Primary Survey Airway Evaluation

Aka: Primary Survey Airway Evaluation, Emergency Airway Management

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II. Precautions

  1. Maintaining a patent airway is the most critical first-line step in Resuscitation, without which all else fails
  2. Tongue most commonly obstructs unconscious patient
  3. Belligerent Trauma patients may have impending airway compromise or Hypoxia causing their Agitation

III. Signs

  1. Agitation (may be due to Hypoxia)
  2. Somnolent (may be due to hypercarbia)
  3. Cyanosis (circumoral skin, nail beds)
  4. Respiratory accessory Muscle use or intercostal retractions
  5. Noisy Breathing (snoring or gurgling respirations)
  6. Asymmetric lung sounds or chest wall movement
  7. Stridor
  8. Hoarseness

IV. Evaluation

  1. See Rapid ABC Assessment
  2. Monitor for signs of impending airway compromise
    1. Oxygen Saturation
    2. End-Tidal CO2 is a more reliable and earlier marker of impending Respiratory Failure than Oxygen Saturation
  3. Evaluate for Trauma related airway compromise
    1. Maxillofacial Trauma
    2. Neck Trauma
    3. Laryngeal or tracheal Trauma (e.g. Laryngeal Fracture, Tracheal Laceration)
      1. Hoarseness
      2. Subcutaneous Emphysema

V. Management

  1. Assume Cervical Spine Injury
    1. Maintain inline Cervical Spine stabilization
    2. Consider SCIWORA in pediatric patients
  2. Airway Suction
    1. Use with wall device capable of -300 mmHg at full suction and 40 L/min flow
      1. However use lowest effective level of suction (<-150 mmHg in adults)
    2. Suction while withdrawing suction catheter
      1. Occlude side port to suction
      2. Rotate or twist the suction catheter in your fingers while suctioning
      3. Limit suction depth from tip of the nose to the ear lobe (similar to nasopharyngeal length)
      4. Limit suction attempts to 10 seconds (apply 100% oxygen before and after suction attempts)
      5. Interrupt suctioning for Bradycardia, Hypoxia or clinical deterioration
    3. Suction Blood, Mucus and Dental fragments
      1. Perform as needed, and before/after placement of NPA, OPA, Extraglottic Devices and ETT
  3. Open Airway
    1. Head Tilt-Chin Lift
    2. Jaw Thrust (if Cervical Spine Injury is suspected)
  4. Maintain Airway
    1. Nasopharyngeal Airway (NPA)
    2. Oropharyngeal Airway (OPA, in unconscious patients)

VI. Pitfalls: Trauma

  1. Advanced Airway
    1. See Advanced Airway for intubation indications
    2. See Rapid Sequence Intubation
    3. Anticipate Difficult Airway (e.g. LEMON Mnemonic)
      1. Be prepared for failed airway with surgical airway backup (Cricothyrotomy)
    4. Elastic Bougie can simplify intubation of a patient with C-Spine Immobilization
    5. Video Laryngoscopy is also very helpful when neck movement is restricted
  2. Cervical Spine Injury
    1. Immobilize c-spine until definitive spine evaluation with C-Spine CT (instead of Cross Table lateral)
    2. Assistant should provide head down, neck inline c-spine stablization during Primary Survey (instead of Cervical Collar)
      1. Provides countertraction as the intubating provider lifts Mandible
      2. Assistant can also help keep mouth wide open
    3. Inline c-spine stabilization during intubation may not prevent movement and may increase Laryngoscope forces
      1. Santoni (2009) Anesthesiology 110(1): 24-31 [PubMed]
      2. Turner (2009) J Trauma 67(1): 61-6 [PubMed]
      3. Manoach (2007) 50(3): 236-45 PMID:17337093 [PubMed]
    4. In-line stabilization significantly prolongs intubation time and decreases first-pass success
      1. Thiboutot (2009) Can J Anaesth 56(6): 412-8 PMID: 19396507 [PubMed]
  3. Airway Compromise
    1. Foreign body in airway (e.g. Loose teeth or dentures)
    2. Facial Fracture (Mandibular Fracture, Maxillofacial Fracture)
    3. Tracheal Fracture or Larynx disruption
    4. Blunt supraclavicular Trauma
    5. Posterior dislocation of the clavicular head
  4. Loss of airway protection
    1. Altered Level of Consciousness
    2. Aspiration of gastric contents
    3. Multisystem Trauma

VII. References

  1. Trauma (and ATLS)
    1. (2008) ATLS Manual, American College of Surgeons
    2. (2012) ATLS Manual, American College of Surgeons
    3. Majoewsky (2012) EMR:RAPC3 2(1): 1-2
  2. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org
    2. (2010) Guidelines for CPR and ECC [PubMed]
    3. (2005) Circulation 112(Suppl 112):IV [PubMed]
    4. (2000) Circulation, 102(Suppl I):86-9 [PubMed]

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