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1 Prehospital Care ofPenetrating Trauma
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6% dextran 70 (hypertonic saline/dextran, HSD), 7.5% saline
(hypertonic saline, HS), or 0.9% saline (normal saline, NS)
administered by out-of-hospital providers. Eight hundred
fty-three treated patients were enrolled: 62% were with
blunt trauma and 38% with penetrating trauma. There was no
difference in 28-day survival: HSD 74.5%, HS 73.0%, and
normal saline: 74.4%, p=0.91. There was a higher mortality
for the postrandomization subgroup of patients who did not
receive blood transfusions in the rst 24 h, who received
hypertonic uids. This study remains challenging to interpret
as the study was stopped early (23% of proposed sample
size) for futility and potential safety concern. Further exploratory sub-group analysis may guide researchers toward a
specic group of patients that may benet the most from
hypertonic saline resuscitation.
1.4.5 Prehospital Blood Transfusion
Blood is the preferred resuscitation uid for trauma; until
recently this has only been available in hospitals. There are
two important randomized controlled trials of prehospital
use of blood: COMBAT & PAMPer.
In the Control of Major Bleeding After Trauma Trial
(COMBAT), Moore et al. randomized consecutive trauma
patients in hemorrhagic shock (dened as systolic blood
pressure [SBP] ≤70 mmHg or 71–90 mmHg plus heart
rate≥108 beats per min) to receive plasma or normal saline
(control). Ambulances carried coolers containing two units
of frozen plasma or a placebo of frozen water. If water in the
kit, then paramedics infused saline. There were 125 treated
patients. The groups were similar at baseline and had similar
transport times (plasma group median 19min [IQR 16–23]
vs. control 16min). The groups did not differ in mortality at
28 days (15% in the plasma group vs 10% in the control
group, p=0·37). In the intention-to-treat analysis, there was
no difference between the groups in safety outcomes and
adverse events.
A second RCT to determine the efcacy and safety of prehospital administration of thawed plasma in injured patients
who are at risk for hemorrhagic shock (systolic blood pressure<90mmHg and HR>108/min, or systolic blood pressure<70mmHg) was conducted in an air medical transport
system. The Prehospital Air Medical Plasma (PAMPer) trial
randomized patients to transfusion of thawed plasma or use
of crystalloid. Five hundred and one patients were evaluated:
230 patients received plasma (plasma group) and 271
received standard-care resuscitation (standard-care group).
Mortality at 30days was signicantly lower in the plasma
group than in the standard-care group (23.2% vs. 33.0%; difference, −9.8 percentage points; 95% condence interval,
−18.6 to −1.0%; p=0.03). This represents a number needed
to treat of 10. No signicant differences between the two
groups were noted with respect to multiorgan failure, acute
lung injury-acute respiratory distress syndrome, nosocomial
infections, or allergic or transfusion-related reactions.
The different outcomes between these trials may be
related to transport duration and severity of illness. Pusateri
et al. performed a post hoc combined analysis of the
COMBAT and PAMPer trials to describe associations with
outcomes. Cox regression analysis showed a signicant
overall survival benet for plasma (hazard ratio [HR], 0.65;
95% CI, 0.47–0.90; p = 0.01) after adjustment for injury
severity, age, and clinical trial cohort (COMBAT or PAMPer).
A signicant association with prehospital transport time was
detected (from arrival on scene to arrival at the trauma center). Increased mortality was observed in patients in the standard care group when prehospital transport was longer than
20 min (HR, 2.12; 95% CI, 1.05–4.30; p = 0.04), while
increased mortality was not observed in patients in the prehospital plasma group (HR, 0.78; 95% CI, 0.40–1.51;
p=0.46).
Many prehospital systems have adopted blood transfusion
for the treatment of severe hemorrhage, including New South
Wales, Australia, British Columbia, Canada, Norway, and
Washington, United States of America.
