By Robert Rainer, MD; Emir Udovcic, MD; and Benjamin Ostro, MD
EXECUTIVE SUMMARY
- The jaw thrust maneuver, in which anterior pressure is applied to the angles of the mandible, anteriorly displaces the mandible and relieves upper airway obstruction. This is the preferred maneuver in trauma patients with suspected cervical spine injury.
- A definitive airway is defined as a tube placed into the trachea with a cuff inflated below the level of the vocal cords. The goals of establishing a definitive airway are to successfully intubate the trachea in the shortest amount of time possible, maintain oxygenation and ventilation, and protect the lungs from aspiration. A definitive airway can be established by orotracheal intubation, nasotracheal intubation, or surgical airway/front of neck airway.
- The Advanced Trauma Life Support Guidelines advocate for use of the LEMON mnemonic for pre-intubation evaluation to help predict difficulties with direct laryngoscopy, since many of the factors considered are highly relevant in management of trauma airways.
- Unfortunately, anatomic markers have been shown to be relatively poor predictors of difficult intubation, and approximately 90% of difficult airways are unpredicted.
- Numerous studies have shown that using a pre-intubation checklist is linked to fewer peri-intubation complications and improved adherence to safety protocols. This enables the trauma team to ensure that the necessary equipment is available, including suction, oxygenation supplies, medications, appropriate monitoring devices, and advanced airway equipment, including laryngoscopes, endotracheal tubes, airway adjuncts, rescue airways, and surgical airway tools.
- Video laryngoscopy offers several benefits when compared to direct laryngoscopy. Video laryngoscopy has been shown to improve first-pass success rates and requires less force to achieve optimal views, thereby decreasing cervical spine movement during intubation compared to direct laryngoscopy. Video laryngoscopy also has resulted in improved views of the glottis and vocal cords, fewer failed intubations, fewer hypoxic events during intubation, decreased airway trauma, and better recognition of inadvertent esophageal intubation. These benefits have been consistent throughout all settings, including the operating room, intensive care unit, emergency department, and prehospital.
- External laryngeal manipulation may improve views during laryngoscopy and has been shown to decrease cervical spine motion during intubation, which may limit secondary cervical spine injury.
- There are limited data that the routine use of pretreatment medications (atropine, fentanyl, lidocaine) improves clinical outcomes, and, for this reason, pretreatment medications are used infrequently.
- Several studies have demonstrated that performing endotracheal intubation with cervical spine immobilization using video laryngoscopy, compared to direct laryngoscopy, results in increased first-pass success rates, improved visualization of the glottis and vocal cords, and decreased cervical spine motion.
Rapid assessment and management of the airway in trauma patients is critical, and timely, decisive, and skillful intervention often can make the difference between life and death. Every emergency medicine physician must have an escalating stepwise approach to securing even the most difficult airway. The authors comprehensively review the initial airway assessment, basic and advanced methods and techniques for establishing a definitive airway through endotracheal intubation and surgical airways, airway adjuncts, medications selection, and strategies to address specific factors that complicate airway management in trauma.
— Ann M. Dietrich, MD, Editor
According to the Centers for Disease Control and Prevention (CDC), trauma is the leading cause of death in the United States in individuals up to 45 years of age and the fourth leading cause of death overall.1 Airway compromise remains a leading cause of immediate death following trauma, highlighting the importance of airway management.
Emergency physicians play a key role in airway management, initial resuscitation, and stabilization of trauma patients. Airway evaluation and management generally are the priority in management of trauma patients. Delayed recognition of an airway problem or insufficient oxygenation and ventilation due to an inadequate airway inevitably will result in a rapid death. Rapid assessment and management of the airway in trauma patients is critical, and timely, decisive, and skillful intervention often can make the difference between life and death. For these reasons, all clinicians involved in the care of trauma patients should be familiar with the best practices for airway assessment and management.
Airway management is a broad topic with extensive debate regarding optimal equipment, technique, medication choice, and the ideal approach to the difficult airway. This review will discuss the initial airway assessment, basic and advanced methods and techniques for establishing a definitive airway through endotracheal intubation and surgical airways, airway adjuncts, medications selection, and strategies to address specific factors that complicate airway management in trauma.
Airway and Ventilation Assessment
Airway assessment typically is performed simultaneously with basic airway management. During the trauma primary survey, the airway is assessed to ascertain patency. The easiest way to assess airway patency is to speak to the patient to stimulate verbal response by asking the patient their name. The ability to provide an appropriate verbal response with a clear voice indicates a patent airway as well as adequate ventilation and cerebral perfusion. Failure to provide such a response may indicate direct injury to the airway or an altered level of consciousness that compromises the patient’s ability to protect the airway. In either scenario, further evaluation is warranted.2-6
An initial visual inspection should be conducted to assess for signs of airway obstruction and/or compromise, specifically considering:
- maxillofacial, head, neck, or chest trauma;
- asymmetric chest movement with respiration, which may indicate pneumothorax, or paradoxical movement, which indicates flail chest injury/rib fractures;
- facial burns and evidence of inhalational injury, such as singed nasal or facial hair, oral edema or erythema, or soot/blackened secretions in the oropharynx;
- airway contamination, such as foreign bodies, blood, emesis, or secretions, that may cause partial or total obstruction and increase risk of aspiration;
- cyanosis, which indicates hypoxemia;
- evidence of labored breathing, such as retractions, accessory muscle use, tachypnea, or tripoding;
- patient mental status and behavior, such as agitation or obtundation, which may indicate hypoxia, hypoperfusion, hypercarbia, intoxication, or head injury.
Additionally, auscultation also should be used to assess for signs of airway obstruction and/or compromise, specifically considering:
- noisy or sonorous respirations, which can indicate partial airway obstruction;
- gurgling, which suggests upper airway fluid accumulation, such as blood, emesis, or secretions;
- stridor, which suggests laryngeal or tracheal obstruction;
- wheezing, which may indicate inhalational injury;
- voice hoarseness, which can indicate laryngeal trauma or inflammation;
- silence, indicating complete obstruction or apnea.2-9
A patient’s level of consciousness should be assessed as part of the trauma primary survey and has important implications for airway management. Classically, the Glasgow Coma Scale (GCS), a tool that assesses a patient’s eye, verbal, and motor response, is used to provide an objective assessment of a patient’s level of consciousness. In the setting of trauma, a GCS ≤ 8 raises concern regarding a patient’s ability to protect their airway and is an indication for establishing a definitive airway.2-6,9
Airway patency in trauma is dynamic. An airway that appears patent initially may deteriorate over time because of worsening edema, expansion of hematomas, or progression of clinical course. For this reason, it is essential to perform frequent reassessments and closely monitor for signs of clinical decompensation that may require intervention.4,8
Airway Management
Initial Interventions and Basic Management
A patient with a patent airway, spontaneous ventilation, and adequate oxygen saturation does not require any intervention. Patients with mild hypoxemia can be managed with the application of supplemental oxygen alone, either by nasal cannula or simple face mask.2-4,10
If these criteria are not met, basic airway maneuvers can be employed to maintain or open an airway.2-5,10 Any fluid or foreign body should be suctioned or removed with Magill forceps under direct visualization to minimize the risk of iatrogenic injury or displacement of the foreign body further down the airway.2,3,6,7,9 The jaw thrust maneuver, in which anterior pressure is applied to the angles of the mandible, anteriorly displaces the mandible and relieves upper airway obstruction. This is the preferred maneuver in trauma patients with suspected cervical spine injury. The head-tilt/chin-lift maneuver, on the other hand, should be avoided in patients with suspected cervical spine injury. This maneuver is associated with greater cervical spine movement compared to the jaw thrust and can increase the potential risk of secondary cervical spinal cord injury.3,11 However, the jaw thrust maneuver may not be possible in patients with facial trauma due to distorted anatomy.6,7,9
Airway adjuncts, such as oropharyngeal airways (OPAs) or nasopharyngeal airways (NPAs), also can be used to maintain or open an airway. An OPA is placed in the mouth and moves the tongue anteriorly to open the upper airway. The correct size of an OPA can be estimated by measuring from the corner of the mouth to the angle of the mandible. OPAs are contraindicated in conscious patients or patients with an intact gag reflex because their use can induce vomiting and increase the risk of aspiration. The ability to tolerate placement of an OPA should prompt consideration of a definitive airway as the absence of a gag reflex should raise concerns regarding a patient’s ability to protect their airway.2,3 An NPA is placed in the nares and opens the nasopharyngeal passage. The correct size on an NPA can be estimated by measuring from the nares to the ear lobe. NPAs can be used in conscious or semiconscious patients but are contraindicated in patients with evidence of basilar skull fracture, since there may be disruption of the cribriform plate, which can allow passage of the NPA intracranially.2,3,5,6,10,12
If the previously mentioned maneuvers and adjuncts are successful in maintaining airway patency and the patient is spontaneously ventilating, supplemental oxygen can be applied. If these maneuvers and adjuncts are successful in maintaining airway patency but the patient is not oxygenating or ventilating, bag valve mask ventilation should be initiated to improve oxygenation and ventilation. This can be used in conjunction with basic airway maneuvers and airway adjuncts.5,12 Bag-valve-mask ventilation can be limited by several factors, such as facial hair interfering with mask seal, maxillofacial trauma, obesity, lack of dentition, and underlying lung disease.2-7,9,12,13
Definitive Airway
Inadequate oxygenation or ventilation, decreased level of consciousness with failure to protect the airway, and declining clinical course with impending airway compromise are indications for establishing a definitive airway.2,4-6 A definitive airway is defined as a tube placed into the trachea with a cuff inflated below the level of the vocal cords. The goals of establishing a definitive airway are to successfully intubate the trachea in the shortest amount of time possible, maintain oxygenation and ventilation, and protect the lungs from aspiration.6 A definitive airway can be established by orotracheal intubation, nasotracheal intubation, or surgical airway/front of neck airway.4,5,7,9,12,14
Endotracheal Intubation
Orotracheal intubation is the preferred and most common route for establishing a definitive airway and is considered to be the standard of care. Nasotracheal intubation is another potential option that is discussed in the Advanced Trauma Life Support (ATLS) Guidelines. Nasotracheal intubation has the advantage that it can be performed blind and in patients with limited mouth opening.7 However, nasotracheal intubation is associated with increased complication rates, such as pressure necrosis, sinusitis, and increased rates of tube dislodgement. It is contraindicated in patients with maxillofacial, basilar skull, and cribriform plate fractures, and it requires a spontaneously breathing patient, thereby limiting its use in trauma airway management.2,5 For these reasons, further discussion of endotracheal intubation will focus on orotracheal intubation.
