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Airway management in the adult with direct airway trauma for emergency medicine and critical care

Airway management in the adult with direct airway trauma for emergency medicine and critical care
Literature review current through: Jan 2024.
This topic last updated: Jan 09, 2023.

INTRODUCTION — Airway management in patients who have sustained direct trauma to the airway is among the most challenging problems for emergency clinicians. Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway obstruction.

Immediate, definitive airway management is needed when the patient cannot protect their airway or is unable to adequately oxygenate or ventilate. Emergency or urgent airway management is indicated when a patient develops respiratory distress or when symptoms are progressing rapidly. In addition, airway management often is indicated when the patient appears clinically stable, but the clinician anticipates clinical decline (eg, smoke inhalation, edema, subcutaneous air, hematoma) or feels that an unprotected airway presents a risk to the patient who requires transport to another facility or to radiology for extensive diagnostic studies. The higher rate of complicated airways in this population mandates that the clinician be prepared to use advanced airway techniques, including a surgical airway.

Airway assessment and management in adults with direct airway trauma will be reviewed here. Other aspects of airway management, including a general approach to the difficult airway, the decision to intubate, and advanced tools for airway management, are discussed separately.

(See "Overview of advanced airway management in adults for emergency medicine and critical care".)

(See "Approach to the difficult airway in adults for emergency medicine and critical care".)

(See "Rapid sequence intubation in adults for emergency medicine and critical care".)

(See "Devices for difficult airway management in adults for emergency medicine and critical care".)

(See "The decision to intubate".)

(See "Basic airway management in adults".)

The general management of trauma to the head and neck is also discussed separately.

(See "Initial evaluation and management of facial trauma in adults".)

(See "Penetrating neck injuries: Initial evaluation and management".)

(See "Skull fractures in adults".)

CAUSES OF AIRWAY TRAUMA — Common causes of direct airway trauma include the following:

Blunt or penetrating maxillofacial injury

Blunt or penetrating neck injury

Smoke inhalation or facial burns

Caustic ingestion

Face and neck injuries from blunt or penetrating trauma can cause severe bleeding into the oropharynx, expanding hematomas within soft tissue, and disruption of bone and soft tissue. Smoke inhalation, burns of the face and oropharynx, and caustic ingestions are all capable of causing mucosal injury and severe swelling and edema within the oropharynx, larynx, and tracheobronchial tree.

It is crucial that emergency airway managers recognize that such injuries are dynamic and that conditions can deteriorate quickly. Hematomas and soft tissue swelling can expand rapidly, converting a partially obstructed airway into a completely obstructed airway.

Non-airway management of the injuries listed here is discussed separately.

(See "Initial evaluation and management of facial trauma in adults".)

(See "Penetrating neck injuries: Initial evaluation and management".)

(See "Emergency care of moderate and severe thermal burns in adults".)

(See "Caustic esophageal injury in adults".)

(See "Inhalation injury from heat, smoke, or chemical irritants".)

AIRWAY ASSESSMENT

Determining the need for immediate intervention — The first step in managing patients with direct airway trauma is to rapidly assess the patient and their airway to determine whether an emergency definitive airway is needed. Unresponsive patients and those with inadequate respiratory function are intubated during or immediately following evaluation. Patients in obvious respiratory distress also require prompt intubation. This includes patients struggling to breathe because of their injuries and those who have sustained severe burns of the face or who demonstrate blistering or edema of the oropharynx. Patients incapable of protecting their airway, as demonstrated, for example, by inability to clear debris from the oropharynx (eg, teeth, bone fragments, foreign bodies, emesis), also require prompt intubation.

A simple assessment consisting of four basic questions often distinguishes patients requiring intubation from those who may be observed. An affirmative answer to any of the following questions identifies the need for intubation in nearly all scenarios involving direct airway trauma:

Is there failure of airway maintenance or protection?

Is there failure of ventilation?

Is there failure of oxygenation?

Is deterioration, particularly of the airway, anticipated? (ie, What is the expected clinical course?)

This approach to intubation and management of the failed airway is discussed in detail separately. (See "The decision to intubate" and "Approach to the failed airway in adults for emergency medicine and critical care".)

