2/9/2017 Airwaymanagementintrauma

IndianJAnaesth.2011SepOct55(5):463469. PMCID:PMC3237145
doi:10.4103/00195049.89870

Airwaymanagementintrauma
RashidMKhan,PradeepKSharma, 1andNareshKaul

DepartmentofAnesthesiaandICU,NationalTraumaCentre,Muscat,Oman
1
DepartmentofAnesthesia,SultanQaboosUniversityHospital,Muscat,Oman
Addressforcorrespondence:Dr.RashidKhan,POBOX96,AlHarthyComplex,Oman.Email:seeras_alig@rediffmail.com

Copyright:IndianJournalofAnaesthesia

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,whichpermits
unrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract Goto:

Traumahasassumedepidemicproportion.10%ofglobalroadaccidentdeathsoccurinIndia.Hypoxiaandairway
mismanagementareknowntocontributeupto34%ofprehospitaldeathsinthesepatients.Ahighdegreeof
suspicionforactualorimpendingairwayobstructionshouldbeassumedinalltraumapatients.Objectivesignsof
airwaycompromiseincludeagitation,obtundation,cyanosis,abnormalbreathsoundanddeviatedtrachea.Iftime
permits,oneshouldcarryoutabriefairwayassessmentpriortoundertakingdefinitiveairwaymanagementinthese
patients.Simpletechniquesforestablishingandmaintainingairwaypatencyincludejawthrustmaneuverand/oruse
oforoandnasopharyngealairways.Allattemptsmustbemadetoperformdefinitiveairwaymanagement
wheneverairwayiscompromisedthatisnotamenabletosimplestrategies.Theselectionofairwaydeviceand
routeoralornasal,fortrachealintubationshouldbebasedonnatureofpatientinjury,experienceandskilllevel.

Keywords:Airwayalgorithms,airwaymanagement,airwaytrauma

INTRODUCTION Goto:

TheglobalstatusreportonroadsafetypublishedinMay,2011byworldhealthorganizationnotedthatIndiahad
themaximum(125,000)deathsduetotraumaonroads.Thisis10%ofglobalroadaccidentdeath.Thereportalso
addsthatatleast2.2millionssustainseriousinjurieseachyear.[1]Unfortunately,amajorityoftraumasurvivors
areeitherconfinedtobedorwheelchairfortherestoftheirlivesduetoeitherbrainorspinalinjury.[2]

ThetragedyofIndiaisthat78%ofthevictimsaremenintheagegroupof20to44years,causingsignificant
impactonproductivity.[3]

Whydothesetraumavictimsdie?Thisispredominantlyduetohypoxiaandairwaymismanagementwhichare
knowntocontributeupto34%ofprehospitaldeathsinthesepatients.[4]

Severalstudieshaveshownthat7to28%ofpatientswithtraumarequiredefinitiveairwaymanagementintheform
ofeitherendotrachealintubation(ETI)orasurgicalairway.[57]

Althoughemergencydefinitiveairwaymanagementisknowntobeassociatedwithcomplications(1),avoidingit
resultsinunacceptablyhighmorbidityandmortality.[8,9]

Thebeststrategytosalvagepatientswithtraumaistoprovidethemwithimmediatetraumacare,includingairway
managementintheprehospitalsettingandadvancetraumacarewithinthefirsthouroftraumaorthesocalled
GoldenHour.[2]

Theaimofthisarticleistoreviewthemorerecenttheoreticandpracticalinformationthatpertainstoairway
managementinvictimsoftrauma.Thisshallincludeidentifyingcausesofdifficultiesinairwaymanagement,

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predictionofairwaydifficultiesandthebeststrategiesintermsofairwaydevices,techniquesormaneuversthat
maybeusefulinthemanagementofairwayinthetraumasetting.

CAUSESOFAIRWAYMISMANAGEMENT Goto:

Airwaymismanagementintraumavictimsmaybeattributedtoanyoneorcombinationofthefollowingcauses:
[10]

1.Failuretorecognisetheinadequateairwayinthetraumavictim.
2.Failuretoestablishaclearairwaywithorwithoutanairwaydevice.
3.Failuretorecognisethattheairwaydevicethathasbeenemployedisincorrectlyplaced.
4.Displacementofapreviouslyestablishedairway.
5.Failuretorecognisetheneedforventilation,andlastly.
6.Aspirationofgastriccontents.

