FRCA Notes

Airways in the Trauma Patient

Resources


Direct traumatic effects Indirect effects of trauma Intervention-related
Disrupted soft tissue and bony architecture Swelling Neck-immobilisation with collar/blocks/tape
Blood | secretions | foreign body in the airway ↓ consciousness leading to loss of airway/aspiration Manual in-line stabilisation


  1. Actual, or impending, airway compromise
  2. Ventilatory failure
  4. Reduced GCS
    • Combative or agitated patients (especially after TBI)
    • To facilitate regulation of ICP via PCO2
    • Humanitarian for analgesia e.g. severe burns, traumatic amputation
  5. Anticipated clinical course requiring intubation e.g. CT, theatre

  • General issues affecting all modes of airway intervention include:
    • Lack of patient co-operation
    • Risk of aspiration
    • Risk of 'can't oxygenate' scenario
    • C-spine injury

  • The severely injured trauma patient should ideally undergo RSI and intubation, but depending on the case's individual factors theoretical options include:
Non-intubation Oral intubation Front of neck
Supraglottic device RSI → intubation Retrograde intubation
Inhalational induction → intubation Awake tracheostomy
Awake tracheal intubation Awake cricothyroidotomy

Supraglottic devices

  • Benefit from simplicity
  • Do not secure the airway

RSI

  • Intubation may be complicated by the presence of MILS and cricoid pressure
  • Facial injury may impair effective pre-oxygenation
  • Induction agents may exacerbate existing cardiovascular instability

  • Evidence suggests videolaryngoscopy has a higher first pass success rate for patients with immobilised C-spines vs. direct laryngoscopy (BJA, 2021)

Inhalational induction

  • Facial injury may impair mask seal
  • Slow induction exacerbates aspiration risk
  • Possible airway obstruction from oedema or blood

  • (Unlikely to ever be used but came up as a potential answer in a past question, so is included here for completeness)

Awake tracheal intubation

  • Issues:
    • Presence of blood/secretions may lead to inadequate topicalisation with LA or distort/preclude airway anatomy
    • Abnormal anatomy may make awake intubation technically difficult
  • In a RCT of VL vs. fibrescopic intubation in patients with C-spine immobilisation, VL had a greater first pass success rate and a shorter time to intubation (Anaesthesia, 2023)

  • Gastric volume in the trauma patient is related to the interval between the last meal and the time of injury
  • There is little evidence that prolonged fasting time pre-procedure reduces the risk of aspiration i.e. little benefit in delaying surgery
  • The use of opioids exacerbates the effect of trauma on gastric emptying by further decreasing gastric transit