airway management in trauma patients can be particularly challenging because of the presence of difficult airway and disrupted anatomy. Anatomical implications, airway assessment in trauma, airway management, helpful airway devices were all mentioned in this presentation.

1. Airway Management In
Trauma Patients
by
Mohammed Taher Rageh
mohammedtaher112@gmail.com

2. Airway management in case of trauma can be
CHALLENGING
Difficult Airway
Need Rapid Action
Disrupted
Anatomy
Failure or delay = high morbidity and
mortality
Introduction

3. Spotting light on recent recommendations and guidelines will help
every anesthesit to avoid risks and to success in airway
assessment and management which could help in saving many
lives
Introduction

4. Anatomical considerations
Cribriform plate may be fractured so in the presence of basal skull
fractures nasogastric tube insertion or nasotracheal intubation is
contraindicated

5. Anatomical considerations
During nasotracheal intubation:
•The tube should be lubricated
• Vasoconstricting solutions should be applied
•The bevel of the tube should be parallel to the nasal
septum
•The tube directed vertically downward, at a right angle to
the horizontal, until it reaches the oropharynx.
In The oral cavity:
•The uvula is a useful landmark for assessing the ease or
difficulty of tracheal intubation
•The tongue can be displaced posteriorly obstructing the
airway in unconscious patients

6. Anatomical considerations
In The larynx:
•The external application of pressure to the cricoid cartilage
is a technique used to make aspiration less likely by
compression of the esophagus against cervical vertebrae
•The Cricothyroid ligament lies between the thyroid cartilage
and the cricoid. It is the recommended site for emergency
laryngotomy in cases of laryngeal obstruction

7. Anatomical considerations
Effect of Recurrent laryngeal nerve injury:
•Complete cut of the RLN causing
paralysis of both abductors and
adductors, the affected cord lies
in a position midway between
abduction and adduction.
• Partial RLN injury results in
a selective abductor paralysis,
sparing the adductors.
The affected vocal cord is adducted
to the midline.

8. Mechanisms of Trauma
Injury is a leading cause of death worldwide
•Motor vehicle traffic-related injury.
•Motorcycle collision
•Pedestrian vehicle collision
•Falls
•Fire and burn
•Penetrating trauma
Types:

9. Airway Assessment in Trauma
Selection of airway devices, techniques, and procedures all
pivot on airway evaluation
• Previous intubation successes or failures
• Patient’s medical records
• Medic alert bracelet
Historical indicators of Airway Difficulty:

10. Airway Assessment in Trauma
• Neck: Bull neck, obesity and decreased head extension or
neck flexion.
•Tongue: Large tongue.
•Mandible: Receding mandible and decreased jaw
movement.
•Teeth: Buck teeth.
Anatomical indicators of Airway Difficulty:

11. Airway Assessment in Trauma
•Maxillofacial: Fractures or plethora.
•Oropharyngeal : Edema, hematoma, inflammation and
foreign body.
•Glottis: Edema, vocal cord paralysis and tumor.
•Neck: Mass or hematoma, subcutaneous emphysema,
rheumatoid arthritis, spondylitis and C-spine injury.
Pathological indicators of Airway Difficulty:

12. Airway Assessment in Trauma
Airway examination:
Eleven-Step Airway
Examination

13. Airway Assessment in Trauma
Mallampati test:
Class I: soft palate, tonsillar fauces, tonsillar pillars, and uvula visualized
Class II: soft palate, tonsillar fauces, and uvula visualized (except the tip )
Class III: soft palate and base of uvula visualized
Class IV: uvula not visualized
Class 0 : epiglottis is visualized.

14. Airway Assessment in Trauma
Cormack and Lehane classification:
• Class I: Most of the glottis is visible
• Class II: Only the posterior part of the glottis is visible.
• Class III: The glottis is not visible but the epiglottis can be seen.
• Class IV: The epiglottis is not visible..

15. Airway Assessment in Trauma
Other measurments:
Upper Lip Bite Test

16. Airway Assessment in Trauma
Imaging in airway assesment:
X-ray findings indicating DI:
• Short neck.
• Receding lower jaw.
• Obtuse mandibular angles.
• Protruding upper incisors.
• Relative overgrowth of the premaxilla.
• Short descending ramus of the mandible.
• High arched palate with narrow oral cavity.
Computerized facial analysis.

17. Airway Assessment in Trauma
Ultrasonography:
•Important structures could be seen using USG from the mouth
to the mid-trachea.
• Highly relevant images in airway management:
Identification of the cricothyroid membrane and tracheal rings
inter-space and depth in percutaneous tracheostomy.

