Airway Management in Trauma

In the paper

“even in patients with known cervical spine injuries, secondary neurologic deterioration is rare, with a reported incidence of 0.03%.33,[37][38][39]”

What the sources say

• ?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
• Disputed

  In “Evidence of Cervical Injury Following Intubation” (page not available), the paper says approximately 5% of patients admitted with traumatic cervical injury deteriorate neurologically, not 0.03%. It separately describes published reports of deterioration associated with intubation as few, but gives no 0.03% incidence for patients with known cervical spine injuries. (LLM, conf=0.88)

  Checked by a reasoning model — may be wrong.

  cites [37] Durga, 2014, Neurological deterioration during intubation in cervical spine disorders, Indian J Anaesth sourceExperimental — accuracy not yet measured
• ?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 [39] Farmer, 1998, Neurologic deterioration after cervical spinal cord injury, J Spinal Disord source

In the paper

“Although patients with mandibular fractures in 2 or more locations may be easier to intubate due to increased mobility of the mandible and attached soft tissues”

What the sources say

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

  In “Maxillofacial Trauma and Airway Injuries” (page unavailable), the paper says a bilateral anterior mandibular fracture may displace the tongue backward and block the airway. “The Complexity of the situation” describes maxillofacial trauma as often making intubation difficult. The paper does not describe increased mandibular mobility as making these patients easier to intubate. (LLM, conf=0.78)

  Checked by a reasoning model — may be wrong.

  cites [66] Krausz, 2009, Maxillofacial trauma patient: coping with the difficult airway, World J Emerg Surg 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
• Disputed

  The opening section acknowledges that catheter oxygenation is inherently risky but says refinements have made complication rates significantly lower. “Evidence of Safety and Need for Ongoing Training” reports few complications when the prescribed technique was used. The paper discusses how to mitigate barotrauma, rather than concluding that complications are unacceptably high. (LLM, conf=0.85)

  Checked by a reasoning model — may be wrong.

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

  The Emergency surgical airway and Discussion sections report a high failure rate for cannula cricothyroidotomy, but do not identify those attempts as jet ventilation or assess jet-ventilation complications. Searches for “jet ventilation” and “trans-tracheal jet ventilation” found no passage addressing the attributed claim. (LLM, conf=0.70)

  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
• ?Could not verify

  The Methods (Types of interventions; page unavailable) describe how a transtracheal catheter can be used with a jet ventilator, but do not assess complications from jet ventilation. A search for jet-ventilation complications, barotrauma, and adverse events found no passage in our copy calling their rate unacceptably high. (LLM, conf=0.76)

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

In the paper

“there is very limited published evidence to support the notion that cervical spine collars and immobilization prevent secondary spinal cord injury.28,29”

What the sources say

• Supported

  The Results section reports that no randomised controlled trials of spinal immobilisation strategies in trauma patients were found. The Discussion says their effect on neurological injury remains uncertain, supporting the claim that evidence for preventing secondary spinal cord injury is very limited. The review includes collars among the immobilisation devices considered; it does not establish that they prevent such injury. (LLM, conf=0.91)

  cites [28] Kwan, 2001, Spinal immobilisation for trauma patients, Cochrane Database Syst Rev source
• ?Not checked — no full text of the sourcecites [29] Oteir, 2014, Should suspected cervical spinal cord injuries be immobilised? A systematic review protocol, Inj Prev source

In the paper

“with 90% of difficult intubations unanticipated”

What the sources say

• ?Not checked — no full text of the sourcecites [18] Yentis, 2002, Predicting difficult intubation–worthwhile exercise or pointless ritual?, Anaesthesia source
• ?Not checked — no full text of the sourcecites [19] Nørskov, 2016, Effects of using the simplified airway risk index vs usual airway assessment on unanticipated difficult tracheal intubation—a cluster randomized trial with 64,273 participants, Br J Anaesth source
• Partly supported

  The article (pp. 3–5) reports that 89–91% of difficult intubations were unanticipated in an analysis that excluded patients initially assigned an alternative intubation method. It then says that exclusion is inappropriate and favors an analysis in which approximately half of difficult intubations were predicted. The unqualified 90% claim omits that condition and the authors’ preferred interpretation. (LLM, conf=0.88)

  cites [20] Teoh, 2016, Prediction in airway management: what is worthwhile, what is a waste of time and what about the future?, Br J Anaesth sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [21] Vannucci, 2016, Bedside predictors of difficult intubation: a systematic review, Minerva Anestesiol

