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.
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Procedure Outline
Table of Contents
Transcription
CHAPTER 1
Hi everybody, I'm Dr. Nicholas Ludmer.I'm one of the emergency medicine doctors hereat the University of Chicago.Today, I'm going to be talking you guysthrough the basics of the airway assessmentin the setting of a trauma patient.So every patient that comesinto 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 approachto trauma patients when they comeinto our emergency department.It outlines a steady structureof 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 interveneon what's going to kill the patient the fastest.So the way that ATLS is arrangedwith airway first, breathing second,circulation third, disability fourth,and then exposure fifth, is that is kind of the orderin which problems with the patient are going tokill the patient fastest.So, the problems with the airwayare generally going to kill the patient fasterthan problems with breathing.And then problems with breathinggenerally are going to kill the patient fasterthan problems with circulation.So that's why it's arranged the way it is.So the airway assessment is one of the key partsof 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 youthrough our basic assessment of the patient's airwaywhen they come in during a trauma.
CHAPTER 2
First most important thing is to determinewhether the airway is open,whether the patient is able to move airin and out through their airway.And the fastest way to do thatis 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 airin and out through his airway well, okay?So we say the airway is patent.The airway is open.And that reassures the entire teamthat we don't need to do -we may not need to doany immediate intervention right now, okay?It's still important to completean assessment of the airway.Because even though he's talking now,he may have some injuries that might be obstructinghis airway or getting in the way of his airway, all right?And there may be other interventionsthat we need to do to make surethat 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 issueswith 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 soundas air moves in and out past a narrow opening.So like - [breathes deeply and loudly] - is stridor.And that can be indicative of airway swellingor impending airway closure, okay?In which case we may need to intervene on his airway.
CHAPTER 3
So in addition to listening to the patient speakand making sure their airway is patent,as well as listening to the quality of their voicefor 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 fracturethat might obstruct his airwayor 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 mouththat'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 patientcould accidentally get into their windpipeor get into their airway that we need to take care of.Once you've examined the nasopharynxand the nasal cavity as well as the oral cavity -the mouth and the oropharynx,you also want to be able to take a lookat 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 herein 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 traumaswill come in with a cervical collar in placeand may often also be on a backboard, all right?Because one of the special considerationswe 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 worseby 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 askone of our other colleagues,one of our other coworkers to actually holdthe patient's head still, okay?Where it's called manual inline stabilization, okay?They're going to hold the patient's neck stillto prevent any injury to his cervical spine,to his neck, while we take the collar offand actually examine the front of the neck, okay?So because we're limited in personnel,we're not going to have somebody hold itfor the sake of this video.But in real life, and what you'll seein some of the cases, is that whenever you removethis collar, somebody is going to be holdingmanual 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 collarso that you can complete your visual inspectionof the airway, you can complete your evaluationof 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 visualizationyou'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 examineand 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 sideor it looks deviated, is what we call it,that can be a sign of an injury to the tracheaor an injury to the larynx - an airway injury,which is something we may needto intervene on quickly, okay?So you look to make sure that the airway is midline, okay?You also look for other injuries around the neckthat 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 airwayor cause an impending injury to the airway.Sometimes trauma can also cause bleeding in this area.And so you can get expanding collectionsof 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 airwayand compromise the airway.So you want to complete your visual inspection.You can often also sometimes just feeland press the skin lightlyand see if there's any air under the skinthat might indicate that the trachea,or the windpipe, has been injured, okay?So sometimes injuries to the windpipecan 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?
CHAPTER 4
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 signsof bony fracture, deformity,and also any signs of air in the neckthat 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 releaseinline 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 interventionsin the subsequent videos.