Airway Management in Trauma

In the paper

“administering too small a dose (<1.0 mg/kg) of rocuronium, particularly in low-flow states, will result in inadequate intubating conditions and a larger dose is recommended (1.2-1.6 mg/kg).101,102”

What the sources say

• Disputed

  The Subgroup analysis reports fewer excellent conditions with 0.6–0.7 mg/kg rocuronium than with succinylcholine, but it does not establish that every dose below 1.0 mg/kg produces inadequate conditions. It finds no conclusive evidence that increasing rocuronium doses improves conditions, and the Authors’ conclusions recommend 1 mg/kg when rocuronium is needed—not 1.2–1.6 mg/kg. The cited passages do not address low-flow states. (LLM, conf=0.88)

  Checked by a reasoning model — may be wrong.

  cites [101] Tran, 2015, Rocuronium versus succinylcholine for rapid sequence induction intubation, Cochrane Database Syst Rev sourceExperimental — accuracy not yet measured
• Partly supported

  The Commentary (page not provided) says rocuronium dose may affect intubating conditions and reports that succinylcholine produced better conditions at rocuronium doses of 0.6–0.7 mg/kg. It does not say that every dose below 1.0 mg/kg causes inadequate conditions: it found no difference at 0.9–1.0 mg/kg. It does not address low-flow states or recommend 1.2–1.6 mg/kg. (LLM, conf=0.88)

  cites [102] Welch, 2016, Update: does rocuronium create better intubating conditions than succinylcholine for rapid sequence intubation?, Ann Emerg Med sourceExperimental — accuracy not yet measured

In the paper

“Another theoretic concern is that application of MILS results in the need for an increased applied force during laryngoscopy, which paradoxically may lead to more movement during intubation than occurs without MILS.40,41”

What the sources say

• Supported

  The Discussion reports that laryngoscope-blade pressure doubled with MILS compared with control in a study it cites. It also says that this pressure may be transmitted to the cervical spine and increase the movement MILS is intended to prevent. The citing sentence presents that movement risk as a theoretical concern, consistent with the source. (LLM, conf=0.90)

  cites [40] Thiboutot, 2009, Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial, Can J Anaesth source
• ?Not checked — no full text of the sourcecites [41] LeGrand, 2007, Craniocervical motion during direct laryngoscopy and orotracheal intubation with the Macintosh and Miller blades: an in vivo cinefluoroscopic study, Anesthesiology source

In the paper

“the incidence of c-spine injuries is relatively low (occurring in approximately 2% in the general trauma population”

What the sources say

• ?Not checked — no full text of the sourcecites [30] Mulligan, 2010, A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures, J Trauma source
• ?Not checked — no full text of the sourcecites [31] Dupanovic, 2010, Management of the airway in multitrauma, Curr Opin Anaesthesiol source
• Partly supported

  The Characteristics of study subjects section reports that 320 of 17,208 patients (2%) had a clinically important cervical spine injury. The Abstract specifies that these were patients presenting to nine tertiary-care emergency departments after acute blunt trauma to the head or neck, not the general trauma population. The 2% figure is supported, but the claimed population is broader than the study's. (LLM, conf=0.88)

  cites [32] Thompson, 2009, Association of injury mechanism with the risk of cervical spine fractures, CJEM sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [33] Manoach, 2007, Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions, Ann Emerg Med source

In the paper

“and 6%-8% in patients with head and facial trauma)”

What the sources say

• ?Not checked — no full text of the sourcecites [30] Mulligan, 2010, A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures, J Trauma source
• ?Not checked — no full text of the sourcecites [31] Dupanovic, 2010, Management of the airway in multitrauma, Curr Opin Anaesthesiol source
• ?Could not verify

  The Characteristics of study subjects section reports cervical spine injury in 320 of 17,208 patients (2%) enrolled after blunt head or neck trauma. Our copy does not report an incidence for patients with head and facial trauma, so it cannot verify the claimed 6%–8% for that group. (LLM, conf=0.72)

  cites [32] Thompson, 2009, Association of injury mechanism with the risk of cervical spine fractures, CJEM sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [33] Manoach, 2007, Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions, Ann Emerg Med source

In the paper

“Although not studied in a clinical setting, the Ducanto suction-assisted laryngoscopy airway decontamination (SALAD) approach has gained acceptance as a method to manage the soiled airway.57,58”

