A review of airway management for trauma providers, including EMTs, advance practice providers, and physicians.

1. Airway Management
for the Trauma
Provider
SarahBeth Hartlage, MD MS
Assistant Professor
Department of Anesthesiology and Perioperative Medicine
University of Louisville

2. Disclosures
• No financial relationships to disclose

3. Objectives
• When and why to intubate
• Basics of airway management
• Recognizing difficult airways
• Emergency situations

4. WHY TO INTUBATE

5. Noninvasive Oxygen Therapy
Device FiO2
Room Air 21%
Nasal Cannula 1L 24%
NC 2L 28%
NC 4L 36%
NC 6L 44%
Simple Face Mask 6L 35%
FM 8L 40-45%
FM 10L 55-60%
Nonrebreather Mask 6L 60%
NRBM 8L 80%
NRBM 10L 95%
NRBM 15L ~100%
Venturi Mask 4-8L 24-40%
Venturi Mask 10-12L 40-50%

6. Noninvasive Ventilation
• CPAP/BiPAP
• Bag Valve Mask

7. Aids to Mask Ventilation
• Head Tilt / Chin Lift
• Oral Airway (OPA)
• Nasal Airway (Trumpet)

8. Indications for Endotracheal
Intubation
• Inability to oxygenate/ventilate adequately
• Via spontaneous respiration [respiratory failure]
• Via noninvasive ventilation [need for increased support]
• Inability to protect the airway
• GCS <8
• Hyporeflexia / areflexia
• Inability to maintain cardiac output [code situation]

9. Airway Anatomy

10. Mallampati Score
• Class I – complete visualization of
soft palate, uvula, anterior and
posterior tonsillar pillars
• Class II – complete visualization of
soft palate, uvula; partial
visualization of tonsillar pillars
• Class III – complete visualization of
soft palate; partial visualization of
uvula
• Class IV – no visualization of soft
palate; hard palate and tongue only
visible structures
Evaluate the airway with the patient sitting
upright, with head in neutral position.

11. HOW TO INTUBATE

12. 7 P’s of Airway Management
• Planning
• Preparation
• Positioning
• Preoxygenation
• Paralysis
• Placement
• Proof

13. Planning Preparation Positioning Preoxygenation Paralysis Placement Proof
Time
0
T +1 T +3T -3T -5

14. Planning and Preparation
• Plan
• Evaluate the patient for necessity of intubation
• Examine the airway
• Equipment
• Suction, oxygen, monitors
• Bag valve mask
• Ancillary noninvasive devices – oral and nasal airways
• Laryngoscope handle and blade(s)
• Endotracheal tube(s) and stylet(s)
• Backup equipment – bougie, LMA, surgical airway kit
• Drugs
• Relevant personnel
• Physician, nurse, respiratory therapist
• Defined roles for team members
• Communication is key

15. Airway Tools - Basics

16. Airway Tools - Laryngoscope

17. Airway Tools – Endotracheal Tube

18. Airway Tools - Ancillary

19. Positioning
• “Sniffing Position” aligns oral / pharyngeal / laryngeal axes
• Requires alignment of the tragus with the sternal notch
• Typically the shoulders remain on the bed while the head is
lifted 3 or more inches
• Obese patients may require ramping of the shoulders and
significantly more elevation of the head
• Note that this is not simple “extension of the spine”
• Caution in patients with cervical spine injury or unknown
pathology

20. Flexion of cervical
spine
Extension of
atlantoaxial joint

22. Preoxygenation
• Used to “denitrogenate” the lungs and extend the safe apnea
period
• Safe apnea = time until saturation falls below ~90%
• 1-2 minutes if breathing room air
• Up to 8 minutes if fully preoxygenated
• Reduced in patients with decreased FRC (pregnancy, extremes of
age, obesity, ascites), increased O2 consumption (sepsis,
hypermetabolic state), shunt physiology, etc
• If adequate respiratory effort, may use FiO2 100% fo 3
minutes of tidal breathing OR 8 vital capacity breaths
• If patient unable to perform above, may “preoxygenate” with
positive pressure breaths

