Trauma Airway Management

The Journal of Emergency Medicine, Vol. 46, No. 6, pp. 814–820, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2013.11.085 Trauma Reports TRAUMA AIRWAY MANAGEMENT Cheryl Lynn Horton, MD, Calvin A. Brown III, MD, and Ali S. Raja, MD, MBA, MPH Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Ali S. Raja, MD, MBA, MPH, Department of Emergency Medicine, Brigham and Women’s Hospital75 Francis Street, Neville House 312E, Boston, MA 02115 , Abstract—Background: Airway management in a saturation of 97% on room air. He had sustained obvious trauma patient can be particularly challenging when both head, face, and chest injuries. He was placed in a cervical a difficult airway and the need for rapid action collide. collar, extricated, and brought to the ED on a backboard. The provider must evaluate the trauma patient for airway Immediately upon arrival to the ED, his primary sur- difficulty, develop an airway management plan, and be vey was notable for incoherent speech and a hoarse voice. willing to act quickly with incomplete information. Discus- He had decreased breath sounds on the right, 2+ symmet- sion: Thorough knowledge of airway management algo- rithms will assist the emergency physician in providing ric pulses throughout, and visible right chest wall ecchy- optimal care and offer a rapid and effective treatment mosis. His initial ED vitals signs revealed a blood plan. Conclusions: Using a case-based approach, this article pressure of 95/70 mm Hg, a pulse of 115 bpm, a temper- reviews initial trauma airway management strategies along ature of 37.2 C, and an oxygen saturation of 96% on with the rationale for evidence-based treatments. Ó 2014 room air. His Glasgow Coma Scale (GCS) score was Elsevier Inc. 11, as he was only opening his eyes to vocal commands and speaking incoherently, yet was moving all of his , Keywords—trauma; airway; intubation; tracheobron- extremities in response to painful stimuli. An extended cheal injury; tracheal injury focused abdominal sonography for trauma (E-FAST) examination was only positive for free fluid in Morrison’s CASE REPORT pouch and demonstrated normal lung sliding bilaterally. Two large-bore peripheral lines were established and a A 34-year-old man presented to the emergency depart- cardiac monitor was applied. ment (ED) of a Level I trauma center via emergency med- His secondary survey was notable for a large 15-cm ical services (EMS) after a motor vehicle collision. He laceration extending from his forehead to his occipital was the unrestrained driver in a high-speed single-car ac- scalp, with active bleeding and a moderate amount of cident with significant front-end damage and a prolonged blood on the backboard. His pupils were equal and reac- extrication period. Witnesses reported that he was tive. Upon removal of the cervical collar, he was noted to swerving for approximately half a mile before he eventu- have ecchymosis with mild edema of his anterior neck, as ally ran off of the road and struck a tree. Upon EMS well as subcutaneous emphysema that extended down to arrival, they noted that he was confused and exhibited re- his nipple line on the right. His trachea was midline but petitive speech. Prehospital vitals revealed a blood pres- seemed tender to palpation. No stridor was audible, but sure of 110/89 mm Hg, a pulse of 112 beats/min (bpm), he had decreased breath sounds on the right and was ten- a respiratory rate of 18 breaths/min, and an oxygen der on his right chest wall and in his right upper RECEIVED: 25 September 2012; FINAL SUBMISSION RECEIVED: 20 September 2013; ACCEPTED: 17 November 2013 814 Downloaded from ClinicalKey.com at Presence Resurrection Medical Center March 01, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. Trauma Airway Management 815 abdominal quadrant. The remainder of his examination this reflex is weak in up to 25% of the normal adult was unremarkable and he continued to be able to move population and its absence does not necessarily indicate all four extremities in response to pain. His vital signs the need for intubation (2). Failure to appropriately were rechecked and found to be unchanged. oxygenate and ventilate can be assessed clinically by A portable chest x-ray study was notable for an opacity evaluating a patient’s respiratory effort, oxygen satura- in the right middle lobe, concerning for a pulmonary tion, and overall sense of the patient’s injuries. The antic- contusion but did not show a pneumothorax or pleural ipated clinical course helps to guide the decision to effusion. His pelvis x-ray study was normal. Given his in- intubate in patients who do not have an immediate prob- juries, the emergency physician and trauma surgeon lem with airway protection, ventilatory effort, or oxygen- decided that he should have his airway protected before ation. It is better to err on the side of intubating early and going to computed