Predicting the Difficult Airway
According to the American Society of Anesthesiologists (ASA), a difficult airway is defined as the situation in which an experienced provider encounters difficulty with any or all of face mask ventilation, direct or indirect laryngoscopy and tracheal intubation, or ventilation via a supraglottic airway device.15 An intubation can be considered difficult either because of an inability to obtain adequate visualization of the glottis and vocal cords during laryngoscopy or because of difficulty passing an endotracheal tube once a view is obtained. Several tools have been developed to assess the potential for difficult intubation. The ATLS Guidelines advocate for use of the LEMON mnemonic for pre-intubation evaluation to help predict difficulties with direct laryngoscopy, since many of the factors considered are highly relevant in management of trauma airways.2,4,5,12
LEMON:
- L – Look externally: for factors that are known to contribute to difficult intubation, such as facial trauma;
- E – Evaluate the 3-3-2 Rule: allows for alignment of the oral-pharyngeal-laryngeal axes: mouth opening (3 fingerbreadths); hyoid-mental distance (3 fingerbreadths); thryro-hyoid distance (2 fingerbreadths);
- M – Mallampati score: to assess visualization of the hypopharynx;
- O – Obstruction;
- N – Neck mobility: limited in trauma due to the need for cervical spine immobilization.
Unfortunately, such anatomic markers have been shown to be relatively poor predictors of difficult intubation, and approximately 90% of difficult airways are unpredicted.9 Furthermore, given the emergent nature of trauma airway management, time available for airway assessment may be limited before definitive management is necessary and the use of such tools may not be feasible.5,6 It is important to note that the Mallampati score and LEMON mnemonic were validated based on anesthesiologists intubating in the controlled setting of the operating room where adequate time for airway assessment is readily available.
Several factors contribute to difficult intubation in a trauma patient, including maxillofacial or direct airway trauma with disrupted anatomy or distorted landmarks; airway contamination with blood, emesis, secretions, or foreign bodies; the need for cervical spine immobilization; burns with inhalational injury and airway edema; unknown fasting time with increased risk of aspiration; and/or patient agitation or lack of cooperation.4-9,11,12,14,16-18 The presence of facial burns and inhalational injury specifically should prompt consideration for early intubation because edema can progress rapidly and difficulty of intubation will only increase with time.6
Given the limited time available for extensive assessment as well as the previously described factors, trauma airways always should be considered potentially difficult, and one should prepare accordingly.9,14
Preparation
As with most procedures, thorough preparation is essential for optimizing success. Numerous studies have shown that using a pre-intubation checklist is linked to fewer peri-intubation complications and improved adherence to safety protocols.19 This enables the trauma team to ensure that the necessary equipment is available, including suction, oxygenation supplies, medications, appropriate monitoring devices, and advanced airway equipment, including laryngoscopes, endotracheal tubes, airway adjuncts, rescue airways, and surgical airway tools.
Ideally, the trauma intubation team consists of four people. Roles should be clearly assigned and understood. These include the intubation proceduralist, intubation assistant, medication administrator, and manual in-line C-spine stabilizer. Keep in mind that depending on staffing, such a team may not always be feasible, and it may be necessary for team members to perform multiple roles.
There are several mnemonics that have been created to assist with preparation for intubation. SOAP-ME is one that frequently is used and is explained further following.
SOAP-ME – Preparation for Intubation:
- S – Suction;
- O – Oxygen: nasal cannula, non-rebreather, bag-valve-mask;
- A – Airways: endotracheal tube with stylet, rescue devices, and adjuncts;
- P – Pre-oxygenation and positioning: non-rebreather at “flush,” nasal cannula at 15 L for apneic oxygenation;
- M – Medications and monitoring: cardiac monitor, pulse oximetry, blood pressure cuff;
- E – Equipment: end tidal CO2, laryngoscope, bougie.
Pre-Oxygenation
Pre-oxygenation is used to delay the onset of hypoxia during airway management by increasing oxygen reserves, thereby maximizing time for laryngoscopy, intubation, or airway rescue.5,6,13 This can be achieved in three to five minutes by administering supplemental oxygen via simple face mask or non-rebreather in a spontaneously breathing patient, or via bag valve mask in a hypoventilating or apneic patient. To deliver maximal oxygen via a non-rebreather, turn the knob as far as possible. This will deliver > 40 L/min and is what is referred to as “flush.” Initial desaturation from 100% to 90% occurs slowly, but below 90%, oxygen saturation can drop precipitously. In a healthy adult, apnea can result in oxygen saturation to < 90% within one to two minutes in the absence of pre-oxygenation. However, pre-oxygenation can delay this to eight minutes.13 This can be particularly important in patients with traumatic brain injuries in whom adequate oxygenation is essential to prevent secondary brain injury.6,9
Apneic oxygenation also is strongly recommended to further limit hypoxia during airway management. This can be accomplished using a nasal cannula at 15 L to provide continuous passive oxygenation during attempts at airway management.5,10 High-flow nasal cannula also has been suggested as a potential method to achieve apneic oxygenation, although evidence for this is limited.13
Airway Equipment and Adjuncts
Direct Laryngoscopy
Direct laryngoscopy (DL) requires the alignment of the oral, pharyngeal, and laryngeal axes to provide for direct visualization of the glottis and vocal cords.20 This can be accomplished using a Macintosh or a Miller blade. The Macintosh blade is curved and is inserted into the vallecula to engage the hyoepiglottic ligament, indirectly elevating the epiglottis. The Miller blade is straight and is used to directly elevate the epiglottis. Direct laryngoscopy offers the benefit of a lower cost; may be preferred in contaminated airways where blood, secretions, or vomit can impair visualization; and is highly effective when used by experienced operators.4,10,12,14 However, direct laryngoscopy also requires optimal positioning to allow for a direct view of the airway. This typically is achieved by placing patients in the “sniffing” position, in which the patient is supine with the neck flexed and the head extended. However, this method can be limited in trauma, where cervical spine immobilization is required.