23. Preoxygenation
• Useful in the optimal situation – clearly not always the case
• Do the best you can
• Can also “preoxygenate” with bag-valve mask in some cases

24. Paralysis - A Brief Note on Drugs
• Many choices for medications
• Induction agent
• Midazolam 0.1-0.3mg/kg
• Fentanyl 2-10mcg/kg
• Propofol 1-2.5mg/kg
• Etomidate 0.3-0.4mg/kg
• Ketamine 1.5-2mg/kg
• Paralytic
• Succinylcholine 1mg/kg
• Rocuronium 1.2mg/kg
• Vecuronium 0.25mg/kg

25. Placement – Technique
• Position the patient
• Open the mouth – spread the molars with your right hand
• Insert the laryngoscope with your left hand
• Direct blade (Macintosh, Miller) – insert on right of mouth, sweep
tongue to left
• Indirect 60° video blade (Glide, D) – insert down center of tongue
• Remove right hand from mouth, may need for cricoid pressure
or other optimization of positioning
• Advance blade, visualize epiglottis
• Macintosh – advance anterior to epiglottis, into vallecula
• Miller – advance posterior to epiglottis
• Indirect – advance anterior to epiglottis, into vallecula

26. Placement – Technique
• Lift epiglottis to reveal vocal cords – lift up and away, never
back
• Miller blade – active lifting of epiglottis
• Macintosh, indirect video blades – passive lifting
• Use right hand to place endotracheal tube between vocal
cords
• After passing glottic opening, ask assistant to remove stylet
• Advance tube to desired depth
• Remove laryngoscope
• Inflate ETT cuff
• Ventilate

29. Proof of ETT Placement
• Fog in tube
• End Tidal CO2
• POC detector changes from purple  yellow when exposed to
CO2
• Continuous capnography will show ventilatory pattern
• Bilateral breath sounds
• Stable / increasing SpO2
• Tidal volumes / compliance
• Chest X Ray

30. Planning Preparation Positioning Preoxygenation Paralysis Placement Proof
Time
0
T +1 T +3T -3T -5

31. WHAT TO DO WITH A DIFFICULT AIRWAY

32. Difficult Airway
• Bread and butter for anesthesiologists, but also…
• One of the most common causes of lawsuits in closed claims
analysis
• Incidence of difficult intubation in OR 1.5-8%
• Incidence of difficult intubation out of OR as high as 30%
“The difficult airway is
anticipated; the failed airway is
experienced.”

33. Difficult Airway
“[…]the clinical situation in which a conventionally trained
Anesthesiologist experiences difficulty with facemask
ventilation, difficulty in supraglottic device ventilation, difficulty
in tracheal intubation or all three.”
- ASA definition

34. Inadequate
Ventilation
Esophageal
Intubation
Airway
Obstruction
Bronchospasm
Difficult
Intubation
Aspiration
Premature
Extubation
Other
% CLAIMS
Death
Brain Damage
Nerve Damage
MI / CVA
Miscellaneous
% COMPLICATIONS

35. Signs of Difficult Intubation
Testing
• Mallampati score ≥3
• Thyromental distance ≤5cm
• Upper lip bite test
• Class I – lower incisors reach
above vermillion border
• Class II – lower incisors reach
upper lip below vermillion
border
• Class III – lower incisors cannot
bite upper lip
• Each has poor sensitivity with
decent specificity; improved
utility when used together
Other Exam Findings
• Facial trauma, burns
• Obstruction / foreign
body
• Obesity
• Secretions, blood,
edema in airway
• Personal history of
difficult intubation

36. Signs of Difficult Mask Ventilation
• Beard
• Obesity
• Edentulous
• Elderly
• Sleep apnea, diagnosed or suspected

39. Emergency Surgical Airway
• Needle cricothyrotomy
• Open cricothyrotomy
• Open tracheostomy

40. Things to Remember in a
Difficult Airway Situation
• When in doubt, give a shout
• Call for help early
• The harder I practice, the luckier I get
• Your first experience shouldn’t be in an emergency
• Doing the same thing and expecting different
results is insane
• Do not keep repeating a failed technique

41. Nobody ever died from failure to
intubate, but patients die every day from
failure to oxygenate.