In a systematic review and meta-analysis evaluating prehospital blood transfusion safety, Rijnhout etal. reviewed
trauma patients who received transfusion. Patients received
simultaneous use of packed red blood cells (pRBCs) and
plasma showed a statistically signicant reduction in longterm mortality (OR=0.51; 95% CI, 0.36–0.71; p<0.0001).
Transfusion with pRBCs alone showed no difference in
long-term mortality (OR = 1.18; 95% CI, 0.93–1.49;
p=0.17). This suggests that plasma be part of a prehospital
blood program, either as plasma alone or included in whole
blood.
Whole blood has several advantages and makes logical
sense to utilize although studies of use in the prehospital setting are still in progress. Compared to a balanced blood
resuscitation using plasma, platelets, and red blood cells,
whole blood can replace more coagulation factors contain an
effectively higher hematocrit, and has about a third of the
citrate which can lead to hypocalcemia. Whole blood
research is ongoing, and we look forward to reading more
about the benet of this near-ideal blood product. In an
observational study in one trauma system, patients were
stratied based on prehospital whole blood transfusion or no
prehospital transfusion. In the group of 538 patients, those
receiving blood transfusion had worse shock physiology and
greater reversal of shock. In a propensity-matched subgroup
of 214 patients with prehospital shock, improvement in
shock index (HR/SBP) between scene and ED was greatest
for patients in the transfusion group with a lower trauma bay
mortality (0% vs. 7%, p=0.04). Pokorny etal. describe their
prehospital blood program to give low-titer O+ whole blood
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D. Carlbom and E. M. Bulger
to patients. They suggest patients with any one of these criteria to administer prehospital whole blood:
• Systolic blood pressure<70mmHg
• Systolic blood pressure<90mmHg with heart rate≥110
beats per min OR.
• ETCO2<25
• Witnessed cardiac arrest <5min prior to provider arrival
and continuous CPR throughout downtime
• Age≥65years and SBP≤100 AND HR≥100 beats per
minute
1.5 Treatment: Hemorrhage Control
1.5.1 Hemostatic Agents
Several chemical hemostatic agents have been well-tested in
animals and are used in battleeld operations. These agents
are of two primary classes: minerals and chitosan. Mineral
formulations work by two primary methods; they absorb
water rapidly, thus concentrating platelets and clotting factors and inducing rapid clotting. They also form a barrier
over severed blood vessels that provides strength to invivo
clot. Minerals used include zeolite, magnesium, and potassium silicates. The major drawback of these compounds is
the local heat generated which can raise wound temperature
as high as 53.5°C. These formulations have been removed
from use and should be removed from equipment caches.
Chitosan formulations bind to RBCs due to their negative
charge and activate the intrinsic pathway of clotting. They do
not generate as much heat as some of the mineral formulations. Most of the hemostatic agents now come packaged in
a dressing or porous bag, which helps contain the compound
and facilitates operative repair by not contaminating the
wound with powder.
Research groups have developed several animal models
for the investigation of effectiveness of these dressing materials. They range from low ow venous bleeding to large
arterial high ow bleeding states. All hemostatic agents performed well, and in one study were associated with improved
survival.
In case series of human use, primarily on the battleeld of
Iraq, these dressings appear effective at hemorrhage control.
In one series of 103 patients treated with hemostatic agents,
bleeding was controlled in 92% of patients. In another review
of 64 uses by the military, bleeding was controlled in 97% of
cases.
Prehospital systems could consider these agents; how-
ever, their use would likely be infrequent as the battleeld
injuries caused by explosive devices and high-velocity missiles are markedly different than the typical injuries of the
civilian world. Their use should be considered a low fre-
quency event and receive special training or be limited to a
select team of paramedics, such as a tactical medic group.
Other special training should include wound packing for
EMS providers.
1.5.2 Tourniquets
Exsanguinating hemorrhage from injured extremities is a
rare occurrence in civilian trauma, but still remains one of
the leading causes of preventable death during wartime, typically as a result of explosions.
