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 as secondary traumatic swelling or edema. Smoke inhalation can directly injure the airway mucosa resulting in severe swelling and edema. Providers need to be aware that this is a dynamic process, with the potential for rapid deterioration in the patient’s ability to ventilate.

Many patients will have obvious signs of airway compromise and need for intervention such as marked decreased level of consciousness, dyspnea, stridor, hypoventilation, or apnea. Other indirect signs include trismus, drooling, odynophagia, or evidence of direct trauma and resulting anatomical abnormalities to the head, oropharynx, or neck.

Providers need to be familiar with signs for potential impending airway compromise including severe bleeding in the oropharynx from mouth or nose, alteration in voice phonation such as hoarseness, subjective sensation of dyspnea despite supplemental oxygen, hematoma in the neck or lower face, and subcutaneous air in the neck or upper chest. Burn patients should be examined closely for evidence of inhalation injury including singed facial hair, edema, erythema, soot, or worsening upper airway swelling. In addition, initially stable patients may benefit from early airway intervention prior to progression to a difficult airway. This includes the burn patient with signs of inhalation injury, unstable facial fractures, uncontrolled bleeding into the oropharynx, and worsening or fluctuating level of consciousness.

Patients with penetrating trauma to the face or neck may not need cervical spine immobilization unless they present with an obvious neurologic deficit attributable to a cervical spinal cord injury. If the patient is conscious and there is no evidence of cervical spinal cord injury on presentation, a patient with a penetrating injury to the face or neck should be allowed to sit up and lean forward to facilitate spontaneous respirations and removal of damaged soft tissues, blood, and secretions from the airway. The patient may receive medications for intubation while sitting up and only laid flat immediately prior to establishing a definitive airway. Despite the gruesome appearance of these injuries at presentation, the majority will be able to have their airway controlled with rapid sequence orotracheal intubation (Fig. 11-2).

Airway management is one of the most essential interventions in care of the critically ill or injured patient in the prehospital environment. It is important to recognize the differences in managing airways in the challenging environment outside the hospital versus the reasonably controlled setting of the emergency department or operating room. In-hospital care allows for a well-lit room, proper patient positioning, and access to multiple trained personnel and advanced airway interventions. Outside the hospital, patients often present with limited access to medical history or known diagnoses and have the additional challenges of the physical setting in which they are being cared for. Emergency medical services (EMS) providers may have to treat patients in the dark, rain, or confined environments, and may have limited tools to work with.

Prehospital Priorities

With the evolution of prehospital care, airway management of trauma patients has continued to change. Endotracheal intubation was long considered to be an essential skill for EMS personnel. Severely injured patients were considered in need of a definitive or “secure” airway, which suggested endotracheal intubation as early as possible in the sequence of the patient’s care. However, a large number of studies have demonstrated the difficulty in satisfactorily completing this procedure outside the hospital, with strong suggestions of worse patient outcomes as well as difficulties in developing and maintaining proficiency in the skill.^3,4 Patient environment, competency of the provider, access to induction and paralytic medications, and variable postintubation management have all been postulated as contributing factors to worse or adverse outcomes. Subsequently, there has been a slow shift from endotracheal intubation as the procedure of choice in addition to the development of numerous alternative airways that may be placed more quickly and reliably by EMS providers. It is becoming apparent that maintaining appropriate oxygenation and ventilation for these patients likely results in improved outcomes rather than establishing a more definitive “protected” airway through endotracheal intubation.

Prehospital Personnel

In addition to a variety of devices, there is significant variability in the skill level of EMS providers. The extent in which they can provide airway interventions is based on their training, licensure, and their medical director delegated practice. In the United States, there are essentially three levels of training or licensure in paramedicine. There is the first responder, often including firefighters or occasionally law enforcement personnel, that maintain basic life support (BLS) skills including minimally invasive techniques such as bag-valve-mask (BVM) ventilation, and placement of nasopharyngeal airway (NPAs) or oropharyngeal airway (OPAs). Some BLS providers also have been delegated to use alternative airway devices that can be placed blindly and generally sit in the supraglottic space. Intermediate life support (ILS) medics are also typically allowed to place these blind insertion airways and may have the benefit of giving some intravenous medications. Paramedics, or advanced life support (ALS) providers, generally maintain a skill set that includes endotracheal intubation, and in some systems, are allowed to perform drug-assisted intubations with induction and paralytic medications. Air medical providers typically maintain ALS skills at a minimum, and often include respiratory therapists and flight nurses. These personnel are usually highly trained and may have access to more advanced equipment and medications, including video laryngoscopes and transport ventilators.