Aninadequateairwaywouldleadtoasphyxiathatmayprogresstocerebralhypoxia,braindamageandfinally
death.

Whatarethelocationsatwhichairwaymismanagementoccursinthesetraumapatients?Theanswertothis
includesairwaymismanagementcanoccurattheaccidentsiteorthetraumacentre.Causesofairway
mismanagementattheaccidentsiteincludethefollowing:

1.Unfavourableconditions(e.g.,darkness,inadequatespace,limitedaccesstothepatient'sairway).
2.Poorpatientpositioningwhomaybelyingontheroad,crampedsmashedcarsandtrainsbesidesothersuch
unusuallocations.
3.Unknownassistingpersonnelwithdifferentlevelsofairwaytraining.

Causesofairwaydifficultiesleadingtoairwaymismanagementatthetraumacentremayincludethefollowing:

1.Oropharyngealorpulmonaryhaemorrhageand/orfacialtraumaobscuringpatientairwaydetails.
2.AnimmobilisedcervicalspinesuchasincervicalcollarorHaloframe.
3.Apossiblefullstomachandtheassistantapplyingfaultycricoidpressure(Sellick'smaneuver).
4.Anuncertainvolumestatusputtingadilemmaontheuseofpharmacologicaladjuncts.
5.Hypoxaemiaputtingstressontheoperator.
6.Anuncooperativeorcombativepatient.

Allorsomeofthesefactors,aswellaspoorairwayskillsoftheoperatorthemselves,resultinadifficultyin
managingtheairwayin7to10%oftraumapatients.Toavoidairwaymismanagement,itisessentialthatthe
physicianorparamedicattendingtothepatientiswelltrained,remainscalmanddoesnotpanic.Oneshouldstrictly
followtheA,B,C.rulesofAdvancedTraumaLifeSupportguidelines.[10]

PREDICTIONOFINADEQUATEAIRWAYINPATIENTOFTRAUMA Goto:

Potentialtraumapatientswhocanhaveinadequacyofairwayincludepatientswith:[10]

1.Alteredconsciousnesssecondarytoheadinjury,drugsoralcohol.
2.Directtraumatoairway(faciomaxillary,neck,larynxandthroat).
3.Severelywoundedpatientshavingprofoundbleedingorarecomatose.
4.Respiratoryfailuresecondarytoblastorinhalationalinjury,orexposuretochemicalagents.

Notallthesepatientswillhaveacompromisedairway.Thefollowingstepsshallhelptoidentifytheobstructed
airwayofsomeofthesepotentialpatients:[10]

1.Look:Lookforobtundation,agitation,cyanosis,retractionand/oruseofaccessorymusclesofrespiration,
andasymmetricalriseandfallofchest.
2.Listen:Listentopatientattemptingtotalkbutfailingtodoso,abnormalbreathsoundsassociatedwith
snoring,gurgling,stridorandcrackles.Asymmetricalbreathsoundsoverbothhemithoraciesandtachypnea
alsosuggestaninadequateairway.
3.Feel:Feelforadeviatedtracheaand/orsubcutaneousemphysema.
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Patientswithanyorcombinationoftheaboveshouldbepresumedtohaveaninadequateobstructedairway
needingappropriatemanagement.Allpatientsoftraumashouldbesuspectedtohaveanalteredorcompromised
airwaytillruledout.Theyshouldcontinuetoreceivesupplementaloxygenandhavecervicalimmobilisationdone
usingmanualinlinestabilisationduringexaminationandairwaymanagement.

Whiletryingtoidentifyaninadequateairway,taketheopportunitytotakeaSAMPLEhistoryifpatient'scondition
permits.Thisincludesthefollowing:

The8theditionadvancedtraumalifesupport(ATLS)guidelinesstronglysuggestthatifthepatientiswell
oxygenatedandisreasonablystable(i.e.,doesnotneedtobeintubatedinthenext2to3minutes),amethodical
stepwiseplantoassessfordifficultairwayshouldbemade.Foreaseofremembrance,oneisencouragedtousethe
followingmnemonicforassessingthedifficultairwayinthesepatients:LEMONandBONES.

