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com [25712]

The European Trauma Course Manual

Edition 4.0
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3.
Airway management in the trauma patient
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
QAssessing a patient’s airway
QBasic airway management and the use of simple airway adjuncts
QThe use of supraglottic airway devices
QTechniques for ventilation of the patient’s lungs
QRecognising the potential for a difficult airway
QThe use of surgical airways in the resuscitation room
Introduction
Establishing a clear airway and ensuring adequate
oxygenation are essential prerequisites for successful
resuscitation and are therefore part of the key initial
interventions by the team in the trauma patient.
Failure to recognize and clear an obstructed airway
will rapidly result in hypoxemia and ultimately,
cardiopulmonary arrest. Unfortunately, fatalities still
occur in patients because inadequate attention is paid
to the principles of basic airway management.
Once patent, the airway must be secured to enable
continuous, efficient oxygenation (and ventilation)
whilst at the same time minimising the risk of
aspiration. If the cervical spine is injured, the spinal
cord may be jeopardised if airway interventions are
not controlled carefully. This chapter will describe how
to assess, clear, and secure the airway and oxygenate
the trauma patient, while minimising the risk of
injuring the spinal cord.
Standby preparation and transfer
Although all equipment must be checked regularly,
the airway personnel must complete a final check of
equipment while waiting for the patient to arrive.
On arrival at hospital, the patient’s airway must be
assessed immediately, as part of the 5-second round. If
there is evidence of compromise, clear and secure the
airway using simple techniques while simultaneously
immobilising the head and neck. This may be with
a semi-rigid cervical collar alone or combined with
lateral blocks and tapes or a vacuum mattress,
depending on local protocols. Alternatively, manual
in-line stabilisation (MILS) of the cervical spine can be
used. Ensure that there is no uncontrolled movement
of the spine or loss of airway patency during transfer
to, or within, the resuscitation room.
Primary survey
Immediate evaluation of the patient’s airway is carried
out in order to identify and treat current problems
and to anticipate potential problems. Regular re-
evaluation is also mandatory during the primary
survey as the situation is dynamic and problems may
develop over time. The quickest way of evaluating the
airway is to ask the patient ‘Are you alright?’. A lucid
reply implies patency, a reasonable vital capacity
breath and a cerebral perfusion sufficient to maintain
consciousness. If the patient fails to reply or their
response is impaired a more detailed assessment is
made using the look, listen and feel approach:
QLOOK specifically for chest and abdominal
movement;
QLISTEN for any noise associated with breathing.
Normal breathing should be quiet, noisy breathing
indicates partial airway obstruction;
QFEEL for airflow at the mouth and nose.
Patient’s airway is clear
Breathing should be quiet with no abnormal noises
and with good airflow at the mouth and nose. A clear
airway is associated with a normal pattern of chest
CHAPTER 3 AIRWAY MANAGEMENT IN THE TRAUMA PATIENT | 35
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and abdominal movement, although the respiratory
rate may be increased due to hypoxia or hypercarbia.
Therefore oxygen should be given via a facemask and
a pulse oximeter applied to assess oxygenation.
Although the patient may have a clear airway, this
does not guarantee adequate ventilation as there
may be other injuries e.g. to the chest. If ventilation is
inadequate, it must be supported.
An obstructed airway
Obstruction may be partial or complete and sited at
any level from the upper airway (nose/mouth) down to
the lower airway (bronchi). Common causes include:
Qloss of upper airway muscle tone, usually due to a
reduced conscious level
Qthe presence of blood, vomit or foreign bodies
Qtrauma to the face or neck
Qlaryngeal spasm
Qbronchospasm
Partial obstruction
Look at the patient:
Qthey are usually tachypnoeic (respiratory rate
>25/min), agitated, and sweaty due to hypoxia and
hypercarbia;
Qthe accessory muscles of respiration are used - the
neck and the shoulder muscles contract to assist
movement of the thoracic cage. There may also be
suprasternal, intercostal and subcostal recession
and a tracheal tug.
Listen for:
Qinspiratory stridor - caused by obstruction at the
laryngeal level or above
Qexpiratory wheeze - suggests obstruction of the
lower airways, which tend to collapse and obstruct
during expiration
Qgurgling - suggests the presence of liquid or
semisolid foreign material in the upper airways
Qsnoring - arises when the pharynx is partially
occluded by the tongue or palate
Qbreath sounds - on auscultation, air entry will be
diminished
Feel:
Qthere will be reduced airflow at the nose and mouth.
Complete obstruction
Look at the patient:
Qsearch for paradoxical movement of thorax and
abdomen (inward movement of abdominal wall on
inspiration). This may in some cases be vigorous.
Listen for:
Qthere will be no sounds due to absence of airflow.
Feel:
Qno airflow is felt at the mouth or nose.
Unless airway obstruction is relieved and oxygenation
and ventilation restored rapidly, hypoxia will cause
injury to the brain and other vital organs. Ultimately a
36 | EUROPEAN TRAUMA COURSE
cardiac arrest ensues. While the techniques described
below are implemented to relieve the obstruction,
high concentration oxygen should be given via a
facemask as complete obstruction is relatively rare.
Basic techniques for opening the airway
If there is evidence of foreign material in the airway
it should be removed. Small amounts of blood and
secretions need to be cleared from the oral cavity by
using a suction catheter. Large amounts of blood or
vomit are best removed using a rigid, wide bore sucker
(Yankauer). Solid debris such as food or teeth is best
removed with forceps (Magill) or similar device.
Initial manoeuvres to relieve obstruction of the airway
include chin lift and jaw thrust. Assess the effectiveness
of these manoeuvres using the look, listen and
feel approach described above, whilst at all times
maintaining immobilisation of the cervical spine.
Chin lift (see skills section)
KEY POINTS
Indication: airway obstruction or occlusion
Procedure: grasp the patient’s chin and lift the
mandible anteriorly
Complications: failure, loss of the airway on release
Common insufficient force used to lift the mandible
pitfalls:
Jaw thrust (see skills section)
KEY POINTS
Indication: partial or complete airway obstruction
Procedure: upwards and forwards pressure at the
angles of the mandible
Complications: movement of the cervical spine, loss
of the airway on release, may worsen
obstruction if the mandible is fractured
Common failure to clear the airway, failure to
pitfalls: recognize inadequate oxygenation and/
or ventilation
Adjuncts to basic airway techniques
The oropharyngeal (Guedel) airway and the
nasopharyngeal (Wendl) airway are curved plastic
tubes that are designed to overcome airway
obstruction caused by the backward displacement
of the tongue or by the soft palate. They do not
guarantee a secure airway and may need to be used in
conjunction with a jaw thrust. Once inserted, reassess
airway patency using look, listen, and feel approach. A
patient who tolerates an oropharyngeal airway has an
unprotected airway and is at risk of regurgitation and