The U.S.Army Institute of Surgical Research published
an observational study of trauma patients who had tourniquets applied and were cared for at the combat support hospital in Baghdad. They documented 232 patients who had
428 tourniquets applied to 308 injured limbs. The overall
mortality was 13%, with a marked difference in mortality
when the tourniquet was placed before the development of
hemorrhagic shock. Patients in shock when the tourniquet
was applied had a mortality of 90% compared to 10% for
those patients not in shock. Prehospital use was also associated with better survival: 11% mortality in patients with tourniquet placed prehospital compared to 24% mortality when
placed in the Emergency Department. The authors were able
to identify a matched cohort of patients who meet criteria for
tourniquet use but did not have one applied and compared to
a group of similar injury pattern and severity who did receive
a tourniquet for hemorrhage control. Mortality was 23% in
the latter group compared to 100% for those without a tourniquet applied. They also report only four transient nerve
palsies for the entire cohort.
Hashmi et al. used the United States National EMS
Information System to describe tourniquet use by prehospital providers. A total of 7161 tourniquets were applied among
4,571,379 trauma activations (1.6/1000 activations). Patients
in the tourniquet cohort were younger (40±18 vs. 52±26
mean±SD years), were more hypotensive (16.1% vs. 2.5%),
and had higher initial acuity (65.0% critical/emergent vs.
20.6%) [p
tourniquet trauma patients, patients in tourniquet cohort had
a higher nal acuity (80.8% vs. 75.0%, p < 0.01), lower
scene time (15.4±13.6 vs. 17.0±14.2 mean±SD minutes,
p<0.01), and higher survival-to-hospital (83.6% vs. 75.1%,
p<0.01).
In a retrospective cohort study using Los Angeles County
Emergency Medical Services data, patients who sustained
extremity vascular were divided into prehospital tourniquet
or no-tourniquet group. Ninety-seven of the 944 patients had
prehospital tourniquets placed. In multivariable analysis,
prehospital tourniquet use was signicantly associated with
improved mortality (adjusted odds ratio 0.32; 95% CI, 0.16–
0.85; p = 0.032). There was no signicant difference in
< 0.01 for all]. Compared to matched non-
1 Prehospital Care ofPenetrating Trauma
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delayed amputation rates (adjusted odds ratio 1.07; 95% CI,
0.21–10.88; p<0.097).
Although there are no randomized data to support their
use, tourniquets are safe and reduce mortality; they should be
employed to control life-threatening exsanguination from
severe extremity wounds. Tourniquets are now well accepted
in the civilian trauma setting with public education programs
teaching bystander use, such as Stop The Bleed.
1.6 Summary
The prehospital care of the critically injured victim of penetrating trauma begins with systematic organization to place
the proper staff, equipment, and other resources in position
to aggressively treat these patients. Prehospital providers
must ght the clock and be in a state of constant motion
toward the denitive care offered by the trauma surgeon. The
traditional treatment dichotomy of “stay & stabilize” vs.
“scoop & go” should be modied to “treat during transport.”
Paramedics must be given adequate ongoing experience in
caring for these exigently ill patients to facilitate rapid correction of deciencies in the patient’s airway, breathing, and
circulation. New techniques, including tourniquets for lifethreatening extremity hemorrhage and hemostatic dressings,
are important skills for the management of external hemorrhage. With rapid transport and simultaneous treatment, prehospital personnel can signicantly change the outcome of
their patient’s disease, transitioning them from moribund to
salvageable.
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Airway Management inPenetrating
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Trauma
PudkrongAichholz, AndreasGrabinsky,
andEileenM.Bulger
2
2.1 Airway Assessment andInitial
Management
Assessment of trauma patients begins with the airway,
regardless of injury location(s). While this is a basic principle of Advanced Trauma Life Support (ATLS), providers
may become distracted by an impressive injury elsewhere in
the body and miss the fact that the patient has airway compromise. Airway patency in trauma patients is dynamic and
can worsen over time; thus, prompt and frequent reassessment is critical.
