3:E5–9.PubMedGoogle Scholar
  50. 50.
    Greenland KB, Acott C, Segal R, Goulding G, Riley RH, Merry AF. Emergency surgical airway in life-threatening acute airway emergencies—why are we so reluctant to do it? Anaesth Intensive Care. 2011;39:578–84.PubMedGoogle Scholar
  51. 51.
    King DR, Ogilvie MP, Velmahos G, Alam HB, Demoya MA, Wilcox SR, Mejaddam AY, Van Der Wilden GM, Birkhan OA, Fikry K. Emergent cricothyroidotomies for trauma: training considerations. Am J Emerg Med. 2012;30:1429–32.PubMedGoogle Scholar
  52. 52.
    King D, Ogilvie M, Michailidou M, Velmahos G, Alam H, deMoya M, Fikry K. Fifty-four emergent cricothyroidotomies: are surgeons reluctant teachers? Scand J Surg. 2012;101:13–5.PubMedGoogle Scholar
  53. 53.
    Kirkpatrick AW, Ball CG, D’Amours SK, Zygun D. Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy. Can J Surg. 2008;51:57–69.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Matthes G, Bernhard M, Kanz KG, Waydhas C, Fischbacher M, Fischer M, Böttiger BW. Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients. Unfallchirurg. 2012;115:251–64. In German.PubMedGoogle Scholar
  55. 55.
    Sinex JE. Pulse oximetry: principles and limitations. Am J Emerg Med. 1999;17:59–67.PubMedGoogle Scholar
  56. 56.
    Petterson MT, Begnoche VL, Graybeal JM. The effect of motion on pulse oximetry and its clinical significance. Anesth Analg. 2007;105:S78–84.PubMedGoogle Scholar
  57. 57.
    Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104:1293–318.PubMedGoogle Scholar
  58. 58.
    Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med. 2007;50:236–45.PubMedGoogle Scholar
  59. 59.
    Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009;110:24–31.PubMedGoogle Scholar
  60. 60.
    Kill C, Risse J, Wallot P, Seidl P, Steinfeldt T, Wulf H. Videolaryngoscopy with glidescope reduces cervical spine movement in patients with unsecured cervical spine. J Emerg Med. 2013;44:750–6.PubMedGoogle Scholar
  61. 61.
    Robitaille A, Williams SR, Tremblay MH, Guilbert F, Thériault M, Drolet P. Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy. Anesth Analg. 2008;106:935–41.PubMedGoogle Scholar
  62. 62.
    Bhardwaj N, Jain K, Rao M, Mandal AK. Assessment of cervical spine movement during laryngoscopy with Macintosh and Truview laryngoscopes. J Anaesthesiol Clin Pharmacol. 2013;29:308–12.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet. 1961;2:404–6.PubMedGoogle Scholar
  64. 64.
    Haslam N, Parker L, Duggan JE. Effect of cricoid pressure on the view at laryngoscopy. Anaesthesia. 2005;60:41–7.PubMedGoogle Scholar
  65. 65.
    Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007;50:653–65.PubMedGoogle Scholar
  66. 66.
    Bhatia N, Bhagat H, Sen I. Cricoid pressure: where do we stand? J Anaesthesiol Clin Pharmacol. 2014;30:3–6.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Ralph SJ, Wareham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia. 1991;46:40–1.PubMedGoogle Scholar
  68. 68.
    Heath KJ, Palmer M, Fletcher SJ. Fracture of the cricoid cartilage after Sellick’s manoeuvre. Br J Anaesth. 1996;76:877–8.PubMedGoogle Scholar
  69. 69.
    Mechlin MW, Hurford WE. Emergency tracheal intubation: techniques and outcomes. Respir Care. 2014;59:881–92.PubMedGoogle Scholar
  70. 70.
    Boylan JF, Kavanagh BP. Emergency airway management: competence versus expertise? Anesthesiology. 2008;109:945–7.PubMedGoogle Scholar
  71. 71.