Video Laryngoscopy
Video laryngoscopy (VL), on the other hand, does not require a direct line of sight to visualize the glottis and vocal cords. Instead, a camera is used to achieve an indirect view. Several video laryngoscopes are available, such as the Glidescope, C-Mac, McGrath, KingVision, and Airtraq.7 Video laryngoscopy makes it easier to obtain the view required for endotracheal intubation, but passing the endotracheal tube may prove to be more difficult.7,14
Video laryngoscopy offers several benefits when compared to direct laryngoscopy. Video laryngoscopy has been shown to improve first-pass success rates and requires less force to achieve optimal views, thereby decreasing cervical spine movement during intubation compared to direct laryngoscopy.10,11,18,20-23 Video laryngoscopy also has resulted in improved views of the glottis and vocal cords, fewer failed intubations, fewer hypoxic events during intubation, decreased airway trauma, and better recognition of inadvertent esophageal intubation.4-6,10,12,13,18,20-24 These benefits have been consistent throughout all settings, including the operating room, intensive care unit, emergency department, and prehospital.20
Video laryngoscopy also enables the use of hyperangulated blades, which further improves glottic visualization in patients with predicted difficult laryngoscopy. The use of such blades is only possible when using indirect laryngoscopy and requires the use of a rigid stylet to pass an endotracheal tube.20
There is concern that contaminated airways may limit the efficacy of video laryngoscopy, since blood, secretions, or vomit could obscure the camera of the laryngoscope.4,5,12,14 However, recent studies suggest that video laryngoscopy outperforms direct laryngoscopy even when used in severely soiled airways.20 Additionally, the Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) technique has been presented as a potential strategy to allow for effective use of video laryngoscopy in such situations.6,9,16,17,20
Hyperangulated Video Laryngoscopy vs. Standard Geometry Video Laryngoscopy
There are two main types of video laryngoscopes, and the key differentiating feature lies in the shape of the blade. Standard geometry video laryngoscopes (SG-VL) use a blade with a conventional Macintosh shape. SG-VL allows for both direct laryngoscopy and indirect laryngoscopy (i.e., video laryngoscopy).25,26 The technique for obtaining glottic visualization and passing the endotracheal tube with SG-VL is akin to that of DL and can be optimized with similar interventions, such as patient positioning or use of a bougie.26,27 SG-VL also allows for the transition from VL to DL if needed, such as if the camera is obscured by airway contaminants.25
Hyperangulated video laryngoscopes (HA-VL) use a blade with a higher degree of anterior angulation, typically 60 degrees to 70 degrees.25,27 HA-VL allows for only indirect laryngoscopy, but the greater anterior angulation of the blade allows for improved glottic views compared to standard geometry blades, especially when used in airways with anticipated difficult DL.25-27 HA-VL necessitates the use of a correspondingly curved stylet, such as a rigid stylet or a traditional malleable stylet bent at a 90-degree angle approximately 8 cm from the distal tip (“hockey stick”) to ensure that the endotracheal tube is directed anteriorly enough.25 While the technique for SG-VL is similar to that of DL, there are significant differences in the technique used for HA-VL to optimize glottic visualization and facilitate endotracheal tube passage.
Typically, when using HA-VL, blade insertion via a midline approach is recommended to obtain the optimal view.25,28 However, in patients with a small mouth or large tongue, such an approach may make passage of the endotracheal tube more difficult. In this scenario, the operator should consider inserting the blade left of midline to allow adequate room on the right side of the mouth for endotracheal tube passage.25,28 Alternatively, the operator can insert the blade via a midline approach and, once the view is obtained, shift the blade handle leftward.25,28
While use of HA-VL allows for improved glottic visualization, achieving the “best view” with complete insertion and advancement of the blade into the oropharynx may adversely affect one’s ability to subsequently pass the endotracheal tube.25-30 This is due to the steeper angle of approach that the endotracheal tube must take to reach the larynx, decreased tube delivery area between the blade tip and vocal cords, and decreased visualization of endotracheal tube delivery.25,28-30 Instead, a deliberately restricted view is recommended to facilitate intubation. This deliberately restricted view is defined by the 50-50 rule — for HA-VL, aim for a view that achieves less than 50% of glottic opening (POGO) and limits the glottic opening to the top 50% of the screen.26,28 Such a view usually can be achieved by withdrawing the blade 1 cm to 2 cm, thereby expanding the field of view, improving glottic exposure, and optimizing angle of approach to facilitate the passage of the endotracheal tube through the cords.25-30 Levitan has coined the “Kovac’s sign” as an indicator that the angle of approach when using HA-VL is excessive and will make passage of the endotracheal tube difficult, referring to the fact that if the blade is over-inserted, the cricoid ring will be visible between the vocal cords.30 The use of a deliberately restricted view with HA-VL has been shown to improve time to intubation and subjective ease of intubation.29
Several techniques that involve manipulation of the endotracheal tube and stylet also have been described to facilitate endotracheal tube passage during HA-VL. The endotracheal tube and stylet should be held more proximally, allowing greater maneuverability of the distal end of the tube and improved fine motor control, thereby facilitating passage of the endotracheal tube through the cords.25,28 If difficulty is encountered when trying to pass the tube through the cords, the stylet can be withdrawn 3 cm to 5 cm, straightening the tip of the endotracheal tube, allowing advancement into the trachea.25-28,30 Rotation of the endotracheal tube and stylet can be used to overcome resistance due to the bevel of the endotracheal tube. If resistance is encountered in the larynx, this likely is because of the bevel abutting the posterior arytenoid cartilage, and a 90-degree counterclockwise (leftward) rotation can be performed to move the bevel off the paraglottic structures and allow tube passage (“leftward at larynx”).28 If resistance is encountered below the vocal cords, this likely is because of the bevel abutting the anterior tracheal rings, and a 90-degree clockwise (rightward) rotation can be performed to align the bevel with the trachea and allow tube passage (“rightward at rings”).28,30
Bougie
Conventionally, endotracheal intubation is performed using a stylet, a malleable metal rod that is used to facilitate passage of the endotracheal tube into the trachea. However, a bougie (also known as a gum elastic bougie [GEB] or Eschmann tracheal tube introducer), a thin plastic rod with a coudé tip, also can be used to facilitate passage of an endotracheal tube.2,4,5,10,13,14,31,32 The bougie has classically been considered an adjunct or rescue device that can be used when managing a difficult airway and suboptimal vocal cord visualization. The bougie offers several advantages compared to an endotracheal tube with stylet, which has cemented its role in difficult airway management. The narrow diameter of a bougie enables better visualization and improved maneuverability during tracheal cannulation.31 The coudé tip allows for improved guidance to the glottic opening and vocal cords when a difficult view is obtained.31 The bougie also offers tactile feedback such as “clicks” as the coudé tip is advanced over tracheal rings, or the “hold up” sign, when resistance to advancement occurs at the carina, whereas if the bougie is inadvertently placed in the esophagus, the full length will pass without resistance.2,13,31 However, case reports have been published indicating that the “hold up” sign may be associated with airway trauma.13,31 Once the bougie is placed into the trachea, an endotracheal tube then can be advanced over the bougie to facilitate endotracheal intubation. Support for use of the bougie for routine airway management has been equivocal; studies evaluating operators familiar with the bougie have shown improved first-pass success rates with its use; however, other studies have failed to demonstrate such outcomes.31,32 Use of a bougie has been shown to demonstrate the greatest benefit in patients with difficult airway characteristics, but operator experience, overall and with specific devices, has a major effect on first-pass success.31,32
Awake Fiberoptic Intubation
Awake fiberoptic intubation typically is a consideration for patients with anticipated difficult airways.4,5,7,9,12-14 Unfortunately, there is a limited role for this technique in a trauma setting. This procedure requires time, patient cooperation, special equipment, operator expertise, and preparation that likely is not feasible in a trauma scenario in which emergent airway management often is required.5-7,12 However, in patients with suspected laryngeal, tracheal, or bronchial injuries, fiberoptic intubation should be considered because it allows for inspection of the airway, assessment of injury below the vocal cords, and appropriate placement of a cuff below the level of injury.4,8,9 Endotracheal intubation in patients with laryngeal or tracheal trauma is more likely to fail, can create false tracts, and may further disrupt anatomy, making fiberoptic intubation the preferred method.8
External Laryngeal Manipulation
External laryngeal manipulation (ELM) refers to the application of backward, upward, and rightward pressure (BURP) on the thyroid cartilage to assist with visualization of the vocal cords.2,33 This frequently is confused with cricoid pressure, which refers to the application of pressure to the cricoid cartilage in an effort to occlude the esophagus between trachea and anterior cervical vertebral bodies to decrease the risk of aspiration of gastric contents. ELM may improve views during laryngoscopy and has been shown to decrease cervical spine motion during intubation, which may limit secondary cervical spine injury.33
Rapid Sequence Intubation
Rapid sequence intubation (RSI) refers to the process of administering a sedative followed by a neuromuscular blocking agent (NMBA), or paralytic, in rapid succession to facilitate endotracheal intubation.2,13,14,34 This is the preferred method for intubation for patients presenting to the emergency department. RSI aims to minimize the time between induction and intubation to decrease the risk of aspiration of gastric contents, which is crucial in patients in need of emergent intubation in whom the last oral intake may be unknown.6,12,14,34 This method also serves to attenuate the physiologic response that occurs with laryngoscopy and intubation and quickly optimizes conditions for intubation.34 Several pre-treatment medications also have been discussed in the setting of RSI to further attenuate potential physiologic responses to intubation, such as hypertension, elevated intracranial pressure, or bradycardia.2,6,34 It is imperative to adequately resuscitate and appropriately preoxygenate patients to address hemodynamic instability or hypoxemia, respectively, prior to induction since, otherwise, RSI could result in critical hypoxemia or total cardiovascular collapse.9
Medication Selection
Medications for RSI are selected based on their pharmacokinetic profile, adverse effects, and patient-specific factors, such as the indication for intubation, hemodynamic status, and preexisting medical conditions.34 The ideal medications should have a rapid onset, wide therapeutic window, minimal hemodynamic effects, and a favorable side effect profile.14,34 (See Table 1.)
