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 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 life-saving maneuvers designed to establish and maintain a patent airway in trauma patients. The following monograph will present a detailed discussion regarding the assessment and management of the airway for trauma patients in the prehospital setting and emergency department.
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 can be considered to have 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. While traditional difficult airway scoring systems such as the Mallampati and LEMON scores are not applicable in trauma patients due to the emergent nature of the airway intervention, several physical examination findings may be useful to determine increasing difficulty with airway management. Keeping in mind that the vast majority of trauma patients will have limited neck mobility due to cervical spine immobilization and cervical collar, additional physical examination findings that portend a difficult airway include presence of a beard or facial hair, obesity, and evidence of direct injuries to the head, face, and neck.
Trauma patients may present with blunt or penetrating injuries to the head, neck, or face, which ultimately may result in airway obstruction. This obstruction can be immediate or delayed. It is imperative to manage any airway that cannot by protected by the patient or any patient unable to be adequately oxygenated or ventilated. Additionally, the provider needs to anticipate the potential for obstruction and intervene prior to ventilatory failure. Common causes of direct airway trauma include blunt or penetrating maxillofacial or neck injuries, burns, and smoke inhalation. Airway obstruction can occur from excessive bleeding, expanding hematomas (Fig. 11-1), direct anatomic disruption, as well ...