Difficult Airway Management in Trauma: A Review of Current Guidelines - Trauma EXTRA Supplement (Trauma CME)

Table of Contents

 

About This Issue

The American Society of Anesthesiologists the Difficult Airway Society in the United Kingdom have produced the most widely cited difficult airway guidelines; however, these algorithms are not trauma specific. Recommendations for airway management, standardized equipment, and the development of difficult airway management programs in a community hospital setting. In this issue of Emergency Medicine Practice: Trauma EXTRA!, you will learn:

The key recommendations in the most widely adopted difficult airway management guidelines;

Techniques to use when intubation is not possible in patients with face and neck trauma;

Best practices in the management of the physiologically difficult airway;

The components and implementation guidance for initiating a difficult airway program in a trauma-level hospital.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Select Abbreviations
6. Etiology and Pathophysiology
   1. Epidemiology
   2. Trauma Epidemiology
   3. Causes of Difficulty in Trauma
      1. Facial Trauma
      2. Blunt Neck Trauma
      3. Penetrating Neck Trauma
      4. Burns
      5. Physiologically Difficult Airways
   4. Human Factors
7. Guideline Assessment
   1. 2022 American Society of Anesthesiologists Guidelines
   2. 2015 Difficult Airway Society Guidelines
   3. Trauma-Specific Guidelines
   4. Airway Trolley or Cart
8. Prehospital Care
9. Emergency Department Evaluation
10. Diagnostic Studies
11. Treatment
    1. Medications
    2. Direct Versus Video Laryngoscopy
    3. Supraglottic Airway Device Insertion
    4. Awake Tracheal Intubation
    5. Fiberoptic Intubation
    6. Front-of-Neck Access
    7. Preprocedural Ultrasound
    8. Jet Ventilation
    9. Verifying and Securing the Endotracheal Tube
12. Special Populations
    1. Pediatric Patients
    2. Patients With Congenital or Acquired Conditions
    3. Older Patients
    4. Pregnant Patients
    5. Patients With Obesity
13. Difficult Airway Response Programs
    1. Implementation in a Community Hospital Setting
14. Summary
15. Risk Management Pitfalls for Difficult Airway Trauma
16. Time- and Cost-Effective Strategies
17. Case Conclusions
18. Tables and Figures
19. References

Abstract

The American Society of Anesthesiologists and the United Kingdom's Difficult Airway Society have generated and revised guidelines over the past 30 years based on analyses of the causes of airway catastrophes. Guideline components include airway management algorithms, equipment standardization, and routine training. Algorithms utilize intubation, supraglottic airway insertion, fiberoptic intubation, awake intubation, and front of neck surgical access. This review summarizes difficult airway management guidelines and discusses their application to trauma patients, including patients with physiologically difficult airways and patients with maxillofacial and laryngotracheal trauma.

Case Presentations

A 24-year-old man arrives by private vehicle with a dish-face deformity (in which the face appears flattened or concave) as a result of an injury sustained while skiing...

• On examination, his face is free floating. He has bilateral periorbital hematomas and trismus.
• His Glascow Coma Score was 14 on arrival but it is steadily declining.
• He desaturates rapidly with supine positioning. How will you secure his airway?

A 27-year-old woman is expected by EMS with severe face, neck, and chest burns secondary to falling into a campfire while intoxicated…

• An experienced EMS crew notifies the ED before arrival that they failed 2 attempts to intubate by video laryngoscopy and are ventilating by bag valve mask; her oxygen saturation is 89% on 100% oxygen.
• They are coming to your non–trauma-designated community ED as they anticipate imminent loss of her airway.
• ETA is 4 minutes. How do you prepare?

A 32-year-old man presents to the ED with a self-inflicted knife wound across his anterior neck...

• He cut himself deeply with a hunting knife before being apprehended by police.
• EMS reports he is maintaining his airway.
• What are your initial concerns regarding possible injuries? What might your airway stabilization options be?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Risk Management Pitfalls for Difficult Airway Trauma

2. “EMS reported they were unable to intubate an 8-year-old patient who had been in a MVC. I’m residency trained in emergency medicine and expected I could easily secure the airway. However, the child had findings consistent with Pierre Robin sequence. I was unable to intubate, and I didn’t have an appropriate size SAD.” NAP4 and Closed Claims Analysis found that poor preparation was the cause of unnecessary mortalities.^6,7 An EMS report of a difficult airway should prompt appropriate preparation, including opening the difficult airway cart.

3. “I called the on-call ENT and told him that we had a patient coming in who had tried to hang himself and was hypoxic despite SAD placement. ENT replied, 'OK, I’m available,' and hung up. ENT never arrived at the bedside.” Closed loop communication is essential to ensure that emergency clinicians and consultants understand each other. Development of a DART would also ensure that there were shared institutional expectations and accountability in such situations.

6. “I decided to prophylactically intubate my burn patient for transport even though she was effectively breathing spontaneously. We used RSI with etomidate and rocuronium. I was unable to intubate her or place an SAD, and she began to desaturate. I decided to awaken her, but it took 10 minutes to obtain sugammadex from pharmacy, by which time she had coded.” Weigh the risks versus benefits before proceeding with elective intubation and ensure that all rescue medications and airway adjuncts are readily available. A reversal agent should always be immediately available if long-acting paralytics are used.

Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology. 2022;136(1):31-81. (Guidelines) DOI: 10.1097/ALN.0000000000004002

4. * Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848. (Guidelines) DOI: 10.1093/bja/aev371

10. * Patel A, Saadi R, Lighthall JG. Securing the airway in maxillofacial trauma patients: a systematic review of techniques. Craniomaxillofac Trauma Reconstr. 2021;14(2):100-109. (Systematic review; 16 studies) DOI: 10.1177/1943387520950096

11. * Mercer SJ, Jones CP, Bridge M, et al. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. Br J Anaesth. 2016;117 Suppl 1:i49-i59. (Systematic review) DOI: 10.1093/bja/aew193

15. * Pincet L, Lecca G, Chrysogelou I, et al. External laryngotracheal trauma: a case series and an algorithmic management strategy. Eur Arch Otorhinolaryngol. 2024;281(4):1895-1904. (Case series) DOI: 10.1007/s00405-024-08456-9

18. * Kornas RL, Owyang CG, Sakles JC, et al. Evaluation and management of the physiologically difficult airway: consensus recommendations from Society for Airway Management. Anesth Analg. 2021;132(2):395-405. (Guidelines) DOI: 10.1213/ANE.0000000000005233

24. * Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020;75(4):509-528. (Guidelines) DOI: 10.1111/anae.14904

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Keywords: difficult airway, airway compromise, craniomaxillofacial trauma, laryngotracheal trauma, intubation, supraglottic airway device (SAD), front of neck access (FONA), physiologically difficult airway, extubation, surgical airway procedure, Difficult Airway Response Team (DART), direct laryngoscopy (DL), video laryngoscopy (VL), endotracheal tube (ETT), fiberoptic bronchoscopy, fiberoptic intubation, rapid sequence induction (RSI), laryngeal handshake, “stab, twist, bougie, tube” technique, cricothyroidotomy, difficult airway cart, modified Mallampati test, bag valve mask ventilation