This document discusses airway management approaches for trauma patients. It begins with pre-hospital management focusing on oxygen, hemorrhage control, and immobilization. Upon arrival, the primary and secondary surveys are conducted to evaluate ABCs and for injuries. Difficult airways may require alternate techniques like video laryngoscopy, FOB, or surgical airway. Maxillofacial, neck, and chest injuries often complicate intubation and may require awake techniques. C-spine injuries require in-line stabilization during intubation. Direct airway trauma from blunt or penetrating injuries also increases challenges and risks of standard intubation methods.

1. APPROACH TO A CASE OF DIFFICULT AIRWAY WITH
SPECIAL REFERANCE TO TRAUMA
Dr Shadab Kamal

2. • Pre hospital management
• Initial evaluation and resuscitation
• Airway obstruction and its management
• Full stomach consideration
• Airway evaluation and intervention
• Some definations
• Difficult airway management in general
• Important consideration in head, eye, major blood
vessel, cervical spine injury and direct airway injury like
maxillofacial trauma, neck trauma and tharacic trauma

3. Prehospital Management
• Controling airway,
external hemorrhage,
rapid transport with
supplemental oxygen.
• Immobilization of the
C-spine, combination
of a hard collar and
sandbags on opposite
sides of the head.
3

4. Initial Evaluation and Resuscitation
Rapid Overview Primary Survey, Secondary Survey
The strategy of initial management will be
continuous, priority-driven process of patient
assessment, resuscitation, and reassessment.
The general approach for evaluation of the
acute trauma victim:

5. Rapid overview takes only a few seconds and is
used to determine whether the patient is stable,
unstable, dying, or dead.
Primary survey involves rapid evaluation of
functions that are crucial to survival.
ABCs i.e. airway patency, breathing, and
circulation, Brief neurologic examination is
performed, Examination for any external injuries.

6. The secondary survey : More elaborate
systematic examination of the entire body
Radiographic and other diagnostic
procedures may also be performed if the
stability of the patient permits.
The anesthesiologist:
Manage the airway, Contributes for
evaluation and resuscitation, Gather
information needed for possible future
anesthetic management.

8. Neurologic stability by AVPU or GCS Scale
GCS < 9 requires definite airway intervention to prevent aspiration
pneumonitis, to insure adequate oxygen delivery and to avoid hypercarbia.
Patency of the airway is always first priority
verbal contact, clear phonation by the patient establishes that the airway is
patent.
Initial assesment, ABCDE sequence
Any impairment of Airway, Breathing and Circulation, resuscitation must
initiated immidiately

9. Airway Obstruction; Partial or complete
Posteriorly displaced or lacerated pharyngeal soft tissues;
Soft tissue edema of the pharynx
Cervical or mediastinal hematoma; peripharyngeal hematoma
Blood or debris in the oropharynx
Teeth or foreign bodies in the pharynx
Bleeding, secretions, or foreign bodies within the airway
Displaced bone or cartilage fragments
Airway obstruction

10. Management of Airway obstruction
• The initial steps in airway
management are
– Chin lift,
– Jaw thrust,
– Clearing of the oropharynx
by suctioning,
– Administration of 100%
oxygen.
– Placement of an oro-
pharyngeal, naso-
pharyngeal airway or LMA,
in inadequately breathing
patients, ventilation with a
self-inflating bag.

11. If they do not provide adequate ventilation, the trachea must be
intubated immediately using either direct laryngoscopy or a
cricothyroidotomy, depending on the results of airway assessment.
It provide temporary measures and serve as a bridge for a brief
period to re-establish the airway patency or to facilitate intubation
aided by a FOB.
A oropharyngeal, nasopharyngeal or laryngeal mask airway (LMA)
may permit ventilation with a self-inflating bag, donot provides
protection against aspiration of gastric contents.

