Airway Management in Trauma

Trauma Airway: Initial Assessment - Red Alert Airways

• Key Challenges: C-spine injury (MILS vital), full stomach (aspiration risk), facial/neck trauma, shock, ↓GCS. Anticipate difficult airway.
• Assessment:
  • 📌 LEMON for difficult airway:
    • Look: Facial trauma, small mouth, dentures.
    • Evaluate: 3-3-2 rule (mouth opening, hyomental, thyromental distances).
    • Mallampati: Often impractical/deferred.
    • Obstruction: Stridor, hematoma, foreign body.
    • Neck mobility: Assume limited (C-spine).
• Red Alerts (Impending Loss/Difficult Airway):
  • Stridor, hoarseness, gurgling.
  • Subcutaneous emphysema, crepitus.
  • GCS < 8.
  • SpO2 < 90% despite O2.
  • Severe maxillofacial/neck trauma (e.g., Le Fort II/III).
  • Expanding neck hematoma.

⭐ Assume C-spine injury in ALL trauma patients; maintain Manual In-Line Stabilisation (MILS) during airway management to prevent secondary neurological injury.

Trauma Airway: Adjuncts & Techniques - Lifesaving Lineup

• Airway Adjuncts:
  • Oropharyngeal Airway (OPA): For unconscious patients, no gag reflex. Size: incisors to angle of jaw.
  • Nasopharyngeal Airway (NPA): For conscious/semiconscious patients. Size: nares to tragus. ⚠️ Avoid if basal skull fracture.
  • Supraglottic Airways (SGA, e.g., LMA, i-gel): Rescue device, difficult airway, bridge to ETT.
• Laryngoscopy:
  • Direct Laryngoscopy (DL): Standard technique. Manual In-Line Stabilization (MILS) crucial.
  • Video Laryngoscopy (VL): Improved view, less C-spine movement. Preferred in suspected C-spine injury.
• Endotracheal Intubation (ETT):
  • Confirmation: 📌 Capnography (EtCO₂ - gold standard), Chest rise (bilateral), Condensation in tube. Auscultate: air entry, no gastric sounds.
  • ETT cuff pressure: 20-30 cm H₂O to prevent aspiration & tracheal injury.
  • Secure ETT firmly.

⭐ Continuous waveform capnography is the most reliable method to confirm and monitor endotracheal tube placement.

Trauma Airway: RSI Protocol - Go-Time Protocol

RSI for trauma airway. MILS if C-spine suspected. 📌 "7 P's of RSI" guides this.

• Induction Agents:
  • Etomidate: 0.3 mg/kg IV (cardio-stable).
  • Ketamine: 1-2 mg/kg IV (hypotension/bronchospasm).
• Neuromuscular Blockers (NMB):
  • Succinylcholine: 1-1.5 mg/kg IV (rapid; ⚠️ hyperkalemia risk: crush/burns >24h).
  • Rocuronium: 1-1.2 mg/kg IV (alternative, longer).

⭐ Ketamine is often preferred in hemodynamically unstable trauma patients due to its sympathomimetic properties, but caution with isolated severe TBI.

Trauma Airway: Difficult Airway - SOS Airways

• Difficult Airway (DA) Predictors (Trauma):

  • C-spine immobilization, facial/neck trauma, burns.
  • LMO, airway blood/vomit, agitation.
  • 📌 LEMON (adapted): Look, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility.

• SOS Airway Management (CICO Protocol):

  • Recognize failure: Max 2-3 intubation attempts or failed oxygenation.
  • Call for HELP (senior anesthesiologist, surgeon).
  • Oxygenation pathway: FMV → SGA. If both fail & CICO confirmed → FONA.

• Surgical Airway (FONA - Front of Neck Access):
  • Indication: CICO.
  • Preferred: Surgical cricothyroidotomy (scalpel-bougie, ET tube size 6.0 mm).
  • Needle cricothyroidotomy: temporary, for oxygenation; barotrauma risk.

⭐ In CICO, immediate surgical cricothyroidotomy is life-saving and must not be delayed.

High‑Yield Points - ⚡ Biggest Takeaways

• C-spine immobilization is paramount during all airway interventions.
• Rapid Sequence Intubation (RSI) is standard for trauma, assuming a full stomach.
• Anticipate difficult airway; have backup devices and surgical airway ready.
• Ketamine is preferred for induction in hemodynamically unstable trauma.
• Avoid nasotracheal intubation in suspected basal skull fracture or severe midface trauma.
• Maintain Manual In-Line Stabilization (MILS) during laryngoscopy and intubation.
• Capnography (EtCO2) is essential to confirm endotracheal tube placement.