Direct trauma to the airway can cause conditions that deteriorate precipitously leading to complete airway obstruction. Examples include expanding hematomas following blunt or penetrating trauma and soft tissue swelling following smoke inhalation or caustic ingestion. Of note, the progression of an airway injury, such as a soft tissue hematoma, may involve the deep tissue planes of the neck and therefore not become clinically apparent until airway obstruction is nearly complete and the chance for successful intervention is slim. Therefore, the risk of rapid airway compromise is a common and important reason for early intubation in patients with direct airway trauma.

Of note, a patient with a penetrating injury may have concomitant blunt injuries. Examples include a patient who is shot and then falls down a flight of stairs or a patient who sustains a stab wound to the neck while simultaneously being beaten about the head and neck with blunt objects.

Signs of airway compromise — In patients with direct trauma to the face, neck, or upper chest who do not have a forced-to-act scenario, the clinician performs a careful examination looking for signs of airway compromise. These signs may include any of the following:

Direct signs of airway compromise:

Dyspnea

Stridor

Indirect signs of airway compromise:

Drooling

Trismus

Painful swallowing (odynophagia)

Tracheal deviation or other anatomical abnormality involving the larynx or trachea

Signs of developing airway compromise:

Non-superficial burns of the face or neck

Severe bleeding in the oropharynx or nasopharynx

Subcutaneous air (crepitus) in the neck or upper chest

Hematoma in the neck or lower face

Hoarseness or other alterations in voice

Subjective sense of shortness of breath despite adequate oxygen saturation

If any such signs are identified, it is generally prudent to secure the patient's airway early, before significant further deterioration occurs. Of note, the signs listed above may not be present during the clinician's initial examination. Frequent reexamination is needed in patients who have sustained significant direct trauma to the airway but whose airway is not secured early. (See 'Patients appropriate for observation' below.)

A subset of initially stable patients is at higher risk of progressing to an unstable and potentially difficult airway. Patients with any of the following signs or conditions often require early intubation to prevent subsequent airway compromise or collapse:

Unstable mandible or midface injuries

Steady bleeding into the oropharynx or nasopharynx

Worsening or fluctuating level of consciousness

Determining difficulty with airway management — Whenever possible, emergency clinicians should assess the patient's airway for potential difficulty with bag-mask ventilation, endotracheal intubation, rescue device placement, and cricothyrotomy. Mnemonics that can be used for these assessments are provided here and discussed in detail separately (table 1 and table 2 and table 3 and table 4) [1]. (See "Approach to the difficult airway in adults for emergency medicine and critical care".)

Difficulty with bag-mask ventilation should be anticipated in patients who have sustained severe maxillofacial injuries that disrupt bones and create instability or disfigurement in the middle or lower face. Such injuries make it difficult to maintain a proper mask seal. Obstruction from heavy bleeding, soft tissue swelling, or hematoma can interfere with effective bag-mask ventilation. Posterior displacement of severe fractures of the maxilla or mandible can also obstruct the patient's airway [2].

Subcutaneous air in the neck or communicating injury that establishes an external opening from any part of the airway (mouth, oropharynx, larynx, trachea) makes bag-mask ventilation impossible and also increases the likelihood that bag-mask ventilation will further distort anatomy, making subsequent airway rescue maneuvers more difficult.

Bleeding and disruption of normal anatomy can make laryngoscopy and intubation extremely difficult. Mouth opening may be limited and should be carefully assessed with the anterior portion of the cervical collar removed. Bleeding, soft tissue swelling, and debris can obscure the view of the glottis during laryngoscopy, making effective suction essential.

Placement of a rescue device (eg, laryngeal mask airway) can be difficult if mouth opening is limited, if the airway is disrupted or distorted (eg, by swelling), or if debris such as teeth or bone fragments are present. Cricothyrotomy can be difficult if normal anatomic relationships are disrupted or a hematoma is present at the anterior neck.