12. Full stomach
• A trauma patient is always considered to have a
full stomach and to be at risk for aspiration, and
the urgency of securing the airway often does not
permit adequate time for pharmacologic measures
to reduce gastric volume and acidity.
• Thus, selection of a safe technique for securing the
airway is employed:
– Rapid-sequence induction with cricoid pressure
for patients without serious airway problems,
– Awake intubation with sedation and topical
anesthesia, for those with anticipated serious
airway difficulties.

13. Airway Evaluation and Intervention
Airway evaluation involves
The diagnosis of any
trauma to the airway
or surrounding
tissues,
Recognition and
anticipation of the
respiratory
consequences of
these injuries,
Prediction of the
potential for
exacerbation of
these or other
injuries by any
contemplated airway
management
maneuvers

14. • Although nontraumatic causes of airway difficulty, such
as pre-existing factors may be present.
• L-E-M-O-N:
– Look externally
– Evaluate 3-3-2 rule
– Mallampati classification
– Obstruction
– Neck mobility
• ASA difficult airway algorithm can be applied with
certain modifications.
• cancellation of airway management when difficulty
arises may not be an option.

15. Difficult airway
According to ASA
“The clinlcal situation in
which a conventionally
trained anesthesiologist
experiences difficulty with
mask ventilation, difficulty
with laryngoscopy and
intubation, or both”.
Result of
complex
interactions
between
Patient
factors
Clinical
setting
Skills &
preferences of
practitioner

16. Difficult Mask Ventilation:
• As defined by ASA task force, when it is not possible
for the unassisted anesthesiologist to maintain
oxygen saturation > 90% using 100% oxygen &
positive pressure ventilation in a patient whose
oxygen saturation was > 90% before anesthetic
intervention.
Difficult Laryngoscopy:
• “It is not possible to visualize any portion of vocal
cords with conventional laryngoscope”
• Usually corresponds to Cormack & Lehane’s grade IV
view.

17. Difficult Endotracheal Intubation:
As per ASA task
force “proper
insertion of
tracheal tube
requires more
than 3 attempts
or more than 10
min”
As per Canadian Airway Focus Group
“an experienced laryngoscopist ,
using direct laryngoscopy, requires:
• More than 2 attempts with same blade
• A change in blade or an adjunct to DL ex
bougie
• Use of an alternative device or technique
following failed intubation using DL

18. The American Society of
Anesthesiologists (ASA)
algorithm for management
of difficult airways is a
useful starting point for the
trauma anesthesiologist,
whether in the ED or the
OR
Emergency
airway
management
algorithm

19. Advance Airway Management
Advanced
airway
management
is indicated if
there is
Cardiac
arrest,
Apnea,
Persistent
obstruction,
Severe head
injury,
Maxillofacial
trauma,
Penetrating
neck injury
with an
expanding
hematoma,
Major chest
injury(flail
chest),
Inability to
maintain SpO2
>90% by
facemask

20. Patient preparation
• Monitoring equipments: EtCO2, Pulse-
Oximeter, NIBP, ECG
• Oxygenation equipments:
• Wide bore Suction catheter of appropriate size
• I.V. access & premedication
• Intubation equipments:
• Gum elastic bougie or intubating stylet
• Surgical or needle cricothyrodotomy kit:
• Equipments for checking tube position:
• Prevention of gastric aspiration:
• Patient positioning:

21. The approach depends upon the patient’s injuries,
airway status and the care provider’s experience with
such equipment & procedures.
There is no single universal technique of intubation
which may be favorable in all circumstances.
Regardless of the associated injuries, the primary
means of securing the airway in the vast majority of
acutely desaturating patients with maxillofacial
trauma is awake orotracheal intubation via direct
laryngoscopy.