Prehospital Airway Options

BLS AIRWAYS

Many trauma patients can be managed initially in the prehospital setting with simple BLS techniques (Table 11-1). Oxygenation can be improved with supplemental O₂ provided via nasal cannula or simple facemask. Patients with need for a higher FiO₂ or higher flow oxygen can be treated with a nonrebreather mask. In the event of poor respiratory effort, more significant respiratory compromise, or apnea, providers must be competent in providing active ventilatory support via bag-valve-mask ventilation (BVM). Key components for BVM include a self-inflating bag, oxygen reservoir, and conforming facemask. The technique can be performed by one or two providers, and includes maintaining a tight seal with the mask and the patient in a jaw-thrust position. Although a single provider can execute the procedure, it is certainly more reliable with two due to the need for good patient positioning and maintaining a firm seal while ventilating. This may be a limiting factor, especially with longer patient transports or with units that have access to only two providers. Other adjuncts used to facilitate ventilation include the oropharyngeal airway (OPA) and nasopharyngeal airway (NPA). The OPA is a rigid, curved plastic device placed into the patient’s mouth. It is designed to improve airway patency by displacing the tongue away from the posterior pharynx. The NPA is a soft, pliable plastic tube inserted into the patient’s nose. One or two can be used, as it helps to lift the soft palate to facilitate air passage. During BVM, either or both of these adjuncts is recommended for use to improve both oxygenation and ventilation and can be used with simple or nonrebreather face masks as well. It should be noted, however, that placement of an OPA may induce gagging or vomiting in less obtunded patients.

ALTERNATIVE AIRWAYS

There has been significant progress in the development of alternative airways for use both in and out of hospital use. There are a number of logistical issues that arise with continued BLS management, most importantly the difficulties if performing adequate ventilation by a single provider over long transports. In addition, there are considerations with developing and maintaining competency with endotracheal intubation skills and the association with worse outcomes. Subsequently, there has been a new emphasis on airway management using devices that can be placed rapidly and reliably by EMS crews.⁵ There are a number of terms used for these devices including rescue airway, failed airway device, supraglottic airway, or back-up airway. However, these devices are increasingly being used as a primary device in order to minimize potential hypoxic time or other adverse events associated with repeated intubation attempts. Considering these devices are placed without direct or indirect visualization of the glottic opening, the most appropriate descriptive term is a blind-insertion airway device (BIAD). The most commonly used BIADs include the King laryngotracheal (King LT) airway, the I-gel supraglottic airway, the laryngeal mask airway (LMA), and the esophageal tracheal combitube (ETC).

The King LT consists of a single lumen tube that is placed blindly into the patient’s oropharynx and intended to enter the esophagus. A single insufflation port inflates two balloons simultaneously with the distal balloon intended to obstruct any gastric secretions and the proximal balloon to protect the airway from above. A ventilation port lies between the two balloons with the intention of being placed directly over the glottic opening. Oftentimes the tube will need be adjusted by advancing or pulling back slightly to improve lung aeration once the tube is placed, and this adjustment may be necessary throughout transport or upon arrival into the emergency department. The King LT comes in multiple sizes for both adult and pediatric use, and some versions include an esophageal port allowing placement of an orogastric tube for gastric decompression. There are a number of studies demonstrating the King LT’s effectiveness and ease of reliable placement, however there still is limited data suggesting trauma patients may have improved outcomes with the device.⁶

The I-gel supraglottic airway looks similar to an LMA but has a soft, gel-like, non-inflatable cuff designed to fit snugly over the laryngeal inlet. It has a wider, oblong-shaped tube designed for stability in the patient’s mouth and also functions as a bite block. Similar to the King LT, the I-gel has a port for an orogastric tube and comes in multiple sizes. Both the King LT and I-gel promote the ability to float an endotracheal tube introducer (gum elastic bougie) through the lumen and into the trachea, facilitating the exchange of the device with an endotracheal tube. There are a number of studies promoting the ease, reliability, and speed of the I-gel placement.^34,35,36 The lack of an inflatable cuff may have the advantage of not only less time required for placement of the device, but some cadaver studies suggest it may actually provide a better seal and protect the airway better than an LMA. In addition, this may be an advantage in air medical transports at higher altitudes where cuff pressure may become as issue (Fig. 11-3).