MANAGEMENT

Guiding principle: Secure the airway early — It is best to secure the airway early whenever signs of active or impending obstruction are identified or there is doubt about the extent of the injuries or their likely course. Doing so enables clinicians to secure the airway under relatively controlled circumstances before complete obstruction occurs and a crisis ensues. An algorithm outlining the basic approach to the traumatized airway is provided (algorithm 1).

Injuries sustained from direct trauma to the airway are often dynamic and conditions can deteriorate quickly [3]. As examples, hematomas and soft tissue swelling can expand rapidly, converting a partially obstructed airway into a completely obstructed airway. Signs suggestive of imminent obstruction are described above. (See 'Signs of airway compromise' above.)

The basic and advanced techniques used to manage the airway are discussed separately. (See "Rapid sequence intubation in adults for emergency medicine and critical care" and "Approach to the difficult airway in adults for emergency medicine and critical care" and "Basic airway management in adults" and "Devices for difficult airway management in adults for emergency medicine and critical care".)

No time available (ie, forced-to-act scenario) — Patients with direct trauma to their airway may present in extremis, unresponsive to the examiner and without effective ventilation or circulation. The basic approach to the forced-to-act scenario remains unchanged in such patients and is discussed separately. (See "Rapid sequence intubation in adults for emergency medicine and critical care" and "Approach to the difficult airway in adults for emergency medicine and critical care" and "Approach to the failed airway in adults for emergency medicine and critical care".)

Management of the patient with an exposed trachea, most likely from a stab wound to the neck or a "clothesline" type injury, differs from the standard management of a forced-to-act scenario. In such a circumstance, the airway manager prevents the inferior portion of the trachea from retracting into the chest by grasping it with a towel clip or clamp and the exposed trachea is then intubated directly. The general management of penetrating neck wounds is discussed separately. (See "Penetrating neck injuries: Initial evaluation and management".)

Time available and difficult airway anticipated — The difficult airway algorithm provides the fundamental approach to the patient with direct airway trauma who requires intubation and whose airway is anticipated to be difficult (algorithm 1 and algorithm 2). The specific approach selected is determined by the patient's injuries, patient attributes that suggest difficult airway management, the skills of the airway manager, and the resources available. The traumatized airway can be difficult to manage and it is important to obtain whatever help is available (eg, colleagues from emergency medicine, anesthesiologists, trauma surgeons, respiratory therapists, paramedics). The general approach to the difficult airway is discussed separately; aspects of management related to the traumatized airway are discussed below. (See "Approach to the difficult airway in adults for emergency medicine and critical care".)

The most important questions to ask when faced with a traumatized airway (or any difficult airway) are:

Is there time? In other words, can the patient's oxygen saturation (SpO2) be maintained above 90 percent?

Is difficulty with bag-mask ventilation (BMV) anticipated?

If the SpO2 can be maintained above 90 percent, there is some time to consider different approaches and to make preparations. If adequate oxygenation cannot be maintained, a failed airway is present, and a definitive airway must be established promptly (algorithm 3). (See "Approach to the failed airway in adults for emergency medicine and critical care".)

If the SpO2 remains above 90 percent and no risk factors for difficult BMV are identified, the clinician may elect to use standard rapid sequence intubation (RSI) to secure the airway. If difficult BMV is anticipated, RSI may pose risks, and an “awake” approach to intubation may be best.

Alternatively, RSI may be undertaken using a "triple setup" in which the patient undergoes RSI with one or two brief attempts at laryngoscopy, then temporizing with the extraglottic device (if appropriate) followed by proceeding to a cricothyrotomy if intubation is not possible. The triple setup implies a primary intubating plan is in place, followed by a non-surgical rescue device (eg, an extraglottic device), and lastly a surgical rescue plan (most often an open surgical bougie-assisted cricothyrotomy). These rescue options are identified and readied before beginning the intubation sequence. In other words, while medications and equipment are readied for RSI or an awake approach, an extraglottic device is prepared and the patient's neck is cleaned, landmarks identified, and a cricothyrotomy kit opened and prepared at the bedside. This enables the airway manager to shift instantly from an attempt at tracheal intubation should a failed airway develop suddenly. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults" and "Rapid sequence intubation in adults for emergency medicine and critical care".)