aspiration. The team leader should be informed and
plans made to secure the airway using an advanced
technique.
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Insertion of oropharyngeal airway (see skills section)
KEY POINTS
Indications: partial or complete airway obstruction
Procedure: insertion of an oropharyngeal airway
Complications: vomiting due to gag reflex if too long,
bleeding do not use if there is a known
or suspected base of skull fracture,
laryngeal spasm
Common backward displacement of the tongue
pitfalls: exacerbating obstruction, assuming a
patent airway means oxygenation
The nasopharyngeal airway is a soft plastic tube,
bevelled at one end with a flange at the other. They
are better tolerated than oropharyngeal devices by
patients who are not deeply unconscious. It may also
be life-saving in patients with maxillofacial injuries or
trismus.
Insertion of nasopharyngeal airway (see skills section)
KEY POINTS
Indications: partial or complete airway obstruction,
particularly when trismus is present
Procedure: insertion of a nasopharyngeal airway
Complications: vomiting due to gag reflex if too long,
bleeding, do not use if there is a known
or suspected base of skull fracture
Common failure to insert as pushed ‘up’ the
pitfalls: patient’s nose, rather than along the floor
of the nose
Cervical spine immobilisation
At all times while managing the airway, consideration
must be given to the possibility of injury to the cervical
vertebrae and spinal cord. If a patient arrives without
their cervical spine being immobilised, this should
be achieved initially by a member of the team using
MILS. Once the airway has been assessed and any
intervention required completed, MILS should be
replaced with a semi-rigid collar, blocks and tapes
or a well moulded vacuum mattress according to
local policy. In patients who arrive with cervical
immobilisation already applied, this will need to be
removed temporarily to allow airway management,
in particular tracheal intubation or a surgical airway.
In these circumstances, MILS must be applied before
any of the immobilising devices are removed and
maintained until they are fully reapplied. Tracheal
intubation should not be attempted with a semi-rigid
collar in place as the procedure is made much more
difficult and puts the patient at risk of oesophageal
intubation, failed intubation and hypoxia.
Manual in-line stabilisation (MILS) (see skills section)
KEY POINTS
Indications: actual or potential risk of injury to the
cervical vertebrae or spinal cord
Procedure: stabilisation of the head and neck by a
team member
Complications: difficulties with airway management
Common exacerbation of injury due to use of
pitfalls: excessive force
Adequacy of oxygenation
After insertion of either of the above devices, re-check
the patency of the airway using the look, listen and
feel technique. It is usually necessary to maintain a
jaw thrust. Assuming that these simple manoeuvres
allow the patient to breathe spontaneously, give
oxygen via a good fitting facemask with a reservoir at
15 l/min. The reservoir needs to be full before the mask
is applied and should inflate and deflate with each
breath. If spontaneous ventilation is inadequate, or
the patient remains apnoeic despite a patent airway,
they will need to be ventilated.
Bag-mask ventilation
This is the simplest and most widely used device to
oxygenate and ventilate a patient whose own efforts
are inadequate or absent. The mask covers the mouth
and nose, the bag is squeezed and its contents are
delivered to the lungs. On release, the expired gas is
diverted to the atmosphere and the bag refills with
air and oxygen if attached. When used alone, the
lungs are inflated with air (21% oxygen). This can be
increased to a maximum of around 80% if high flow
oxygen and a reservoir are attached.
The use of a bag-mask apparatus by a single person
requires considerable skill because it is difficult to
achieve a gas-tight seal, and maintain a patent airway
with one hand whilst squeezing the bag with the
other. Any significant leak will cause hypoventilation
and if the airway is not patent, gas may also be
forced into the stomach. This will reduce ventilation
further and greatly increase the risk of regurgitation
and aspiration. There is a natural tendency to try to
compensate for a leak by excessive compression of the
bag, which causes high airway pressures and forces
more gas into the stomach. Most of these patients will
ultimately need an advanced airway; a supraglottic
device, tracheal tube or surgical airway depending on
the urgency and the skills available within the team
members. Once an advanced airway device is in place,
the bag can be connected to ventilate the patient.
If there is any possibility of injury to the cervical
vertebrae or spinal cord, all airway interventions
must be performed while maintaining alignment and
immobilisation of the head and neck.
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Bag mask ventilation (see skills section)
KEY POINTS
Indications: inadequate spontaneous ventilation,
apnoea
Procedure: bag-mask ventilation
Complications: leak around the mask, gastric insufflation
Common inadequate ventilation, excessive
pitfalls: ventilation
Pulse oximetry
This is essential in all trauma patients to assess
adequacy of oxygenation which can be impaired
as a result of either ‘A’ or ‘B’ problems as well as
‘C’ (e.g. haemorrhagic shock), and ‘D’ problems
(e.g. high spinal cord injury). The oximeter probe
is attached to the tip of a digit or earlobe and the
device displays the SpO2 both as a waveform and
a digital reading. Pulse oximeters are accurate to
± 2%. The heart rate is usually also displayed. The pulse
oximeter therefore provides information about both
the circulatory and respiratory systems. However, there
are several important limitations to pulse oximetry:
QA saturation of 100% normally equates a PaO of
2
12 kPa, whereas a saturation of 90% equates to a
PaO2 of only 8kPa (60mmHg). That is a 10% drop
in saturation, but a 40% drop in partial pressure.
Below this, the oxygen content of blood decreases
even more rapidly.
Figure 3.1 Difficult Airway Algorithm (with permission of the Difficult Airway Society) http://das.uk.com
38 | EUROPEAN TRAUMA COURSE
QIt is unreliable when there is severe
vasoconstriction because of the reduced
pulsatile component of the signal.
QIt provides no indication of adequacy of ventilation.
Profound hypercapnia (increased PaCO2) is possible
with normal oxygen saturations, particularly when
using a high inspired oxygen concentration.
QIt is unreliable with certain haemoglobins:
w
O hen carboxyhaemoglobin is present (smoke
inhalation), it overestimates SpO2
when methaemoglobin is present (intoxication
O
with methaemoglobine forming agents), SpO2 is
underestimated at values greater than 85%
QIt progressively under-reads the arterial blood
saturation as the haemoglobin decreases (but is
not affected by polycythaemia)
QIt is affected by extraneous light and unreliable
when there is excessive movement of the patient
Advanced airway techniques
A number of situations may occur when it is
inappropriate or impossible to maintain a patent
airway and achieve adequate oxygenation and
ventilation using the techniques described above. In
these circumstances an advanced airway technique is
indicated. Common indications include:
Qinadequate airway with basic techniques, e.g.
severe facial fractures
Qreduced conscious level, tolerating an
oropharyngeal airway
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Qairway at risk from swelling, e.g. burns, multiple
cervical vertebral fractures, massive subcutaneous