Table 1. Commonly Used Rapid Sequence Intubation Medications | |||||
Medication | Dose | Onset of Action | Duration of Action | Adverse Effects | Consideration for Use |
Sedative/Induction Agents | |||||
Etomidate | 0.3 mg/kg IV (max 40 mg) | 5-15 seconds | 5-15 minutes |
|
|
Ketamine | 1-2 mg/kg IV (max 200 mg) 4-6 mg/kg IM (max 500 mg) | 30-90 seconds | 10-30 minutes IV 25-45 minutes IM |
|
|
Propofol | 1-2 mg/kg IV (max 200 mg) | 15-30 seconds | 5-10 minutes |
|
|
Midazolam | 0.1-0.3 mg/kg IV or IM | 1-3 minutes IV 5-15 minutes IM | 10-30 minutes |
|
|
Paralytic/Neuromuscular Blocking Agent (NMBA) | |||||
Succinylcholine | 1.5 mg/kg IV | 30-45 seconds | 5-10 minutes |
|
|
Rocuronium | 1-1.2 mg/kg IV | 45-60 seconds | 45-60 minutes |
|
|
IV: intravenous; IM: intramuscular; ICP: intracranial pressure; RSI: rapid sequence intubation; TBI: traumatic brain injury | |||||
Sedative/Induction Agent
The purpose of administering a sedative is to enhance conditions for endotracheal intubation, provide amnesia, and attenuate the sympathetic response associated with laryngoscopy and intubation.34 Some commonly used induction agents are etomidate, ketamine, propofol, and midazolam.
Etomidate is a non-benzodiazepine, non-barbiturate sedative that functions as a gamma-aminobutyric acid (GABA) receptor agonist. Etomidate typically is dosed at 0.3 mg/kg when used for RSI. Etomidate has a favorable pharmacokinetic profile because it has a relatively quick onset of action and short duration of action. Additionally, etomidate has the benefit of being largely hemodynamically neutral, with minimal effect on heart rate and blood pressure, which makes it an advantageous option for use in trauma patients.2,5,10,14,34 Etomidate also serves to decrease cerebral metabolic rate, which may decrease the risk of anoxic injury given decreased oxygen consumption.5 There is notable concern regarding the fact that etomidate has the potential adverse effect of adrenal suppression. This study included critically ill sepsis patients, which may not be generalizable to trauma patients.35 Furthermore, despite the concern for potential etomidate-induced adrenal suppression, this has not been associated with a significant effect on clinical outcomes or increased mortality.
Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist with dissociative, analgesic, amnestic, anticonvulsant, and anxiolytic properties. Ketamine typically is dosed at 1 mg/kg to 2 mg/kg when used for RSI. Ketamine is the only induction agent that has analgesic properties, which may be beneficial in injured trauma patients.9,34 Ketamine also has a favorable hemodynamic profile because of its sympathomimetic effect and causes increases in heart rate and blood pressure by inhibiting catecholamine reuptake.5,9,10,14,34 For this reason, ketamine often is suggested as the superior option for use in a trauma resuscitation and is highly considered to be the drug of choice for patients in shock or at high risk of peri-intubation hypotension.34 Historically, there has been concern regarding the use of ketamine in patients with traumatic brain injuries because of the theoretical risk of increased intracranial pressure (ICP). However, several studies have shown that this is an unlikely adverse effect, and ketamine is considered safe to use in this patient population.2,5,6,9,14,34
Propofol, a GABA agonist, and midazolam, a short-acting benzodiazepine, are other commonly used induction agents. Propofol acts as a direct myocardial depressant, reducing blood pressure and cerebral perfusion pressure, and is associated with higher rates of hemodynamic instability. Midazolam also has been shown to carry a dose-dependent risk of hypotension. These medications should be avoided in hemodynamically unstable patients and, therefore, propofol and midazolam are not frequently used for RSI in trauma patients.2,5,14,34
Paralytic/Neuromuscular Blocking Agent
Succinylcholine is a depolarizing neuromuscular blocking agent. Succinylcholine typically is dosed at 1.5 mg/kg when used for RSI. Succinylcholine has a favorable pharmacokinetic profile given its rapid onset of action (typically 30-60 seconds) and short duration of action (typically 5-10 minutes).2,5,6,10,13,14,34 Succinylcholine carries a wide range of potential adverse effects and contraindications, which may limit its use. Notably, succinylcholine is associated with intracellular potassium release, causing a transient increase in serum potassium (typically 0.5 mEq/L to 1.0 mEq/L). For this reason, succinylcholine should be avoided in patients with baseline renal disease, neuromuscular disease or muscular dystrophy, chronic spinal cord injuries or paralysis, electrical injuries, seizures, and burns and crush injuries if greater than 24 hours following the time of injury.2,5,6,13,14,34 Succinylcholine also has the potential adverse effects of bradycardia, malignant hyperthermia, increased metabolic rate and oxygen consumption due to fasciculations, and, in rare cases, masseter spasm.6,13,14,34 Additionally, succinylcholine can cause a transient increase in intracranial pressure and, therefore, is not preferred in patients with suspected traumatic brain injuries.6,14 The short duration of succinylcholine in itself can be considered a benefit. Given the short duration of effect, paralysis will wear off quickly, enabling physicians to perform a neurological exam without the need for a reversal agent.34 Additionally, in the case of a potential failed intubation, a patient may be able to be ventilated using a bag valve mask until paralysis wears off, offering a potential method to avoid a cannot intubate/cannot ventilate scenario.5,9,13,14
Rocuronium is a non-depolarizing neuromuscular blocking agent. Rocuronium is classically dosed at 0.6 mg/kg to 1.2 mg/kg; however, it exhibits a dose-dependent action of onset and when dosed at 1.0 mg/kg to 1.2 mg/kg, approaches the rapid onset of succinylcholine (60-90 seconds).5,10,13,14,34 Compared to succinylcholine, rocuronium has a significantly longer duration of action (30-60 minutes on average, but up to two hours has been demonstrated). Rocuronium has significantly fewer adverse effects and contraindications compared to succinylcholine.5,10,13,14,34 Rocuronium is preferred for RSI in patients with traumatic brain injury because it is not associated with a transient increase in intracranial pressure like succinylcholine.6 The main concern that has been cited regarding the use of rocuronium for RSI is the prolonged duration of action. There is concern that in the case of a failed intubation, it would not be possible to adequately ventilate the patient until the effect of the medication has subsided.5,9,14,34 However, the availability of sugammadex, a reversal agent for non-depolarizing neuromuscular blocking agents, has somewhat alleviated this concern.5,14,34 Sugammadex is dosed at 16 mg/kg for immediate reversal of neuromuscular blockade. Unfortunately, this medication is relatively expensive and may not be readily available in the emergency department.34 Sugammadex does not guarantee airway patency or spontaneous respirations.9,13 Furthermore, prolonged neuromuscular blockade actually may be beneficial in the setting of a failed intubation since paralysis ensures optimal conditions for not only laryngoscopy, but also bag-valve-mask ventilation, supraglottic airway device use, and surgical airway management.9
Pretreatment Medications
Pretreatment medications are used to attenuate potential negative physiological responses to laryngoscopy and intubation, such as hypertension, bradycardia, or elevated intracranial pressure. These typically are administered two to three minutes prior to induction. There are limited data that the routine use of pretreatment medications improves clinical outcomes, and, for this reason, pretreatment medications are used infrequently. The most commonly referenced pretreatment medications include atropine, fentanyl, and lidocaine.34
Atropine is a muscarinic receptor antagonist and is used to prevent bradycardia secondary to vagal nerve stimulation associated with laryngoscopy. This effect is especially pronounced in pediatric patients younger than 2 years of age. Atropine is dosed at 0.01 mg/kg for adult patients and 0.02 mg/kg for pediatric patients, with a maximum dose of 0.5 mg.34 Studies have failed to provide evidence for the routine use of atropine as pretreatment to prevent bradycardia, and the 2015 Pediatric Advanced Life Support Guidelines no longer endorse routine use. However, atropine still could be considered in patients at increased risk of bradycardia, such as children younger than 1 year of age or if succinylcholine is used for neuromuscular blockade.34,36,37
