Guidelines for Emergency Tracheal I

ntubation Immediately after Traumat

ic Injury
[CLINICAL MANAGEMENT UPDATE]

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l.com/
Acute postinjury respiratory system ins
ufficiency
 The primary concern is hypoxemic hypoxia
and subsequent hypoxic encephalopathy o
r cardiac arrest.
 A secondary problem is hypercarbia, cere
bral vasodilation and acidemia.
 An additional concern is aspiration, pneum
onia, or ARDS and acute lung injury.
 The primary categories of respiratory
system insufficiency
 Airway obstruction, hypoventilation, lung injury,
and impaired laryngeal reflexes
 Airway obstruction can occur with cervical spine
injury, severe cognitive impairment (GCS<= 8),
severe neck injury, severe maxillofacial injury, or
smoke inhalation.
 Hypoventilation can occur with airway
obstruction, cardiac arrest, severe cognitive
impairment, or cervical spinal injury.
Trauma patients requiring emergency t
racheal intubation
 The mean study Injury Severity Score (ISS) is 29
; ( varies from 17 to 54).
 The average study GCS score for trauma patient
s is 6.5 (3–15).
 The mean study mortality rate for emergency tra
cheal intubation in trauma patients is 41%, ( 2%
to 100% ).
Substantial variation in the percentages of tr
auma patients undergoing emergency trache
al intubation
 For aeromedical settings, the percentage of pati
ents is 18.5%; ( 6% to 51% )
 The ground EMS studies indicate that the rate of
patients is 4.0% ( 2% to 37% )
 For trauma center settings, the percentage of pa
tients undergoing tracheal intubation is 24.5% (
9% to 28%)
 Indications of emergency tracheal int
ubation in trauma patients
a) Airway obstruction
b) Hypoventilation
c) Severe hypoxemia (hypoxemia despite
supplemental oxygen)
d) Severe cognitive impairment
(GCS score <= 8)
e) Cardiac arrest
f) Severe hemorrhagic shock
Indications of emergency tracheal intu
bation in smoke inhalation patients
a) Airway obstruction
b) Severe cognitive impairment (GCS score <= 8)
c) Major cutaneous burn (>=40%)
d) Prolonged transport time
e) Impending airway obstruction:
i. Moderate to severe facial burn
ii. Moderate to severe oropharyngeal burn
iii. Moderate to severe airway injury seen on endo
scopy
SCIENTIFIC FOUNDATION TO
CHARACTERIZE PATIENTS IN
NEED OF
EMERGENCY TRACHEAL
INTUBATION IMMEDIATELY
AFTER TRAUMATIC INJURY
Trauma Patients with Airway Obstruction
 C- spine injury can have airway obstruction seco
ndary to cervical hematoma
 The need for emergency tracheal intubation in p
atients with C-spine injury is 22%.
 Other patients with severe cognitive impairment
severe neck injury, laryngotracheal injury,
severe maxillofacial injury, commonly have airwa
y obstruction and associated hypoxemia
 Level I Recommendation
Trauma patients with airway obstruction need
emergency tracheal intubation.
Trauma Patients with Hypoventilation
 That patients with cervical spinal cord injury ofte
n have hypoventilation. The need for emergenc
y tracheal intubation is 22% (14–48%).
 Other patients with severe cognitive impairment
have abnormal breathing patterns and can have
hypoventilation.
 Level I Recommendation
Trauma patients with hypoventilation need eme
rgency tracheal intubation
 Trauma Patients with Severe Hypoxemia
 Severe hypoxemia is defined as persistent hypoxemia, d
espite the administration of supplemental oxygen.
 Hypoxemia may be secondary to airway obstruction, hyp
oventilation, lung injury, or aspiration
 Blunt or penetrating thoracic injury can cause respiratory
distress and hypoxemia.
 Emergency tracheal intubation is required for 40% to 60
% of patients sustaining pulmonary contusion, chest wall
fractures, or flail chest.
 Level I Recommendation
Trauma patients with severe hypoxemia need em
ergency tracheal intubation.
 Trauma Patients with Severe Cognitive
Impairment (GCS Score <= 8)
 The trauma patients with severe cognitive impair
ment (GCS score <= 8) commonly have airway o
bstruction, hypoventilation, and hypoxia. The res
piratory system insufficiency worsens the neurol
ogic outcome for postinjury severe cognitive imp
airment
 EMS ground crews may intubate a much lower p
ercentage of patients with severe cognitive impai
rment (33%) as opposed to patients managed by
aeromedical crews (85%).
 Scientific Evidence
 Winchell and Hoyt found a significant reduction in
mortality with prehospital tracheal intubation.
With severe brain injury and extracranial trauma
: 35.6% VS 57.4%
Isolated severe brain injury: 22.8% VS 49.6%
 Cooper and Boswell showed a decrease in injury-r
elated complications
 Hicks et al. demonstrated a reduction in hypoxemi
a during transfer to a trauma center
 Level I Recommendation
Trauma patients with severe cognitive impairme
nt (GCS score <= 8) need emergency tracheal
intubation.
 Trauma Patients with Cardiac Arrest
 10 studies of trauma patients (3567 patients ) un
dergoing emergency tracheal intubation provide
evidence that patients with cardiac arrest need tr
acheal intubation.