emphysema
Qcompromise of normal respiratory function, e.g.
chest trauma
Qspecific need for ventilation, e.g. traumatic brain injury
Advanced airway management in a patient with
residual airway patency and/or respiratory effort
usually requires the employment of anesthetic drugs.
This makes it a procedure with a high risk of potentially
lethal complications. It should therefore only be carried
out by a team of clinicians who are experienced in
emergency advanced airway management.
To reduce the risk of complications, we recommend the
implementation of several precautions in your system.
First is a difficult airway algorithm. Throughout
Europe, the Difficult Airway Society (DAS) guidelines
have generally been adopted. The main flow diagram
of the DAS guideline is shown in figure 3.1 Although
ETC recommends the use of the DAS algorithm, it
is not the only difficult airway algorithm. ETC also
recommends to verify which algorithms are in use in
your own system to assure everyone follows the same
protocols in an emergency. Independent of which
exact algorithm
Figure 3.2 Shaping the mind set; The Vortex Approach (with kind permission of Nicholas Chrimes, www.vortexapproach.org)
Second is a systematic approach to unexpected
difficulties in airway management. One such approach
is the Vortex approach, which describes a mindset,
which can be overlaid on any difficult airway algorithm.
Conceptually, airway management is described like a
funnel (figure 3.2). The upper edge of the funnel is the
safe “green zone” in which a patient can oxygenate
and ventilate him- or herself. Once anesthesia is
induced, the green zone is left and oxygenation spirals
down the funnel. Once started, there are maximum
three attempts at three ways (total of nine attempts)
to restore oxygenation and get back into the green
zone: intubation, supraglottic airway and bag mask
ventilation. Once a “best effort” for either of these
three has been done, there is no point in further
pursuing that technique even if it was the first attempt.
With each best effort failing, status escalates towards
a cannot intubate cannot oxygenate (CICO) situation
and an emergency surgical airway is required.
That said, practice of advanced airway management
varies considerably, both in the equipment used and
application of the technique. Countries with physician-
based pre-hospital systems will often use drugs-
assisted tracheal intubation at an early stage, whereas
in other systems this will not occur until reaching
the Emergency Department and an anaesthetist is
CHAPTER 3 AIRWAY MANAGEMENT IN THE TRAUMA PATIENT | 39
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in attendance. The European Trauma Course (ETC)
therefore cannot hope to cover all eventualities
in this complex area, but supports the concept of
competency-based training to allow individuals to
follow local protocols in a safe and effective manner.
Supraglottic airway devices
Second-generation SAD are recommended since
they offer greater protection against aspiration than
first-generation devices. However, the type of device
used will depend on local availability, but common
examples include:
Qlaryngeal mask airway (LMA) and variants
Qi-gel
Qlaryngeal tube (LT) and variants
These all have a similar function, allowing gas
flow through the device and into and out of the
hypopharynx. If there is no obstruction at the level of
the larynx, gas passes into the trachea and subsequently
the lower airways. Air leakage is prevented by sealing
the hypopharynx with a cuff, either air or gel-filled.
One of the greatest advantages of these devices is
their ease of insertion and lack of need for anaesthetic
drugs to achieve this; all members of the trauma team
should therefore be competent in using a supraglottic
airway device. In all patients, once the airway is secure,
a gastric tube should be inserted.
Insertion of a SGA device (see skills section)
KEY POINTS
Indications: need for advanced airway and limited
skills available, failed tracheal intubation
and failed ventilation with bag-mask
Procedure: insertion of a SGA device
Complications: leak, gastric insufflation, trauma to the
airway
Common unrecognised inadequate ventilation
pitfalls: when using the device, patient’s level of
consciousness prevents insertion
Tracheal intubation
This involves the insertion of a tube into the patient’s
trachea via the mouth (orotracheal intubation).
The tube is placed under direct vision using a
laryngoscope and a cuff on the distal end is inflated
with air to provide a gas-tight seal. This allows
ventilation of the lungs using positive pressure and
prevents aspiration of regurgitated gastric contents.
To maintain oxygenation during the course of tracheal
intubation, pre-oxygenation and apneic techniques
are recommended in trauma patients. Although
tracheal intubation has many advantages, it is
technically difficult in a patient with a cervical spine
immobilisation in place as this will restrict opening of
their mouth. The team leader should ensure that the
team member tasked with airway management has the
40 | EUROPEAN TRAUMA COURSE
skills to perform tracheal intubation; if not anaesthetic
help must be summoned urgently. To maximise
the safety and efficacy of tracheal intubation
it must be carried out by those who are trained
and competent in the use of anaesthetic drugs.
In major trauma Rapid Sequence Induction (RSI) of
general anaesthesia is the recommended method for
tracheal intubation. The effect of drugs in patients in
shock, with low cardiac output, is delayed. Clinicians
are often wrongly tempted to give a repetition drug
doses, which can lead to rapid decompensation and
cardiovascular collapse. Therefore, implementation of
simple standardised RSI protocols, clearly defining the
choice of an appropriate induction drug, is essential.
Furthermore, starting controlled ventilation impedes
venous return to the heart and can also lead to
cardiovascular collapse. This must be taken into
consideration when anaesthetising a compromised
major trauma patient.
Tracheal intubation checklists (Fig. 3.3), including data
on preparation of the patient, required equipment,
choice of induction drugs and clear definition of roles
within the trauma team, as well as identification of
back-up plans, should be used for all major trauma
patients. The only exceptions to this are patients who
are moribund or in cardiorespiratory arrest.
All patients who require tracheal intubation require
a rapid assessment to try and predict difficulty. If the
assessment suggests difficulty, tracheal intubation
should only be undertaken by those experienced in
managing difficult airways and with the appropriate
equipment to deal with the possible problems. The
only exception is an immediate threat to life.
Recognising a potentially difficult airway
A difficult airway can be divided into two main types:
1. Difficult or impossible to oxygenate the patient with
a mask and simple adjuncts alone, which may be due
to:
Qfacial trauma, e.g. unstable bony injuries, lacerations;
Qcervical immobilisation
Qupper airway obstruction, e.g. blood, vomit
Qabnormal anatomy, e.g. dysmorphic or asymmetrical
features, macroglossia
Qsevere cachexia, obesity
Qfacial hair
2. Difficult laryngoscopy; an inadequate view of the
larynx prevents insertion of the tube under direct
vision, which may be due to:
a. Pre-existing anatomical factors; these patients may
have a medical alert warning giving useful information:
Qreduced neck mobility, e.g. rheumatoid arthritis
Qprominent upper incisors
Qreceding mandible
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EMERGENCY INDUCTION CHECKLIST

