II. Precautions
- Maintaining a patent airway is the most critical first-line step in Resuscitation, without which all else fails
- Tongue most commonly obstructs unconscious patient
- Belligerent Trauma patients may have impending airway compromise or Hypoxia causing their Agitation
III. Signs
- Agitation (may be due to Hypoxia)
- Somnolent (may be due to hypercarbia)
- Cyanosis (circumoral skin, nail beds)
- Respiratory accessory Muscle use or intercostal retractions
- Noisy Breathing (snoring or gurgling respirations)
- Asymmetric lung sounds or chest wall movement
- Stridor
- Hoarseness
IV. Evaluation
- See Rapid ABC Assessment
- Monitor for signs of impending airway compromise
- Oxygen Saturation
- End-Tidal CO2 is a more reliable and earlier marker of impending Respiratory Failure than Oxygen Saturation
- Evaluate for Trauma related airway compromise
- Maxillofacial Trauma
- Neck Trauma
- Laryngeal or tracheal Trauma (e.g. Laryngeal Fracture, Tracheal Laceration)
- Hoarseness
- Subcutaneous Emphysema
V. Management
- Assume Cervical Spine Injury
- Maintain inline Cervical Spine stabilization
- Consider SCIWORA in pediatric patients
-
Airway Suction
- Blood
- Mucus
- Dental fragments
- Open Airway
- Head Tilt-Chin Lift
- Jaw Thrust (if Cervical Spine Injury is suspected)
- Maintain Airway
VI. Pitfalls: Trauma
-
Advanced Airway
- See Advanced Airway for intubation indications
- See Rapid Sequence Intubation
- Anticipate Difficult Airway (e.g. LEMON Mnemonic)
- Be prepared for failed airway with surgical airway backup (Cricothyrotomy)
- Elastic Bougie can simplify intubation of a patient with C-Spine Immobilization
- Video Laryngoscopy is also very helpful when neck movement is restricted
-
Cervical Spine Injury
- Immobilize c-spine until definitive spine evaluation with C-Spine CT (instead of Cross Table lateral)
- Assistant should provide head down, neck inline c-spine stablization during Primary Survey (instead of Cervical Collar)
- Provides countertraction as the intubating provider lifts Mandible
- Assistant can also help keep mouth wide open
- Inline c-spine stabilization during intubation may not prevent movement and may increase Laryngoscope forces
- In-line stabilization significantly prolongs intubation time and decreases first-pass success
- Airway Compromise
- Loss of airway protection
- Altered Level of Consciousness
- Aspiration of gastric contents
- Multisystem Trauma
VII. References
- Trauma (and ATLS)
- Cardiopulmonary Resuscitation Guidelines