Of note, subcutaneous emphysema usually represents a contraindication to BMV because gases forced into the airway during BMV can expand the neck's soft tissues, compromising subsequent efforts to ventilate or to intubate. In patients with very minimal detectable subcutaneous air, gentle, controlled bag-mask ventilation might be attempted, but its effectiveness is not assured and it should be abandoned if the subcutaneous air increases in volume.

The awake approach to securing the airway involves sedation to the level used for common emergency department procedures (eg, using propofol or ketamine) in conjunction with topical airway anesthesia (eg, using atomized or nebulized lidocaine, or lidocaine paste or jelly). This approach allows the patient to continue to breathe spontaneously while sedation and topical anesthesia enable the clinician to overcome the patient's protective airway reflexes. Excessive blood or secretions in the airway limit the effectiveness of topical anesthetics and may preclude use of the awake approach if adequately deep sedation without topical anesthesia cannot be achieved. (See "Approach to the difficult airway in adults for emergency medicine and critical care", section on 'Awake techniques'.)

The awake but sedated patient can undergo standard direct laryngoscopy, video laryngoscopy, or flexible endoscopic laryngoscopy. The presence of a large amount of upper airway blood will likely make flexible endoscopic laryngoscopy difficult or impossible. If the vocal cords are visualized, the clinician can opt to intubate during the awake look without additional medications or to withdraw the laryngoscope and perform standard RSI. We believe in general it is best not to remove the laryngoscope and perform RSI in a patient with direct airway trauma due to the risk of the glottic view deteriorating during the interim.

Direct, flexible endoscopic, and video laryngoscopy are the primary awake intubation techniques used in the setting of the traumatized airway. Flexible endoscopy require patient stability, time, and operator expertise. Rigid endoscopic devices (eg, optical stylet) may enable clinicians to obtain a more rapid view of the glottis. Copious blood or secretions in the airway can make endoscopic laryngoscopy difficult or impossible. Devices used for difficult airway management are discussed separately. (See "Devices for difficult airway management in adults for emergency medicine and critical care".)

In some instances the clinician will judge RSI to be the best approach despite the presence of a potentially difficult airway, particularly if performed early before significant deterioration occurs (ie, when the anatomy is still close to normal). The results of several observational studies suggest that RSI is effective in patients with traumatized airways [4,5]. An approach incorporating a triple setup is often prudent when managing patients with traumatized airways, whether laryngoscopy is anticipated to be difficult or not.

In some patients, a surgical airway may be the first and only choice for airway intervention. Severe injuries to the face, larynx, or supraglottic tissues may create an obstruction or an anatomic disruption that prevents the airway manager from gaining access to the glottis and performing tracheal intubation. A surgical airway is also necessary in the patient with direct airway trauma that has an SpO2 below 90 percent despite optimal BMV, or in whom BMV cannot be performed. Of note, there is no absolute contraindication to cricothyrotomy in a patient who is dying of respiratory causes and who cannot be intubated orally.

In the patient with an injury below or at the level of the cricothyroid membrane, a double setup (RSI with surgical rescue plan since extraglottic device would not be appropriate) can be used. If the trachea is lacerated and exposed, then direct intubation of the secured trachea may be possible (see 'No time available (ie, forced-to-act scenario)' above). In the case of a small direct injury or expanding hematoma, tracheal intubation (assisted by laryngoscopy) may still be possible, passing the tube below the level of injury. If this fails, then emergency cricothyrotomy or tracheostomy are potential options (algorithm 1).

Supraglottic devices such as the laryngeal mask airway (LMA), laryngeal tube, or pharyngeal tube may be used as rescue techniques for the patient with direct airway trauma who can be effectively oxygenated by BMV. Such devices should not be used when a supraglottic airway obstruction exists, or when anatomy is significantly distorted. The concurrent use of video laryngoscopy enables the clinician to visualize the airway and can aid in placement of the supraglottic device. (See "Extraglottic devices for emergency airway management in adults".)

Blind passage of endotracheal tubes should NOT be attempted in patients with direct trauma to their airway because of the risk of exacerbating a preexisting injury. A surgical airway may be the best option in cases where the glottis cannot be seen.

