Airway Assessment for Trauma Patients
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Airway injury remains a leading cause of early mortality in patients with trauma.1,2 Despite its rarity,2 direct traumatic airway injury and tracheobronchial injury (TBI) pose significant challenges for emergency clinicians, with an estimated incidence of 0.5–2% among trauma patients.3 Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway blockage. Trauma can cause airway obstruction by itself or by blood clots, tissue edema, or gastric contents clogging the airway lumen. The added complexity of associated spinal injuries further underscores the need for precise and timely airway assessment.
In the context of trauma patients, a fundamental aspect of care involves prompt airway assessment. The Advanced Trauma Life Support (ATLS) algorithm, a cornerstone in trauma care, outlines a systematic approach focusing on a sequential assessment and management of Airway, Breathing, Circulation, Disability, and Exposure (ABCDE), as part of the initial evaluation of the injured individual. While adapted for battle and disaster environments, the ATLS algorithm consistently emphasizes the timely assessment and treatment of life-threatening airway and breathing issues before shifting focus to circulation problems. The CAB sequence has become more widely embraced in the last ten years, surpassing the airway-breathing-circulation (ABC) model for individuals with serious bleeding injuries. When bleeding is severe or life-threatening, prioritizing control of the bleeding takes precedence over interventions related to airway and breathing․4
This video provides a step-by-step guidance for the airway evaluation based on the ATLS algorithm. The primary step in airway assessment is determining its patency by evaluating the patient’s ability to speak and answer simple questions appropriately. As highlighted in the video, it is equally important to evaluate the quality of speech and identify any abnormal sounds. Subsequent steps include airway examination via visual inspection starting from nostrils and progressing down to the oropharynx to identify any evidence of injury, facial fracture, swelling, or vomitus. Special attention is given to the oropharynx and the anterior neck, although the latter may meet challenges when a cervical collar is in place. In such cases one coworker stabilizes the neck using the manual in-line stabilization (MILS) technique, while the other one performs the examination. This action is performed with the aide positioned at the head or beside the bed, utilizing the fingers and palms of both hands to stabilize the patient's occiput and mastoid processes․ In the cases with blunt neck injuries it is recommended to remove cervical collar as soon as feasible (Level 3 recommendations)․4 Patients with cervical trauma can present with one or a combination of the following symptoms and signs: subcutaneous emphysema, crepitus, bleeding, hematoma, stridor, dysphonia, dysphagia, hemoptysis, and tracheal deviation.5
Considering the dynamic nature of trauma, the airways should be reassessed frequently at least for duration of several hours, particularly in cases where injury may lead to insidious swelling around the airway, over time causing delayed complications.6
In conclusion, timely and thorough airway assessment is fundamental in trauma care, as airway injuries contribute significantly to early mortality. The steps outlined in this video, reflective of the ATLS algorithm, provide a systematic and structured approach tailored for active engagement by healthcare professionals from both emergency and trauma surgery teams.
Citations
- Bhojani RA, Rosenbaum DH, Dikmen E, et al. Contemporary assessment of laryngotracheal trauma. J Thorac Cardiovasc Surg. 2005;130(2). doi:10.1016/j.jtcvs.2004.12.020.
- Kummer C, Netto FS, Rizoli S, Yee D. A review of traumatic airway injuries: potential implications for airway assessment and management. Injury. 2007;38(1). doi:10.1016/j.injury.2006.09.002.
- Prokakis C, Koletsis EN, Dedeilias P, Fligou F, Filos K, Dougenis D. Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment. J Cardiothorac Surg. 2014;9(1). doi:10.1186/1749-8090-9-117.
- Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Traum Inj Inf Crit Care. 2009;67(3). doi:10.1097/TA.0b013e3181ae583b.
- Jain U, McCunn M, Smith CE, Pittet JF. Management of the traumatized airway. Anesthesiology. 2016;124(1). doi:10.1097/ALN.0000000000000903.
- Hutchison I, Lawlor M, Skinner D. ABC of major trauma. Major maxillofacial injuries. BMJ. 1990;301(6752). doi:10.1136/bmj.301.6752.595.