LEMON[10,11]forassessingdifficultintubation:

Difficultmaskventilationmaybeanticipatedifthepatienthas2or>ofthefollowingparametersinthemnemonic.

BONES

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Onceithasbeenidentifiedthatthepatienthasaninadequateairway,onecanadopt:

1.Simpleairwaystrategy
2.Definitiveairwaystrategy(ETIorsurgicalairway),or
3.Semidefinitiveairwaystrategyformakingtheairwaypatentasperexistingsituation.

However,beforeinitiatinganyoftheairwaymaintenancestrategies,itisessentialtoclearanybloodclotand
mucousfromtheoralcavityandnose.Removeforeignbodiessuchasbrokendenturesoravulsedteeth.One
shouldalsocontrolthetonguepositionincaseofsymphysealbilateralfractureofthemandible.Wordsofcaution
whensuctioningtheoralcavity:neversuctionfurtherthanyoucansee,alwayssuctiononthewayout,never
suctionforlongerthan15secondsandalwaysoxygenatethepatientbeforeandaftersuctioning.

SIMPLEAIRWAYSTRATEGY Goto:

ThisincludesHeadtiltandChinlift(avoidinpatientswithcervicaltrauma)/jawthrustortheuseofbasicadjuncts
suchasoropharyngealairwayinunresponsivepatientswithoutgagreflex,and/ornasopharyngealairwayin
patientswithmoreactivereflexesbutwithoutevidenceoffractureofbaseofskull.

DEFINITIVEAIRWAYSTRATEGY Goto:

ThisincludeseitherETIorasurgicalairway.Indicationsfordefinitiveairwaystrategyincludethefollowing:[10]

1.Presenceofapnoea.
2.Needforairwayprotectionformaspiration:vomitus,bleeding.
3.Unconsciousness:GlasgowComaScale<8.
4.Severefaciomaxillaryfractures.
5.Riskforobstruction:neckhaematoma,laryngeal/trachealinjury.
6.Impendingorpotentialairwaycompromise:inhalationinjury.
7.InabilitytomaintainSpO2>90%byfacemaskoxygenation.

OptionsforachievingETImayincludeanyoneofthefollowingairwayaidsdependingonthesituation,device
availabilityandpresenceofoperatorwithnecessaryexpertise.

1.Directlaryngoscopyandtrachealintubation.
2.Videolaryngoscopyandintubation.
3.Fibreoptictrachealintubation.
4.Lightwandguidedtrachealintubation.
5.IntubatingLMA/CTrachaidedtrachealintubation.
6.Bullard,UpsherScopeorWuScopeaidedintubation.
7.Retrogradetechniqueoftrachealintubation.
8.Blindnasalintubation.

Directrigidlaryngoscopyusingastraightoracurvedbladelaryngoscopeisstillthemostsuccessfulaidin
performingETIinpatientswithtrauma.Thisisbecausewehavevastexperiencewithitsdailyusevisionisnot
hamperedinthepresenceofblood/secretion/vomitus,anditisrobustenoughwhiledealingwithan
uncooperative/combativepatient.Ithasbeenerroneouslybelievedthatdirectconventionallaryngoscopyis
associatedwithsignificantmovementofthecervicalspine.Cadavericandstudiesdoneonlivetraumapatientshave
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failedtosupportthisassumption.Today,thereisenoughevidencethatagentledirectlaryngoscopywithMILSis
notassociatedwithanyaggravationofspinalcordinjury.[12,13]

VideolaryngoscopessuchasGlideScope(Verathon,Bothell,Washington),TruviewPCD(Truphatek,Israel),
McGrathAircraftMedicalLtd.,Edinburgh,UK)andothersgivetheabilitytoviewtheimagesonamonitor,
therebyprovidingimmediatefeedbacktoanassistantapplyingexternallaryngealmanipulation.[14]Inaddition,
videolaryngoscopictechniquesalsohaveagreatpotentialforteachingtheartofairwaymanagementintrauma
patients.Butthesetechniqueshavetheirshareofdisadvantagessuchasblurringofviewinpresenceofbloodand
secretionsbesidesbeingexpensive.

