1. Introduction

2. Determine if Airway is Open

3. Visual Inspection of Airway

4. Closing Comments

Airway injury remains a leading cause of early mortality in patients with trauma. Despite its rarity, 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. 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. Notably, there is no empirical evidence supporting alterations to this sequence in the treatment of non-military trauma.

<h4>CHAPTER 1</h4>

<p>Hi everybody, I'm Dr. Nicholas Ludmer.
I'm one of the emergency medicine doctors here
at the University of Chicago.
Today, I'm going to be talking you guys
through the basics of the airway assessment
in the setting of a trauma patient.
So every patient that comes
into the University of Chicago under trauma,
we treat basically through the ATLS treatment algorithm.
ATLS is the advanced trauma life support.
And what it does is it outlines a common approach
to trauma patients when they come
into our emergency department.
It outlines a steady structure
of sort of airway, breathing,
circulation, disability, and exposure.
And what that does is it helps us with two things.
First is it helps us not to miss any injuries.
It also helps us to intervene
on what's going to kill the patient the fastest.
So the way that ATLS is arranged
with airway first, breathing second,
circulation third, disability fourth,
and then exposure fifth, is that is kind of the order
in which problems with the patient are going to
kill the patient fastest.
So, the problems with the airway
are generally going to kill the patient faster
than problems with breathing.
And then problems with breathing
generally are going to kill the patient faster
than problems with circulation.
So that's why it's arranged the way it is.
So the airway assessment is one of the key parts
of the ATLS guidelines, and one of the most important -
one you need to intervene on the fastest.
So what I'm going to do is take you
through our basic assessment of the patient's airway
when they come in during a trauma.</p>

<h4>CHAPTER 2</h4>

<p>First most important thing is to determine
whether the airway is open,
whether the patient is able to move air
in and out through their airway.
And the fastest way to do that
is really just to talk to the patient.
So you say, "Hey, bud, what's your name?"
Nikita.
Nikita, okay?
And if Nikita can speak,
that means that he's able to move air
in and out through his airway well, okay?
So we say the airway is patent.
The airway is open.
And that reassures the entire team
that we don't need to do -
we may not need to do
any immediate intervention right now, okay?
It's still important to complete
an assessment of the airway.
Because even though he's talking now,
he may have some injuries that might be obstructing
his airway or getting in the way of his airway, all right?
And there may be other interventions
that we need to do to make sure
that Nikita's airway stays open, all right?
So in addition to talking to the patient,
and making sure that he can speak,
we're also going to listen for any abnormal sounds.
We're going to listen to the quality of his speech.
So if he speaks, and there's sort of gurgling sounds,
or there's coarse sounds in the airway,
that may mean that maybe he's got some fluid in the airway,
maybe he's got some swelling, okay,
that may become a problem and cause issues
with his airway in the immediate future, okay?
So we're going to listen for any abnormal sounds:
gurgling, coarse sounds, stridor,
which is sort of a high-pitched sound
as air moves in and out past a narrow opening.
So like - [breathes deeply and loudly] - is stridor.
And that can be indicative of airway swelling
or impending airway closure, okay?
In which case we may need to intervene on his airway.</p>

