Difficult airway management algorithm in trauma

BMV: bag-valve mask; CP: cricoid pressure; DA: difficult airway; DL: direct laryngoscopy; FIS: flexible intubation scope; FSI: flexible scope intubation; GA: general anesthesia; LMA: laryngeal mask airway; MILS: manual in-line stabilization; RSI: rapid sequence intubation; SGA: supraglottic airway; VAL: video-assisted laryngoscopy; ASA: American Society of Anesthesiologists.

* Confirm ventilation, tracheal intubation or SGA placement with standard confirmatory techniques (exhaled CO₂, misting of tube, auscultation of breath sounds, improving SpO₂). If perfusion (and exhaled CO₂) absent, use additional confirmation methods (eg, repeat laryngoscopy, bronchoscopy, esophageal detector device, chest radiograph).

• Ventilation with a face mask or SGA might be difficult or impossible in a patient with maxillofacial trauma.
• Local anesthesia infiltration or regional nerve blockade are of limited value in extensive trauma surgery.

Δ Invasive airway access includes surgical or percutaneous cricothyrotomy or tracheostomy, transtracheal jet ventilation and retrograde intubation.

◊ Emergency non-invasive airway ventilation consists of SGA.

§ Aborting the case and awakening the patient to optimize and re-attempt intubation via a different airway technique (eg, awake intubation) is impractical in most trauma cases due to the emergent condition of the patient.

¥ Alternative difficult intubation approaches include (but are not limited to): VAL, SGA (eg, LMA as an intubation conduit with or without flexible scope guidance), flexible scope intubation, intubating stylet or tube changer, and light wand. Blind intubation (oral or nasal) is discouraged in patients with maxillofacial trauma and laryngeal or tracheal injury.