Time available and difficult airway NOT anticipated — The patient with direct airway trauma who requires intubation and whose airway is NOT anticipated to be difficult is best managed by rapid sequence intubation (RSI). Assessment of the traumatized airway is discussed above, while the performance of RSI is discussed separately. (See 'Airway assessment' above and "Rapid sequence intubation in adults for emergency medicine and critical care".)

When preparing to perform definitive airway management in the apparently stable patient with direct airway trauma, the clinician must remain alert for signs of early or sudden airway compromise. Traumatized airways can deteriorate unexpectedly without obvious external signs of injury. Both basic and advanced equipment for difficult airway management, including an extraglottic device and surgical airway, must be available at the bedside. In many cases, it is best to use a triple setup, in which preparations are made to perform RSI, an extraglottic device is identified, and the neck is prepared simultaneously for a surgical airway, with the cricothyrotomy kit open and prepared at the bedside. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

Emergency clinicians should revert to the difficult airway management algorithm if signs of a potentially difficult airway manifest after the initial airway evaluation (algorithm 2). (See 'Time available and difficult airway anticipated' above.)

In-line stabilization and removing the cervical collar — Opening the cervical collar while maintaining in-line stabilization of the neck is recommended for all trauma patients during intubation. Even with partial removal of the cervical collar, complete direct visualization is usually impaired; video laryngoscopy provides a better view than standard laryngoscopy in these patients. (See "Initial management of trauma in adults", section on 'Cervical spine immobilization' and "Devices for difficult airway management in adults for emergency medicine and critical care", section on 'Advanced laryngoscopes'.)

In patients with penetrating trauma to either the cranium or neck, the role of c spine immobilization is rarely indicated [6]. (See "Penetrating neck injuries: Initial evaluation and management", section on 'Cervical spine immobilization'.)

Although in-line stabilization should be maintained if the clinician harbors any doubt about spinal column injury, the risk of unstable bony injury is so low in isolated penetrating injury with an intact neurological examination that if the clinician is unable to see the glottis adequately it may be preferable to relax spinal immobilization somewhat to achieve a gentle intubation rather than allow hypoxia to develop. Judgment is required to determine which of the two patient threats (hypoxemia caused by a failed airway versus spinal cord injury caused by spinal column movement) is more likely.

Patients appropriate for observation — If the patient with direct airway trauma maintains normal vital signs, pulse oximetry, and mental status, and manifests none of the signs of impending airway compromise listed above, the patient is a candidate for observation. However, many patients who sustain direct airway trauma show no initial signs of airway instability but do show signs that suggest impending compromise. These patients need early definitive airway management. By securing the airway early, emergency clinicians avoid precipitant crises when immediate action is required to save the patient's life, the airway has become more difficult to manage, and equipment, medications, and personnel may not be ready. (See 'Airway assessment' above.)

Some patients develop airway and breathing difficulties suddenly, despite the absence of external signs of airway compromise. Thus, all patients with direct airway trauma must be monitored closely, and the equipment necessary to place a definitive airway, including those necessary for a surgical airway, should be placed at the bedside. Early flexible endoscopic examination of the upper airway is often advisable when the patient has minimal or no external signs of trauma, but there is evidence of internal injury, (eg, hoarseness).

The monitoring and disposition of patients with direct airway trauma depends upon the nature and severity of injury. Most patients with airway trauma of any significance should remain in the ED or be admitted to a step down or intensive care unit overnight for monitoring. Observation should include frequent reassessment of pulse oximetry, voice quality, adequacy of respiration, swallowing, and bleeding in the airway, late developing hematoma, or any sign of worsening condition.

If early flexible endoscopic examination reveals no internal injury and there is no external evidence of significant injury (eg, no hematoma, crepitus, or bruising) a shorter period of observation in the ED may suffice. There is no literature defining a sufficient period of observation in such cases, but we suggest a minimum of four hours. If the patient is intoxicated or otherwise displays an altered mental status, observation is continued until the mental status is normal and the patient can be reliably assessed. Again, observation is performed for a minimum of four hours following the injury.