Fibreoptictrachealintubationisconsideredtobethepreferredmethodforintubatingapatientwithanunstable
cervicalspine.Leastcervicalspinemovementisassociatedwithfibreoptictrachealintubation.[15]Inthe
emergencydepartment,thesuccessrateofthisairwayaidrangesbetween50and90%.[1618]However,one
shouldrememberthatitismostlikelytofailinthepresenceofblood,secretionandvomitusorinanuncooperative,
combativepatient.

Lightwand(Trachlight:LaerdalMedicalCorp.,WappingersFalls,NewYork)isasafe,effective,rapidand
inexpensiveintubatingdevice.Lightwandtrachealintubationisasuitableairwayaidintraumapatientswhere
intubationistobedoneintheneutralpositionorwithminimalheadextension.Itssecondmajoradvantageisthatits
successisnotsignificantlyimpactedbythepresenceofbloodandsecretion.However,sincethismethodof
intubationisablindapproach,itshouldbeavoidedinpatientswithexpandingneckmassesorlaryngopharyngeal
trauma.[14]

IntubatingLMA/CTrachaidedtrachealintubationhasbeenusedintraumapatientsforachievingtracheal
intubation.Theyrequireminimalheadandneckmovementwhileplacingthemintothepatient'soropharynxand
facilitateETIasthepatientisbeingsimultaneouslyventilated.However,Brimacombeetal.havedemonstratedthat
itsusemaybeassociatedwithsignificantdisplacementoftheunstablecervicalvertebra.[15]Intubatinglaryngeal
maskairway(LMA)hasbeennotedtocausegreatercervicalvertebradisplacementascomparedwithconventional
orotrachealintubation.[19]Hence,oneshouldbecautiousinitsuseinpatientswithcervicalinjury.

Bullardlaryngoscope(CirconCorp.,Stamford,Connecticut),UpsherScope(MercuryMedical,Clearwater,
Florida)orWuScope(AchiCorp.,SanJose,California)aidedtrachealintubationhavetheadvantageof
conventionalfibreopticscope.Inaddition,theyaremorerobustandneedlessintensivetraining.[20]Becauseof
theiranatomicallycurvedshape,theyareespeciallysuitedforpatientswithcervicalspineinjuryasnoheadand
neckmovementisnecessaryfortheiruse.Cricoidpressureandinlinestabilisationoftheheadandneckdoesnot
seemtointerferewiththeutilityofBullardscope.[21]Likeanyotherfibreopticlaryngoscopes,theseare
handicappedbytheirinabilitytoaidvisualisationofthelarynxinthepresenceofblood,vomitusorsecretions.
However,WuScopeispartlyprotectedfromthishandicapasitsopticalsystemisrelativelyprotectedinits
tubularblade.[14]

Blindnasotrachealintubation,thoughstillapartofATLS,[10]hasveryfewindicationsintraumapatients.One
suchindicationmaybelimitedmouthopeningasallotherdevicesdetailedaboverequireamouthopeningofat
least2cmfororotrachealintubation.Insuchsituation,nasotrachealintubationmaybeattemptedifsurgicalairway
isnotimmediatelyindicated.Oneshouldrememberthatitshouldbeundertakenonlybyexpertpersonnel.
Contraindicationstonasotrachealintubationaresignificantmidfacetraumaandcoagulopathy.[14]

Oncetrachealintubationhasbeenachieved,itisessentialtoconfirmcorrecttrachealtubeplacement.Thisisdone
byeithervisualisingthetrachealtubepassthroughthevocalcordsorusingothermethodssuchaswatchingthe
chestmoveandauscultating5pointsonthepatient'schestCO2detectorandachestXray.Capnography
(continuousCO2detectionwithawaveform)istherecommendedmethodnow.Onlywhenitisnotavailable,
capnometry(singlemeasurementofCO2)shouldberesorted.Oncecorrectlyplaced,donotforgettosecurethe
endotrachealtubelestitgetsdisplaced.