The esophageal tracheal combitube is similar to the King LT in that it has distal and proximal balloons, however differs in that it has dual lumens. The tube is placed blindly and typically the smaller distal balloon will travel into the esophagus, and the larger proximal balloon will fill the oropharynx. By ventilating the longer blue lumen, air exchange occurs through holes placed between the two balloons. If the distal portion of the tube happens to be placed in the trachea, then the shorter, white-colored lumen is ventilated. It is recommended that end tidal capnography be utilized to localize tube placement. The combitube has been demonstrated to by reliably placed and used in the prehospital setting; however it is also associated with a higher rate of complications including esophageal perforation, oropharyngeal bleeding and edema, and aspiration pneumonitis^5,6 (Fig. 11-4).

The laryngeal mask airway (LMA) was originally designed for use in the operating room. It includes a tube blindly inserted into the oropharynx with a distal inflatable cuff shaped to fit around the laryngeal structures. There are limited studies evaluating its use by EMS providers and it has not been widely adopted, likely due to concerns for inadequate airway protection or risk of becoming dislodged (Fig. 11-5).

Endotracheal Intubation

Paramedics have maintained skills in endotracheal intubation (ETI) for greater than 25 years, and it continues to be included in their training curriculum. Generally, higher-level providers such as paramedics have performed intubation; however select basic-level EMTs are now being trained in the technique, including both the use of alternate airways as well as intubation methods. ETI has long been considered a vital skill for paramedics to maintain, but recently there has been a large body of evidence linking prehospital intubation with worse outcomes or adverse events. A number of these studies have demonstrated patients arriving to emergency departments either with tube misplacements, or they are being hyper- or hypoventilated. Other adverse events that have been noted include prolonged hypoxic times or bradycardia during intubation attempts.^3,4 Additionally, there is wide variability in access to adjuncts for intubation including medications to assist the procedure or advanced equipment such as video laryngoscopes.

In general, there are three main approaches to oral endotracheal intubation by prehospital providers: direct oral intubation (nonmedicated), sedation-assisted intubation, and full drug-assisted intubation (rapid sequence induction, RSI). There are still a number of programs that perform nasal–tracheal intubation; however this seems to be rapidly falling out of favor with the development of new techniques and airway devices.

Direct, nonmedicated oral endotracheal intubation is typically reserved for the extremely obtunded or cardiac arrest patients and is associated with a high failure rate due to poor visualization and oftentimes lack of confirmatory data such as end tidal capnography. Sedation-assisted intubation has been promoted to be potentially safer than RSI since the patient theoretically maintains some respiratory drive and native airway reflexes. The concern with this approach is that it still does not provide ideal intubating conditions due to lack of muscle relaxation and many of the same adverse events occur as RSI. Success rates are considered borderline, although there is some anecdotal evidence suggesting this approach may ultimately require more attempts with the potential for prolonged hypoxia. There are a number of programs that continue to support drug-assisted intubation using the rapid sequence induction method in which an intravenous sedative is given in combination with a neuromuscular blocker. Although the literature suggests that endotracheal intubation in general may result in worse outcomes, there are select groups this may not apply to. For example, a study of air medical providers actually demonstrated improved outcomes with this technique. It is postulated that this is likely due to the highly trained nature of the crews, both in the procedure and postintubation management, and access to a larger relative proportion of high acuity patients. Outcomes of patients are not based on establishing the airway alone, but rather in overall patient management including access to appropriate medications and airway tools, confirmation of airway placement, and postintubation management. This is evident when comparing performance of groups with varying experience and resources. Ultimately, it is clear that prehospital programs that feel there is a regional need to perform drug-assisted intubation must develop and maintain resources for adequate training and maintaining competency in the skill and postintubation management, provide access to appropriate tools and medications, and provide a rigorous quality control program to evaluate and continually improve performance.⁴

One final approach that is gaining popularity in EMS is the idea of a “rapid sequence airway” in which the patient is given IV sedation with or without a paralytic in order to facilitate placement of a device. An alternative airway then is placed as the primary device, or if one or two intubation attempts are unsuccessful.