 Level I Recommendation
Trauma patients in cardiac arrest need emerge
ncy tracheal intubation.
 Trauma Patients with Severe
Hemorrhagic Shock
 10 studies of trauma patients (5633) undergoing
emergency tracheal intubation provide evidence
that patients with severe hemorrhagic shock nee
d tracheal intubation
 Level I Recommendation

Emergency tracheal intubation is needed for s

evere hemorrhagic shock in trauma patients
and is essential when emergency thoracotomy
or celiotomy is required.
 Patients with Smoke Inhalation
 Acute respiratory system insufficiency can be ca
used by CO toxicity and thermal or combustion-p
roduct tissue injury
 Typical acute manifestations of smoke inhalation
are airway obstruction, hypoventilation, and seve
re cognitive impairment.
 Although severe hypoxemia is not typical, it can
occur if there has been pulmonary aspiration or tr
aumatic lung contusion.
 Tracheal intubation is needed in 16.6% of burn p
atients. The incidence of smoke inhalation injury
for patients who have burn injury is 10.7%
Clinical indicators of smoke inhalation
* Closed-space injury
* Facial burns
* Singed nasal vibrissae
* Soot in oropharynx
* Oropharyngeal burns
* Hoarseness
* Airway obstruction
* Wheezing
* Carbonaceous sputum
* Uunconsciousness
 Scientific Evidence
 Investigators have described 16 groups of smoke inhalatio
n patients who needed tracheal intubation. The overall ra
te of emergency tracheal intubation was 62.2% (605 of 97
2).
 The American College of Surgeons Committee on Trauma list
s the following as indicators of smoke inhalation injury:
facial burns, singeing of the eyebrows and nasal vibrissa
e, carbon deposits and acute inflammatory changes in the
oropharynx, carbonaceous sputum, history of impaired ment
ation and/or confinement in a burning environment, explos
ion with burns to head and torso, and carboxyhemoglobin l
evel greater than 10% if the patient is involved in a fir
e. 149 The College endorses tracheal intubation in smoke
inhalation patients with a prolonged transport time or st
ridor.
 The National Association of Emergency Medical
Technicians recommends intubation when the p
otential for losing the airway exists because of pr
ogressive edema.
 The American College of Emergency Physician
s and the National Association of EMS Physician
s advocate tracheal intubation for (1) patients re
quiring secondary transport to a burn center and
receiving large-volume fluid infusion, (2) stridor,
or (3) unconsciousness.
 Level I Recommendation
 Smoke inhalation patients with the following conditions n
eed emergency tracheal intubation:
 1. airway obstruction
 2. severe cognitive impairment (GCS score <= 8)
 3. a major cutaneous burn (>=40%)
 4. impending airway obstruction:
 a) moderate to severe facial burn
b) moderate to severe oropharyngeal burn
c) moderate to severe airway injury seen on endoscop
y
5. a prolonged transport time
 RECOMMENDATIONS FOR
PROCEDURAL OPTIONS IN
TRAUMA PATIENTS
UNDERGOING EMERGENCY
TRACHEAL INTUBATION
1. Orotracheal intubation guided by direct laryngo
scopy is the emergency tracheal intubation proc
edure of choice for trauma patients.
2. When the patient’s jaws are not flaccid and OTI i
s needed, a drug regimen should be given to ac
hieve the following clinical objectives:
a) neuromuscular paralysis
b) sedation, as needed
c) maintain hemodynamic stability
d) prevent intracranial hypertension
e) prevent vomiting
f) prevent intraocular content extrusion
3. Enhancements for safe and effective emergenc
y tracheal intubation include:
a) availability of experienced personnel
b) pulse oximetry monitoring
c) maintenance of cervical spine neutrality
d) application of cricoid pressure
e) carbon dioxide monitoring
4. Cricothyrostomy is appropriate when emergenc
y tracheal intubation is needed and the vocal co
rds cannot be visualized during laryngoscopy or
the pharynx is obscured by copious amounts of
blood or vomitus.
Emergency Orotracheal Intubation in Tr
auma Patients
 The overall failure-to-intubate rate for OTI withou
t drug-assistance was 20.8%
 The overall intubation success rate for OTI with
drug-assistance was 96.3%
 The overall complication rate for OTI with drug-a
ssistance was calculated to be 3.6%
 The typical indication for drug-assisted OTI is
jaw rigidity
 A drug regimen used to enhance OTI success
should consider the need for patient sedation, an
d patient-induced paralysis
Emergency Nasotracheal Intubation in T
rauma Patients
 The overall intubation success rate was 76.8%
 NTI is likely to fail in a significant percentage of t
rauma patients
 The principle indications for emergent NTI in trau
ma patients were jaw rigidity and cervical spine i
njury
Emergency Fibroptic Tracheal Intubatio
n in Trauma Patients
 During the past 22 years, attempts at emergency
tracheal intubation with fiberoptic assistance hav
e been described in 42 trauma patients and was
successful in 35 patients
 Indications for emergency fiberoptic-assisted tra
cheal intubation were rigid jaws, cervical spine in
jury, laryngotracheal injury,and obscured pharyn
x from blood or vomitus
Comparing Emergency Tracheal Intubat
ion Procedures in Trauma
Patients
 OTI was the most common method for emergen
cy tracheal intubation
 Emergency intubation procedure success rates
were OTI without drug-assistance, 79.2% ; OTI
with drug-assistance, 96.3%; NTI, 76.8%; and cri
cothyrostomy, 95.7%
 Emergency intubation failure rates were OTI with
out drug-assistance, 20.8% ; OTI with drug-assis
tance, 3.7% ; NTI, 23.2% ; and cricothyrostomy,
4.3%
 Level I Recommendations
* neuromuscular paralysis
* sedation, as needed
* maintain hemodynamic stability
* prevent intracranial hypertension
* prevent vomiting
* prevent intraocular content extrusion
Enhancements for safe and effective emergency tracheal
intubation in trauma patients include the following
* availability of experienced personnel
* pulse oximetry monitoring
* maintenance of cervical spine neutrality
* application of cricoid pressure
* carbon dioxide monitoring
Emergency Cricothyrostomy and Trach
eostomy in Trauma Patients