<h4>CHAPTER 3</h4>

<p>So in addition to listening to the patient speak
and making sure their airway is patent,
as well as listening to the quality of their voice
for any abnormal sounds,
we're also going to do a visual inspection of the airway.
Remember, the airway is composed of the nares,
which are the nostrils,
the nasal cavity, which is the space just behind those.
The nasopharynx, which is even further back.
The mouth, which is the oral cavity, okay?
And the oropharynx, which is the back of the throat.
And then finally, the structures in the neck:
the larynx and the trachea.
We're going to do a visual inspection of all of it, okay?
So you're going to take a light, usually an otoscope,
oftentimes with a speculum,
which is the little cone part you put on front,
and we're going to take a look in the patient's nose.
So we're just going to shine a light up.
See if there's any evidence of injury, okay,
bleeding, any evidence of facial fracture
that might obstruct his airway
or block his airway, all right?
We're going to ask the patient to open their mouth.
So go ahead and open your mouth wide?
You're going to shine the light in,
and again, we're looking at everything.
You're looking for - is the tongue swelling?
Are there any injuries to the tongue?
Is there any other swelling in the mouth
that's going to end up blocking his airway?
Is there any fluids that we need to suction?
Is the patient bleeding?
Did they vomit, okay?
Do we need to suction the patient's airway?
Are there any signs of injuries that might block it?
So any loose teeth that the patient
could accidentally get into their windpipe
or get into their airway that we need to take care of.
Once you've examined the nasopharynx
and the nasal cavity as well as the oral cavity -
the mouth and the oropharynx,
you also want to be able to take a look
at the anterior neck,
the front part of the neck, all right?
Because the airway also involves the larynx and the trachea,
which make up your windpipe right here
in the front, all right?
So in order to do that -
that can be a little bit more difficult in a trauma patient.
Oftentimes, people who are in traumas
will come in with a cervical collar in place
and may often also be on a backboard, all right?
Because one of the special considerations
we worry about in trauma is -
does this patient have a cervical spine injury,
an injury to their spinal cord,
that we don't want to make worse
by doing our evaluation, okay?
So once we've taken a look inside the nose,
we've taken a look inside the mouth,
we also want to examine the front of the neck.
And to do that, we're going to ask
one of our other colleagues,
one of our other coworkers to actually hold
the patient's head still, okay?
Where it's called manual inline stabilization, okay?
They're going to hold the patient's neck still
to prevent any injury to his cervical spine,
to his neck, while we take the collar off
and actually examine the front of the neck, okay?
So because we're limited in personnel,
we're not going to have somebody hold it
for the sake of this video.
But in real life, and what you'll see
in some of the cases, is that whenever you remove
this collar, somebody is going to be holding
manual inline stabilization.
They're going to hold the neck still, all right?
But for the sake of the video -
say somebody is holding inline stabilization,
you can remove the front of the collar
so that you can complete your visual inspection
of the airway, you can complete your evaluation
of the larynx and the trachea,
which basically compose the windpipe, right in the middle.
So I'll actually have you sort of lean your head back.
And again, you wouldn't do this in a trauma setting.
You wouldn't have the patient move their neck,
but just for the sake of visualization
you're going to take a look at the patient's neck.
And there are a few things you're going to look for.
First, you're going to examine
and make sure that the patient's airway,
their windpipe, is in the middle of the neck,
right? Where it should be, okay?
You want to make sure that's in the middle.
If it's off to one side
or it looks deviated, is what we call it,
that can be a sign of an injury to the trachea
or an injury to the larynx - an airway injury,
which is something we may need
to intervene on quickly, okay?
So you look to make sure that the airway is midline, okay?
You also look for other injuries around the neck
that might compromise the airway.
So maybe he's got a foreign body in his neck.
Maybe he was stabbed in the neck,
something else that might impede on the airway
or cause an impending injury to the airway.
Sometimes trauma can also cause bleeding in this area.
And so you can get expanding collections
of blood, or what we call hematomas.
So you want to make sure that there's no swelling in the neck,
around the neck that might push on the airway
and compromise the airway.
So you want to complete your visual inspection.
You can often also sometimes just feel
and press the skin lightly
and see if there's any air under the skin
that might indicate that the trachea,
or the windpipe, has been injured, okay?
So sometimes injuries to the windpipe
can cause air to release under the skin,
and you'll get this Rice Krispies Treat type feeling.
If you press on it, it'll kind of crinkle and crunch,
kind of like you're pressing on Rice Krispies, all right?
Or like crepitations, okay?</p>

<h4>CHAPTER 4</h4>

<p>So you're going to do your - talk to the patient,
make sure that their airway is patent,
listen to the quality of the airway sounds.
Are there any abnormal sounds?
Stridor, gurgling, coarse sounds, okay?
You're going to look in the nares,
in the oral cavity, in the oropharynx,
and you're going to look at the anterior neck, okay?
And then you can also feel for any signs
of bony fracture, deformity,
and also any signs of air in the neck
that might suggest a tracheal injury.
All right?
And once you're done with your examination,
you're going to replace the patient's collar, all right?
And your coworkers can then release
inline stabilization once the collar is secure.
All right?
That's the basics of the airway evaluation in trauma.
If you find something wrong,
you intervene before moving on to the next examination.
So if we find something wrong with the airway,
we fix it before we move on to examining breathing, okay?
And we're going to talk about some of those interventions
in the subsequent videos.</p>


Watch this video of Dr. Ludmer at UChicago Medicine describing the airway assessment for a trauma patient.

DOI
Publication Date	2024/01/12
Article ID	299.12
Production ID	0299.12
Volume	2024
Issue	299.12
https://doi.org/10.24296/jomi/299.12

Airway Assessment for Trauma Patients

Procedure Outline

Table of Contents

1. Introduction

2. Determine if Airway is Open

3. Visual Inspection of Airway

4. Closing Comments