Surgical Airways

Most advanced level EMS providers will receive training in the procedure of establishing a surgical airway when the situation of “can’t intubate, can’t ventilate” arise. This typically will be in the setting of severe maxillofacial trauma or facial/neck burns that preclude the ability to place an airway device or perform even BLS airway maneuvers. These procedures are potentially lifesaving, but clearly providers need explicit instruction in the appropriate use of the technique. Similar to endotracheal intubation, there are a number of different methods that are employed. While a standard surgical approach is still employed by some, many groups have adopted pre-packaged cricothyrotomy kits that utilize a seldinger-type approach with a needle and wire. Due to the infrequency with the procedure, there is little data on success rate or associated complications.

Management of Prehospital Placed Airways

Upon arrival to the emergency department, it is vital to determine the efficacy and placement of any prehospital placed airway device. For those patients who have undergone endotracheal intubation, confirmation of appropriate placement can be accomplished with the use of end tidal capnography and/or direct visualization. Patients presenting with an alternative airway in place present different challenges to the trauma team, including evaluation of its effectiveness and the need for longer-term assisted ventilation. Questions that need to be addressed upon arrival of the patient with these devices include:

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  Is the patient being adequately oxygenated and ventilated?

  
  
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  If so, what is the status of patient and what other trauma priorities need to be addressed?

  
  
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  What logistical factors determined the use of the alternative airway? For example, does the patient have a difficult airway and it was placed after multiple ETI attempts?

General considerations for management include immediately exchanging the device in favor of endotracheal intubation if the alternative airway is not adequately oxygenating and/or ventilating the patient. If the device seems to be functioning adequately, it is likely prudent to delay any exchange until the primary survey is completed at a minimum. Attempting to exchange the device immediately is often unnecessary and can be associated with complications or delays in getting the patient completely assessed. These devices can often provide adequate airway protection and ventilation long enough for not only the primary and secondary surveys to be completed, but also completion of further ancillary studies determining the need for other surgical interventions or the likelihood for longer-term ventilation support. In the event the alternative device is to be exchanged, preparation is vital and anticipation should be made for a difficult airway. Use of the device may have been secondary to multiple intubation attempts with secondary iatrogenic trauma, or the device itself can create significant oropharyngeal edema or bleeding. Both I-gel and King LT airways promote the use of an endotracheal tube introducer to be floated directly through the lumen of the device into the trachea, facilitating the exchange with an endotracheal tube and potentially reducing interruptions in assisted ventilations and hypoxic time.

Preparation, Monitoring, and Equipment

Successful airway management starts with planning and preparation. Planning begins by assembling an airway kit or cart containing the necessary equipment for intubation and rescue devices. The practitioner should take the time to inventory the equipment prior to the intubation, ensuring function and availability. The implementation of checklists has been demonstrated to be very effective in minimizing medical errors in both the operating room and intensive care settings. The use of an airway checklist (Table 11-2) can be used to ensure all the appropriate personnel, equipment, and medications are in place before proceeding with any interventions.

Equipment

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.

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 devices are now available to assist with difficult intubation and failed airway, including alternative airways, lighted wand stylets, retrograde intubation kits, a variety of video laryngoscopic devices, and the endotracheal tube introducer (gum elastic bougie).

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. The optimal intubating team should consist of a minimum of three to four members including the intubator, a respiratory therapist, and assistants to maintain cervical spine alignment or to provide cricoid pressure.

Monitoring and Troubleshooting

The intubating team should have the patient attached to a cardiac monitor, blood pressure cuff, and pulse oximeter. Intravenous access should be established. Intraosseous devices can be used as well in the event of delayed or difficult intravenous access. The patient should receive supplemental oxygen via a nonrebreather mask or a bag valve mask (BVM) depending on the patient’s inherent respiratory drive. The correct size of endotracheal tube should be brought to the bedside and a correctly sized stylet should be inserted. The endotracheal balloon should be checked for leaks. Once the balloon has been checked, a 10-cm³ syringe is left attached to the pilot balloon. A suction device with a large catheter tip should be readily available and be placed near the right side of the patient’s head. The laryngoscope handle/blade connection should be checked for a functional light source. Video laryngoscopes should also be checked for functionality and appropriate power source.

