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The Priority of the Airway

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In the crucial initial management of the injured patient, securing the airway is quite literally the single most important priority; failure to oxygenate and ventilate represents the difference between life and death as well as functionality and disability. Airway loss initiates a terminal and irreversible cascade of events. Not only are hypoxia and hypoventilation common injury-related causes of mortality, but also they additionally represent one of the most common causes of preventable mortality following injury. The trauma patient represents a unique and exquisite airway challenge, from both anatomic and physiologic perspectives. The multisystem trauma patient represents the culmination of interrelated insults to oxygenation and ventilation, where under extreme duress, clinicians must rapidly recognize compounding injury and prioritize the airway in what may be multiple conflicting priorities.

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Preparation for Airway Management

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Successful airway management starts with planning and preparation. Planning begins by assembling an airway kit or cart containing the necessary equipment for intubation. The practitioner should take the time to inventory the equipment prior to the intubation, ensuring function and availability.

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Equipment

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The airway cart should consist of drugs, endotracheal tubes, airways, laryngoscopes, airway adjuncts, a variety of syringes and needles, and equipment to establish a surgical airway.

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The primary components of the airway kit are the endotracheal tube and laryngoscope. The airway cart should have a variety of tubes in both cuffed and uncuffed types, including tubes down to a 2.0 internal diameter size for pediatrics, and a variety of stylet sizes. Both Miller and Macintosh laryngoscope blades should be included. In addition, the airway cart should be stocked with both the oropharyngeal airway (OPA) and nasopharyngeal airway (NPA) in all sizes. In the event of failed intubation, several airway adjuncts should be included in the standard airway cart. An array of adjuncts is now available to assist with difficult intubation and failed airway, including supralaryngeal airways, lighted wand stylets, retrograde intubation kits, a variety of video laryngoscopic devices, and the gum elastic bougie (GEB).

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The goal of airway management in the trauma admitting area is to closely simulate the control of the operating room. Key personnel should work as a team to assure a successful intubation (Fig. 11-1). The optimal intubating team should consist of at least three members including the intubator, a respiratory therapist, and an assistant to maintain cervical spine alignment or to provide the Sellick maneuver to prevent aspiration.

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Figure 11-1
Graphic Jump Location

The optimal rapid sequence intubation team is comprised of (1) the intubating provider at the head of the bed, (2) an assistant to the patient’s right to facilitate passage of necessary equipment from the airway cart (to the intubating provider’s right) and to provide cricoid cartilage pressure, (3) a provider to administer drugs ...

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