Emergency airway management in the adult with direct airway trauma
- Trevor J Mills, MD, MPH
Trevor J Mills, MD, MPH
- Professor of Emergency Medicine
- University of California, Davis
- Peter DeBlieux, MD
Peter DeBlieux, MD
- Professor of Clinical Medicine
- Louisiana State University School of Medicine
Airway management in patients who have sustained direct trauma to the airway is among the most challenging problems for emergency clinicians. Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway obstruction.
Immediate, definitive airway management is needed when the patient cannot protect their airway or is unable to adequately oxygenate or ventilate. Emergent or urgent airway management is indicated when a patient develops respiratory distress or when symptoms are progressing rapidly. In addition, airway management often is indicated when the patient appears clinically stable, but the clinician anticipates clinical decline (eg, smoke inhalation, edema, subcutaneous air, hematoma) or feels that an unprotected airway presents a risk to the patient who requires transport to another facility or to radiology for extensive diagnostic studies. The higher rate of complicated airways in this population mandates that the clinician be prepared to use advanced airway techniques, including a surgical airway.
Airway assessment and management in adults with direct airway trauma will be reviewed here. Other aspects of airway management, including a general approach to the difficult airway, the decision to intubate, and advanced tools for airway management, are discussed separately. (See "The difficult airway in adults" and "Rapid sequence intubation for adults outside the operating room" and "Devices for difficult emergency airway management in adults" and "The decision to intubate" and "Basic airway management in adults".)
The general management of trauma to the head and neck is also discussed separately. (See "Facial trauma in adults" and "Penetrating neck injuries: Initial evaluation and management" and "Skull fractures in adults".)
CAUSES OF AIRWAY TRAUMA
Common causes of direct airway trauma include the following:
- Murphy MF, Walls RW. Identification of the difficult and failed airway. In: Manual of Emergency Airway Management, 3rd, Walls RM, Murphy MF. (Eds), Lippincott Williams & Wilkins, Philadelphia 2008.
- Krausz AA, El-Naaj IA, Barak M. Maxillofacial trauma patient: coping with the difficult airway. World J Emerg Surg 2009; 4:21.
- Walls RW. Trauma. In: Manual of Emergency Airway Management, 3rd, Walls RW, Murphy MF. (Eds), Lippincott Williams & Wilkins, Philadelphia 2008.
- Bair AE, Filbin MR, Kulkarni RG, Walls RM. The failed intubation attempt in the emergency department: analysis of prevalence, rescue techniques, and personnel. J Emerg Med 2002; 23:131.
- Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000; 35:221.
- Connell RA, Graham CA, Munro PT. Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Injury 2003; 34:912.
- CAUSES OF AIRWAY TRAUMA
- AIRWAY ASSESSMENT
- Determining the need for immediate intervention
- Signs of airway compromise
- Determining difficulty with airway management
- Guiding principle: Secure the airway early
- Crash airway: No time available
- Time available and difficult airway anticipated
- Time available and difficult airway NOT anticipated
- In-line stabilization and removing the cervical collar
- Patients appropriate for observation
- SUMMARY AND RECOMMENDATIONS