A means to secure the endotracheal tube should be available. Dentures should be removed just before intubation, particularly if the patient is being bagged and his or her dentures allow for a tight mask seal. If cervical spine injury has been excluded, the patient should be positioned with the neck slightly flexed and the head slightly extended on an imaginary axis through the patient’s ears. Placing a pillow or towel under the patient’s occipital region and elevating the head approximately 10 cm may facilitate this position. Due diligence with respect to preparation of both personnel and equipment makes for a less stressful intubation and improves the practitioner’s chances of successfully intubating the patient.

Pulse Oximetry

The pulse oximeter is a portable, noninvasive, and reliable device that measures SpO₂. Although very accurate in analysis of peripheral oxygen delivery, the pulse oximeter may display inaccurate readings in the case of carbon monoxide poisoning, high-intensity lighting, hemoglobin abnormalities, poor perfusion or pulseless extremity, or in severe anemia.

Capnography

End-tidal carbon dioxide (ET_CO2) detectors measure the partial pressure of carbon dioxide in a sample gas. The patient’s PaCO₂ is typically 2–5 mm Hg higher than the ET_CO2 and a normal reading in a trauma patient is approximately 30–40 mm Hg. ET_CO2 reading may be used to confirm placement of an endotracheal tube. The presence of carbon dioxide in the exhaled air strongly suggests correct placement of the endotracheal tube in the trachea in a perfusing patient. The disposable capnometer indicates the presence of carbon dioxide with a color change. The electronic capnometer provides the health care provider with a numerical ET_CO2 and plots the CO₂ concentration against time. Although the use of capnometry as an adjunct to monitor the patient’s exhaled carbon dioxide has met some success, conditions such as hypotension, increased intrathoracic pressure, and pulmonary embolus resulting in an increased dead space ventilation may decrease the accuracy of the capnometer.

Noninvasive Airway Management

Before any airway maneuver is undertaken, a quick visual inspection of the oropharyngeal cavity should be done. Any foreign or loose material should be swept clear with a gloved finger or removed with suction. Blood may be present in the mouth of a trauma patient and adequate suctioning is essential to maintaining an open airway. Administration of oxygen prior to suctioning may prevent hypoxemia due to prolonged suctioning. The tongue can cause airway obstruction in the unresponsive patient as it often lacks tone and falls into the oropharynx. Manual airway maneuvers serve to elevate the tongue out of the hypopharynx.

Jaw Thrust

The cervical spine should be kept in normal alignment. The provider should grasp the sides of the patient’s face with fingers 3–5 along the ramus portion of the mandible. The provider’s thumb is on the patient’s cheek and the index finger on the chin and lower lip. These two fingers can open the patient’s lips or serve to seal the mask on a BVM. The provider’s fingers should form an “E” with the three lower fingers and a “C” with the thumb and index finger. Force is applied to the angle of the mandible forcing the mandible forward and anteriorly, while simultaneously opening the mouth with the index finger on the chin.

Chin Lift

With either a free, gloved hand or another provider’s gloved hand, the provider’s thumb is placed into the patient’s mouth, the patient’s lower incisors and chin are grasped, and the patient’s mandible is lifted anteriorly. This maneuver supplements the jaw thrust and works to lift the mandible anteriorly, elevating the tongue out of the oropharynx.

Basic Mechanical Airway Devices

Oropharyngeal Airway

Oropharyngeal and nasopharyngeal devices can be inserted into either the mouth or nose of the patient, serving to elevate the tongue out of the oropharynx. The OPA is a curved, plastic or hard rubber device, which comes in various sizes and has channeling for suction catheters. The device is sized by placing the OPA in the space between the patient’s ear and corner of the mouth. A correctly sized OPA will extend from the patient’s mouth to the angle of the jaw.