What the sources say

• Partly supported

  The Introduction describes SALAD as a simulation-based suction approach for managing vomit or blood in the airway, and the Discussion says the study did not evaluate real-world clinical outcomes. The Results report favorable ratings from 40 learners, but do not establish that the approach had gained acceptance as a clinical method for managing soiled airways. Page numbers were not available in our copy. (LLM, conf=0.85)

  cites [57] DuCanto, 2017, Novel airway training tool that simulates vomiting: suction-assisted laryngoscopy assisted decontamination (SALAD) system, West J Emerg Med sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [58] Brainard, 2015, The art of SUCTIONING, JEMS

In the paper

“Posterior displacement from fractured maxillofacial segments may cause soft tissue collapse and occlude the airway, which may be worsened by the presence of c-spine collar.64,65”

What the sources say

• Not checked yetcites [64] Bowman-Howard, 2000, Management of the traumatized airway
• Supported

  The AIRWAY section says posterior displacement of the maxilla or mandible in multiple facial fractures can decrease airway patency. MANAGEMENT > Initial assessment warns that a spinal collar can inadvertently displace the mandible posteriorly, complicating the airway, and notes that displaced tissue can cause delayed airway compromise. (LLM, conf=0.91)

  cites [65] Jose, 2016, Management of maxillofacial trauma in emergency: an update of challenges and controversies, J Emerg Trauma Shock source

In the paper

“Success with awake intubation is dependent on meticulous airway topicalization, and in general requires an awake and cooperative patient.72,73”

What the sources say

• ?Not checked — no full text of the sourcecites [72] Higgs, 2016, Airway management in the critically ill: the same, but different, Br J Anaesth source
• Partly supported

  The paper’s Abstract says some agitated patients cannot undergo awake intubation and describes using topical anesthetic or a local anesthetic spray in an awake, breathing patient. It does not say success depends on meticulous topicalization or generally requires a fully awake and cooperative patient; it explicitly describes successful awake intubation in ICU patients whose consciousness may be reduced by illness. (LLM, conf=0.85)

  cites [73] Lapinsky, 2015, Endotracheal intubation in the ICU, Crit Care sourceExperimental — accuracy not yet measured

In the paper

“Most of the literature comparing DL with VL in the bloody or vomitus-filled airway is simulation-based, and concern exists about the vulnerability of VL camera lens in the contaminated airway.55,56”

What the sources say

• ?Not checked — no full text of the sourcecites [55] Ohchi, 2016, Evaluation of gum-elastic bougie combined with direct and indirect laryngoscopes in vomitus setting: a randomized simulation trial, Am J Emerg Med source
• Partly supported

  The Methods describe a manikin simulation using simulated vomitus and blood, and the Discussion reports that the AWS video monitor was severely disturbed by both contaminants. The Conclusion calls for trials in actual patients. These passages support the simulation example and the concern about a contaminated video view, but do not establish that most of the literature is simulation-based or specifically identify the camera lens as the vulnerable component. Page numbers are unavailable in our copy. (LLM, conf=0.87)

  cites [56] Mihara, 2015, Comparison of direct and indirect laryngoscopes in vomitus and hematemesis settings: a randomized simulation trial, Biomed Res Int sourceExperimental — accuracy not yet measured

In the paper

“Literature comparing intubation devices in c-spine immobilized patients has yielded inconsistent findings, and no consensus as to the optimal approach.38,44,45,48,49”

What the sources say

• ?Not checked — no full text of the sourcecites [38] Crosby, 2006, Airway management in adults after cervical spine trauma, Anesthesiology source
• ?Not checked — no full text of the sourcecites [44] Michailidou, 2015, A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients, World J Surg source
• Supported

  The Results (Intubation failure at first attempt; page unavailable) report a significant reduction with Airtraq but not with four other devices, supporting the description of differing findings across devices. The Discussion (page unavailable) says it remains unclear whether Airtraq should be recommended first and that evidence is insufficient to recommend other devices, supporting the absence of a settled optimal approach. (LLM, conf=0.87)

  cites [45] Suppan, 2016, Alternative intubation techniques vs Macintosh laryngoscopy in patients with cervical spine immobilization: systematic review and meta-analysis of randomized controlled trials, Br J Anaesth source
• Partly supported

  The Discussion (page unavailable) says the optimal videolaryngoscope may differ with the circumstances of the difficult airway, supporting the absence of one universally optimal device. But it also says prior studies agree that videolaryngoscopes have higher success rates than the Macintosh laryngoscope, so it does not support a blanket characterization of the findings as inconsistent. This trial used simulated cervical-spine immobilization with reduced mouth opening, rather than studying all immobilized patients. (LLM, conf=0.84)

  cites [48] Kleine-Brueggeney, 2016, Evaluation of six videolaryngoscopes in 720 patients with a simulated difficult airway: a multicentre randomized controlled trial, Br J Anaesth sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [49] Norris, 2016, Limitations of videolaryngoscopy, Br J Anaesth source