Lidocaine, a sodium channel blocker, and fentanyl, a short-acting synthetic opioid, have been used to prevent increases in intracranial pressure in patients with suspected traumatic brain injury. When used for this purpose, lidocaine is dosed at 1.5 mg/kg and fentanyl is dosed at 3 mcg/kg. There is limited evidence supporting the use of these medications as pretreatment for RSI to blunt potential intracranial pressure increase.6,34
Delayed Sequence Intubation
Delayed sequence intubation (DSI) can be thought of as medication-assisted preoxygenation. DSI can be considered in patients with significant hypoxia who may require prolonged preoxygenation or who are unable to tolerate preoxygenation because of mental status. DSI involves the administration of an induction agent with a significant delay in administering a neuromuscular blocking agent, with the goal of achieving adequate preoxygenation and decreasing the risk of peri-intubation desaturation or hypoxia.4,6,9,34 Ketamine is the medication of choice for DSI, given the favorable effects profile discussed previously as well as its ability to preserve spontaneous respiration. While the use of DSI in trauma patients may be limited, it should be considered for agitated or uncooperative patients.4,6,9,34 Once the sedative medication is administered, preoxygenation can occur via nasal cannula, nonrebreather, or noninvasive positive pressure ventilation, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP). When the patient has been adequately preoxygenated, the neuromuscular blocking agent is administered, and intubation can be performed.
Post-Intubation Management
Following intubation, verification of appropriate endotracheal tube positioning should be performed. This is essential for avoiding complications such as hypoxia, anoxic brain injury, or death associated with inadvertent esophageal intubation, or barotrauma and pneumothorax that can be associated with right-main stem (or endobronchial) intubation.38 Classically, verification is achieved by monitoring equal bilateral chest rise, auscultation of bilateral breath sounds and absent sounds over the epigastrium, and monitoring for tube fogging or moisture. These findings can suggest, but do not confirm, appropriate tracheal intubation.2,5,10,13,38 The combination of direct visualization of the endotracheal tube passing between the vocal cords and end-tidal carbon dioxide monitoring approaches 100% sensitivity for verification of appropriate endotracheal tube placement.2,5,10,13,38 End-tidal carbon dioxide monitoring can be performed via qualitative (i.e., colorimetric detector) or quantitative (capnography) methods, with quantitative capnography demonstrating better reliability.2,5 The use of ultrasound to ensure verification of appropriate endotracheal intubation also has been shown to be a reliable method.38 Once appropriate tracheal intubation has been verified, a chest X-ray should be obtained to verify appropriate endotracheal tube depth but does not confirm tracheal intubation.2,5 Once appropriate placement and positioning has been confirmed, the endotracheal tube should be secured. Appropriate post-intubation sedation and analgesia should be ordered.
The Importance of First-Pass Success
Endotracheal intubation, although relatively frequently performed, is a high-risk procedure with complications that can range from local injury such as bleeding or edema to critical hypoxemia, cardiovascular collapse, anoxic brain injury, and even death. This risk is further increased in trauma patients, who often are critically ill and in whom several factors contribute to increased difficulty with intubation and risk of complications. Ideally, successful intubation should occur on the first attempt. The term “first-pass success” (FPS) often is used in airway literature and refers to the concept of successful intubation on the first attempt. When managing the airway of a trauma patient, every measure should be taken to optimize the chance of successful intubation on the first attempt.2,6,9,10,12-14 Unfortunately, this is not always possible and subsequent attempts at establishing a definitive airway often are required. Appropriate preoxygenation delays hypoxia and allows for maximal time during attempts. If subsequent attempts are warranted, efforts should be made to adequately preoxygenate between attempts.2,10 The greater the number of attempts, the greater the complication rates. Additionally, each attempt will worsen airway conditions by causing increasing soft tissue edema, bleeding, or secretions, resulting in a decreased chance of success with each attempt.6,12 In the case of a failed intubation, any subsequent attempts should be performed by the most experienced operator present. Some experts have even suggested the routine use of difficult airway equipment for all intubations as a potential method to increase the chance of successful intubation.14 Ultimately, FPS is dependent on operator expertise and experience, and the ideal choice of equipment and technique is that with which the operator is most familiar and comfortable.32
Cervical Spine Immobilization
Cervical spine immobilization is critical in trauma for the prevention of secondary cervical spinal cord injury that may occur with excessive movement of the cervical spine. The cervical spine is protected by the application of a rigid cervical collar. However, if airway management is indicated, the front of the cervical collar should be removed, and an additional team member should apply manual in-line stabilization (MILS) to maintain neutral alignment of the head and neck.2,5,6,9,11,18,33,39 When applying MILS for the purpose of airway management, it is important to use appropriate technique — immobilization of the head and neck without immobilization of the mandible — to allow adequate mouth opening and mandibular displacement needed for laryngoscopy.9
Several studies have shown that cervical spine immobilization inhibits optimal positioning for laryngoscopy and intubation, resulting in worsened views of the glottis and vocal cords with direct laryngoscopy, increased time to intubation, increased failed intubation attempts, and increased risk of difficult intubation.9,11,18,21 This effect is most pronounced when using direct laryngoscopy, which requires neck extension to achieve alignment of the oral, pharyngeal, and laryngeal axes for direct visualization of the glottis and vocal cords. Video laryngoscopy, conversely, obtains an indirect view of the glottis and vocal cords and does not require alignment of the oral, pharyngeal, and laryngeal axes. Several studies have demonstrated that performing endotracheal intubation with cervical spine immobilization using video laryngoscopy, compared to direct laryngoscopy, results in increased FPS rates, improved visualization of the glottis and vocal cords, and decreased cervical spine motion.10,12,14,18,20-22,33
Several other techniques to optimize the success of endotracheal intubation in the setting of cervical spine immobilization have been discussed in the literature. The use of a bougie for intubation has been shown to increase the FPS rate in patients with cervical spine immobilization compared to the traditional stylet.11 The use of direct epiglottis elevation, where a laryngoscope is used to directly lift the epiglottis, compared to indirect epiglottis elevation, where the tip of the laryngoscope blade is inserted into the vallecula and engages the hyoepiglottic ligament to lift the epiglottis, has been shown to decrease cervical spine motion associated with intubation.22 External laryngeal manipulation (ELM), the application of BURP on the thyroid cartilage, has classically been used to improve the view of the glottis with direct laryngoscopy. When ELM is used with video laryngoscopy, cervical spine motion is further decreased compared to video laryngoscopy alone.33
Ultimately, there is little evidence to suggest that the use of a rigid cervical collar or MILS prevents secondary cervical spinal cord injury, and even in patients with known cervical spinal cord injury, the risk of secondary neurologic deterioration is exceedingly rare at 0.03%.9 The risk of secondary cervical spinal cord injury due to endotracheal intubation is unknown but likely overestimated.11
The Contaminated Airway
Contamination refers to the presence of blood, emesis, or any other liquid or semi-liquid material present in the airway.6,9,16,17 Airway contamination inhibits visualization of the glottis and vocal cords with both direct and video laryngoscopy and is associated with decreased FPS and increased failed intubation rates regardless of the device used.9,16,17 When managing the contaminated airway, the degree of blood, emesis, or secretions that are visible externally represents only a fraction of what will be encountered during endotracheal intubation.9,16,17 The ability to clear an airway of contaminants is essential to ensure successful intubation.