Here, we will discuss airway evaluation in a general
sense; in patients with suspected or known maxillofacial and
neck injury; and in intubated patients.
If the patient is not already intubated, begin your assess-
ment by having the patient talk to you. The ability to articulate coherent response with a clear voice conveys a patent
airway and sufcient respiration and cerebral perfusion. If
patients cannot speak, is it “functional” obstruction because
they are obtunded (and hence unable to protect their airway),
“mechanical” obstruction (foreign body, blood or secretions
in the airway, trismus from mandible fractures, laryngeal
obstruction), or both? or is it simply volitional (i.e., the
patient does not want to talk due to pain)? Hoarseness or difculties swallowing, especially in conjunction with other
ndings, portends impending airway obstruction and compromise. Hypoxemia can cause agitation in patients and is
often misdiagnosed as the patient being combative or intoxicated. Hypercarbia can cause somnolence. Visual inspection
of the airway and neck should occur simultaneously with or
soon after vocal assessment. Signs of respiratory distress,
P. Aichholz · A. Grabinsky (*)
Department of Anesthesiology and Pain Medicine, University of
Washington, Harborview Medical Center, Seattle, WA, USA
e-mail: grabi@uw.edu; pudkrong@uw.edu
E. M. Bulger
Department of Surgery, University of Washington, Harborview
Medical Center, Seattle, WA, USA
e-mail: ebulger@uw.edu
chest asymmetry, and agitation will usually be obvious. If
signs of airway obstruction such as noisy breathing or paradoxical breathing are present, airway maneuver such as jaw
thrust, or placement of an oropharyngeal airway, should be
utilized to mitigate the obstruction at least temporarily.
Maxillofacial and neck penetrating injuries can be
grouped into three categories in respect to anticipated difculties managing the airway:
1. Soft tissue injury of the face without teeth or bone
involvement
2. Soft tissue injuries with additional teeth and/or bone
involvement
3. Soft tissue, teeth/bone injuries, and involvement of
aerodigestive tract structures such as soft palate, tongue,
epiglottis, and larynx/trachea
While patients in the rst category are usually easy to
intubate despite impressive injuries, category 2 injuries will
likely require advanced airway techniques and category 3
will often need a surgical airway.
The goal of the initial assessment is to determine the likelihood of injuries to the above-mentioned structures. Make
note of any entry or exit wounds to gauge the trajectory of
the injury, and look for expanding hematoma, air and secretions leaking through a neck laceration, and tracheal deviation. If tracheal cartilage is exposed, does it appear to be
violated or transected? If a cervical collar is present, do not
delay removing it to inspect the neck (with manual in-line
stabilization, if appropriate): failure to do so is a common
cause of missed neck injuries. Always open the mouth and
inspect; relatively benign-appearing entry wounds in the
neck, face, or head may cause signicant injury to the oropharynx without obvious external damage (see Fig. 2.1).
Mandible fractures, especially when bilateral, may cause
trismus.
If facial injuries are present, you should pay special attention to ongoing bleeding which may lead to potential aspiration in the supine patient, especially massive epistaxis, and
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_2
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Fig. 2.1 GSW to face. The patient was shot with a high-caliber rie.
The entry wound and exit wound demonstrate relatively little damage
externally. When the patient was paralyzed, he proved very difcult to
bag mask ventilate. CT scan revealed severe, comminuted mandibular
fractures and soft tissue edema. This example reveals how, with penetrating facial and neck trauma, relatively benign-appearing external
wounds may mask signicant airway damage
oral lacerations. Awake patients with signicant bleeding
from the face affecting the airway should not be positioned
supine, but rather sitting upright if there isno contraindication from other injuries. Unconscious patients with signicant bleeding are unable to protect their airway and need
immediate airway management. Facial arterial injuries can
also lead to signicant blood loss and may require later angiographic intervention for bleeding control.
