APPROACH TO THE AIRWAY IN TRAUMA PATIENTS:

The A of ABC

 

The most immediately life threatening complication of any trauma is loss of airway patency.  Maintaining oxygenation and preventing hypercarbia are critical in managing the trauma patient, especially if the patient has sustained a head injury.  Thus, the first step in evaluating and treating any trauma patient is to assess airway patency and, if compromised, restore it: the A of A (airway), B (breathing), C (circulation).  Any patient who is awake, alert and able to talk has a patent airway.  Whether they need supplemental oxygen can be determined by vitals and physical exam.  Patients who are unconscious or have signs suggestive of respiratory compromise, however, require immediate attention.

All patients should be immobilized due to increased risk of spinal injury.  Assessment of the patient should be done while maintaining the cervical spine in a stable, neutral position.  Begin the primary survey by rapidly assessing airway patency: rapidly assess for obstruction.  Maintain an airway with jaw thrust or the chin lift maneuver.   Clear the airway of foreign bodies.  If the patient is likely to vomit, position them in a lateral and head down position to prevent aspiration.  All trauma patients should be administered supplemental oxygen! 

Determine the patient’s needs.  Signs and symptoms suggestive or airway or ventilatory compromise include:

  • maxillofacial trauma
  • neck trauma
  • laryngeal trauma (with hoarseness or subcutaneous emphysema)

LOOK for:

  • obtundation
  • agitation (which may suggest hypercarbia)
  • cyanosis
  • retractions/accessory muscle use
  • symmetrical rise and fall of the chest wall

LISTEN for:

  • abnormal breath sounds
  • snoring
  • stridor
  • crackles
  • dysphonia
  • symmetrical breath sounds over both hemithoraces
  • tachypnea

FEEL for:

  • a deviated trachea
  • subcutaneous emphysema

 

The ladder of tools available for respiratory support in order of increasing invasiveness are:

  • Nasal cannula
  • Face mask, nonrebreather face mask
  • Nebulizer
  • Oral-pharyngeal airway/Nasoparyngeal airway
  • Bag-mask ventilation
  • Intubation – Any patient exhibiting airway symptoms (stridor, hoarseness, severe cough, voice change) and all unconscious patients should be intubated.  Endotracheal intubation is far superior to bag-mask ventilation because it provides larger tidal volumes and prevents aspiration.  Particularly in the trauma patient population – often time obtunded or unconscious, with loss of or diminished gag reflexes – the prevention of aspiration is of key importance.
  • Emergency Cricothroidotomy – Two large bore needles (14 guage) needles are inserted into the cricothyroid membrane

 

THE DEFINITIVE AIRWAY:

A definitive airway can be: an endotracheal tube, an nasotracheal tube, or a surgical airway (cricothroidotomy).

  • The need for a definitive airway is based upon a number of clinical findings:
  • the presence of apnea
  • inability to maintain a patent airway by less invasive means
  • need to protect the lower airway from aspiration of blood or vomitus
  • impending or potential airway compromise (following inhalational injury, facial fractures, retroparygeal hematoma or sustained seizure activity)
  • presence of a closed head injury requiring assisted ventilation
  • inability to maintain adequate oxygenation by face mask oxygen supplementation
  • any patient with a Glasgow coma score of 8 or less

 

In the trauma situation, the decision whether to proceed with orotracheal or nasotracheal intubation is based upon the experience and discretion of the supervising attending or chief resident.  Both techniques are safe and effective when performed properly.  (All apneic patients should be intubated orally).

If the decision is made to proceed with orotracheal intubation, the two person technique with in-line cervical spine immobilization should be used.

Nasotracheal Intubation: Nasal intubation is similar to oral intubation except that the ETT is advanced through the nose into the oropharynx before laryngoscopy.  If the patient is awake, local anesthetic drops and nerve blocks can be used.  A lubricated ETT is introduced along the floor of the nose, below the inferior nasal turbinate, perpendicular to the face.  The tube is advanced until it can be visualized in the oropharynx. Via laryngoscopy, the tube is then advanced in between the abducted vocal cords.

**Nasal instrumentation (with ETTs, NPOs, or nasal catheters) is contraindicated in all patients with severe midfacial trauma.

Surgical Cricothyroidotomy: Surgical cricothyroidotomy is performed by making a skin incision that extends through the cricothyroid membrane. The incision is dilated using a curved hemostat and small endotracheal tube or trachesotomy tube can be inserted.  because of potential damage to the cricoid cartilage (the only circumferential support to the upper trachea, this procedure is not recommended in children under the age of 12.

 

American College of Surgeons Airway Decision Scheme – designed to foster rapid decision making in patients who are apneic (in acute respiratory distress) and in need of immediate airway AND in whom cervical spine injury is suspected.

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