When managing the contaminated airway, physicians should have two large-bore suction catheters available. In this situation, large-bore DuCanto suction catheters are strongly preferred over the smaller-bore Yankauer catheters; large particulate matter and thick liquids will quickly overwhelm a standard Yankauer.9,16,17 Any solid foreign bodies should be removed with Magill forceps under direct visualization to minimize the risk of iatrogenic injury or displacement of the foreign body further down the airway.3,6,7 Positive pressure ventilation should be minimized because higher ventilatory pressures are more likely to ventilate the stomach, leading to gastric insufflation and increasing the risk for regurgitation and aspiration.9,16,17
Several strategies have been suggested to improve the chance of successful intubation in the contaminated airway. Maxillofacial trauma may be associated with significant bleeding; any accessible bleeding should be addressed prior to induction if time permits, such as suturing of lacerations, injection of lidocaine with epinephrine for local vasoconstriction, or packing of epistaxis if no basilar skull fracture is suspected.6,7,9,12,16,17 Deliberate esophageal intubation can be performed to direct emesis away from the field of view. This endotracheal tube then can be connected to suction to allow for continuous gastric emptying until the airway is secured.9,16,17 If using video laryngoscopy, a standard geometry blade should be used so that the operator can transition to direct laryngoscopy if needed.9,16,17 The bougie has been associated with increased FPS and decreased time to intubation when used in contaminated airways.9,16,17,32 Lastly, the SALAD technique, in which a rigid suction catheter is positioned with the tip at the esophagus and stabilized with the laryngoscope on the left side of the mouth to allow for continuous suction of the hypopharynx, may be used.6,9,16,17 If contamination remains overwhelming despite these techniques, establishing a surgical airway should be considered since bag-valve-mask ventilation and supraglottic airway devices are unlikely to be effective.9
Supraglottic Airway/Supraglottic Airway Device
Supraglottic airway devices are used as rescue devices in patients who require advanced airway management, but intubation has failed or is unlikely to succeed.2-5,7,10,12,13 These are not definitive airways and do not protect against aspiration because there is no cuff below the level of the vocal cords.2,3,5,7 These devices are blindly inserted into the oropharynx, require minimal experience to place correctly, and allow for ventilation while awaiting a definitive airway. The first-generation devices, such as the LMA Classic, carry the highest risk of aspiration. The second-generation devices, such as the iGel, LMA Supreme, and Pro-Seal LMA, incorporate a second gastric channel through which an orogastric tube can be inserted, decreasing the risk of aspiration.5,7 Certain devices, such as the Intubating LMA, can be used to guide placement of an endotracheal tube and assist with intubation.2 It must be emphasized that supraglottic airway devices are not definitive airways and, when used for airway management in trauma, serve as a rescue device or temporizing measure while preparing for further attempts at securing a definitive airway.
Surgical Airway/Emergency Front of Neck Airway
Classically, the primary indication for a surgical airway is a “cannot intubate, cannot oxygenate” (CICO) scenario, in which attempts to manage an airway with endotracheal intubation, supraglottic airway devices, and bag-valve-mask ventilation have all failed.13,40 CICO occurs in one out of every 5,000 to 10,000 cases overall, one out of every 300-800 cases in an emergent scenario, and potentially as often as one out of every 200 cases in the emergency department.20 Failure to immediately recognize a CICO scenario and immediately establish a surgical airway will result in rapid hypoxic brain damage, critical hypoxemia, and death.2,3,13,40,41 Establishing a surgical airway is the final step in all emergency airway management or difficult airway algorithms and can be performed via cricothyroidotomy or tracheostomy.41
Cricothyroidotomy
A cricothyroidotomy is performed to establish a surgical airway via the cricothyroid membrane. There are three main approaches for cricothyroidotomy: needle cricothyroidotomy, percutaneous cricothyroidotomy using a Seldinger technique, and surgical cricothyroidotomy.2-4,9,13,41-43
Needle cricothyroidotomy with transtracheal jet ventilation (TTJV) involves inserting a large-bore needle and catheter (12-14 gauge for adults; 16-18 gauge for children) through the cricothyroid membrane into the trachea. The cannula then is connected to a high-pressure jet ventilator to allow for oxygenation until a definitive airway can be established.2,42 This method allows for 30-45 minutes of oxygenation, but because of limited exhalation, ventilation is inadequate, and progressive hypercarbia will occur.2 There is no cuff inflated below the level of the vocal cords, so this is not a definitive airway, and the risk of aspiration is present. For these reasons, needle cricothyroidotomy with TTJV is a temporizing measure that can be used as a bridge to a definitive airway. Furthermore, needle cricothyroidotomy, compared to surgical cricothyroidotomy, has a higher failure rate due to dislodgement, catheter kinking, and misplacement; requires a high-pressure ventilator that is not universally available; and has a higher rate of complications, such as breath stacking and barotrauma.2,3,9,41-43 As a result, this method has largely fallen out of favor for adult use, but it remains the standard of care for pediatric patients younger than 12 years of age and still is included in the ATLS Guidelines.2,3,9,41,43
Percutaneous cricothyroidotomy involves inserting a large caliber cannula through the cricothyroid membrane, often using a Seldinger technique over a guidewire.42 Various kits are available for this technique. When compared to surgical cricothyroidotomy, this technique has a higher failure rate, increased placement time, and a higher complication rate, and therefore is not the preferred method for establishing a surgical airway.3,4,9,13,41,42
Surgical cricothyroidotomy involves the use of a scalpel to make an incision into the cricothyroid membrane, through which an endotracheal or tracheostomy tube can be inserted.2,42 Compared to the needle cricothyroidotomy and percutaneous cricothyroidotomy, this technique has been shown to be faster, more reliable with higher success rates, and is associated with fewer complications.2-4,9,13,41-43 There are several techniques for performing a surgical cricothyroidotomy, but scalpel bougie assisted cricothyroidotomy (SBACT), also known as the “scalpel-bougie” technique, is highly favored because it requires minimal equipment (scalpel, bougie, and 6.0 endotracheal tube), is relatively simple with few steps, and has a high success rate.4,5,9,13,41-43 This technique begins with a “laryngeal handshake,” using the thumb and middle fingers of the nondominant hand to stabilize the larynx while using the index finger of the nondominant hand to palpate the cricothyroid membrane. A transverse stab incision then is made into the cricothyroid membrane, and the scalpel is rotated caudally to open the incision. Lateral traction is held with the scalpel, and a bougie is inserted into the trachea along the scalpel blade. Once the bougie is in the appropriate position, an endotracheal tube can be passed over the bougie to establish a definitive airway.4,5,9,41,43 This method relies on palpation of the cricothyroid membrane. If the clinician is unable to palpate the cricothyroid membrane because of obesity or difficult anatomy, the “scalpel-finger-bougie” technique should be used. In this technique, an 8 cm to 10 cm vertical incision is made and blunt dissection with the fingers is used to identify and stabilize the larynx. At this point, the clinician would proceed with the remaining steps of the “scalpel-bougie” technique as discussed.4,9,13,41,43
Tracheostomy
A tracheostomy is performed to establish a surgical airway by directly accessing the trachea through the anterior neck, typically 1 cm to 2 cm inferior to the cricoid cartilage. There are two main approaches for tracheostomy: surgical tracheostomy or a percutaneous tracheostomy using a Seldinger technique. Cricothyroidotomy is preferred over tracheostomy for emergent airway management because tracheostomy is associated with increased bleeding, increased time to ventilation, and higher complication rates.2-4,12,13,40,41 For these reasons, emergent tracheostomy has a limited role in trauma airway management. However, if there is suspected or confirmed laryngeal or tracheal trauma, emergent tracheostomy is the preferred method for establishing a surgical airway.2,4,9 Otherwise, surgical cricothyroidotomy should be considered the technique of choice.