22. In agitated and uncooperative
patients, topical anesthesia of
the airway is impossible,
sedative agents may result in
apnea obstruction, aspiration
After locating the cricothyroid
membrane and denitrogenating
the lungs, RSI with direct
laryngoscopy or, immediate
cricothyroidotomy.
Acute obstruction from upper
airway trauma may require
emergency cricothyrotomy or
percutaneous or surgical
tracheostomy .
If facial or neck injuries
preclude endotracheal
intubation, tracheostomy under
local anesthesia should be
considered.
An awake intubation under direct
laryngoscopy or fiberoptic bronchoscopy
with topical anesthesia can be attempted
if the patient is cooperative.
22

23. Maxillofacial, neck, and chest injuries, as well as
cervicofacial burns, are the most common trauma-related
causes of difficult tracheal intubation.
Rapid examination of the anterior neck for feasibility of
access to the cricothyroid membrane.
Tracheostomy takes longer to perform than a
cricothyroidotomy and requires neck extension,
If cricothyroidotomy will be in place for more than 2 to 3
days, Consider for conversion to tracheostomy.
C/I to cricothyroidotomy include: age < 12 years and
suspected laryngeal trauma

24. • RSI is reserved for an uncooperative patient
• In this technique –100% oxygen for 3 min
• Do not bag and mask ventilate for fear of aspiration
• Direct Laryngoscopy and orotracheal intubation with
MILS in suspected C-spineis, Avoid Neck
hyperextension and excessive axial traction
• Cricoid pressure is applied.
• Ketamine for hemodynamically unstable /
thiopentone in stable patients
• Succinylcholine 1.0-1.5 mg/kg
• ETI and confirmation
24

25. Oral Vs Nasotracheal Intubation
In general, oral intubation is preferable to nasal
intubation in the emergency setting because
• Epistaxis.
• Risk for sinusitis in a patient who will be
mechanically ventilated for > 24 hours.
• use of a smaller-diameter tube will also increase the
difficulty of subsequent airway suctioning and
fiberoptic bronchoscopy.
• of the risk of injury to the brain in the presence of a
basilar skull or cribriform plate fracture.
25

26. • However, If nasal intubation is most likely
to be successful in a given situation, then
prefer nasal, Change to an oral tube once
the patient's condition has stabilized.
• ATLS guidelines suggest that airway
management provider should proceed
with the method of intubation with which
they are most proficient.

29. Head, Open Eye, and Contained Major
Vessel Injuries
• Adequate oxygenation and ventilation, deep
anesthesia and profound muscle relaxation
required.
• This helps prevent hypertension, coughing,
bucking, and thereby minimizes ICT, IOP, or BP,
which can result in herniation of the brain,
extrusion of eye contents, or dislodgment of a
hemostatic clot from an injured vessel,
respectively.
• Anesthetic sequence preferred includes
preoxygenation and opioid loading, followed by
relatively large doses of an intravenous
anesthetic and muscle relaxant.

30. • Succinylcholine, may be used with prior
administration of defasciculating dose of NDMRs.
Alternatively, rocuronium can be used.
• Neither muscle relaxants nor intravenous
anesthetics are indicated when initial assessment
suggests a difficult airway.
• In any other trauma patient, hypotension
dictates either reduced or no intravenous
anesthetic administration.

31. 31

32. Cervical Spine Injury
Initial evaluation:
• Emergency airway management may have to be
performed without ruling out C-spine injury while the
patients are in a rigid collar and neck stabilizing
devices due to lack of time to evaluate the injury, and
• Clearance of the neck at the earliest possible time
after airway management should be performed to
minimize the complications associated with the collar,
such as pressure ulceration, ICP elevation in head
injured patients, compromised central venous access,
and airway management challenges if reintubation is
needed.

33. According to the American
National Emergency X-
Radiography Utilization Study
(NEXUS) no need for
radiographic evaluation in
conscious patient with:
no posterior midline
tenderness in the neck
no focal neurologic deficit
with a normal level of
alertness,
no evidence of
intoxication,
absence of painful distracting
injury

34. • Canadian rule is more reliable than those for
NEXUS in diagnosing C-spine injury in responsive
patients.
• Diagnostic capability:
Three-view plain films < CT scans < MRI
• CT is not sensitive in picking up soft tissue and
ligamentous C-spine injury, and MRI is the gold
standard for ruling out C-spine injury. However,
it is so sensitive that it can detect subtle injuries
that are clinically insignificant.