In the paper

“there is a growing body of evidence that prehospital advanced airway management may increase mortality for trauma patients in some circumstances.8,[12][13][14]”

What the sources say

• ?Not checked — no full text of the sourcecites [8] Eckstein, 2000, Effect of prehospital advanced life support on outcomes of major trauma patients, J Trauma source
• ?Not checked — no full text of the sourcecites [12] Stockinger, 2004, Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation, J Trauma source
• Supported

  The Results (passage 6) report that field intubation was associated with increased mortality among major trauma patients (adjusted OR 2.8, 95% CI 1.6–5.0). The Interpretation (passage 2) likewise reports higher mortality among patients undergoing prehospital endotracheal intubation after adjustment. The claim’s cautious wording reflects an association rather than asserting causation. (LLM, conf=0.93)

  cites [13] Stiell, 2008, The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity, CMAJ source
• Supported

  The Background reports lower 30-day survival among seriously injured patients intubated before or upon hospital arrival, while cautioning that uncontrolled data may reflect other factors. The paper’s study summaries also report higher hospital mortality with paramedic prehospital intubation in some trauma cohorts. These findings support the claim’s qualified wording, not a definitive causal conclusion. (LLM, conf=0.90)

  cites [14] Lecky, 2008, Emergency intubation for acutely ill and injured patients, Cochrane Database Syst Rev source

In the paper

“Given the relatively high incidence of peri-intubation desaturation, hypocapnea, and hypotension in emergency intubations”

What the sources say

• Partly supported

  The Introduction (Background and Significance; page unavailable) says hypoxia occurs frequently and hypotension is very common during prehospital care of patients with traumatic brain injury. It does not establish their incidence specifically around emergency intubation, and the passages do not address hypocapnea. (LLM, conf=0.86)

  cites [23] Spaite, 2017, The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury, Ann Emerg Med sourceExperimental — accuracy not yet measured
• Partly supported

  The Main Results report oxygen desaturation in 59 of 166 emergency department rapid sequence intubations (35.5%). The paper does not report incidence rates for peri-intubation hypocapnea or hypotension; its discussion of hemodynamic instability does not establish their incidence. (LLM, conf=0.90)

  cites [24] Bodily, 2015, Incidence and duration of continuously measured oxygen desaturation during emergency department intubation, Ann Emerg Med sourceExperimental — accuracy not yet measured
• Partly supported

  The Discussion reports a high oxygen-desaturation incidence during rapid sequence induction and intubation (55/153, 35.9%), and the techniques section reports hypotension in 23 patients (15%). The study involved patients undergoing operations under general anesthesia with rapid sequence induction, rather than emergency intubations generally. Our copy does not report an incidence of hypocapnea. (LLM, conf=0.89)

  cites [25] Gebremedhn, 2014, The incidence of oxygen desaturation during rapid sequence induction and intubation, World J Emerg Med sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [26] Heffner, 2012, Predictors of the complication of postintubation hypotension during emergency airway management, J Crit Care source

In the paper

“Despite significant advances in prehospital care, injury prevention, and the development of trauma systems, early mortality from trauma has essentially remained unchanged.3”

What the sources say

• ?Could not verify

  The available copy contains bibliographic information identifying a study of laryngoscopes in manikins, but no passage addressing early trauma mortality. Searches for the mortality statement and for prehospital care, injury prevention, and trauma systems found no matching passage; the claim cannot be verified from this copy. (LLM, conf=0.75)

  cites [3] Pieters, 2016, Comparison of seven videolaryngoscopes with the Macintosh laryngoscope in manikins by experienced and novice personnel, Anaesthesia sourceExperimental — accuracy not yet measured

In the paper

“Anatomic markers are in general poor predictors of difficulty with airway management”

What the sources say

• ?Not checked — no full text of the sourcecites [18] Yentis, 2002, Predicting difficult intubation–worthwhile exercise or pointless ritual?, Anaesthesia source
• ?Not checked — no full text of the sourcecites [19] Nørskov, 2016, Effects of using the simplified airway risk index vs usual airway assessment on unanticipated difficult tracheal intubation—a cluster randomized trial with 64,273 participants, Br J Anaesth source
• Partly supported