18. Airway Management in Trauma
Essential preparations:
• Oxygen source
• Ventilation:
- Bag-valve-mask device (connect to O2 source).
- Soft nasal airway
- Rigid oral airway
- Transtracheal jet ventilation equipment
- Laryngeal mask airway
- Esophageal-tracheal Combitube

19. Airway Management in Trauma
Essential preparations:
• Intubation :
- Laryngoscope with new tested batteries
- #3 and #4 Macintosh blades with functioning light bulbs
- #2 and #3 Miller blades with functioning light bulbs
- Endotracheal tubes – various sizes styletted with
balloon tested
- Tracheal tube guides (gum elastic bougie, stylets)
- Flexible fiberoptic intubation equipment
- Retrograde intubation equipment
- Adhesive tape or umbilical tape for securing ETT

20. Airway Management in Trauma
Essential preparations:
• Suction device.
• Monitor : Capnography, pulse oximeter, ECG, BP.
• Drugs: IV induction, Muscle relaxants, Vasopressors and
resuscitation drugs.

21. Airway Management in Trauma
Conventional trauma airway management:
Position:
• The sniffing position is the optimum orientation for laryngoscopy-
assisted orotracheal intubation.
• It involves forward flexion of the neck on the chest and atlanto-
occipital extension of the head at the neck.
• This position attempts to create a line-of-sight between the
operator’s eye and the patient’s larynx
• Contraindicated whenever C-spine injury is suspected

22. Airway Management in Trauma
Sniffing position:

23. Airway Management in Trauma
Rapid sequence induction principles:
• preoxygenation with 100 percent O2 for five minutes
• application of cricoid pressure
• IV administration of an induction drug such as Midazolam or
Propofol
• Rapid-acting neuromuscular blockade drug such as
succinylcholine
• As soon as airway reflexes are lost, the laryngoscope is used to
visualize the glottis and facilitate placement of a styletted ETT
• Modification to the RSI technique involves gentle bag-mask
ventilation with 100 percent O2 while maintaining cricoid pressure

24. Airway Management in Trauma
Difficult trauma airway techniques :
Awake technique:
• Recommended for trauma patients with known or anticipated
difficult airways, provided they are cooperative, stable,
spontaneously ventilating and time allows.
• An awake fiberoptic flexible bronchoscope (FOB) guided
technique is generally safe and appropriate for stable trauma
scenarios. Even when a surgical airway is planned

25. Airway Management in Trauma
Difficult trauma airway techniques :
Techniques/Devices for Unstable, Uncooperative, or Apneic patient
:
The guidelines covering the anesthetized limb of the American Society
of Anesthesiologists (ASA) difficult airway algorithm are followed .

26. ASA difficult algorithm
(modified for trauma)

27. Airway Management in Trauma
Surgical airway options:
Transtracheal jet ventilation:
• Considered when the reason for failure to ventilate is supra laryngeal
or peri-laryngeal and the LMA and Combitube have failed.
• It involves:
- Advancing a 14-gauge angio-catheter through the
cricothyroid membrane in the midline aimed about 45
degrees, and caudally from the perpendicular direction
- The catheter is connected to adaptor of a high-pressure
inflation system

28. Airway Management in Trauma
Surgical airway options:
Transtracheal jet ventilation:

29. Airway Management in Trauma
Surgical airway options:
Percutaneous Cricothyroidotomy :
• TTJV technique is used to place a thin wall (14 G or larger)
needle into the trachea.
• Wire is passed through the needle into the trachea by using the
Seldinger technique.
•The cricothyroidotomy site is dilated. Then, using the Seldinger
technique, the cricothyrotomy tube is advanced, confirmed to be
intratracheal and secured in place

30. Airway Management in Trauma
Surgical airway options:
Open Cricothyroidotomy :
Step 1: Identification of the cricothyroid membrane
Step 2: Horizontal stab incision through skin and membrane
Step 3: Caudal traction on the cricoid membrane with a tracheal
hook
Step 4: Intubation of the trachea by the tube

31. Airway Management in Trauma
Surgical airway options:
Tracheostomy :
• The first few tracheal rings are exposed
• a horizontal incision is made between the first and second
tracheal rings
• the tube is introduced into the trachea

32. Considerations for specific injuries
Maxillofacial trauma:
• Airway obstruction could occur due to:
- Pharyngeal blood clots
- loose teeth
- posterior displacement of the tongue and periglottic tissues
• limited mouth opening.