Pediatric Airway Management in Trauma
In the United States, trauma is a leading cause of morbidity and mortality among children and youth 1 to 19 years of age with traumatic injuries, accounting for approximately 60% of pediatric deaths.44 Furthermore, the inability to maintain airway patency and the associated inadequate oxygenation and ventilation is the most common cause of pediatric cardiac arrest. Within the ATLS framework, the primary survey aims to detect life-threatening injuries and prioritize prompt interventions through the “ABCDE” approach, with a focus on stabilizing the airway as a top priority. Trauma airways are, by definition, difficult airways.2 When coupled with the evolving anatomy and physiology of pediatric patients, this population presents distinct challenges in airway management.
Anatomical Differences of Pediatric Airway Management
The pediatric airway experiences substantial changes in the early stages of life, typically reaching a mature state resembling that of an adult airway by the age of 8 years. Anatomic differences are most pronounced in neonates and infants younger than 1 year of age. In pediatric patients younger than 2 years of age, the head is proportionally larger with a prominent occiput, thus causing neck flexion when supine, leading to airway obstruction and complicating the axial alignment of the airway during laryngoscopy.44-47 Additionally, several factors in children can complicate endotracheal tube insertion and vocal cord visualization. These include a more cephalad and anterior larynx, a less cartilaginous epiglottis that is more prone to collapse, a larger tongue relative to the oropharynx, more prominent adenoids and tonsils, a more compressible trachea, and a shorter tracheal distance, which increases the risk of right mainstem intubation.44-48 Furthermore, since the narrowest part of the pediatric airway is at the cricoid cartilage rather than the vocal cords, difficulties with endotracheal tube (ETT) passage still can arise even after successfully navigating past the vocal cords.45 To avoid mucosal injury and airway edema in cases where the ETT is difficult to pass, a smaller ETT can be exchanged via bougie.
Physiological Differences of Pediatric Airway Management
Physiologically, pediatric patients have several factors that can predispose them to hypoxemia. Neonates, infants, and children have a relatively lower functional residual capacity, greater oxygen demand and consumption, and smaller airway volumes with a smaller oxygen reserve, and therefore experience more rapid desaturation during periods of apnea compared to adults.45-47 Pediatric patients are especially intolerant of prolonged episodes of hypoxia, and several studies have demonstrated adverse clinical outcomes with even a single hypoxic episode.46 For this reason, prior to undertaking any invasive airway management, ensure adequate preoxygenation. Additionally, apneic oxygenation with nasal cannula is strongly recommended because it has been shown to increase FPS without physiological instability, increase oxygen saturation during intubation, and decrease incidence of hypoxemia.46,49 Additionally, the pediatric airway is small, so even minor narrowing due to edema or inflammation can significantly affect respiratory function.
Airway Optimization and Positioning
Several techniques and maneuvers can be used to increase FPS when considering the anatomy of a pediatric airway. To counteract oropharyngeal-laryngeal malalignment caused by neck flexion, a towel can be placed underneath the shoulders and a head tilt/chin lift maneuver can be used, resulting in better airway alignment during laryngoscopy.45-48 It is important to note that, because of the trachea’s flexibility, overextension should be avoided to prevent airway obstruction.45 Using an oral or nasal airway and performing a jaw-thrust maneuver can help address the challenges posed by the larger tongue of pediatric patients. These actions can enhance ventilation using noninvasive methods and improve the visibility of the airway by reducing the accompanying airway obstruction caused by the tongue.44,45,47,48
Pediatric Airway Assessment
Initial airway assessment in a pediatric trauma patient follows similar principles to that of adult trauma patients. Airway patency can be confirmed if the patient is talking or crying. Signs indicating imminent airway compromise that may require emergent intubation include alterations in consciousness, facial trauma, bleeding, burns, or evidence of inhalation injury.48,50,51 Visual inspection and airway assessment before intubation are valuable tools for predicting airway difficulty. This allows for appropriate preparation and planning to maximize FPS and identify potential challenges with bag-valve-mask ventilation and laryngoscopy.52
There are multiple tools and approaches for the initial airway assessment. One frequently used approach is the Mallampati classification, which assesses how well the oral cavity can be visualized relative to tongue size. The greater the degree of obstruction caused by the tongue, the more difficult the airway may be. However, in pediatric patients, the Mallampati airway score, as well as other less commonly used difficult airway prediction scores, are less predictive and frequently limited due to patient cooperation.44,48 Many exam findings that have been discussed previously in the adult difficult airway literature, such as limited head extension/neck mobility, cervical spine immobilization, facial trauma, limited mouth opening, decreased mandibular space, and increased tongue size, also apply to pediatric patients.48 Younger patients, specifically ages younger than 1 year of age, are associated with increased risk of difficult airways. Lastly, be aware of any baseline craniofacial abnormalities (i.e., Pierre-Robin syndrome, Treacher-Collins syndrome, cleft lip or palate) that also may predispose to difficulty with airway management.48
Similar to adults, the LEMON mnemonic is a widely used airway assessment tool in pediatric trauma situations. It has demonstrated its effectiveness in pre-anesthesia evaluations, with many of its components also being relevant to trauma care.48 Its strength lies in combining various aspects of airway assessment rather than depending on a single factor.
Pediatric Airway Management
Basic Airway Management
Initial airway management should focus on ensuring adequate oxygenation and ventilation. For spontaneously breathing patients, this often can be accomplished with the application of supplemental oxygen via nasal cannula or a simple face mask. An altered level of consciousness can cause decreased tone of pharyngeal tissues, resulting in partial or complete upper airway obstruction. In this scenario, a head-tilt/chin-lift or jaw-thrust maneuver can be implemented to tighten pharyngeal musculature and improve airway patency. However, the head-tilt maneuver, with associated neck extension, should be avoided if there is potential concern for cervical spine injury. To avoid this, cervical spine stabilization should be maintained, and the jaw-thrust can be used. Any airway debris, such as blood or emesis, should be suctioned. Alternatively, the patient can be turned laterally while maintaining cervical spine immobilization if suction is unavailable.44,45,47,48,50
Airway Adjuncts
Airway adjuncts, such as an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA), can be used to relieve airway obstruction caused by the tongue. An OPA is indicated in the obtunded or unconscious patient without a gag reflex; use in conscious patients with a preserved gag reflex can result in emesis, further contaminating the airway. These can be sized using the length from the corner of the mouth to the angle of the jaw. It is imperative to ensure that the selected OPA is sized appropriately, since an OPA that is too large or too small potentially can worsen airway obstruction. For adults, providers often are taught to insert these backward and perform a 180-degree rotation to place. However, this should be avoided in pediatric patients because this potentially could result in soft tissue trauma. Instead, consider using a tongue depressor to assist with insertion. An NPA, in contrast, can be used in a conscious or semiconscious patient with an intact gag reflex. To appropriately size an NPA, measure the length from the nares to the ear lobe. NPAs are contraindicated in patients with possible basilar skull fractures and facial trauma with disruption of the midface, nasopharynx, or cribriform plate.44,47,48
Definitive Airway
If there is persistent inadequate oxygenation, inadequate ventilation, lack of neuromuscular respiratory drive, evidence of impending airway compromise, or an absence or airway protective resources despite the initial airway interventions described earlier, a definitive airway must be established. Additionally, in the setting of trauma, a patient with a GCS < 8 in the setting of suspected traumatic brain injury (TBI) also warrants securing a definitive airway.44 If there is concern for possible cervical spine injury, manual in-line cervical spine immobilization should be held during attempts to establish a definitive airway.