Auscultate both the chest and neck and focus on asymmetry and signs of airway edema. Stridor, a high-pitched,
turbulent sound heard with respiration, indicates the development of airway compromise and impending obstruction.
Finally, palpation can offer insight into potential airway
compromise. Palpate the face, neck, and chest closely for
signs of subcutaneous emphysema, and closely feel along
the cricoid and tracheal cartilages for signs of crepitus.
For intubated patients, do not be lulled into complacency: conrm tube position with capnography and auscultation of breath sounds. While capnography is the gold
standard for conrming endotracheal placement of the
endotracheal tube (ETT), auscultation is still required to
conrm bilateral lung ventilation. If these ndings are
P. Aichholz et al.
equivocal, especially in the event of very low cardiac output or cardiac arrest, you should use an additional techniques such as visualization with direct or video-assisted
laryngoscope or point-of-care ultrasonography to conrm
tracheal intubation. If you are unsure and other clinical
signs suggest an esophageal intubation (hypoxia, absent
breath sounds, no end-tidal CO2), you should reintubate. If
ventilation problems persist, the tube placement should be
conrmed with a ber-optic scope by placing the scope
through the endotracheal tube to identify the tracheal rings.
If no tracheal rings can be identied, the tube could be in
the esophagus or in a false passage caused by a tracheal
injury. In the latter case, a surgical airway should be established as soon as possible.
2.2 Deciding Who Needs aDenitive
Airway
A denitive airway is dened as a tube placed in the trachea
with the cuff inated below the vocal cords. This can occur
via three primary modes of tracheal intubation: nasal, oral,
and surgical. Emergent intubation is common in patients
with penetrating trauma and is inuenced by the location and
severity of injuries. Patients with penetrating neck injuries
require emergency airway management in 46% of cases, and
60% require intubation at some point during their
hospitalization.
The indications for intubation cannot be boiled down to a
simple list of criteria, yet it is useful to consider a few broad
categories. Table2.1 summarizes indications for intubation
recommended by the Eastern Association of Surgery of
Trauma (EAST) practice management guideline.
It should be stressed that determining who needs a denitive airway is a clinical decision and the use of objective
criteria such as pulse oximetry, arterial blood gases (ABG),
Glasgow Coma Scale (GCS), and vital signs, while useful,
should not be relied upon alone. The mechanism and magnitude of injury, as well as patient respiratory effort, is
equally important. Patients with impending airway disasters may display no vital sign or laboratory abnormalities.
The anticipated clinical course, the likelihood of deterioration, and planned procedure or intervention (CT scan, angiography) should all be used to guide the decision to
intubate.
The following three questions can help you determine if a
denitive airway is indicated.
1. Is there an obvious airway compromise or failure to pro-
tect the airway?
2. Is there a failure of oxygenation or ventilation?
3. Will the predicted clinical course and planned interven-
tion require airway control?
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Table 2.1 Indications for intubation according to the Eastern
Association of Surgery of Trauma (EAST) practice management guideline on emergency tracheal intubation immediately following traumatic
injury
Strong indications for
intubation May consider intubation
• Airway obstruction • Facial or neck injury with the
potential for airway obstruction
• Hypoventilation • Moderate cognitive impairment
(GCS score>9–12)
• Persistent hypoxemia
(SaO2≤90%) despite
supplemental oxygen
• Severe cognitive
impairment (GCS
score≤8)
• Severe hemorrhagic
shock
• Cardiac arrest • Cervical spinal cord injury with
• Persistent combativeness refractory
to pharmacologic agents
• Respiratory distress (without
hypoxia or hypoventilation)
• Preoperative management (pain
management or undergoing painful
procedure)
any evidence of respiratory
insufciency (complete cervical
SCI or incomplete injuries to C5
and above)
2.2.1 Failure toMaintain or Protect
theAirway
Airway obstruction can result from a variety of causes ranging from functional (i.e., in the obtunded patient) to mechanical (from edema, hematoma, or foreign body). Patients who
are obtunded often lose the muscle tone of their posterior and
oral pharynx, causing their tongue to drop back, leading to
functional obstruction. While the obstruction may easily be
relieved with simple maneuvers such as the jaw thrust, chin
lift, or the placement of an oropharyngeal airway (OPA), the
patient remains at a high risk for aspiration. If a patient can
tolerate an OPA, he/she cannot protect the airway and intubation is indicated. If a patient displays signs of frank
mechanical obstruction, simple basic life support (BLS)
maneuvers are unlikely to help, and therefore, a denitive
airway should be established.