Indications for the use of the OPA include a patient who is unable to maintain his or her airway or to prevent an intubated patient from biting the endotracheal tube. Advantages for use of the OPA include the following:

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   Prevention of obstruction by the patient’s teeth and lips

   
   
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   Maintenance of the airway in a spontaneously breathing unconscious patient

   
   
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   Ease of suctioning

   
   
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   Use as a bite block in a patient who is having a seizure

The OPA is contraindicated in a conscious patient as it may stimulate a gag reflex. In addition, it does not isolate the trachea, nor can it be inserted through clenched teeth. It may obstruct the airway if it is improperly placed and can be dislodged easily. To place the OPA, the mouth is opened and the OPA is inserted with the curve reversed and the tip pointing toward the roof of the patient’s mouth. Using a twisting motion the OPA is rotated into position behind the base of the patient’s tongue. Alternatively, a tongue blade can be used to depress the tongue with the OPA placed directly into the oropharynx.

Nasopharyngeal Airway

The NPA is a soft rubber or latex uncuffed tube that is designed to conform to the patient’s natural nasopharyngeal curvature. It is designed to lift the posterior tongue out of the oropharynx. Like the OPA, it is indicated for patients who cannot maintain their airway. The advantages of the NPA include ease and speed of insertion, patient tolerance and comfort, and effectiveness when the patient’s teeth are clenched. Disadvantages of the NPA include its smaller size, the risk of nasal bleeding during insertion, and lack of utility when a basilar skull fracture is suspected.²

The provider should first size the NPA by selecting an NPA that is slightly smaller than the patient’s nostril. The distance from the patient’s nose to earlobe determines the length. The NPA should be liberally lubricated with lidocaine gel prior to insertion. The right nare is preferentially chosen, as it is typically larger. Gentle pressure should be applied until the flange rests against the patient’s nostril. After a basic mechanical airway has been inserted, the patient should be oxygenated with supplemental oxygen or a BVM.

Bag Valve Mask

The BVM assists the provider with oxygenation and ventilation in the apneic or hypoventilating patient. With an effective mask seal and an open airway, the BVM can deliver tidal volumes approaching 1.5 L and nearly 100% inspired oxygen with an attached oxygen reservoir. The BVM consists of a bag with a volume of 1.6 L and a standard face mask attached via a one-way, nonrebreathing valve. A reservoir bag and oxygen source is attached to the opposite end of the bag. Multiple sizes are available to treat neonatal, infant, children, and adult patients. To effectively use the BVM, a second provider may be required to establish a properly fitted mask seal while the second provider squeezes the bag. Utilizing a basic mechanical airway and proper jaw thrust and chin lift techniques while “bagging” the patient can improve maintenance of oxygenation and ventilation.

The majority of injured patients are able to undergo successful orotracheal intubation (OTI). In compliance with the ATLS course, the preferred definitive airway is tracheal intubation through the mouth using direct laryngoscopy.

Guidelines for Emergency Tracheal Intubation

Indications:

Indications for intubation relate to the following three simple questions:

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  First, is the patient able to oxygenate and ventilate?

  
  
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  Second, is the patient able to maintain an airway?

  
  
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  Third, will the underlying injury and physiology of the patient lead to a failure to maintain the airway, oxygenate or ventilate?

The practice management guidelines of the Eastern Association for the Surgery of Trauma (EAST) published in 2012 calls for emergency tracheal intubation in trauma patients exhibiting the following characteristics:⁷

Trauma patients with any of the following traits:

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  Acute airway obstruction

  
  
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  Hypoventilation

  
  
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  Severe persistent hypoxemia (SpO₂ ≤ 90%) despite supplemental oxygen

  
  
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  Severe cognitive impairment (Glasgow Coma Scale score ≤ 8)

  
  
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  Cardiac arrest

  
  
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  Severe hemorrhagic shock

  
  

  Smoke inhalation patient with any of the following traits:

  
  
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  Airway obstruction

  
  
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  Severe cognitive impairment (Glasgow Coma Scale score ≤ 8)

  
  
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  Major cutaneous burn (> 40% TBSA)

  
  
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  Major burns and/or smoke inhalation with an anticipated prolonged transport time to definitive care

  
  
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  Impending airway obstruction as follows:

  
  
  
  
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    Moderate to severe facial burn

    
    
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    Moderate to severe oropharyngeal burn

    
    
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    Moderate to severe burn as seen on endoscopy

  
  

  Other relative considerations for intubation include:

  
  
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  Facial or neck injury with the potential for airway obstruction

  
  
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  Moderate cognitive impairment (GCS 9–12)

  
  
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  Persistent combativeness refractory to pharmacological agents

  
  
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  Respiratory distress (without hypoxia or hypoventilation)