Gumelasticbougieisanunderutilisedairwayaidinthesettingoftraumaairwaymanagement.Itsadvantagelies
notonlyinmakingadifficultintubationpossiblewhenonlyaportionoflaryngealinletorepiglottisaloneis
visualised,butitsuseisalsonotaffectedbythepresenceofbloodandsecretion.[10,22,23]Alltraumacare
operatorsshouldbesatisfiedwithaCormackandLehane'sclass2or3viewanduseabougietoaidtracheal
intubationratherthanuseforcetoobtainclass1viewandaggravatecervicalinjury.
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Surgicalairwayshouldberesortedwhenthereissevereglottisoedemaand/ororopharyngealhaemorrhage,fracture
ofthelarynxandwhenendotrachealtubefailstobepassedthroughthevocalcords.1%oftraumapatients
requiringintubationrequireasurgicalairway.[24]Surgicalairwaytechniquesincludecricothyrotomy.[10]
Cricothyrotomycanbeperformedusingthefollowingthreetechniques:

1.Aneedleusinga1214gaugecannula.Thecannula,afterwithdrawingtheneedle,isconnectedto4050psi
sourcedeliveringoxygenat15l/minute.Intermittentinsufflation,1secondonand4secondoff,canprovide
satisfactoryjetinsufflation.
2.Aneedleairwayprocedureasabove,butwheretheventilationisprovidedbylowpressureventilation.
3.SurgicalAirwaywhereacuffedtubeisinsertedintothetracheathroughthecricothyroidmembraneand
ventilationisperformedthroughaselfinflatingbagorotherventilatingtechnique.

Percutaneoustracheostomy(PCT)isnotrecommendedinthetraumasetting.[10]Thisisessentiallybecausefor
performingPCT,oneneedstohyperextendthepatient'sneck.Thiscanhavedisastrousconsequencesifthepatient
hasacervicalinjury.Thisprocedurecanbedangerousandistimeconsumingandhencenotadvocated.

SEMIDEFINITIVEAIRWAYSTRATEGY Goto:

Theroleofsemidefinitivedevices(supraglotticairwaydevices)hasbeenclearlydefinedinthemanagementof
traumapatientsinthe8theditionofATLS.[10]Asimplifiedapproachtodefinitiveairwaymanagementintrauma
patientsinpresentedinFigure1.ThethreedeviceswhicharerecommendedincludeLMA,Combitubeand
laryngealtube(LT).

Figure1
Simplifiedapproachtodefinitiveairwaymanagementintraumapatients

Laryngealmaskairway
TheLMAisconsideredausefulairwaydeviceinanypatientwheredefinitiveairwaycouldnotbeestablished.
However,LMAisnotconsideredadefinitiveairwaydevice.ATLSstronglyrecommendsthatphysiciansshould
planforadefinitiveairwaywhenpatientwiththisdevicearrivesintheemergencydepartment.Ithasbeen
recognisedthatforproperplacementofLMA,appropriatetrainingisessential.

Laryngealtube
TheLTissupraglotticairwaydevicewithcapabilitiessimilartoLMA.AswiththeLMA,LTisnotconsidereda
definitiveairwaydevice.LiketheLMA,LTisplacedwithoutdirectvisualisationoftheglottisanddoesnotrequire
significantmanipulationoftheheadandneck.UnlikethecombitubeandETI,LToffersimprovedinsertionsuccess
andlesserplacementtime.[25]

Combitube Itisstillrecommendedasasemidefinitiveairwaydevicetobeusedintraumapatientswherefacilities
fordefinitiveairwaydonotexistorhavefailed.Itisatimepurchasedeviceandallattemptsshouldbemadeto
switchovertoadefinitiveairwaydeviceattheearliest.UnliketheLT,itmayrarelyenterintothetrachea.Insuch
circumstances,animmediateswitchovertotheotherproximallumenshouldbedoneforinitiatingcorrect
ventilation.

Miscellaneousissuesduringtheairwaymanagementoftraumapatient.Theseissuesincludethefollowing:roleof
cricoidpressureandcervicalimmobilisation,dealingwithacombativepatientanddilemmaofawaketracheal
intubation.

Cricoidpressure,theSellick'smaneuver,isnotmentionedinthe8theditionofATLScoursemanualexceptasa
singlelineunderrapidsequenceintubation.[14]Althoughithasbeenusedtopreventregurgitationofgastric
contents,itisknowntodistortthelaryngealviewanddisplaceunstablecervicalspine.Ifstillutilised,cricoid
pressureshouldbereducedoraltogetherremoved,iffeltthatitishamperingtrachealintubationorplacementof
supraglotticdevice.