Even if the primary survey does not reveal obvious signs
of airway obstruction, As clinical course progress,the patient
may lost their protective airway reexes and be at risk for
aspiration. This is particularly true in the patient with a
depressed level of consciousness, which can result from a
variety of causes: shock, intoxication, head injury, etc. The
Advanced Trauma Life Support (ATLS) program recommends that a patient with a GCS <8 be intubated. While a
reasonable cutoff, this should not be a rigid one, and you
should consider intubation if mental status appears to be
declining rapidly even if the GCS is still above 8. The
absence of the gag reex is often cited as evidence of an
inability to protect the airway, though there is scant literature
to support this. Studies have noted the presence of the gag
reex across a broad spectrum of GCS scores, and the
absence of a gag reex has been documented in individuals
who are fully conscious.
2.2.2 Failed Ventilation or Oxygenation
Consider the patient who cannot maintain adequate ventilation or oxygenation despite noninvasive measures such as
supplemental oxygen as likely, but not necessarily, requiring
intubation. The primary survey and adjuncts to the primary
survey (respiratory rate, breath sounds, the presence of cyanosis, pulse oximetry, arterial blood gases) will often make it
clear whether a patient is in frank respiratory failure. Early
assessment of the arterial blood gas may also identify patients
with respiratory acidosis or severe metabolic acidosis that
may require airway management to support ventilation.
2.2.3 Airway Control inAnticipation
ofPredicted Clinical Course or Planned
Intervention
2.2.3.1 Predicted Airway Compromise
Patients with penetrating injuries, particularly of the neck,
are at high risk for developing airway compromise, and an
“intact” airway is not reassuring if early signs of obstruction
are present. Early, mild signs of obstruction include subtle
change in voice, cough, and neck hematoma. These signs do
not mandate immediate intubation but should be monitored
closely and repeatedly. Stridor, expanding neck hematoma
(especially in conjunction with other signs of obstruction),
and obvious tracheal injury mandate early establishment of a
denitive airway before airway swelling makes intubation
more difcult or even impossible. The presence of stridor is
a late stage of obstruction and indicates at least 50% reduction in airway caliber. Expanding neck hematomas, even
when initially small, can lead to precipitous airway obstruction. The swelling of airway structures often requires an
endotracheal tube size smaller than usual. With severe edema
of the airway structures, a tube exchanger catheter (gum
elastic bougie) can be placed into the trachea via direct laryngoscopy, and the tube then advanced over the tube exchanger.
2.2.3.2 Predicted Course ofIntervention
In many cases, the predicted course of treatment and intervention pivot the decision for denitive airway. Examples
include patients who require heavy sedation for extreme agitation or painful procedure, lengthy transportation of patients
into a less-controlled environment such as an ambulance, CT
or MRI scanner, and patients in hemorrhagic shock and
likely to require large-volume uid resuscitation.
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2.3 Approaches toEstablishing
aDenitive Airway
There are numerous approaches to gaining a denitive airway. Deciding on the technique(s) used should take into
account the location(s) of injuries, the physiologic state of
the patients, the presence or suspicion of laryngotracheal
injury, the urgency of airway control, potential difculties of
each techniques, equipment availability, and the experience
of the clinician.
