Assume C-spine injury in trauma.
Jaw thrust (preferred if C-spine not cleared)
Chin lift only if no C-spine concerns
Suction blood, vomitus, secretions
Remove foreign bodies if visible
For unconscious patients without gag reflex
For semiconscious with intact gag reflex
Avoid if facial/basal skull fracture suspected
Apply high-flow oxygen via non-rebreather mask
Use bag-valve-mask (BVM) if:
Apneic
Poor respiratory effort
Oxygen saturation remains low
BVM technique tip: Use two-person technique if possible (one maintains seal, the other squeezes bag)
GCS ≤ 8
Inadequate breathing
Inability to protect airway
Facial trauma, burns, or obstruction
Endotracheal Intubation (ETI): If trained and allowed by protocol
Supraglottic Airways (e.g., i-gel, King LT, LMA):
Good backup or primary if ETI not feasible
Surgical Airway (Cricothyrotomy):
Last resort in "can’t intubate, can’t ventilate" scenario
Only performed by trained personnel
Apply rigid cervical collar
Maintain manual in-line stabilization during any manipulation
Immobilize the patient on a long spine board if indicated
Recheck airway patency
Monitor oxygen saturation and breathing pattern
Prepare for deterioration (e.g., swelling from burns or trauma)
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Establishing an airway in a trauma patient is a critical step and must be done promptly and carefully, as airway compromise is a leading cause of preventable death in trauma. Here's a systematic approach, often guided by Advanced Trauma Life Support (ATLS) principles:
Assess responsiveness (AVPU: Alert, Verbal, Pain, Unresponsive).
Look, Listen, and Feel for signs of airway compromise:
Use of accessory muscles
Cyanosis or hypoxia
Listen: Stridor, gurgling, snoringsilence
Feel: Air movement, crepitus
Since trauma patients, especially with blunt trauma, may have cervical spine injuries, always assume C-spine injury until ruled out.
Manual in-line stabilization (MILS) of the cervical spine should be maintained.
Avoid hyperextension of the neck.
Jaw thrust (preferred if C-spine injury suspected)
Chin lift (if no C-spine concern)
Clear the airway:
Suction blood, vomitus, debris
Remove visible foreign bodies
Oropharyngeal airway (OPA): For unconscious patients without gag reflex
Nasopharyngeal airway (NPA): If semi-conscious or gag reflex intact (avoid in suspected basal skull fracture)
Indications for a definitive airway include:
GCS ≤ 8
Apnea or severe respiratory distress
Inability to protect airway (e.g., facial trauma, burns)
Hemorrhage compromising the airway
Options:
Endotracheal intubation (oral route preferred; nasal generally avoided in trauma)
Rapid Sequence Intubation (RSI):
Preoxygenate
Administer induction agent and neuromuscular blocker
Intubate with MILS
Surgical airway (if intubation fails or is not feasible):
Cricothyrotomy (preferred in emergency)
Tracheostomy (rarely done emergently)
Confirm tube placement with:
End-tidal CO₂ detection (gold standard)
Bilateral chest rise
Auscultation (5-point check)
Secure the airway
Continue cervical spine protection
Ventilate as needed
Facial trauma: May require surgical airway early
Burns/inhalation injury: Early intubation before airway edema worsens
Penetrating neck trauma: Secure airway and prepare for surgical intervention