33. Considerations for specific injuries
Maxillofacial trauma
Algorithm

34. Considerations for specific injuries
Penetrating neck trauma:

35. Considerations for specific injuries
Penetrating neck trauma:
• Zone 1:
Requires emergency airway management because airway is usually
compromised by hemorrhage and the patient may develop profound
shock.
• Zone 2:
Requires intubation for evaluation or surgical repair, in this area major
vascular structures and their sympathetic ganglia and the hypopharynx,
larynx and trachea are all at risk.
•Zone 3:
Direct airway compromise is uncommon.

36. Considerations for specific injuries
Blunt neck trauma:
Initial evaluation of the patient should include:
• Identification of bruising related to the external injury.
• Inspection of the oropharynx to ensure no injury to the tongue or
dentition.
• Careful palpitation from the mandible to the clavicle for the presence
of swellings, tenderness or direct airway injury.

37. Considerations for specific injuries
Airway disruption:
Any interruption of airway integrity due to either blunt or penetrating
trauma

38. Considerations for specific injuries
Cervical spine injury:
• In-line immobilization should be maintained.
• If rigid laryngoscopy is used: gum elastic bougie usage could be
helpful.
• Usage of other intubation techniques as FOB, McCoy blade or
Glidescope would be better due to immobilization.
• If there is associated airway risks, awake technique should be
considered.

39. Helpful airway devices
Supraglottic airway devices:
LMA Classic
• Designed to overcome the disadvantages of the ETT
• Forms a seal around the larynx
• Allow the practitioner to use both hands ( better than
facemask)

40. Helpful airway devices
LMA Flexible
• It’s wire-Reinforced LMA.
• Used successfully in patients undergoing head and neck
procedures when sharing airway between anesthesiologists
and surgeons in required.

41. Helpful airway devices
LMA Fastrach
Intubating LMA facilitate endotracheal intubation without the
need to move the cervical spine during intubation

42. Helpful airway devices
LMA Proseal
Permits access to the stomach using gastric tubes and reduces
the leakage of inspired gases into stomach

43. Helpful airway devices
LMA supreme
Combines the features of the intubating LMA and Proseal LMA

44. Helpful airway devices
LMA CTrach
An intubating LMA which contains fiberoptics to enable
viewing on a liquid crystal display

45. Helpful airway devices
The I-gel
Creates a better anatomical seal with pharyngeal, laryngeal,
and peri-laryngeal structures

46. Helpful airway devices
Baska mask
• Provides 2 large tubes for rapid gastric fluid clearance
• More effective laryngeal seal even with increased pressure

47. Helpful airway devices
SLIPA
• Provides a better protection from regurgitation ( than LMA )
• Effective in DA management esp. with narrow pharyngeal
space

48. Helpful airway devices
Laryngeal tube suction II
Similar to PLMA and much easier to insert than LTS I

49. Helpful airway devices
Rigid Laryngoscopes:
Rigid laryngoscopic blades
Macintosh type : the most commom.
Miller type: different technique from Macintosh
Levering type: useful in recessed mandible and decreased MO
Viewmax: provide better view of the larynx

50. Helpful airway devices
Video-assisted Laryngoscopes:
AIRTRAQ laryngoscope
Requires minimal head manipulation and provides a better view
without the need of alignment of the visual axes

51. Helpful airway devices
Video-assisted Laryngoscopes:
C-MAC laryngoscope
• Comes with regular reusable Macintosh blades. It offers a large colour
display
• reduces the risk of oral or dental injury ( beveled shoulder)
• useful in limited MO ( D-Blade )

52. Helpful airway devices
Video-assisted Laryngoscopes:
Pentax Airwayscope
Video laryngoscope with an LCD colour screen attached to the handle

53. Helpful airway devices
Video-assisted Laryngoscopes:
Glidescope® Video Laryngoscope
High resolution digital camera located in the middle of the blade tip

54. Helpful airway devices
Video-assisted Laryngoscopes:
Flexible fiberoptic laryngoscopes:
• Used when the patient’s neck cannot be manipulated, as when
cervical spine is not stable.
•It can also be used when it is not possible to visualize the vocal cords
because s straight line view cannot be established from the mouth to the
larynx

55. Helpful airway devices
Video-assisted Laryngoscopes:
Rigid fiberoptic laryngoscopes:
• Facilitate tracheal intubation in DA management situations such as
limited mouth opening or neck movement.
• Intubation can be performed via the nasal or oral route and can be
accomplished in awake or anesthetized patients

56. THANK YOU