What is the priority in managing the airway of a trauma patient?

Airway Management Priority in Trauma Patients

Oxygenation of the trauma patient takes absolute priority over definitively securing the airway, unless airway control is required to achieve oxygenation. 1

Immediate Assessment and Intervention Sequence

The fundamental objective is ensuring airway patency and facilitating adequate ventilation and oxygenation, with assessment of the airway occurring first in all unwell trauma patients. 1

Mandatory Indications for Immediate Airway Intervention

Endotracheal intubation or alternative airway management must be performed without delay when any of the following are present: 1

• Airway obstruction
• Altered consciousness (Glasgow Coma Scale ≤ 8)
• Hemorrhagic shock
• Hypoventilation or hypoxaemia

These situations require immediate action regardless of whether complete vital signs (including blood pressure) have been obtained, as airway protection takes priority over obtaining complete hemodynamic assessment. 2

Primary Airway Management Technique

Rapid sequence induction with endotracheal intubation via the oral route remains the gold standard for trauma airway management. 1, 3

Critical Technical Considerations

• Manual in-line stabilization should be applied during intubation rather than relying solely on cervical collar immobilization, as maintaining airway patency and adequate ventilation takes priority over theoretical spinal movement concerns. 1, 4

• Videolaryngoscopy should be used as the first-line technique if available and the operator is experienced, as it increases intubation success rates with minimal cervical spine movement compared to direct laryngoscopy. 1, 4

• Remove only the anterior portion of the cervical collar to facilitate mouth opening while maintaining posterior spinal support. 4

Oxygenation vs. Ventilation Targets

Avoid hypoxaemia at all costs (Grade 1A recommendation), as the negative effects are well-established, particularly in patients with traumatic brain injury. 1

Maintain normoventilation (PaCO₂ 35-40 mmHg) in trauma patients unless signs of cerebral herniation are present. 1, 2

• Hyperventilation should only be used as a life-saving measure in the presence of signs of cerebral herniation (Grade 2C). 1

• Avoid hyperoxaemia (PaO₂ well above normal range) except in the presence of imminent exsanguination, as prolonged hyperoxia is associated with increased mortality. 1

Medication Selection for Rapid Sequence Induction

Succinylcholine can be safely used within 48 hours of acute trauma for rapid sequence induction, as the risk of hyperkalemia from denervation does not develop until after this timeframe. 4, 5

• After 48 hours post-injury, use rocuronium as the neuromuscular blocking agent to avoid hyperkalemia risk. 4

• Dosing for succinylcholine:

  • Adults: 0.6 mg/kg IV (range 0.3-1.1 mg/kg) 5
  • Pediatric patients for emergency intubation: 2 mg/kg for infants and small children; 1 mg/kg for older children and adolescents 5

• Fluid administration is usually required concurrently, as positive intrathoracic pressure can induce severe hypotension in hypovolemic patients. 1

Alternative Airway Management Options

If standard oral intubation fails or is not feasible, a graded response should be employed using the least invasive techniques with highest likelihood of success first. 1

Backup Techniques Include:

• Supraglottic airway devices (second-generation preferred) for temporary oxygenation 1
• Bag-valve mask ventilation with jaw thrust maneuver (not head tilt-chin lift to minimize cervical spine movement) 4
• Emergency front-of-neck airway access (surgical cricothyroidotomy) following Difficult Airway Society guidelines if cannot intubate, cannot oxygenate scenario develops 1

Ultrasound guidance may be used to identify and mark the cricothyroid membrane before induction if the patient is at risk of failed intubation, even with cervical collar in situ. 1

Critical Pitfalls to Avoid

• Do not delay intubation for awake fiberoptic technique in emergency trauma situations, as this requires patient cooperation incompatible with emergency management. 4

• Do not perform multiple intubation attempts if the first attempt fails; have a clear backup plan including front-of-neck airway access. 4

• Do not prioritize spinal immobilization over airway patency and oxygenation, as the risk of secondary neurological injury from airway management is extremely low. 4

• Avoid cricoid force if laryngeal injury is suspected, and remove it if difficulty in intubation is encountered. 1

• Do not administer succinylcholine before unconsciousness is induced except in emergency situations where it may be necessary. 5

Special Trauma Scenarios Requiring Modified Approach

In suspected tension pneumothorax with hemodynamic instability: Perform needle decompression in the second intercostal space, mid-clavicular line immediately before intubation if signs of hemodynamic compromise are present. 6, 2

In patients with major burns, multiple trauma, or extensive denervation: Exercise great caution with succinylcholine administration, particularly after the acute phase (>48 hours), due to hyperkalemia risk. 5

In cervical spine injury: Airway protection takes precedence with manual in-line stabilization during intubation rather than avoiding intubation altogether. 1, 4

Post-Intubation Priorities

• Use waveform capnography for all intubations to verify tube placement and monitor ventilation adequacy, as failure to use capnography contributes to >70% of ICU airway-related deaths. 2

• Maintain adequate oxygenation with tidal volumes of 6-7 mL/kg to avoid excessive ventilation and gastric insufflation. 4

• If hypotension persists after intubation, consider concomitant injuries including hemothorax, cardiac contusion, pulmonary contusion, or intra-abdominal bleeding. 6