  In the main text (page unavailable), the authors report that usual assessment predicted about half of difficult direct-laryngoscopy intubations and that systematically recording seven airway parameters did not improve prediction. This supports limited predictive performance, but the claim generalizes from difficult intubation to airway management overall; the paper also identifies some markers useful for predicting difficulty with other techniques. (LLM, conf=0.84)

  cites [20] Teoh, 2016, Prediction in airway management: what is worthwhile, what is a waste of time and what about the future?, Br J Anaesth sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [21] Vannucci, 2016, Bedside predictors of difficult intubation: a systematic review, Minerva Anestesiol

In the paper

“there was no statistically significant difference in first-attempt success between the more commonly used VL devices (GlideScope, C-MAC) and DL. 45”

What the sources say

• Supported

  The Results section (“Intubation failure at first attempt”) states that first-attempt failure was not significantly different with C-Mac or Glidescope compared with Macintosh laryngoscopy. The finding applies to patients with cervical spine immobilization. (LLM, conf=0.94)

  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

In the paper

“associated condylar fractures may cause a mechanical obstruction limiting mouth opening, making laryngoscopy and intubation difficult.64,66”

What the sources say

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

  In “Approach to the Maxillofacial Trauma Patient’s Airway Management” (page not provided), the paper says temporomandibular joint injury can limit mouth opening and complicate airway management. It does not specifically identify condylar fractures or describe a mechanical obstruction caused by them. (LLM, conf=0.86)

  cites [66] Krausz, 2009, Maxillofacial trauma patient: coping with the difficult airway, World J Emerg Surg sourceExperimental — accuracy not yet measured

In the paper

“In cadaveric studies of unstable c-spine injuries, movement occurring with both direct laryngoscopy (DL) and indirect laryngoscopy do not significantly exceed the physiologic values observed with intact spines.35,36”

What the sources say

• ?Not checked — no full text of the sourcecites [35] Hindman, 2016, Intubation biomechanics: laryngoscope force and cervical spine motion during intubation in cadavers—effect of severe distractive-flexion injury on C3–4 motion, J Neurosurg Spine source
• Supported

  The Discussion (Experiment 3; page unavailable) reports that, in cadavers with a type II odontoid fracture, C1–C2 motion during intubation was not significantly greater than with intact C1–C2 segments. The Results (Experiment 3; page unavailable) report no significant intact-versus-injured difference in either extension or canal-space change with the Macintosh and Airtraq laryngoscopes. This supports the claim for the injury and motion measures this paper studied. (LLM, conf=0.88)

  cites [36] Hindman, 2015, Intubation biomechanics: laryngoscope force and cervical spine motion during intubation in cadavers—cadavers versus patients, the effect of repeated intubations, and the effect of type II odontoid fracture on C1-C2 motion, Anesthesiology source

In the paper

“Maxillofacial fractures may present dramatically and affect airway management in one of several ways.63”

What the sources say

• Supported

  The opening passage (labeled Abstract) says facial injuries can present with airway obstruction and identifies six ways maxillofacial trauma may affect the airway. The Conclusion describes major maxillofacial injuries as intimidating and as obstructing access to the airway, supporting the claim that they may present dramatically and complicate airway management. (LLM, conf=0.94)

  cites [63] Hutchison, 1990, ABC of major trauma. Major maxillofacial injuries, BMJ source

In the paper

“However, having a good view with VL does not mean that easy ETI will follow.46”

What the sources say

• Supported

  The Discussion states that difficulties can delay intubation during indirect video laryngoscopy despite a good view. It also reports faster, subjectively easier intubation with a deliberately restricted GlideScope view than with a full glottic view under the study conditions. This supports the claim that a good view does not guarantee easy intubation. (LLM, conf=0.93)

  cites [46] Gu, 2016, A deliberately restricted laryngeal view with the GlideScope® video laryngoscope is associated with faster and easier tracheal intubation when compared with a full glottic view: a randomized clinical trial, Can J Anaesth source

In the paper

“Manual inline stabilization (MILS) worsens the view obtained with DL in up to 50% of cases.40”