tomography (CT) for evaluation of securing a potentially threatened airway than observing his suspected neurologic, thoracic, and intra-abdominal the patient with a false sense of security originating injuries. from momentarily adequate oxygenation and ventilation. In addition, the patient’s trajectory may include inevi- DISCUSSION table intubation, and the opportunity to intubate early allows a more controlled and planned approach. For Initial Evaluation and Intervention example, a blunt trauma patient with an open femur frac- ture, intractable pain, and agitation may have an indica- Airway management in the trauma patient can be chal- tion for intubation in order to humanely and safely lenging and, for some patients, the need to act urgently perform a thorough trauma and radiologic evaluation, and decisively can be the difference between survival even in the absence of oxygenation difficulties or direct and death. Tenuous hemodynamics, cervical immobility, airway trauma. and direct airway trauma often complicate decision mak- Supplemental oxygenation should be started immedi- ing. Typical intubation methods can be difficult or impos- ately for any hypoxic trauma patient, especially those sible in patients with rapid oropharyngeal hemorrhage, with suspected brain injury (5). Nasal cannula oxygena- reduced oral access, or laryngotracheal injuries. tion may suffice for those with a mild oxygen debt but, Although some decisions are specific to trauma intu- generally, face-mask oxygenation with a reservoir at bations, sound airway-management principles that are 15 L/min flow is used. If intubation is planned, pre- common to all intubations still constitute a foundation oxygenation should be started by having the patient for success. Deciding to intubate is the first step. take full tidal volume breaths of high concentration oxy- Although this is intuitive for many patients, the need gen for 2À3 minutes (6). For patients predicted to desatu- for intubation might not be initially obvious in some pa- rate rapidly, nasal cannula oxygen should be left in place tients. There are three main indications for emergency during the apneic phase of intubation, as this can signifi- intubation that can be uncovered by asking the following cantly prolong the period of safe apnea (7,8). questions: 1) Is there a failure to maintain or protect the airway? 2) Is there a failure of oxygenation or ventila- Intubation of the Trauma Patient tion? or 3) Is there a need for intubation based on the anticipated clinical course? (1). Once the decision to intubate a trauma patient has been A failure to maintain one’s airway is not always clin- made, choosing the best method is paramount and based ically obvious. One approach is to calculate the patient’s on the predicted timeline, clinical scenario, and available GCS score. A GCS score # 8 in the absence of a revers- equipment. For all patients, a difficult airway (DA) ible cause is a clinical coma and these patients generally assessment is necessary before rapid sequence intubation require intubation (2À4). Most patients with a GCS score (RSI) with neuromuscular blockade. There are a number # 12 will have sustained significant brain injury and of DA assessment mnemonics that are easy to remember often will also require intubation. The inability to and can be applied quickly to most patients at the bedside protect one’s airway can be subtle, but in trauma (1). They evaluate for potential difficulty with direct patients this usually occurs in the setting of depressed laryngoscopy, rescue bag and mask ventilation, use of mental status caused by head trauma, hypovolemic an extraglottic device, and performance of a surgical shock, or ingestion of drugs or alcohol. Clinicians can airway. The acronym LEMON (Figure 1) assesses for dif- test for airway protection by evaluating phonation and a ficulty with direct laryngoscopy and has been validated in patient’s ability to swallow and handle secretions. The one ED study (9). The MOANS mnemonic (Figure 2)is gag reflex should never be assessed in a critically made up of a well-validated set of patient characteristics injured, immobilized trauma patient, as doing so can known to result in difficult mask ventilation. These provoke vomiting and worsen the situation. In addition, should be recognized early, as meticulous bagging Downloaded from ClinicalKey.com at Presence Resurrection Medical Center March 01, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. 816 C. L. Horton et al. flexible fiberoptic bronchoscope. A patient must be coop- erative and able to tolerate this examination for it to be successful. Awake laryngoscopy allows the operators to do one of three things: 1) intubate the patient, 2) visualize the cords and determine that intubation is possible and the patient can be intubated with RSI, or 3) determine that Figure 1.

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