CLINICAL MANAGEMENT ௡ UPDATE The Journal of TRAUMA Injury, Infection, and Critical Care Guidelines for Emergency Tracheal Intubation Immediately after Traumatic Injury C. Michael Dunham, MD, Robert D. Barraco, MD, David E. Clark, MD, Brian J. Daley, MD, Frank E. Davis III, MD, Michael A. Gibbs, MD, Thomas Knuth, MD, Peter B. Letarte, MD, Fred A. Luchette, MD, Laurel Omert, MD, Leonard J. Weireter, MD, and Charles E. Wiles III, MD for the EAST Practice Management Guidelines Work Group J Trauma. 2003;55:162–179. REFERRALS TO THE EAST WEB SITE and impaired laryngeal reflexes are nonhypercarbic hypox- Because of the large size of the guidelines, specific emia and aspiration, respectively. Airway obstruction can sections have been deleted from this article, but are available occur with cervical spine injury, severe cognitive impairment on the Eastern Association for the Surgery of Trauma (EAST) (Glasgow Coma Scale [GCS] score Յ 8), severe neck injury, Web site (www.east.org/trauma practice guidelines/Emergency severe maxillofacial injury, or smoke inhalation. Hypoventi- Tracheal Intubation Following Traumatic Injury). lation can be found with airway obstruction, cardiac arrest, severe cognitive impairment, or cervical spinal cord injury. I. STATEMENT OF THE PROBLEM Aspiration is likely to occur with cardiac arrest, severe cog- ypoxia and obstruction of the airway are linked to nitive impairment, or severe maxillofacial injury. A major preventable and potentially preventable acute trauma clinical concern with thoracic injury is the development of Hdeaths.1–4 There is substantial documentation that hyp- nonhypercarbic hypoxemia. Lung injury and nonhypercarbic oxia is common in severe brain injury and worsens neuro- hypoxemia are also potential sequelae of aspiration. logic outcome.5–13 The primary concern with acute postinjury Trauma patients requiring emergency tracheal intubation respiratory system insufficiency is hypoxemic hypoxia and are critically injured; however, the degree of injury is vari- subsequent hypoxic encephalopathy or cardiac arrest. A sec- able. The mean study Injury Severity Score (ISS) is 29; 14–34 ondary problem from acute postinjury respiratory system however, the range varies from 17 to 54. The average insufficiency is hypercarbia and attendant cerebral vasodila- study GCS score for trauma patients undergoing emergency tion or acidemia. An additional concern with acute postinjury tracheal intubation is 6.5; however, the GCS score varies 16–20,24,26–28,30,31,33–51 respiratory system insufficiency is aspiration and the devel- across its spectrum (3–15). The mean opment of hypoxemia, pneumonia, or acute respiratory dis- study mortality rate for emergency tracheal intubation in tress syndrome (ARDS) and acute lung injury. trauma patients is 41%, yet it ranges from 2% to 14–18,20–33,35,37,39,42,44,46,47,52–69 The primary categories of respiratory system insuffi- 100%. ciency are airway obstruction, hypoventilation, lung injury, There is substantial variation in the percentages of and impaired laryngeal reflexes. The physiologic sequelae of trauma patients undergoing emergency tracheal intubation airway obstruction and hypoventilation are hypoxemia and among and between aeromedical, ground Emergency Medi- hypercarbia. Adverse physiologic responses of lung injury cal Services (EMS), and trauma center settings. For aeromed- ical settings, the percentage of patients undergoing tracheal intubation is 18.5%; however, the variation among studies Submitted for publication May 13, 2003. 23,36,38,70–75 Accepted for publication May 15, 2003. ranges from 6% to 51%. The ground EMS studies Copyright © 2003 by Lippincott Williams & Wilkins, Inc. indicate that the rate of patients undergoing tracheal intuba- From St. Elizabeth Health Center (C.M.D.), Youngstown, Ohio, tion is 4.0%, but varies from 2% to 37%.28,29,76–79 For trauma SUNY-Stony Brook (R.D.B.), Stony Brook, New York, Maine Medical center settings, the percentage of patients undergoing tracheal Center (D.E.C.), Portland, Maine, University of Tennessee (B.J.D.), Knox- intubation is 24.5%; however, the variation among studies ville, Tennessee, Memorial Health Center (F.E.D.), Savannah, Georgia, Car- 14,17,40,62,80,81 olinas Medical Center (M.A.G.), Charlotte, North Carolina, Blanchfield ranges from 9% to 28%. Studies describing Army Community Hospital (T.K.), Fort Campbell, Kentucky, Loyola Uni- patients managed by ground EMS crews and a receiving versity Medical Center (P.B.L., F.A.L.), Maywood, Illinois, Allegheny Gen- trauma center staff indicate that the rate of tracheal intubation eral Hospital (L.O.), Pittsburgh, Pennsylvania, Eastern Virginia Medical is 13.6%, but varies from 11% to 30%.19,22,67,82 System (L.J.W.), Norfolk, Virginia, and Lancaster