PREPARE PREPARE PREPARE PREPARE FOR
PATIENT EQUIPMENT TEAM DIFFICULTY


Preoxygenation? 
What monitoring is applied? 
If the airway is difficult, could

Capnography 
Alocate roles:


Applying 100% O2 we wake the patient up?


SPO2 probe

Team leader


Apnoic oxygenation


ECG

First intubator


Second intubator 
What is the plan for a difficult

Is the patient’s position

Blood pressure intubation?


Intubator’s assistant
optimal?

Plan A: RSI

What equipment is checked

Drugs


Consider sitting up

Plan B: BMV
and available?

MILS (if indicated)


Rescue airway

Plan C: Supraglottic airway

Vascular access?

Self-inflating bag

Plan D: “Front of neck access” –


Intravenous cannulation

Working suction FONA


Two tracheal tubes 
How do we contact further


Intraosseous cannulation


Two laryngoscopes help if required?

Where is the relevant

How will anaesthesia be

Bougie equipment, including
maintained after induction?

Supraglottic airway device alternative airway?


DO NOT START UNTIL

Do you have all the drugs AVAILABLE
required?


Induction agent 
Are any specific complications
anticipated?


Muscle relaxant

Vasopressor

Reference: NAP4 Report and findings of the 4th National Audit Project of the Royal College of Anaesthetists

Figure 3.3 RSI Checklist

Qmacroglossia Surgical airway

Qprevious surgery causing scarring This will be required when ventilation has failed using
b. Trauma: the techniques described above and the patient is
Qswelling, e.g. burns becoming increasingly hypoxic. This may be the result
Qfacial trauma, particularly if excessive bleeding of complete airway obstruction e.g. oedema due to
Qneck trauma burns or trauma to the larynx. Before proceeding to
Qreduced mouth opening, e.g. presence of a cervical a surgical airway it is highly recommended to take a
collar time out (10-for 10) and discuss options with the team
briefly. The decision to create surgical airway should
Insertion of a tracheal tube (see skills section) be clearly communicated and actioned immediately.
The technique used will depend upon the skills of the
KEY POINTS team members. All team members must be trained
Indications: need for advanced airway, inadequate to progress to front-of-neck access, and trained
airway with basic techniques, airway at to perform a didactic scalpel technique (surgical
risk, inadequate ventilation with basic airway), by placing a wide-bore tracheal tube (6 mm)
techniques through the cricothyroid membrane into the trachea,
Procedure: insertion of tracheal tube facilitating normal minute ventilation with a standard
Complications: hypotension (drugs), hypoxia, trauma to breathing system. Those lacking the training and
the airway, failure proposed skills of surgical airway may proceed with
Common unrecognised oesophageal intubation, needle cricothyroidotomy, by inserting a large bore
pitfalls: bronchial intubation, hyperventilation cannula through the cricothyroid membrane into the
trachea. However, high-pressure oxygenation through
a narrow-bore cannula is associated with serious
Once an advanced airway has been inserted, morbidity. Both are temporising measures that allow
oxygenation and ventilation should commence using oxygenation and ventilation while more skilled airway
a self-inflating bag with high flow oxygen and reservoir personnel are assembled to assist the trauma team,
attached. Whilst the adequacy of oxygenation must e.g. anaesthetist or surgeon.
be checked with a pulse oximeter, ventilation is
confirmed with capnometry and ultimately by arterial
blood gas analysis.