Equally important as deciding on the intubation technique
is having a preformulated sequence of progression if difculty is encountered. A rescue plan and equipment (e.g., surgical airway) must also be available. The different modes of
obtaining a denitive airway are discussed briey below.
2.3.1 Direct Laryngoscopy (DL)
Direct laryngoscopy is an appropriate initial approach for
most patients when difcult airway is not suspected. It can
be performed in patients with penetrating neck injuries but
should be avoided if there are signs of laryngotracheal injury.
It may worsen injury below vocal cords or lead to intubation
of false passage.
2.3.2 Video-Assisted Laryngoscopy (VAL)
This technique allows a better view for the less-experienced
airway manager and allows other members of the team to
visualize the upper airway anatomy and intubation on the
screen. Compared to DL, VAL nearly always improve glottic
visualization. However, it does not allow visualization below
the vocal cords; thus, like DL, VAL cannot exclude the injury
of the trachea below the vocal cords or intubation into a false
passage. VAL images can be susceptible to lens contamination from secretion or blood. In patients with signicant
amounts of blood in the mouth, direct laryngoscopy is the
preferred method.
2.3.3 Flexible Scope Intubation (FSI)
If available and the clinician is experienced with the technique, exible bronchoscope intubation is a good option
when a difcult airway or laryngotracheal injury is suspected. It allows for identication of injuries below the vocal
cords and placement of the cuff distal to the injury site. It can
be done awake in non-emergent situation if the patient is
cooperative. FSI can also be used to aid tracheal intubation
in patients with an existing supraglottic airway devices
(SGA), and as part of a “combination technique” in conjunc-
tion with either DL or VAL to assist difcult intubation. The
exible scope can be used to conrm tracheal tube position
and evaluate airway structures distal to the ETT after successful intubation with other techniques. However, this technique is limited by patients’ ability to tolerate the procedure
and level of cooperation, and also very susceptible to airway
contaminant such as blood or vomitus. When passing
through, blood or secretions will easily obscure the small
lens of the scope.
2.3.4 Cricothyrotomy
Surgical cricothyrotomy can be used either as the rst
approach when distortion of upper airway anatomy makes
any form of laryngoscopy impossible or unlikely to succeed,
or as a rescue strategy in “‘cannot intubate, cannot oxygenate” (CICO) scenarios. Cricothyrotomy is usually indicated
in patients with obvious laryngotracheal injury above the cricothyroid membrane that demonstrates signs of signicant
airway compromise. However, this approach should be
avoided if there is obvious tracheal injury below the cricothyroid membrane or if the underlying pathology (i.e., tumor
or abscess) makes the approach impossible. Surgical cricothyrotomy is not recommended for children under 12years
of age due to the potential damage to the cricoid cartilage,
the only circumferential support of the upper trachea in children. Needle cricothyrotomy can be used in young children
until denitive tracheostomy can be established.
2.3.5 Direct Intubation Through Neck Wound
This approach should be considered in patients with obvious
large defects of the trachea below the cricothyroid membrane
or in cases of complete tracheal transection.
2.3.6 Blind Nasal Intubation
There is no role for this technique if there is potential for
injury anywhere in the airway. Blind passage may worsen
underlying injuries, create false lumen, and/or lead to complete tracheal transection.
2.3.7 Tracheotomy
This is generally avoided in the emergent setting as it is slower
and carries a higher long-term laryngotracheal complication
rate than cricothyrotomy. In cases where cricothyrotomy is
impossible or there is obstruction or injury below the cricothyroid membrane, this approach may be the only option.