In the paper

“The use of sedation is not routine, and has been associated with increased awake intubation failures.74”

What the sources say

• ?Could not verify

  The Primary airway problem and What do we learn from these observations? sections discuss failed intubation in ICU and emergency departments, but do not identify awake intubation failures or link them to sedation. Searches for awake intubation and sedation found references to sedation holds and tube displacement, not evidence that sedation is non-routine or associated with increased awake intubation failures. Page numbers were unavailable in our copy. (LLM, conf=0.76)

  cites [74] Cook, 2011, Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments, Br J Anaesth sourceExperimental — accuracy not yet measured

In the paper

“and that the scalpel-bougie technique is the technique of choice.89”

What the sources say

• Supported

  In Plan D, the guidelines recommend adopting a scalpel cricothyroidotomy technique using a bougie for emergency front-of-neck access. The Discussion also recommends that all anaesthetists learn scalpel cricothyroidotomy, while acknowledging that other techniques remain valid. (LLM, conf=0.90)

  cites [89] Frerk, 2015, Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults, Br J Anaesth source

In the paper

“Numerous preparatory airway acronyms and checklists have been proposed to reduce errors and adverse events associated with RSI.85,86”

What the sources say

• Partly supported

  The Comments section (page not specified) says airway checklists are increasingly adopted in initiatives designed to reduce adverse events and discusses their use to reduce errors. The paper does not describe preparatory airway acronyms, so it supports the checklist portion but not the full claim. (LLM, conf=0.85)

  cites [85] Hardy, 2016, BET 2: should real resuscitationists use airway checklists?, Emerg Med J sourceExperimental — accuracy not yet measured
• Partly supported

  The Background (page not provided) proposes a mnemonic-based checklist for airway interventions outside the operating room, and the Conclusion says the authors believe it is likely to improve performance. The paper does not establish that numerous such tools have been proposed specifically for RSI or that they reduce errors and adverse events; it notes that supporting data for its checklist may be lacking. (LLM, conf=0.85)

  cites [86] Brindley, 2017, Airway management outside the operating room: how to better prepare, Can J Anaesth sourceExperimental — accuracy not yet measured

In the paper

“Although rare (0.05%-1.7% of ED-based intubations)”

What the sources say

• Supported

  The Incidence and scope of the problem section, Table 1, lists the approximate incidence of surgical airway in the emergency department as 0.05–1.7%. This supports the cited range for front-of-neck airway; the paper cautions that incidence estimates across studies are difficult to compare directly. (LLM, conf=0.93)

  cites [111] Law, 2013, The difficult airway with recommendations for management—Part 1-Intubation encountered in an unconscious/induced patient, Can J Anaesth source

In the paper

“both succinylcholine and rocuronium may be safely used and can provide good intubating conditions.101”

What the sources say

• Partly supported

  The Authors’ Conclusions say succinylcholine reliably creates excellent intubating conditions and rocuronium 1 mg/kg can create acceptable conditions as a second-line option. But the Overall completeness and applicability of evidence section explicitly says the review cannot draw conclusions about safety, so it does not support the claim that both may be safely used. (LLM, conf=0.92)

  cites [101] Tran, 2015, Rocuronium versus succinylcholine for rapid sequence induction intubation, Cochrane Database Syst Rev sourceExperimental — accuracy not yet measured

In the paper

“Numerous studies have evaluated to effectiveness of HFNO as an adjunct to preoxygenation for RSI, and the balance of evidence suggest the procedure as both safe and effective.104”

What the sources say

• Partly supported

  The section on apneic oxygenation in clinical settings reports reduced desaturation in some intubation studies, including one using high-flow nasal oxygen and one involving rapid sequence intubation. But the Conclusion (page unavailable) says most studies were too small to assess serious adverse events and warns that prolonged apneic oxygenation may be risky. The review therefore supports possible effectiveness, not the unqualified claim that HFNO is both safe and effective as an adjunct for RSI. (LLM, conf=0.89)

  cites [104] Wong, 2017, The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review, Can J Anaesth sourceExperimental — accuracy not yet measured

In the paper

“However, recent reviews have shown that complications associated with jet ventilation are unacceptably high and wire-guided approaches are not as easy or successful as once believed.[114][115][116][117]”

What the sources say

• ?Not checked — no full text of the sourcecites [114] Duggan, 2016, Transtracheal jet ventilation in the “can’t intubate can’t oxygenate” emergency: a systematic review, Br J Anaesth source
• ?Could not verify