35. Airway Management in C-spine Injury
• Almost all airway maneuvers, including jaw
thrust, chin lift, head tilt, and oral airway
placement, result in some degree of C-spine
movement.
• To secure the airway with direct laryngoscopy,
manual in-line stabilization (MILS) of the neck is
the standard care of these patients in the acute
stage.
• A hard cervical collar alone, which is routinely
placed, does not provide absolute protection,
especially for rotational movements of the neck.

36. • MILS is best accomplished by
having two operators in
addition to the physician who
is actually managing the
airway.
• The first operator stabilizes
and aligns the head in neutral
position without applying
cephalad traction. The second
operator stabilizes both
shoulders by holding them
against the table or stretcher.
• The anterior portion of the
hard collar, which limits
mouth opening, may be
removed after
immobilization.

37. • Other measures and
techniques, including the
McCoy laryngoscope, rigid
fiberoptic video
laryngoscopes
(Glidescope, Airtraq,
McGrath, King vision),
FOB, lightwand,
translaryngeal
(retrograde) intubation,
and cricothyroidotomy,
can be used to secure the
airway in patients
requiring cervical spine
immobilization.

38. • Supraglottic intubating airways with or without the
aid of FOB can be used, but neck movement with
these devices appears to be comparable to that
produced by conventional laryngoscopes.
• Flexible fiberoptic laryngoscopy, lightwand, and
possibly translaryngealguided intubation cause
almost no neck movement, but blood or secretions in
the airway, a long preparation time, and difficulty in
their use in comatose, uncooperative, reduces FOB
utility during initial management.

39. DIRECT AIRWAY TRAUMA
• Direct airway damage can occur anywhere
between the nasopharynx and the
bronchi.
• it can be classified into broad categories
of blunt and penetrating trauma, and each
of these can be considered in the context
of direct injury to the airway itself versus
compromise or threat to the airway
caused by the proximity of the injury in
the neck.
39

40. Maxillofacial injuries
• A hematoma
or edema in
the face,
tongue, or
neck may
expand during
the first
several hours
after injury
and ultimately
occlude the
airway.
partial or complete airway
obstruction
soft tissue edema of the
pharynx
peripharyngeal hematoma
blood or debris in the
oropharynx
teeth or foreign bodies in the
pharynx

41. • Coronal CT is the
investigation of choice for
facial injuries
• Plain radiograph with
waters view and submental-
vertical view can also be
done
• OrthoPentoGram (OPG) is
done for mandibular
fractures
• Tracheal intubation or a
surgical airway is necessary
as an initial measure to
avert airway compromise in
these circumstances.
41

42. Airway management technique for
maxillofacial trauma.
• When there
is bleeding
into the
oropharynx,
a flexible
fiberoptic
laryngoscope
may be
useless
because of
obstruction
of the view.
Patients who donot
have airway
compromise
Most patients with
isolated facial injuries
do not require
emergency tracheal
intubation
Surgery may be
delayed for as long as
a week with no
adverse effect on the
repair.
Patients who
present with airway
compromise
Patients who present
with airway
compromise may be
intubated using direct
laryngoscopy
the decision about the
use of anesthetics and
muscle relaxants is
based on the results of
airway evaluation

44. • A retrograde technique, using a wire or epidural
catheter passed through a 14-gauge catheter
introduced into the trachea through the
cricothyroid membrane.
• A surgical airway is indicated in airway
compromise, when direct laryngoscopy has
failed or is considered impossible
• Tracheostomy may be indicated as an
emergency procedure in the emergency room
within a few minutes of arrival or as a delayed
procedure in the OR for airway control.