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2.4 Rapid Sequence Induction
andIntubation
Once the decision has been made that a patient requires a denitive airway and that direct laryngoscopy or video- assisted
laryngoscopy is appropriate, the next steps will depend on how
emergent the situation is. A “crash” intubation refers to a
patient who isin frankor near cardiopulmonary arrest orrespiratory arrest despite supplemental oxygen. In such case, try to
oxygenate and bag mask ventilate the patient as best you can
and proceed quickly to laryngoscopy. While many patients
undergoing a crash intubation do not require induction agents
due to the decreased or absent level of consciousness, using a
muscle relaxant can help with existing muscle tone or reexes
which can make an intubation more difcult. If the patient
needs a denitive airway emergently but is not “crashing,” take
time to further assess the airway for potential difculties, prepare equipment, optimize patient positioning, and formulate
backup plans in case the airway fails.
Rapid sequence induction and intubation (RSII or RSI) is
the near simultaneous administration of a sedative/hypnotic
agent with a neuromuscular blocking agent to rapidly achieve
unconsciousness and paralysis. In unconscious or semiconscious patients, the dose of the hypnotic should be reduced.
Thistechnique is commonly usedin emergent and traumasettings wherepatients are likely not fasted and at a higher risk
of aspiration. If done with adequate preoxygenation, it can
often be performed without having to bag mask ventilate the
patient at all, thus reducing gaseous distension of the stomach. If mask ventilation is requiredto maintain oxygenation,
use small tidal volumes to avoid extension of the stomach.
While RSI generally improves intubation success, you
should consider an alternate approach (such as awake FSI) in
spontaneously breathing patients who display predictors of a
difcult airway, especially when difculty with bag mask
ventilation (BMV) or surgical airway is suspected.
Once a standard of care for RSI, cricoid pressure’s role
has been reduced by many clinicians and guidelines due to
its potential to worsen bag mask ventilation and laryngoscopic view and the limited efcacy evidence for the prevention of aspiration.
2.4.1 Predicting theDicult Airway
Before you attempt intubation (in the non-“crash” situation),
you should ask these questions: Will the patient be difcult to
bag mask ventilate? Will the patient be difcult to intubate?
Will it be difcult to perform a surgical airway? In addition,
patient’s risks of rapid desaturation and aspiration should be
assessed. All abovefactors should be taken into accountformulating yourairway management plan. Table 2.2 summa-
rizes factors predictiveof difcult airway management.
The modied LEMON criteria (Table 2.3) is a scoring
system that has been shown to stratify the risk of difcult
intubation with high sensitivity. ATLS supports the use of
this assessment tool as many of its components are particularly relevant in trauma.
2.4.2 Preparing forIntubation
Prior to intubation, it is important to make sure all equipment
is laid out and working—laryngoscope, or videolaryngoscope with different-sized blades, different-sized ETT’s with
stylet, suction, CO2 detector or capnography, airway adjuncts,
Table 2.2 Difcult airway predictors
Difcult bag mask
ventilation Difcult laryngoscopy
Beard Reduced mouth opening Obesity
Elderly Receding chin Anterior neck
Edentulous Obstruction (neck
hematoma, stridor,
tongue swelling)
Perioral trauma
that affects mask
seal
Mandible—
Fracture
Obesity Reduced neck mobility
Signicant
tongue trauma/
edema
Obstruction/
debris/airway
hemorrhage
Table 2.3 Modied LEMON criteria. Total maximum score. Higher
score correlates with higher risk of difcult intubation
Criteria Score
L—look externally
• Facial trauma 1
• Large incisors 1
• Beard or moustache 1
• Large tongue 1
E—evaluate 3-3-2 rule
• Inter-incisor distance <3 ngerbreadths 1
• Hyo-mental distance <3 ngerbreadths 1
• Thyroid notch to oor of mouth (hyoid)<2
ngerbreadths
M—Mallampati score: no longer included in the modied
LEMONcriteria.
O—Obstruction: any cause of obstructing airway 1
N—Neck mobility: limited or with neck immobilizer 1
Large tongue Neck irradiation
Obesity, large/short
neck
(C-collar, ankylosing
spondylitis, radiation
therapy)
Difcult surgical
airway
hematoma
Surgical disruption
(radical neck
dissection, neck
trauma, etc.)
Overlying neck
abscess
1
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