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Cricothyroidotomy (see skills section)

Summary
KEY POINTS Airway obstruction is one of the immediately
Indications: cannot intubate or ventilate using any life-threatening conditions in the trauma patient.
other method Most problems can be managed with basic
Procedure: surgical cricothyroidotomy airway manoeuvres, simple adjuncts and oxygen.
If tracheal intubation is required it should only
Complications: bleeding, damage to local structures,
misplaced tube/cannula
be performed by those who are trained and
competent to do so. Supraglottic devices can
Common delay in recognizing need
be used when the team does not have the skills
pitfalls:
to perform tracheal intubation. Ultimately, the
patients who cannot be ventilated or intubated
Team issues in airway management will require surgical airway management.
Although one medical member of the trauma team is
allocated to manage the patient’s airway, it frequently Having worked through this chapter you are now
requires the involvement of other team members; ready to apply the following knowledge in the
e.g. effective bag-mask ventilation uses a two-person airway workshop:
technique and three people will be required if a cervical Qhow to assess a patient’s airway;

collar has to be opened, in order to maintain MILS. Qapply basic airway management manoeuvres

and use simple airway adjuncts to create and

Whenever the airway person requires assistance maintain a patent airway;
with airway management, the team leader should be Qhow to insert a supraglottic airway device;

informed, so that he amongst other team members can Qbe able to support ventilation using a bag-mask

be re-assigned tasks in the most appropriate manner. device with supplementary oxygen;
The most complex reorganisation of the team will be Qrecognising the potential for a difficult airway;

required if the patient requires tracheal intubation. Qrecognise the need for, and be able to create a

Once this decision has been reached, team members surgical airway.
will need to be allocated key tasks by the team
leader, appropriate to their skills and knowledge; one These cognitive abilities will be integrated with
person applies MILS, one person removes the collar the practical skills during the course workshops.
and any stabilising devices, e.g. tapes, blocks (and
subsequently applies cricoid pressure if appropriate),
one person draws up and gives the anaesthetic drugs.
These actions will be directed by the person carrying
out tracheal intubation to ensure they are coordinated
to facilitate the procedure; this person is in effect
temporarily taking control with the team leader
standing back and remaining ‘hands-off’ to retain
overview and situational awareness. In addition, prior
to any attempt at intubation, the airway personnel
must also clearly identify an escape plan with the team
leader in case of failed intubation/ventilation, e.g. use
of a supraglottic airway device or a surgical airway,
again clearly identifying the team members’ roles in
these circumstances.

Once the airway has been secured and ventilation is

achieved, the team members can resume their normal
activities.

Mechanical ventilation
A mechanical ventilator is usually used in
conjunction with a tracheal tube to prevent hyper-
or hypoventilation. In addition, their use will free-up
the airway personnel to assist others. However, they
should only be used by those who are trained and
competent to do so. The settings used need to be
tailored to each individual patient and guided by
frequent arterial blood gas analysis.

42 | EUROPEAN TRAUMA COURSE

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Insertion of an oropharyngeal airway

Airway and ventilation – skills Indications:
airway obstruction
Q
Chin lift airway maintenance
Q
Indication:
Qairway obstruction. Procedure:
QEstimate the size required by selecting an airway
Procedure:
with a length corresponding to the vertical distance
QPlace the fingertips of one hand under the point
between the patient’s incisors and the angle of the
of the patient’s chin, and gently lift to stretch the jaw (figure 3.5).
anterior neck structures. Ensure that the patient’s QOpen the patient’s mouth and ensure that there is
neck is not hyperextended during the manoeuvre. no foreign material that may be pushed into the
larynx (if there is any, then use suction to remove it).
Complications:
QInsert the airway into the oral cavity in the ‘upside-
Qfailure to clear the airway
down’ position as far as the junction between the
Qloss of airway on release
hard and soft palate and then rotate it through
180° (figure 3.6).
Jaw thrust
QAdvance the airway until it lies in the pharynx.
Indications:
This rotation technique minimises the chance of
Qairway obstruction, during bag-mask ventilation
pushing the tongue backwards and downwards.
QRemove the airway if the patient gags or strains.
Procedure:
QCorrect placement is indicated by an improvement
QIdentify the angle of the mandible
in airway patency and by the seating of the
QWith the index and other fingers placed behind the
flattened reinforced section between the patient’s
angle of the mandible, apply steady upwards and teeth or gums (if edentulous).
forward pressure to lift the mandible (figure 3.4)
Q The thumbs can be used to open the mouth by Complications:
downward displacement of the chin
trauma;
Q

Complications: airway obstruction;

Q

Qlaryngeal spasm;
Qfailure
Qvomiting.
Qexcessive neck movement

Figure 3.5 Sizing an oropharyngeal airway

Figure 3.6 Insertion of an oropharyngeal airway.

Figure 3.4 Jaw thrust. The mandible is lifted upwards with both
hands and pushed caudally with the thumbs to open
the mouth slightly.

CHAPTER 3 AIRWAY MANAGEMENT IN THE TRAUMA PATIENT | 43

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Insertion of a nasopharyngeal airway If there is resistance from the patient when trying
Q
Indications: to move the head to a neutral position, do not use
airway obstruction
Q force to overcome it
airway maintenance
Q

Qfailure to tolerate an oropharyngeal airway

Complications:
Qexcessive force used endangering the spinal cord;

Qdifficulty with access to the airway

Procedure:
QChoose a tube of the appropriate diameter, 7-8mm Bag-mask ventilation
for adults. Indications:
QCheck for patency of the right nostril; some designs
Qinadequate or absent ventilation
require a safety pin to be inserted through the
flange to provide an extra precaution against the Procedure:
airway disappearing beyond the nares.
QChoose a facemask that covers the patient’s nose
QLubricate the airway using water-soluble jelly,
and mouth.
insert the airway bevel end first, vertically along
QWith one hand, apply the mask ensuring a good
the floor of the nose with a slight twisting action
seal with the patient’s face. At the same time, apply
(figure 3.7). The curve of the airway should direct it
a jaw thrust, lifting the patient’s face into the mask.
towards the patient’s feet.
QWith the other hand, squeeze the bag, watching to

If any obstruction is met, remove the tube and try

Q ensure that the patient’s chest rises and falls.
the left nostril. QIf not familiar with this device use a two-person

QChin lift or jaw thrust may still be required to technique; one applies the mask to the patient’s face
maintain airway patency. using both hands and maintains a jaw thrust (figure
3.8) whilst the other person squeezes the bag.
Complications:
Qbleeding Complications:
Qairway obstruction Qlack of adequate seal reducing ventilation

Qlaryngeal spasm Qgastric inflation

Qvomiting Qmovement of the cervical spine

Figure 3.8 Two person technique for using a bag-mask device .

Note the position of the hands of the practitioner holding the
face mask; she performs a jaw-thrust and is pushing the face mask
caudally to open the patient’s mouth.