Orotracheal Intubation
In pediatric patients, orotracheal intubation is the most reliable method for establishing a definite airway and ensuring adequate ventilation. Nasotracheal intubation is avoided in pediatric patients because it is anatomically more difficult compared to adults and there is increased concern for hemorrhage due to the more prominent nasopharyngeal soft tissues.2
Airway Equipment Selection
Selecting the appropriate equipment for pediatric airway management, particularly in major trauma cases, can be challenging. Accurately measuring a child’s weight in these situations often is difficult. However, a length-based resuscitation tape, such as a Broselow tape, can provide reasonably accurate estimates. Such products typically include recommendations for appropriately sized airway equipment and medication dosages based on the child’s height and weight. Additionally, formulas and mnemonics can be helpful and quick ways to remember benchmark ages and appropriate equipment sizes (“Miller 2 at 2 and 3 Blade at 3rd grade,” cuffed ETT = (Age/4) + 3.5, uncuffed ETT = (Age/4) + 4, etc.).45,46,48
A Macintosh blade, which allows for indirect elevation of the epiglottis by placing the tip of the blade in the vallecula, often is used in older patients where airway anatomy is similar to that of an adult. Conversely, in younger patients (younger than 2 years of age), a Miller blade often is preferred because this allows for direct elevation and better control of the epiglottis, resulting in a better view during laryngoscopy.44,47,48
Historically, uncuffed endotracheal tubes were preferred for pediatric intubation. In pediatric patients, the cricoid ring is the narrowest part of the airway, and thereby naturally forms a seal around an uncuffed ETT. This preference was based on the idea that the use of cuffed endotracheal tubes could result in pressure injuries of the subglottic region. However, the use of cuffed endotracheal tubes in pediatric airway management is increasingly common.The risk of airway pressure injuries is minimal in the modern age given the use of low-pressure cuffs. Additionally, cuffed endotracheal tubes improve ventilation and CO2 management while preventing aspiration.2,44,47 Some studies have even shown a potential increased risk of laryngospasm with the use of uncuffed endotracheal tubes.47
Additionally, the shorter trachea of pediatric patients can predispose these patients to right main-stem intubation. To minimize this potential risk, keep in mind that the appropriate depth for endotracheal intubation is classically three times the ETT size (i.e., a size 3.0 ETT should be secured at a depth of 9 cm).45
Medication Selection
Sedative
When selecting appropriate medications for pediatric patients undergoing rapid sequence intubation, several factors should be considered. In trauma, prevention of hypotension and maintenance of hemodynamic stability are crucial.
Propofol, a sedative hypnotic, often is avoided in the setting of trauma because of hypotension. Furthermore, propofol can decrease cerebral perfusion pressure and should be avoided in traumatic brain injury. Similarly, midazolam, a benzodiazepine, can result in hypotension. Both propofol and midazolam can cause respiratory depression. Additionally, when midazolam is used for induction, it often is combined with other medications, such as fentanyl, that can further potentiate this effect.44,46,48 For these reasons, neither propofol nor midazolam is a first-line induction agent for RSI in pediatric patients.
Etomidate, a sedative hypnotic, has minimal effect on heart rate and blood pressure and is a relatively hemodynamically neutral medication, making it a reasonable option for use for RSI in trauma patients. Etomidate carries the potential adverse effect of adrenal suppression, with studies showing this effect can occur even after a single dose. However, studies have shown no long-term difference in clinical outcomes despite this potential risk.44,46,48
Ketamine, a dissociative anesthetic, offers several advantages, including preservation of airway reflexes and spontaneous ventilation, reflex tachycardia and hypertension, and bronchodilation. Due to its favorable hemodynamic profile, ketamine should be strongly considered as a primary induction agent during major trauma. Early studies demonstrated a potential adverse effect of elevated ICP, and ketamine previously had been contraindicated in traumatic brain injury for this reason, but recent studies have failed to confirm this effect, with some studies even suggesting a potential increase in cerebral perfusion pressure.44,46,48
Paralytic
There is considerable debate regarding the optimal paralytic agent. Succinylcholine has a less favorable side effect profile but offers a rapid offset if intubation is unsuccessful. Additionally, there is a theoretical risk of succinylcholine causing hyperkalemia in younger children, particularly those with undiagnosed muscular dystrophy. The introduction of sugammadex, a reversal agent for non-depolarizing agents like rocuronium, allows for the quick reversal of paralysis if intubation fails or to facilitate a rapid neurological exam post-intubation. Clinicians should consider the contraindications of each paralytic agent and choose the one they are most comfortable using.44,46,48
Premedication
Historically, pre-intubation atropine has been used in pediatric patients to prevent reflex bradycardia caused by vagal stimulation, particularly when succinylcholine is used for induction. However, no studies have conclusively demonstrated evidence to support the routine use of atropine during RSI. For this reason, the updated 2015 Pediatric Advanced Life Support Guidelines no longer recommend routine use of atropine for critically ill infants and children. Nevertheless, it is reasonable to use atropine in certain emergency intubations where the risk of bradycardia is higher (i.e., when using succinylcholine for induction). Studies have shown atropine premedication doses of 0.02 mg/kg to be effective without a minimum dose requirement.36,37,46
Post-Intubation Management
The post-intubation process for pediatric patients is largely similar to that for adults. The airway should be secured after successful intubation and appropriate placement should be confirmed. Bilateral auscultation of the chest can be misleading in children because lung sounds are readily transmitted. Although there is no single method that is 100% accurate for confirming correct ETT placement, studies have shown continuous waveform capnography (ETCO2) to be the most reliable method in emergency situations and prehospital care. Following up with a chest X-ray can help reaffirm tube location and assess its position.38,53
Failed Intubation
If an initial attempt at transoral intubation fails, any subsequent attempt should be made by the most experienced clinician. After one to two failed attempts via direct or video laryngoscopy, and ensuring the patient is adequately oxygenated between attempts, it is reasonable for an experienced clinician to re-attempt using a GEB or lighted stylet. Fiberoptic intubation or retrograde wire tracheal intubation are some additional options that can be considered when managing a difficult airway. If all else fails, a supraglottic device can be placed temporarily until a pediatric ear, nose, and throat specialist (ENT) or anesthesiologist can evaluate the patient.46,48
Surgical Airway
CICO is a rare, life-threatening situation that, according to some studies, occurs in one in 3,200 cases in the operating room and one in 500 cases in the emergency department.41 Delays in establishing a rescue airway in such situations can cause irreversible cerebral hypoxia or cardiac arrest, contributing to high morbidity and mortality. Therefore, it is critical for clinicians to recognize such situations and establish a surgical airway early.
In pediatrics, surgical airway management generally can be divided into two options based on age: needle cricothyroidotomy with jet ventilation for younger patients and traditional cricothyroidotomy for older patients. The exact age cutoff that delineates management options is debatable; the American College of Surgeons states that surgical cricothyroidotomy can be performed in patients older than 12 years of age, while several other resources advise an age cutoff of 8 years of age.2
For children younger than 8 years of age who have smaller cricoid membranes, the first-line intervention should be needle cricothyroidotomy with jet ventilation. Clinicians performing this procedure should exercise caution because the cricoid tends to be more compressible in children and, thus, poses a larger risk of piercing through to the esophagus. Additionally, this approach often is a temporary measure (40-60 minutes) and a bridge to a more definitive airway, since the patient can be oxygenated but with very poor ventilation, resulting in progressive hypercarbia. For children older than 8 years of age, a traditional cricothyroidotomy can be performed.45,47,48
For patients younger than 2 years of age, any front-of-neck access procedure can be prohibitively difficult and there is a low probability of success. In this case, consultation with a surgeon who is capable of performing an emergency tracheostomy may be the next best option.48
Conclusion
Airway assessment and management in trauma is complex, and the appropriate approach will vary based on several factors, such as the nature of a patient’s injuries, the patient’s clinical status, and the available clinical and technical expertise. Ultimately, effective trauma care requires a coordinated team approach with clear communication of management priorities. Airway management can be conceptualized as a ladder, with basic interventions at the bottom and increasingly advanced management strategies ascending toward the top. Basic management strategies should be mastered and used appropriately so that advanced maneuvers and their associated risks and complications can be avoided unless necessary. Adequate oxygenation and ventilation are the priorities of trauma airway management. Several techniques and strategies may be used to achieve this goal, and there often is no clear optimal approach. Advances in medical technology have led to incremental improvements in management strategies and patient outcomes. Safely managing both routine and difficult airways is essential in trauma, and this requires familiarity with available equipment and its use as well as anticipation of and planning for challenging situations.
Robert Rainer, MD, is Emergency Medicine Resident, The Ohio State University Wexner Medical Center, Columbus.
Emir Udovcic, MD, is Emergency Medicine Resident, The Ohio State University Wexner Medical Center, Columbus.
Benjamin M. Ostro, MD, is Assistant Professor of Emergency Medicine, Department of Emergency Medicine, The Ohio State University, Columbus.
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Rapid assessment and management of the airway in trauma patients is critical, and timely, decisive, and skillful intervention often can make the difference between life and death. Every emergency medicine physician must have an escalating stepwise approach to securing even the most difficult airway. The authors comprehensively review the initial airway assessment, basic and advanced methods and techniques for establishing a definitive airway through endotracheal intubation and surgical airways, airway adjuncts, medications selection, and strategies to address specific factors that complicate airway management in trauma.
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