Review Article
Abstract
Airway Management for the victims of major trauma is the first priority in the care of the trauma victim and
is a core skill in emergency medicine and critical care. Endotracheal intubation remains the gold standard
for trauma airway management. Airway management in trauma patients is not just the capability to insert an
oral/nasal airway or endotracheal tube beyond the vocal cords. The five components integral to modern,
sophisticated airway management in trauma patients include equipment, pharmacologic adjuncts, manual
techniques, physical circumstances, and patient profile. A trauma patient may require airway management
in a variety of physical circumstances. Whereas, the commonly used airway management algorithms may
not suffice in all these situations, the construction of a truly complete decision tree is also virtually impossible. There is consensus that it is not the intervention per se but rather the conditions, skills, and performance that might be the possible variables that affect outcome. Paramedics have only limited experience and
on-the-job skills for invasive airway management. Difficult airway management is best left for the experienced physicians to handle.
Key Words: Airway, Trauma, Endotracheal Intubation.
Urgency
Inadequate
equipment
Inadequate
assistance
Challenges in
airway
management
Co-morbidity
Neck
injury
Head
injury
Challenging
anatomy
Respiratory
compromise
Cardiovascular
compromise
b. Airway positioning, including chin-lift and jawthrust manoeuvres, to relieve obstruction caused
by the tongue or soft tissues and use of magills
forceps to take out the broken teeth and blood
clots.
2. Advanced (nonsurgical):
a. Bag-valve devices with masks
b. Direct glottic visualization and oral intubation
c. Alternatives to direct glottic visualization and oral
Full
stomach
Difficult Airway
Recognized
Un
Unrecognized
co
op
pa erativ
tie
e
nt
General Anesthesia
Proper
Preparation
No
(Emergency
Pathway)
LMA As An Airway
(Ventilatory Device)
Yes (Non-emergency)
pathway
Intubation
Choices
LMA As An Intubation
(Fiberoptic Conduit)
Choice
LMA As An
Intubation (Fiberoptic
Conduit) Choice
Fail
LMA As An
Intubation (Fiberoptic
Conduit) Choice
LMA As An Airway
(Ventilatory Device)
Confirm
Extubate Over
Jet Stylet
Figure 2: The laryngeal mask airway and the ASA difficult airway
algorithm
100
+/- Paralysis
Mask Ventilation
Awake Intubation
Choices
Surgical airway
Failure
Success
ILMA
Reoxygenate, retry
Cricothyroidotomy
ment in trauma. Trauma Criticare 2003: Page 59. 7th Conference of International Trauma Anaesthesia and Critical
Care Society (Indian Chapter), New Delhi, India.]
Even in patients with a Glasgow Coma Scale score of
3, there is airway reactivity (gag and cough reflexes) with
a considerable potential to promote intubation failure.27
RSI with a sedative induction agent (e.g., thiopental,
ketamine, or etomidate) followed by administration of a
rapidly acting neuromuscular blocking agent (e.g., succinylcholine) to induce unconsciousness and motor paralysis is associated with a decrease in intubation failures and complications28,29 and is the gold standard for
emergency intubation attempts.30
RSI requires familiarity with patient evaluation, airwaymanagement techniques, sedation agents, neuromuscular blocking agents, additional adjunctive agents, and
postintubation management techniques. While the medications for airway management generally are administered intravenously, it should be kept in mind that in paediatric patients intraosseous access is an acceptable
alternative for the administration of several different
agents, including those used for endotracheal intubation.31 The use of succinylcholine may result in fewer difficult intubations in the trauma patient than when a
nondepolarizing neuromuscular blocking agent is used.32
Rocuronium used with propofol creates intubation conditions equivalent to those with succinylcholine.33 but a
can not intubate, can not ventilate situation may become disastrous due to prolonged blockade produced
by rocuronium.34
Maxillofacial trauma
The oropharynx and nasopharynx are frequently compromised in severe maxillofacial trauma, posing an immediate threat to airway from resulting deformity or from
aspiration of teeth, dentures bone and blood. Reduced
level of consciousness form associated closed head injury or shock, may progressively result in airway obstruction.62
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