In this EM Cases main episode podcast, we tackle the complexities of trauma airway management, including direct trauma to the airway. We discuss indications and timing of intubation, penetrating neck trauma, the head injured patient, the agitated patients and the soiled airway. The critical question is: when should we deviate from, delay or modify RSI, and how do we navigate the unique challenges presented by trauma airways and airway trauma? Dr. George Kovacs and Dr. Andrew Petrosoniak answer this and other questions such as: how should we re-sequence the trauma resuscitation depending on immediate life-threats? When is immediate vs delayed intubation recommended? How useful are the Zones of the neck in penetrating neck trauma? What is the optimal dosing of airway medications in the sick trauma patient? How should we modify our airway strategy for the severely head injured patient and/or agitated patient? When should we consider ketamine facilitated fiberoptic intubation in the trauma patient? and many more...



Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Sara Brade, edited by Anton Helman November, 2024

Cite this podcast as: Helman, A. Petrosoniak, A. Kovacs, G. Trauma Airway & Airway Trauma. Emergency Medicine Cases. November, 2024. https://emergencymedicinecases.com/trauma-airway. Accessed November 19, 2024

Résumés EM Cases











Case study: Penetrating neck trauma

Consider a 25-year-old woman who presents with a stab wound to the anterior neck. She arrives with a heart rate of 145, oxygen saturation at 90%, and audible gurgling sounds, indicating potential airway compromise. This is a high-stakes scenario where every decision, especially regarding airway management, could have life-altering consequences. The injury, located just off the midline in the anterior neck, immediately raises concerns about airway obstruction, major vascular injury, or both.

Re-sequencing the trauma airway: A paradigm shift

While working through the standard ATLS approach of A then B then C can be a helpful memory tool, our trauma resuscitations often require simultaneous assessment and management of all three or a total re-ordering of priorities. Some traumas may require a CAB approach or a CBA approach. Intubation is not always the first priority in trauma and, in fact, it may worsen outcomes if done prior to adequate resuscitation. Instead of focusing on letters, we should be focusing on identifying and managing the most immediate threat to life for each patient. Look for and immediately manage the following:



* Massive hemorrhage: For example, a spurting artery that needs immediate management/compression or an unstable pelvis that needs binding.

* Severe airway compromise:



* Dynamic airway: If you wait even minutes, you may miss the opportunity to secure an airway. For example, expanding neck hematoma.

* Critical hypoxia: Despite maximum noninvasive ventilation, O2 saturation is still <90%.





* Obstructive shock:



* Tension pneumothorax/ hemothorax: Consider bilateral finger thoracostomies/ chest tube before airway management.

* Cardiac tamponade: Very high-risk intubations, should likely be done in the OR if patient still has a BP. If cardiac arrest, consider thoracotomy if your resources allow.









The decision to intubate the trauma patient