  The Type and Size of Catheter section reports failures with narrow-gauge catheter puncture, but does not identify those attempts as wire-guided. Searches for wire-guided, guidewire, and Seldinger approaches found no passage assessing their ease or success. The copy therefore does not establish the attributed claim. (LLM, conf=0.76)

  cites [115] Marshall, 2016, Evidence is important: safety considerations for emergency catheter cricothyroidotomy, Acad Emerg Med sourceExperimental — accuracy not yet measured
• Partly supported

  The Emergency surgical airway section (page unavailable) reports that 12 of 19 narrow-bore and 3 of 7 wide-bore cannula cricothyroidotomy attempts failed. The Discussion (page unavailable) calls the high failure rate concerning, but the paper does not identify those attempts as wire-guided or assess whether wire-guided approaches were once thought easier or more successful. (LLM, conf=0.78)

  cites [116] Cook, 2011, Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia, Br J Anaesth sourceExperimental — accuracy not yet measured
• Partly supported

  The Discussion reports that surgical techniques were generally faster than Seldinger-based wire-guided kits, which supports the claim that wire-guided approaches may be less easy than assumed. But it also says both approaches had high success rates and found no statistically significant difference between them; it does not support the claim that wire-guided approaches were less successful than once believed. (LLM, conf=0.86)

  cites [117] Langvad, 2013, Emergency cricothyrotomy—a systematic review, Scand J Trauma Resusc Emerg Med sourceExperimental — accuracy not yet measured

In the paper

“in the emergency department, 20% to 30% intubations are for trauma.1,2”

What the sources say

• ?Not checked — no full text of the sourcecites [1] Brown, 2015, NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations, Ann Emerg Med source
• ?Not checked — no full text of the sourcecites [2] Kerslake, 2015, Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations, Resuscitation source

In the paper

“In contrast to patients with head injury with functional airway obstruction, patients with IBA do not respond to simple airway opening maneuvers alone, and may require brief ventilation support to prevent secondary hypoxic insult.”

In the paper

“A proportion of these patients will respond to basic maneuvers, and those who do not usually have more severe, less survivable injuries.”

In the paper

“For patients with known or suspected airway injury, the safest way to facilitate ETI is placement of the ETT under direct visualization, ideally from the oropharynx to the carina using an FIE.68,70”

What the sources say

• ?Not checked — no full text of the sourcecites [68] Mercer, 2016, Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma, Br J Anaesth source
• ?Not checked — no full text of the sourcecites [70] Horton, 2014, Trauma reports, J Emerg Med source

In the paper

“ventilatory pressures of 20 cm H2O or more are likely to ventilate the stomach, increasing the risk of regurgitation and aspiration.”

In the paper

“The EAST guidelines recommend that aggressive behavior refractory to initial pharmacologic intervention is a discretionary indication for intubation”

What the sources say

• ?Not checked — no full text of the sourcecites [15] Mayglothling, 2012, Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline, J Trauma Acute Care Surg source

In the paper

“Agitation can be multifactorial and may be the result of head injury, hypoperfusion, hypoxemia, or intoxication.”

In the paper

“Distortion of facial structures may make obtaining a seal with a BVM device difficult and patients may poorly tolerate PPV, as disruption of tissues may result in worsening bleeding and in cases of associated lower airway trauma, significant subcutaneous emphysema.”

In the paper

“Clinical findings suggestive of significant laryngotracheal airway injury include dysphagia, hoarseness, stridor, bleeding in the upper airway, subcutaneous emphysema, expanding hematoma, or in open penetrating injuries, obvious disruption of the larynx or trachea.”

In the paper

“practitioners have infrequent or limited experience in managing these patients and existing management guidelines for care of these patients are mostly based on expert opinion.68”

What the sources say

• ?Not checked — no full text of the sourcecites [68] Mercer, 2016, Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma, Br J Anaesth source

In the paper

“Adherence to protocols requiring rigid spinal immobilization and supine positioning may result in catastrophe.”

In the paper

“Recently, Sakles and colleagues 54 retrospectively reviewed more than 4600 intubations and demonstrated that, although airway contamination was associated with a decreased first-attempt success rate, this was irrespective of the choice of GlideScope or DL as the first-attempt device used.”

What the sources say

• ?Not checked — no full text of the sourcecites [54] Sakles, 2017, The impact of a soiled airway on intubation success in the Emergency Department when using the GlideScope or the direct laryngoscope, Acad Emerg Med source

In the paper

“Airway management for the patient with a primary injury to the larynx or trachea is a high-stakes scenario, in which the loss of a stable airway can happen rapidly and with little warning.”