45. • Comminuted mandibular, midfacial
bilateral LeFort III, and panfacial
fractures are likely to be managed
with tracheostomy for definitive
surgery.
• To avoid the possible complications
of tracheostomy, submental or
submandibular intubation, which
involves externalizing the proximal
end of an orotracheal flexible
armored tube through a small
submental incision has been
performed. Thus, the trachea
remains surgically intact.

46. Penetrating Neck Trauma
• Neck is divided into three
zones.
Zone 1 extends from
the clavicles inferiorly to
the level of the cricoid
cartilage superiorly.
Zone 2 extends from
the cricoid cartilage to a line
drawn through the angles of
the mandible.
Zone 3
is the area above the angles
of the mandible.
Cervical Airway Injuries

47. Blunt Neck Trauma
• Inability to localize injury precisely,
blunt injury is usually more
diffuse.
• Initial evaluation:
– Asses for any bruising or
ecchymosis related to the
external injury.
– Inspection of oropharynx to
detect injury to the tongue or
dentition.
– The external neck should then
be palpated carefully from the
mandible to the clavicle. 47
Palpation
Identification of any
swelling, hemorrhage, or
subcutaneous emphysema
Evaluation for tenderness of
the neck and in particular of
the airway structures
Evaluation of upper airway
anatomy direct airway
injury and landmarks for
surgical airway
intervention

49. • Infrequently, direct blunt neck trauma can
cause laryngeal fracture or tracheal
transsection.
• Although a trial of bag-mask ventilation may
be tempting, it promptly produces profound
subcutaneous emphysema and accelerates the
patient's deterioration.
• The best approach is prompt transfer to the
operating room for surgical exploration of the
anterior neck and establishment of the airway
by tracheostomy distal to the transsection.
49

50. • The strategy depends on the clinical
presentation.
• The tracheas of some patients with penetrating
airway injuries, especially stab wounds, may be
intubated through the airway defect without the
need for anesthetics or optical equipment.
• The presence of cartilaginous fractures or
mucosal abnormalities necessitates awake
intubation with an FOB or awake tracheostomy.
• Laryngeal damage will make impossible
cricothyroidotomy.

51. Thoracic Airway Injuries
• Occur due to penetrating trauma to
intrathoracic region, blunt injury involving
membranous trachea, mainstem bronchi and
iatrogenic causes such as tracheal intubation.
• In intubated patients without the suspicion
of a tracheal injury, difficulty in obtaining a
seal around the ETT or the presence on a
chest radiograph of a large radiolucent area
in the trachea corresponding to the cuff
suggests a perforated airway.

52. • Selective conservative management with an
endotracheal tube placed using bronchoscopic
guidance distal to the tracheal injury.
• Patients with lesions >4 cm, cartilaginous rather
than membranous injuries, concomitant
esophageal trauma, progressive subcutaneous
emphysema, severe dyspnea requiring
intubation and ventilation, difficulty with
mechanical ventilation, pneumothorax with an
air leak through the chest drains, and
mediastinitis are still managed surgically.

53. • Mental Status
– Resolution of intoxication
– Able to follow commands
– Noncombative
– Pain adequately controlled
• Airway Anatomy and Reflexes
– Appropriate cough and gag
– Ability to protect the
airway from aspiration
– No excessive airway edema
or instability
• Respiratory Mechanics
– Adequate tidal volume
and respiratory rate
– Normal motor strength
– Required Fio2 less than
0.50
• Systemic Stability
– Adequately resuscitated
(see above)
– Small likelihood of urgent
return to the operating
room
– Normothermic, without
signs of sepsis
Criteria for OR or PACU Extubation of
Trauma Patients

56. • Airway management in the trauma patients
is tailored to the type of injury, the nature
and degree of airway compromise, and the
patient’s hemodynamic and oxygenation
status.
Thankyou