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KEY POINTS

KEY POINTS

  • Airway obstruction can occur from excessive bleeding, expanding hematomas, direct anatomic disruption, traumatic swelling, and edema.

  • Prehospital airway interventions can range from BLS airway devices, alternative or blind inserted airway devices, to endotracheal intubation.

  • Capnography is the measurement of end-tidal carbon dioxide, which is typically 2 to 5 mm Hg lower than the patient’s PaCO2.

  • In the technique of RSI, laryngoscopy and intubation are facilitated by use of sedating induction agents and short-acting neuromuscular blockade.

  • Etomidate and ketamine are the most appropriate induction agents in most RSI protocols.

  • Adequate preoxygenation along with passive oxygenation during intubation attempts are vital in preventing hypoxia.

  • Factors contributing to difficult airways include anatomic features, abnormal vital signs, and airway contamination.

  • General guidelines for appropriate depth of an endotracheal tube are 21 cm for adult women and 23 cm for adult men.

  • Surgical cricothyroidotomy is contraindicated in children less than 12 years old.

  • A commonly used formula in children to select the appropriate size of an uncuffed endotracheal tube (ET) is ET size in mm = 4 + (age in years)/4.

INTRODUCTION

Airway is the first priority for all civilian trauma patients in the prehospital setting, emergency department, and throughout their hospitalization. In all situations, failure to oxygenate and/or ventilate due to an inadequate airway will lead to death within minutes. The airway in a trauma patient may be adequately managed with either noninvasive maneuvers or a definitive airway, most commonly orotracheal intubation. Clinicians charged with caring for trauma patients must be able to quickly recognize a trauma patient in need of an airway intervention as well as develop and sustain the skills necessary required to perform the vast array of lifesaving maneuvers designed to establish and maintain a patent airway. This chapter will present a detailed discussion regarding the assessment and management of the airway for trauma patients in the prehospital setting and emergency department.

AIRWAY EVALUATION

Airway management in trauma patients is most often an emergency intervention complicated by required cervical spine immobilization for blunt trauma patients. The emergent nature of the procedure does not allow time for a detailed and thorough airway evaluation, so every trauma patient should be considered to have a difficult airway to ensure appropriate preparation. However, a brief evaluation of the airway prior to intervention may provide insight to the possibility of a particularly challenging situation.1,2

If the trauma patient is conscious and able to cooperate, a brief history may elicit additional risk factors for a difficult airway including obstructive sleep apnea, arthritis, head and neck cancer or radiation, or any difficulty with previous airway interventions. In addition, history of difficult prehospital airway interventions should be a cue that the current emergency department airway management will be challenging. Although traditional difficult airway scoring systems such as the Mallampati and LEMON (look, e...

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