What the sources say

• Partly supported

  The Abstract and Discussion report that MILS worsened laryngeal visualization during direct laryngoscopy. But the Abstract’s 50% figure is the rate of failed intubation within 30 seconds in the MILS group, not the proportion of cases in which the view worsened. (LLM, conf=0.88)

  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 sourceExperimental — accuracy not yet measured

In the paper

“c-spine immobilization consistently impairs the glottic view with DL”

What the sources say

• Supported

  The Results report that the modified Cormack–Lehane grade was always 3 or 4 at direct laryngoscopy in the 50 patients immobilised with a cervical collar. The Discussion likewise associates collar application with grade-3 or -4 views. The study used simulated immobilisation; none of the patients had a cervical spine injury. (LLM, conf=0.90)

  cites [43] Bathory, 2009, Evaluation of the GlideScope for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar, Anaesthesia 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
• Partly supported

  The paper's background says cervical spine immobilization may disrupt airway alignment and jeopardize glottic visualization during direct laryngoscopy. Its Results (Cormack–Lehane grade; page unavailable) also report poorer glottic views with Macintosh laryngoscopy than with alternative devices in immobilized patients. Neither passage establishes that immobilization consistently impairs the view compared with no immobilization, so “consistently” overstates the evidence. (LLM, conf=0.86)

  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 sourceExperimental — accuracy not yet measured

In the paper

“RSI is the most common approach for airway management in trauma.75,76”

What the sources say

• ?Could not verify

  The paper’s main section discusses RSI in emergency-department patients and its safety and definition, but does not say it is the most common airway-management approach in trauma. Searches for trauma and comparative frequency found no passage addressing that claim; page numbers were not available in our copy. (LLM, conf=0.70)

  cites [75] Dronen, 1999, Rapid-sequence intubation: a safe but ill-defined procedure, Acad Emerg Med sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [76] Mace, 2008, Challenges and advances in intubation: rapid sequence intubation, Emerg Med Clin North Am source

In the paper

“indirect hyperangulated video laryngoscopy (VL) consistently provides an improved glottic view”

What the sources say

• Partly supported

  The Results and Table 2 (page not available in our copy) show that GlideScope views were better than direct Macintosh views in all 50 patients studied. However, the study tested one device under simulated cervical-spine immobilisation; it does not establish that indirect hyperangulated VL consistently improves glottic views across devices and settings. (LLM, conf=0.86)

  cites [43] Bathory, 2009, Evaluation of the GlideScope for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar, Anaesthesia sourceExperimental — accuracy not yet measured
• ?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
• Partly supported

  The Results (Cormack–Lehane grade; page not provided) report significantly better glottic views than Macintosh laryngoscopy for each of five evaluated devices. The claim omits the study's restriction to adults with cervical spine immobilization and describes the devices collectively as indirect hyperangulated VL, a category the reported result does not establish for all five. (LLM, conf=0.85)

  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 sourceExperimental — accuracy not yet measured

In the paper

“A recent meta-analysis by Suppan and colleagues 45 reported more failed intubations for DL compared with several alternative intubating devices in patients with c-spine immobilization.”

What the sources say

• Partly supported

  The Results (‘Intubation failure at first attempt’; page not provided) report more first-attempt failures with Macintosh laryngoscopy than with alternative devices pooled. But among the five devices analysed individually, only Airtraq significantly reduced failures; the other four did not show a significant difference. The claim overstates the device-specific finding by implying that several alternatives each had fewer failures. (LLM, conf=0.88)

  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 sourceExperimental — accuracy not yet measured

In the paper

“With atelectasis, pulmonary contusion, and other lung pathologies, the FRC is diminished and the resultant shunt physiology renders preoxygenation with a high FiO 2 less effective in preventing desaturation.[106][107][108]”

What the sources say

• ?Not checked — no full text of the sourcecites [106] Mosier, 2017, Understanding preoxygenation and apneic oxygenation during intubation in the critically ill, Intensive Care Med source
• ?Not checked — no full text of the sourcecites [107] Nimmagadda, 2017, Preoxygenation: physiologic basis, benefits, and potential risks, Anesth Analg source
• Partly supported

  The ‘Functional residual capacity’ and ‘Physiological shunt and dead space’ sections say that lung disease can reduce FRC and that patients with both shunting and reduced FRC develop hypoxaemia sooner. The ‘Critical illness’ section reports a smaller benefit from preoxygenation in unstable critically ill patients. The paper does not specifically address atelectasis or pulmonary contusion, or establish that shunt physiology itself makes high-FiO₂ preoxygenation less effective in those conditions. (LLM, conf=0.84)

  cites [108] Sirian, 2009, Physiology of apnoea and the benefits of preoxygenation, Cont Educ Anaesth Crit Care Pain sourceExperimental — accuracy not yet measured

In the paper

“In North America, etomidate has been the most commonly used induction agent used for RSI.”