 An overall emergency cricothyrostomy intubation

success rate of 95.8%
 The overall complication rate for emergency cric
othyrostomy was 9.6%
Fiberoptic tracheal intubation versus em
ergency department cricothyrostomy.
 When the vocal cords cannot be visualized
 The fiberoptic intubation success rate described
in the literature was 83.3% ( 42 patients )
 A reliable rate for emergency department cricoth
yrostomy success is not available
 Future trauma patient investigations are necessa
ry to delineate the precise roles for fiberoptic intu
bation and cricothyrostomy
Emergency Tracheostomy in Trauma Pa
tients
 16 studies have described the performance of e
mergency tracheostomy in 135 trauma patients
 Primary reason for emergency tracheostomy
was laryngotracheal injury.
 Level I Recommendation

 Cricothyrostomy is appropriate when emergency

tracheal intubation is needed and
 the vocal cords cannot be visualized during laryn
goscopy or the pharynx is
 obscured by copious amounts of blood or vomitu
s.
Emergency Combitube and Laryngeal M
ask Airway in Trauma Patients
 Emergency Combitube in trauma patients
Indications: obscured pharynx from blood or vomit
us and nonvisualized vocal cords
 Patients undergoing emergency Combitube plac
ement typically had a GCS score of 3 after rapid-
sequencedrug administration with failed OTI or c
ardiac arrest
The success rate in five studies was 90.9%
 Emergency Laryngeal Mask Airway in
Trauma Patients
 Patients undergoing emergency LMA placement
typically had a GCS score of 3 after rapid-seque
nce drug administration with failed OTI
 The indication was failed drug-assisted OTI sec
ondary to nonvisualized vocal cords, obscured p
harynx from blood or vomitus, and cervical spine
injury.
 The published data describing emergency
Combitube and LMA placement in trauma patient
s is limited.
 The American College of Emergency Physicians
and the National Association of EMS Physicians
recommend the Combitube and LMA for endotra
cheal intubation failure in trauma pt’s.
as a short-term airway until endotracheal or surgi
cal airway access can be obtained
SUMMARY
Emergency tracheal intubation is neede
d in trauma patients
a) airway obstruction
b) hypoventilation
c) severe hypoxemia (hypoxemia despite
supplemental oxygen)
d) severe cognitive impairment (GCS score
<= 8)
e) cardiac arrest
f) severe hemorrhagic shock
Emergency tracheal intubation in Smo
ke inhalation patients
 airway obstruction
 severe cognitive impairment (GCS score <= 8)
 a major cutaneous burn (>=40%)
 impending airway obstruction:

a) moderate to severe facial burn

b) moderate to severe oropharyngeal burn
c) moderate to severe airway injury seen on endo
scopy
 prolonged transport time
1. Orotracheal intubation guided by direct laryngoscopy is the emergenc
y tracheal intubation procedure of choice for trauma patients.
2. When the patient’s jaws are not flaccid and OTI is needed, a drug r
egimen should be given to achieve the following clinical objectives:
a) neuromuscular paralysis
b) sedation, as needed
c) maintain hemodynamic stability
d) prevent intracranial hypertension
 VII. e) prevent vomiting
 VIII. f) prevent intraocular content extrusion
 IX. 3. Enhancements for safe and effective emergency tracheal intuba
tion in trauma patients include:
 X. a) availability of experienced personnel
 XI. b) pulse oximetry monitoring
 XII. c) maintenance of cervical spine neutrality
 XIII. d) application of cricoid pressure
 XIV. e) carbon dioxide monitoring
 XV. 4. Cricothyrostomy is appropriate when emergency tracheal intuba
tion is needed and the vocal cords cannot be visualized during laryn
goscopy or the pharynx is obscured by copious amounts of blood or vo
mitus.