A subset of patients may undergo treatment in the ED that sufficiently stabilizes their injury such that the development of airway compromise becomes unlikely. Examples may include maxillary or alveolar ridge fractures that are immobilized by oral surgery, oropharyngeal lacerations that are repaired and show no further sign of hemorrhage or developing hematoma, and cases of minor smoke inhalation in whom upper airway endoscopy does not reveal significant edema or thermal injury.

Following treatment and a brief period of observation (eg, four hours), such patients may be discharged with clear verbal and written instructions to return to the emergency department immediately for any concerns. A responsible adult should accompany such patients for approximately 24 hours following discharge.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Airway management in adults" and "Society guideline links: Penetrating neck injury".)

SUMMARY AND RECOMMENDATIONS

Causes of airway trauma – Common causes of direct airway trauma include blunt or penetrating maxillofacial injury, blunt or penetrating neck injury, smoke inhalation, facial burns, and caustic ingestion. (See 'Causes of airway trauma' above.)

Airway assessment – The first step in managing patients with direct airway trauma is to determine whether the airway needs to be secured immediately or urgently. If this is not the case, clinicians then determine whether there are signs of impending airway compromise and possible difficulty with management. An algorithm outlining the basic approach to the traumatized airway is provided (algorithm 1). (See 'Airway assessment' above.)

Signs of airway compromise – In a patient with direct trauma to the face, neck, or upper chest, signs of airway compromise include any of the following (see 'Signs of airway compromise' above):

Direct signs of airway compromise:

-Dyspnea

-Stridor

Indirect signs of airway compromise:

-Drooling

-Trismus

-Painful swallowing (odynophagia)

-Tracheal deviation or other anatomical abnormality involving the larynx or trachea

Signs of developing airway compromise:

-Non-superficial burns of the face or neck

-Severe bleeding in the oropharynx or nasopharynx

-Subcutaneous air (crepitus) in the neck or upper chest

-Hematoma in the neck or lower face

-Hoarseness or other alterations in voice

-Subjective sense of shortness of breath despite adequate oxygen saturation

Management – Management of the patient with direct airway trauma varies according to the time and resources available and the difficulties anticipated. The most important questions to ask when faced with a traumatized airway are the following (see 'Management' above):

Is there time? In other words, can the patient's oxygen saturation (SpO2) be maintained above 90 percent?

Is difficulty with bag-mask ventilation (BMV) anticipated?

It is best to secure the airway early whenever signs of active or impending obstruction are identified or there is doubt about the extent of the injuries or their likely course. Injuries sustained from direct trauma to the airway are often dynamic and conditions can deteriorate quickly. (See 'Guiding principle: Secure the airway early' above.)

No time available (ie, forced-to-act scenario) – Patients with direct trauma to their airway may present in extremis, unresponsive and without effective ventilation or circulation. The basic approach to this scenario is the same as for patients without airway trauma, except for a patient with an exposed trachea, in which case grasp the trachea with a towel clip or clamp (in order to prevent the inferior portion of the trachea from retracting into the chest) and intubate the exposed trachea directly. (See 'No time available (ie, forced-to-act scenario)' above.)

Time available and difficult airway anticipated – If the SpO2 can be maintained above 90 percent, there is some time to consider different approaches and to make preparations. If adequate oxygenation cannot be maintained, a failed airway is present and a definitive airway must be established promptly. If difficult BMV is anticipated, RSI may pose risks and intubation using an awake approach of "triple setup" (ie, simultaneous preparation for RSI and cricothyrotomy) may be best. (See 'Time available and difficult airway anticipated' above.)

Time available and difficult airway NOT anticipated – If the SpO2 remains above 90 percent and no risk factors for difficult BMV are identified, the clinician may elect to use standard rapid sequence intubation (RSI) to secure the airway. (See 'Time available and difficult airway NOT anticipated' above.)

Candidates for observation – If the patient with direct airway trauma maintains normal vital signs, pulse oximetry, and mental status, and manifests none of the signs of impending airway compromise listed above, the patient may be a candidate for observation. (See 'Patients appropriate for observation' above.)

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