In the paper

“Historically, the application of cricoid pressure (CP) to prevent passive aspiration has been considered an essential component of an RSI.”

In the paper

“Uncooperative, violent, or agitated patients can encumber adequate assessment, leading to missed injuries and inadequate resuscitation.”

In the paper

“One option to improve visual navigation past the airway injury is to use a VL-assisted flexible endoscopic intubation.71”

What the sources say

• ?Not checked — no full text of the sourcecites [71] Sowers, 2016, Use of a flexible intubating scope in combination with a channeled video laryngoscope for managing a difficult airway in the emergency department, J Emerg Med source

In the paper

“However, the use of any sedative, particularly in the presence of other intoxicating ingestions, may inhibit airway reflexes.”

In the paper

“A successful awake intubation is dependent on careful patient selection, and, in particular, identifying anatomic, pathologic, or physiologic features that would make RSI problematic.”

In the paper

“A difficult airway paradox exists here: patients identified as difficult are selected to undergo a technically more challenging awake approach, a procedure that is performed infrequently by most emergency physicians.”

In the paper

“In the supine position, the pooling of blood in the oropharynx may stimulate a gag response or vomiting, which in turn may worsen bleeding.”

In the paper

“swelling and tenderness at the temporomandibular joints suggests the presence of condylar factures and the possibility of mechanical trismus.”

In the paper

“Use of an FIE allows both a diagnostic and therapeutic advantage: visualizing the specific pattern of injury, and facilitating careful ETT placement, while avoiding conversion to a complete transection.”

In the paper

“Maxillofacial fractures may also cause trismus that may resolve with the neuromuscular blockade; however, differentiating this from a mechanical obstruction before intubation is required and is often difficult.”

In the paper

“In the uncommon circumstance in which blood or vomit is overwhelming these management strategies, intubation is not possible and the patient is critically desaturating, rescue oxygenation with a BVM (bag-valvemask) or SGA (supraglottic airway) is unlikely to work and an FONA approach is indicated.”

In the paper

“Safely managing both the anticipated and unanticipated difficult airway requires technical expertise; however, decisions of when and how to intervene are equally important determinants of outcome.”

In the paper

“However, its routine use remains controversial, with some evidence suggesting it may make various aspects of airway management more challenging.”

In the paper

“Inadequate resuscitation of hemorrhagic shock, transition to PPV, loss of sympathetic drive associated with general anesthesia, and the hemodynamic effect of many induction drugs are all contributing factors.”

In the paper

“Then, securing the airway will have the best chance of making a positive difference in trauma patient outcomes.”

In the paper

“Airway management in trauma begins as soon as patient contact is made and rarely starts with placement of an ETT.”

In the paper

“Hemodynamic instability in trauma is most commonly caused by hypovolemia due to hemorrhage.”

In the paper

“Paralysis should have no direct effect on the patient's hemodynamic status”

In the paper

“Whether the team is a doctor, nurse, and transporting paramedics or a group of 10, success is dependent on a shared understanding of the importance of resuscitation before intubation and clear communication of what and when various airway interventions will be performed.”

In the paper

“Vasopressors have traditionally been avoided in trauma based on concerns that they may worsen bleeding.”

In the paper

“Effective trauma care requires a team approach, with resuscitation priorities clearly communicated and interventions guided by the physiologic priorities that ensure adequate oxygen delivery.”

In the paper

“The scalpel-bougie technique has several advantages for the emergency clinician: it relies on gross motor skills (which are more likely to be preserved during periods of acute stress), uses familiar equipment (scalpel, bougie, and a #6 ETT), and has a minimal number of steps.”

In the paper

“Providing advanced airway management is part of the A and B and C parallel resuscitative priorities of trauma care.”

In the paper

“Having the sick trauma patient wake up to a state that he or she will be able rescue his or her own airway is simply not realistic, and will make efforts to secure the airway even more difficult.”

In the paper

“extended, deep paralysis is in fact desirable in this circumstance, as it helps to create optimal conditions for laryngoscopy, BVM and SGA ventilation, and FONA.”

In the paper

“Intravascular depletion shifts the gradient between right atrial pressure Trauma Airway and mean systemic pressure, reducing preload and subsequently mean arterial pressure.”

In the paper

“Gaining intravenous access, beginning fluid resuscitation, and applying oxygen may be lifesaving and/or bridging interventions that allow for the safe execution of downstream more definitive procedures.”