Figure 3.7 Insertion of a nasopharyngeal airway.

Manual in-line stabilisation (MILS) of Insertion of a supraglottic

the cervical spine
Indication:
airway device
immobilisation of the cervical spine.
Q
Laryngeal mask airway (LMA)
Indications:
Procedure:
Qinadequate airway using basic devices;
Hold the patient’s head by placing your hands
Q
Qinadequate ventilation;
against their mastoid processes (figure 3.10)
Qairway at risk and skills of intubation not immediately
QAvoid covering the patient’s ears in order to
available;
maintain communication
Qfailed intubation.
QRestore the head and neck to a neutral, in-line

position without applying traction

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Procedure:
QChoose a device of the appropriate size (5 for men,
4 for women), ensure the cuff is intact by inflating
and deflating. Leave sufficient air in the cuff to
maintain its shape.
QLubricate cuff with water-soluble gel.
QMaintain MILS unless there is no risk of cervical
spine injury – in this case, flex the patient’s neck
slightly and extend the head. Release cricoid
pressure if it is being applied.
QHolding the LMA like a pen, insert it into the mouth.
QAdvance the tip behind the upper incisors with the
upper surface applied to the palate until it reaches
the posterior pharyngeal wall (figure 3.9).
QPress the mask backwards and downwards around
the corner of the pharynx until a resistance is felt as
it locates in the back of the pharynx.
QIf possible, get an assistant to apply a jaw thrust
after the LMA has been inserted into the mouth -
this increases the space in the posterior pharynx
and makes successful placement easier.
QConnect the inflating syringe and inflate the cuff
with air (40 ml for a size 5 LMA and 30 ml for a size
4 LMA); alternatively, inflate the cuff to a pressure
of 60 cmH2O.
QIf insertion is satisfactory, the tube will lift one to two
centimetres out of the mouth as the cuff finds its
correct position and the larynx is pushed forward.
QIf the LMA has not been inserted successfully after
30 seconds, oxygenate the patient using a bag-
mask before reattempting LMA insertion.
QConfirm a clear airway by listening over the chest during
inflation and observing bilateral chest movement.
QA large, audible leak suggests malposition of the
LMA, but a small leak is acceptable provided chest
rise is adequate.
QInsert a bite block alongside the tube if available
and secure the LMA with a bandage or tape.
Complications:
Qinadequate seal and lack of ventilation;
Qtrauma;
Qaspiration;
Qairway obstruction.
Figure 3.9 Insertion of a supraglottic airway.
Laryngeal tube (LT) airway
Indications:
Qinadequate airway using basic devices;
Qinadequate ventilation;
Qairway at risk and skills of intubation not
immediately available;
Qfailed intubation.
Procedure:
QSelect a LT of the appropriate size based on the
patient’s height; size 5 when >180 cm, size 4 when
155-180 cm, size 3 when <155 cm.
QPlace the patient’s head in a neutral position.
QLubricate the tip of the LT with water-soluble gel.
QMaintain MILS unless there is no risk of cervical
spine injury – in this case, flex the patient’s neck
slightly and extend the head.
QIntroduce the LT behind the incisors, and along the
hard palate, down the centre of the mouth until
resistance is felt or the device is fully inserted.
QThe cuffs are then inflated to a pressure of
approximately 60 cm H2O.
QConfirm a clear airway by listening over the
chest during inflation and observing bilateral
chest movement. A large, audible leak suggests
malposition of the LT but a small leak is acceptable
provided chest rise is adequate.
QInsert a bite block alongside the tube if available and
secure the LT with a bandage or tape.
Complications:
Qinadequate seal and lack of ventilation
Qtrauma
Qaspiration
Qairway obstruction
Tracheal intubation
Indications:
Qapnoea
Qobstruction of the airway, partial or complete, not
relieved with basic techniques
Qneed for respiratory support to treat hypoxia or
ventilatory failure
Qhigh risk of airway obstruction
Qneed for targeted pCO management in traumatic
2
brain injury
Qcardiac arrest
Check presence and function of all equipment (table 3.1)
Once this has been completed, there should be
agreement between the team leader and airway
personnel to decide on allocation of roles for the rest
of the team. Commonly, ED Nurse fills in the airway
checklist, the ‘breathing’ person maintains MILS, the
‘circulation’ personnel remove the collar, any other
immobilising devices and apply cricoid pressure (in
accordance with local practice) and the team leader
gives the drugs on the instruction of the airway person.
In addition, the airway person must inform the team
of the plan for failed intubation, failed ventilation and
allocate roles accordingly.
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Monitoring
Ensure the following are attached as soon as possible:
Qpulse oximetry
Qnon-invasive blood pressure
Qcontinuous ECG
Qinspired oxygen concentration
Qcapnometry
Final checks:
Qreview the ABCs
Qensure a neurological assessment has been performed;
GCS, difference between left and right sides and
pupil size and reactivity. Look for the presence of
diaphragmatic breathing, vasodilation, or priapism
Qreview a brief history using the AMPLE approach
Qensure that there are two large-bore intravenous
cannulae in situ before giving induction drugs
Procedure
QPreoxygenation:
O G
 ive 100% oxygen for three minutes before
induction of anaesthesia. A patient who is
breathing inadequately may not achieve enough
alveolar ventilation to replace nitrogen in the lung
with oxygen - these patients may require assisted
ventilation to achieve adequate preoxygenation
before emergency drug-assisted intubation. In a
healthy adult, after effective preoxygenation, the
time taken for arterial blood to desaturate to 90%
may be as long as eight minutes, but is much faster
in critically ill, obese, or elderly patients, or those
with respiratory disease. The duration of apnoea
without desaturation can also be prolonged by
passive oxygenation during the apnoeic period
(apnoeic oxygenation). This can be achieved by
delivering up to 15 l/min of oxygen through nasal
cannulae. Once the pulse oximeter indicates a
SpO2 of 92% or less, ventilate the patient’s lungs
immediately with 100% oxygen.
QManual in-line stabilisation of the cervical spine:
O A
 n assistant kneels at the head of the patient
and to one side to leave room for the person
intubating. The assistant holds the patient’s head
firmly down on the trolley by grasping the mastoid
processes; the tape, lateral blocks, and front of
the collar are removed. The front of a single-piece
collar can be folded under the patient’s shoulder
leaving the posterior portion of the collar in situ
behind the head. Do not attempt laryngoscopy
and intubation with the collar in place – it will
make it very difficult to get an adequate view
of the larynx. MILS can also be provided from
the front of the patient, but it may interfere with
creating a surgical airway, if required..
QInjection of drugs:
O T
 he induction drug produces unconsciousness,
and is followed immediately by a neuromuscular
blocking drug, using a pre-calculated dose. Both
drugs are injected rapidly into a functioning
intravenous line with an infusion running to
46 | EUROPEAN TRAUMA COURSE
expedite drug delivery. An analgesic drug may be
given prior to both to reduce the cardiovascular
reflexes to laryngoscopy and intubation.
QCricoid pressure – use will vary according to local
practices. In many European countries it is not part of
the RSI protocol anymore, as the risks may outweigh
the perceived benefits.
A
O trained assistant applies cricoid pressure as the
patient loses consciousness.
D
O irect firm pressure using two or three fingers is
applied to the cricoid ring.
I nadequate
O pressure will not occlude the
oesophagus; excessive force or incorrect
placement will deform the larynx and make
laryngoscopy and intubation more difficult.
D
O o not apply cricoid pressure if there is active
vomiting because it may cause oesophageal
rupture.
T
O here is no evidence that a second hand applied
behind the neck (two-handed cricoid pressure) in
an attempt to restrict cervical spine movement is
any safer than the standard technique.
Standard intubation technique:
Q
h
O old the laryngoscope in the left hand
o
O pen the mouth using the index and thumb of the
right hand in a scissor action
i nsert the blade of the laryngoscope along the right
O
side of the tongue, displacing it to the left
a
O dvance the tip of the laryngoscope into the gap
between the base of the tongue and the epiglottis
(vallecula)
a
O pply force in the direction the handle is pointing,
thereby lifting the tongue and epiglottis to expose
the larynx
u
O se rigid suction to clear any secretions, blood or
vomit before attempting to insert the tracheal tube
a
O dvance the tube from the right hand corner of the
mouth through the cords
w
O ithdraw the laryngoscope taking care not to
dislodge the tube
inflate the cuff and attempt to ventilate the lungs
O
c
O onfirm the position of the tube and secure it using
tape or a tie
Figure 3.10 RSI in trauma patients is a complex team task that needs
meticulous preparation, clear role allocations and well rehearsed
escape strategies. Up to four persons are required to for a trauma RSI;
1st as airway operator, 2nd to maintain MILS, 3rd to administer drugs,
4th to apply cricoid pressure. (Photograph: Grissom TE. Trauma airway
Personal copy of Patrick45neves@gmail.com [25712]

