Maintaining an adequate airway is the foremost priority in the resuscitation of the trauma patient. The airway management must consider
- Cervical spine stability
- Aspiration of gastric contents
- Facial trauma or burns
- Intracranial injuries
Cervical Spine Stability
2% to 6% of trauma cases would have cervical spine injury. Cervical spine must be stabilized during all transfers and therapeutic interventions. Immobilization of the cervical spine with a hard cervical collar, a spine board, and sand bags on either side of the head, is the standard of care to prevent neurologic injury.
It is recommended to use the manual axial stabilization of cervical spine during intubation. To do this technique, an assistant maintains the head and neck in a neutral position during management of the airway. This along with cricoid pressure protects the cervical spine from injury.
Aspiration of Gastric Contents
Pulmonary aspiration of gastric contents is an another source of morbidity and mortality for the trauma patient. Though the severity may vary depending on volume, pH, and presence of particulate matter in the aspirate, but the entity must be considered.
Because of the unexpected nature of traumatic injury, all patients must be considered to have a full stomach with recent oral intake and delayed gastric emptying.
Moreover, the use of opioid analgesics slows gastric emptying, increases the gastric volume, and predisposes the patient to regurgitation and aspiration.
Endotracheal intubation is considered to be the best method for protecting the airway from this complication.
To reduce the risk of aspiration, trauma patients are premedicated to reduce the volume and increase the pH of the gastric fluid, if time permits, before intubation .
Sellick’s maneuver(The application of cricoid pressure) makes use of the cricoid cartilage for compressing the esophagus to prevent gastric contents from entering the airway during intubation. Firm cricoid pressure is maintained until endotracheal intubation is confirmed by the usual methods.
The best protection against aspiration is prevention with the use of a carefully executed plan for induction and airway management
Severe Facial Trauma or Burns
Maxillofacial fractures are frequently associated with severe facial trauma and may present with bleeding into the upper airway. In addition, the injuries may be such as to cause edema and rapid soft tissue obstruction of the airway.
Nasal intubation is avoided in these patients because of the risk of a basilar skull fracture and the potential for entry of the endotracheal tube into the cranial vault.
Burn victims also have the potential for rapid and severe airway compromise owing to soft tissue edema.
Such patients must be considered for early intubation because of the potential for further airway compromise.
Intracranial Injuries
The optimal resuscitation of the patient with a suspected head injury is focused on the prevention of secondary neurologic injury. When intracranial injuries are suspected and the Glasgow Coma Scale score is 8 or less, endotracheal intubation is indicated for appropriate management.
Usually, protective reflexes are absent at this level of consciousness and tracheal intubation protects against aspiration. Endotracheal intubation permits optimal neurologic management by preventing hypercarbia and reducing ICP to prevent secondary neurologic injury. Intubation also prevents hypoxia, and mechanical ventilation facilitates adequate oxygenation and ventilation.
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