    Kovacs G, Law JA, Ross J, Tallon J, MacQuarrie K, Petrie D, Campbell S, Soder C. Acute airway management in the emergency department by non-anesthesiologists. Can J Anaesth. 2004;51:174–80.PubMedGoogle Scholar
  72. 72.
    Walls RM, Brown CA, Bair AE, Pallin DJ, NEAR II Investigators. Emergency airway management: a multi-center report of 8937 emergency department intubations. J Emerg Med. 2011;41:347–54.PubMedGoogle Scholar
  73. 73.
    Hutchison I, Lawlor M, Skinner D. ABC of major trauma. Major maxillofacial injuries. BMJ. 1990;301:595–9.PubMedPubMedCentralGoogle Scholar
  74. 74.
    Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anesthesia. 2003;58:249–56.Google Scholar
  75. 75.
    Muzzi DA, Losasso TJ, Cucchiara RF. Complication from a nasopharyngeal airway in a patient with a basilar skull fracture. Anesthesiology. 1991;74:366–8.PubMedGoogle Scholar
  76. 76.
    Barak M, Bahouth H, Leiser Y, Abu El-Naaj I. Airway management of the patient with maxillofacial trauma: review of the literature and suggested clinical approach. Biomed Res Int. 2015;2015:724032.PubMedPubMedCentralGoogle Scholar
  77. 77.
    Talving P, DuBose J, Inaba K, Demetriades D. Conversion of emergent cricothyrotomy to tracheotomy in trauma patients. Arch Surg. 2010;145:87–91.PubMedGoogle Scholar
  78. 78.
    Vashishta A, Sharma S, Chugh A, Jain D, Gupta N, Bihani U. Submental intubation: a useful adjunct in panfacial trauma. Natl J Maxillofac Surg. 2010;1:74–7.PubMedPubMedCentralGoogle Scholar
  79. 79.
    Schütz P, Hamed HH. Submental intubation versus tracheostomy in maxillofacial trauma patients. J Oral Maxillofac Surg. 2008;66:1404–9.PubMedGoogle Scholar
  80. 80.
    Eisemann B, Eisemann M, Rizvi M, Urata MM, Lypka MA. Defining the role for submental intubation. J Clin Anesth. 2014;26:238–42.PubMedGoogle Scholar
  81. 81.
    de Toledo GL, Bueno SC, Mesquita RA, Amaral MB. Complications from submental endotracheal intubation: a prospective study and literature review. Dent Traumatol. 2013;29:197–202.PubMedGoogle Scholar
  82. 82.
    Mittal G, Mittal RK, Katyal S, Uppal S, Mittal V. Airway management in maxillofacial trauma: do we really need tracheostomy/submental intubation. J Clin Diagn Res. 2014;8:77–9.PubMedPubMedCentralGoogle Scholar
  83. 83.
    Cavallone LF, Vannucci A. Extubation of the difficult airway and extubation failure. Anesth Analg. 2013;116:368–83.PubMedGoogle Scholar
  84. 84.
    Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Extubation Guidelines Group. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012;67:318–40.PubMedGoogle Scholar
  85. 85.
    Peterson GN, Domino B, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103:33–9.PubMedGoogle Scholar
  86. 86.
    Jahromi HE, Gholami M, Rezaei F. A randomized double-blinded placebo controlled study of four interventions for the prevention of postoperative nausea and vomiting in maxillofacial trauma surgery. J Craniofac Surg. 2013;24:e623–7.PubMedGoogle Scholar

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Authors and Affiliations

  1. 1.The Department of Anesthesiology, Rambam Health Care Campus, and the Ruth and Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael
  2. 2.The Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, and the Ruth and Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael
  3. 3.Department of General Surgery, Pancreatic Surgery Service, Rambam Health Care Campus, and the Ruth and Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael

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