TABLE 3.1
between a tube placed in a main bronchus and
Equipment for emergency drug-assisted intubation one placed in the trachea
Qlook for symmetrical movement of the chest wall
Basic resuscitation equipment
Q Tilting trolley / stretcher / Ramping pillow
with ventilation
Q Oxygen delivery apparatus including mask with reservoir and
Qlisten in both axillae for breath sounds and over the

oxygen tubing / Transnasal humidified high-flow oxygen nasal stomach for absence of sounds
cannulae
Q Sucker
Once tracheal intubation is confirmed, if applied
Q Airway adjuncts:
release cricoid pressure, and secure the tube with tape
• Nasopharyngeal airway (sizes 6 and 7) or a ribbon tie. In a patient with raised intracranial
• Oropharyngeal airway (sizes 2, 3 and 4) pressure use of adhesive tape instead of a tie will avoid
Q IV access equipment / IO access equipment
compression of the jugular veins, which may increase
Q Monitors
intracranial pressure. Insertion of an oropharyngeal
airway next to the tracheal tube reduces the risk of
Advanced airway equipment
Q Bag-mask apparatus with reservoir bag and oxygen tubing
the patient biting on the tube and occluding the
Q Drugs – in labelled syringes
airway. Check the monitors for heart rate, arterial
Q Laryngoscope handles and blades (Macintosh sizes 3 and 4 for
oxygen saturation, blood pressure, and end-tidal CO2.
Finally, the airway person should formally indicate
adults, McCoy) / Videolaryngoscope
Q Magill forceps
that he is handing back leadership of the team to the
Q Intubating bougie and/or stylet
appropriate person.
Q Water-soluble jelly
Complications:
Q Tracheal tubes in a range of sizes

Qdrug induced hypotension

Q 10ml syringe

Qhypertension due to inadequate sedation/

Q Tie and adhesive tape

Q Equipment for exhaled CO detection

analgesia
2
Qunrecognised oesophageal intubation
Q Ventilator

Qhypoxaemia (prolonged attempt, endobronchial

Failed intubation equipment
Q Second generation Supraglottic airway devices
intubation)
Qtrauma to the airway and bleeding
Q Scalpel cricothyroidotomy set
Qregurgitation and aspiration
Q Needle cricothyroidotomy kit with high-pressure injector
Qtension pneumothorax
Drugs
Recent studies demostrated that combined use of fentanyl,
Scalpel cricothyroidotomy (stab – twist –
ketamine and rocuronium effectively attenuates acute hyperten-
bougie – tube technique):
sion during pre-hospital intubation, without causing significant
Indications:
hypotension in patients with major trauma. However, the choice
Qlife-threatening hypoxia and the inability to
should be guided by the operators experience and local practice
but will consist of: oxygenate by any other means
Q Anaesthetic induction drug/hypnotic

Q Neuromuscular blocking drug

TABLE 3.3
Q Analgesic

Q Emergency drugs, e.g. atropine, adrenaline

Equipment for scalpel cricothyroidotomy
Q Scalpel (number 10 blade)
Ref. Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ; Kent, Surrey Q Tube (cuffed 6.0mm ID)
& Sussex Air Ambulance Trust. Significant modification of traditional rapid Q Gum elastic bougie
sequence induction improves safety and effectiveness of pre-hospital trauma
Q Syringe
anaesthesia. Crit Care 2015;19:134.
Q Tapes/ties

management. Anesthesiology News. 2017; Airway Management

Supplement 10th Annual Compendium:81-90.)
Procedure:
QCheck all equipment is present and functioning
Use of MILS makes it more difficult to get a good view
of the larynx and use of an intubating bougie or an (table 3.3).
Q Continuous oxygenation via upper airway, with
intubating stylet is invaluable. For this reason, some
practitioners prefer to use an intubating bougie or appropriate neuromuscular blockade. In the
stylet routinely when intubating trauma patients. absence of trauma to the cervical spine, extend the
Confirmation of tracheal tube placement; patient’s head.
QIdentify the cricothyroid membrane with non-

Q detection of carbon dioxide in exhaled gas dominant hand.