General Hospital (C.E.W.), Lancaster, Pennsylvania. It is clear that trauma patients with acute respiratory Address for reprints: C. Michael Dunham, MD, St. Elizabeth Health system insufficiency commonly have critical injuries, may Center, 1044 Belmont Avenue, Youngstown, OH 44501-1790; email: need tracheal intubation, and develop adverse clinical out- [email protected]. comes. However, there is substantial variation in injury se- DOI: 10.1097/01.ta.0000083335.93868.2c verity, mortality rates, and frequency of intubation. An evi- 162 July 2003 Guidelines for Emergency Tracheal Intubation dence-based literature review was performed to identify V. SCIENTIFIC FOUNDATION TO CHARACTERIZE acutely injured trauma patients who need emergency tracheal PATIENTS IN NEED OF EMERGENCY TRACHEAL intubation and to determine the optimal procedure for tra- INTUBATION IMMEDIATELY AFTER cheal intubation. TRAUMATIC INJURY A. Evidence that Trauma Patients with Airway Obstruction Need Emergency Tracheal Intubation II. GOALS AND OBJECTIVES Background See the EAST Web site (www.east.org/trauma practice There is documentation that patients with cervical spine guidelines/Emergency Tracheal Intubation Following Trau- injury can have airway obstruction secondary to cervical matic Injury). hematoma.83–86 The need for emergency tracheal intubation in these patients with cervical spine injury is 22% (range, 14–48%).41,63,87–89 There is also substantial documentation III. PROCESS that patients with other severe neck injuries may have airway See the EAST Web site (www.east.org/trauma practice obstruction secondary to cervical hematoma and laryngeal or guidelines/Emergency Tracheal Intubation Following Trau- tracheal injury.90–108 matic Injury). Additional literature indicates that patients with severe neck injury have airway obstruction and commonly need emergency tracheal intubation (11–100%).52,57,58,64,68,109–120 IV. RECOMMENDATIONS TO CHARACTERIZE Specifically, patients with laryngotracheal injury frequently PATIENTS IN NEED OF EMERGENCY TRACHEAL have airway obstruction or respiratory distress, and the ma- INTUBATION IMMEDIATELY AFTER jority require emergency tracheal intubation.52,57,58,111,113–120 TRAUMATIC INJURY The literature also indicates that patients with severe maxil- Level I lofacial injury can have airway obstruction and frequently Level I recommendations are typically predicated on need emergency tracheal intubation.121–128 evidence from randomized, controlled trials. The relevant Other patients with severe cognitive impairment com- literature is devoid of randomized, controlled trials and has monly have airway obstruction (26–45%) and associated been comprehensively reviewed to find the best available hypoxemia (15–55%).8,12,129,130 These patients with severe evidence. The recommendations are based on several peer- cognitive impairment typically undergo emergency tracheal reviewed journal publications from institutions throughout intubation.27,30,44,69 In addition, patients with smoke inhala- the United States and are typically supported in multiple tion are at risk for airway obstruction and commonly undergo professional organization and society publications. The com- emergency tracheal intubation.131–143 mittee did not find alternative management strategies that were as effective as the recommendations. In summary, the committee consensus finds the recommendations to reflect Scientific Evidence management principles with a high degree of certainty. Twenty-one studies of trauma patients undergoing 1. Emergency tracheal intubation is needed in trauma emergency tracheal intubation provide evidence that pa- patients with the following traits: tients with airway obstruction need tracheal intubation (Table a) airway obstruction 1).14,16,22,23,31,32,38,41,50,57,65,74,81,109,111,113,115,116,119,144,145 (For b) hypoventilation tables, see EAST Web site: www.east.org/trauma practice c) severe hypoxemia (hypoxemia despite supplemen- guidelines/Emergency Tracheal Intubation Following Traumatic tal oxygen) Injury.) The majority of the 6,486 patients in these studies d) severe cognitive impairment (GCS score Յ 8) underwent emergency tracheal intubation. However, the per- e) cardiac arrest centage of study patients with airway obstruction was often not f) severe hemorrhagic shock available. In virtually all studies, airway obstruction was a pro- 2. Emergency tracheal intubation is needed in smoke tocol criterion for tracheal intubation. Because trauma center inhalation patients with the following conditions: directors and EMS medical directors create protocol criteria and a) airway obstruction are knowledgeable in airway management, these experts in- b) severe cognitive impairment (GCS score Յ 8) dicate that intubation is essential. Also,