Cervicalimmobilisation

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Inanonrandomisedcomparativeevaluationofthreetechniquesofcervicalspineimmobilisation(rigidcervical
collar,tapeacrossforeheadwithsandbagsoneithersideoftheneckandmanualinlinestabilisation)on
laryngoscopicviewoftheglottisduringlaryngoscopy,Heath[26]notedpoorlaryngoscopicview(grade3or4of
CormackandLehane's)in64%patientswhencervicalimmobilisationwasattemptedusingrigidcollarortape
acrossforeheadascomparedwithonly22%whenusingMILS.Hence,MILSshouldbethefavouredtechniqueof
cervicalspineimmobilisationinpatientwithsuspectednecktrauma.

Dealingwithacombativepatient Patientswithtraumamaybecombativeasaresultofintoxication(alcoholor
drugs),butotherequallyimportantfactorsarebecausetheyarehypoxic,hypercarbic,headinjured,frightened,
disorientedorareinseverepain.Oneshouldalsorememberthattheremaybeunderlyingmedicalconditionsuchas
hypoglycaemiacontributingtotheircombativebehaviour.[27]Addressingallthesecontributingfactorsshouldgo
sidebysidetoairwaymanagement.Physicalandchemicalrestraintduringairwaymanagementshouldberestricted
topatientsinwhomtheabovefactorshavebeeneitherruledoutorhavebeenadequatelyattended.Physical
restraintmaybeachievedbyplacingthepatientonalongspineboardwithacervicalcollar,tapeandsandbags.
However,ifthepatientcontinuestostruggle,hecanpotentiallyinjurehisspineandwarrantsfurtheraction.Inthe
haemodynamicallystablepatient,haloperidol,5mg,canbegiveninrepeateddosesintravenouslyevery5minutes
withobservationforeffect.[28]

Awaketrachealintubation Acommonlyheldbeliefinthe1970sand1980swasthatdefinitiveairway
managementinanawakepatientprotectstheinjuredcervicalspineasthenonparalysedneckmuscletoneactsasa
splint.Thereisnoevidencetosupportthisassumption.[27]Infact,suchpatientscansignificantlyaggravatetheir
cervicalinjuryduetocoughing,bucking,gaggingorstruggling.IntheNationalEmergencyAirwayRegistry,a
multicentrestudyofmorethan15,000emergencyintubations,aphasetwodataanalysisoftraumaintubations
showedthat80%ofpatientsunderwentrapidsequenceinductionandintubationusingmusclerelaxantwithout
cervicaldamage.[29]

Rapidsequenceintubation Rapidsequenceinductionandtrachealintubationunderanaesthetic,sedativeand
neuromuscularblockingdrugisstillconsideredhazardous.[10]However,ifthesituationjustifiestheriskof
administeringthesedrugs,oneshouldassurethatskilledpersonnelareavailabletoperformtrachealintubation.

Followingstepsshouldbestrictlyadheredtowhilecarryingoutrapidsequenceintubation:

1.Ensurethepresenceofapersonwithskillstoperformsurgicalairwayintheeventoffailedintubation.
2.Ensurethatsuctionanddevicetoventilatethepatientisreadilyavailable.
3.Preoxygenatewith100%oxygenandapplycricoidpressure(Sellick'smaneuver).
4.Administeretomidate0.3mg/kgor20mgandthenadminister12mg/kgsuccinylcholineintravenously.
Avoidsuccinylcholineinpatientswithseverecrushinjuries,majorthermalandelectricalburns,preexisting
chronicrenalfailure,chronicparalysisandchronicneuromusculardiseaseasithasthepotentialforsevere
hyperkalaemia.Thiopentalandsedativedrugs(midazolamanddiazepam)shouldbeavoidedinpatientswith
hypovolaemia.
5.Performintubationafterthepatientrelaxes.
6.Inflatethecuffoftheendotrachealtubeandconfirmcorrecttrachealtubeplacementbyauscultationand
presenceofCO2inexhaledair.
7.Releasecricoidpressure.
8.Ventilatethepatient.
9.Securethetrachealtubefirmly.

Footnotes Goto:

SourceofSupport:Nil

ConflictofInterest:Nonedeclared.

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