(waveform capnography or colorimetric carbon QIf time permits, prepare the skin with antiseptic

dioxide detector), however, this will not distinguish solution and, if appropriate, infiltrate the skin over

CHAPTER 3 AIRWAY MANAGEMENT IN THE TRAUMA PATIENT | 47

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the cricothyroid membrane with 1% lignocaine C. Post-operative care and follow up

with adrenaline (1:100,000). Urgent surgical review of cricothyroidotomy site.
A. Palpable cricothyroid membrane
Stabilise the thyroid cartilage with one hand and Complications:
make transverse stab incision through cricothyroid Qdamage the posterior tracheal wall by deep

membrane. penetration with the scalpel blade

Turn blade through 90° with sharp edge positioned Qhaemorrhage

caudally. Qmisplaced tube outside the trachea (causing

With the scalpel blade in situ slide coude tip of surgical emphysema)
bougie along blade into trachea. Qincision too small to admit the tube

Remove the scalpel and railroad well-lubricated

6.0mm cuffed tracheal tube into trachea. Management of massive haemorrhage in
Ventilate, inflate cuff and confirm the correct maxillo-facial trauma
position with capnography and observing chest
movement, listen for breath sounds. Presentation:
Secure the tube and suction any secretions from Qongoing haemorrhage into the nasal or oral cavity

the lungs (Fig 3.11)

B. Impalpable cricothyroid membrane Management:
Make an 8-10 cm vertical skin incision, caudad to Follow flow chart as per Fig. 3.12
cephalad.
Use blunt dissection with fingers of both hands to Procedure:
separate tissues. QThe patients’ airway must be secured by tracheal

Identify and stabilize the larynx with one hand. intubation or surgical airway prior to the procedure.
Proceed with technique for palpable cricothyroid QAnatomically reduce and maintain any boney

membrane as above. displacements or fractures.

Figure 3.11 Scalpel cricothyroidotomy (with permission from the Difficult Airway Society)

48 | EUROPEAN TRAUMA COURSE

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Figure 3.13 Anterior

QMandible should be supported by a cervical collar.
and posterior packing is
If a cervical collar is already applied, continue with usually the first choice
the procedure by leaving the collar in place. If in treatment of severe
cervical collar is not applied, further management bleeding in maxillo-facial
requires its placement to avoid displacement of trauma (with permission
from Ajoy Roychoudhury)
the the lose bony fragements and further increase
in blood loss.
QInsert the bite block by holding it between the

thumb and the middle finger of one hand, with

the handle bending away from the mouth. Slowly
slide the bite block towards the back of the mouth,
adjusting it firmly between the molars. Repeat
the same on the opposite side of the mouth. The
bite blocks will strut the maxilla against the fixed
mandible.
QOnce the midface is tabalised through the

combination of biteblocks and mandibular Make sure to pad the nose tissue with gauze to
Q

support from a c-spine collar, then baloon prevent pressure necrosis.

tamponade of the mid-face is the next priority. QIf haemostasis is not achieved a Vaseline gauze can

This can be achieved with a commercial device if be inserted to pack the anterior nasal cavity.
available or a 12-Fr Foley catheter may be used. QIf there is ongoing haemorrhage from the oral

Insert the catheter into the affected nasal cavity cavity the oral cavity also can be packed with gauze
until the balloon is well into the posterior nasal
cavity. Inflate the balloon with 5 to 7 mL of saline Complications:
(posterior balloon tamponade). Pull the partially Qrisk of pneumocephalus

inflated balloon anteriorly until it is snug against Qrisk of displacement of fragments into the orbita

the posterior turbinates. Finish inflating the or the brain

balloon with another 5 to 7 mL saline. If there is
displacement of the soft palate, remove some
of the saline from the balloon. Secure the Foley
anteriorly by placing an umbilical clamp over the
catheter as it exits the nose.

Management of Massive Haemorrhage in Maxillo Facial Injury

Identify source of bleeding

Nasal Intraoral

Anterior Posterior Bone Soft Tissue

Balloon Pressure Balloon Reduction of Pressure

Tamponade packing Tamponade fracture packing

If Persistent Bleeding

Trans Arterial
Embolization OR
ECA ligation

Figure 3.12 treatment algorithm for severe bleeding in maxillo-facial trauma (with permission from Ajoy Roychoudhury)

CHAPTER 3 AIRWAY MANAGEMENT IN THE TRAUMA PATIENT | 49

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References:
http://vortexapproach.org
Q

QPavlov I, Medrano S, Weingart S. Apneic oxygenation

reduces the incidence of hypoxemia during

emergency intubation: A systematic review and
meta-analysis. Am J Emerg Med 2017;35:1184-1189.
QFrerk C, Mitchell VS, McNarry AF, Mendonca C,

Bhagrath R, Patel A, O’Sullivan EP, Woodall NM,

Ahmad I. Difficult Airway Society intubation
guidelines working group. BJA 2015;115:827–848.
th
QNAP4 Report and findings of the 4 National Audit

Project of the Royal College of Anaesthetists

QJose A, Nagori SA, Agarwal B, Bhutia O,
Roychoudhury A Management of maxillofacial
trauma in emergency: An update of challenges and
controversies. J Emerg Trauma Shock. 2016 Apr-
Jun; 9(2): 73–80.

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