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
• Partly supported

  The Discussion (page unavailable) reports that etomidate was used in more than 90% of emergency-department RSIs recorded by a large multicenter registry, supporting its predominance in that setting. The passage does not establish that it was the most commonly used agent for RSI across all of North America or outside emergency departments. (LLM, conf=0.82)

  cites [100] Upchurch, 2017, Comparison of etomidate and ketamine for induction during rapid sequence intubation of adult trauma patients, Ann Emerg Med sourceExperimental — accuracy not yet measured

In the paper

“Hypoxemia during emergency department (ED) RSI is common, occurring in more than one-third of cases.24”

What the sources say

• Supported

  The Abstract reports oxygen desaturation in 59 of 166 ED rapid sequence intubation cases (35.5%), which is more than one-third. The Discussion likewise states that desaturation occurred in more than 1 in 3 cases in this series. (LLM, conf=0.94)

  cites [24] Bodily, 2015, Incidence and duration of continuously measured oxygen desaturation during emergency department intubation, Ann Emerg Med source

In the paper

“The combination of hypoxemia and hypotension is additive, with an adjusted odds of death double that of the increased mortality associated with either event alone.23,97,98”

What the sources say

• Supported

  The Main Results report adjusted odds ratios for death of 6.1 with both prehospital hypotension and hypoxia, versus 2.5 and 3.0 with either alone, in patients with major traumatic brain injury. They also state that the effects were additive on the log-odds scale. (LLM, conf=0.93)

  cites [23] Spaite, 2017, The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury, Ann Emerg Med source
• ?Could not verify

  The Results report adjusted mortality odds for out-of-hospital airway management in shock and TBI groups, not for hypoxemia and hypotension separately or together. A search of our copy for their combined effect found no comparison showing that the adjusted odds of death double relative to either event alone. Page numbers were not available in the indexed passages. (LLM, conf=0.76)

  cites [97] Wang, 2014, Association of out-of-hospital advanced airway management with outcomes after traumatic brain injury and hemorrhagic shock in the ROC hypertonic saline trial, Emerg Med J sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [98] Chou, 2015, Field intubation in civilian patients with hemorrhagic shock is associated with higher mortality, J Trauma Acute Care Surg source

In the paper

“Cognitive and team-based preparation is vital, as the decision to proceed with a FONA is often delayed until critical hypoxemia has occurred.111”

What the sources say

• Supported

  In “Failed oxygenation during attempted tracheal intubation: the emergency strategy” (page unavailable), the paper says clinicians commonly fail to recognize a cannot-intubate, cannot-oxygenate situation promptly, delaying cricothyrotomy and resulting in cerebral hypoxia or cardiac arrest. This supports the claim that the decision to proceed with a front-of-neck airway is often delayed until severe hypoxia has developed. (LLM, conf=0.90)

  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

“AO is facilitated by the pressure gradient between the oropharynx and the alveoli created by the differential uptake of oxygen and delivery of CO2 to and from the alveoli, resulting in the passive transfer of oxygen.104,107”

What the sources say

• Supported

  The “Physiological mechanism of apneic oxygenation” section explains that oxygen leaves the alveoli faster than carbon dioxide enters, creating negative alveolar pressure that draws gas from the pharynx into the alveoli. It specifies that this movement requires a patent upper airway; no page number is supplied in our copy. (LLM, conf=0.94)

  cites [104] Wong, 2017, The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review, Can J Anaesth source
• ?Not checked — no full text of the sourcecites [107] Nimmagadda, 2017, Preoxygenation: physiologic basis, benefits, and potential risks, Anesth Analg source

In the paper

“Although recent literature has focused on extending safe apnea time with passive high-flow nasal oxygenation (HFNO) with or without noninvasive ventilation, the most important determinant of time to desaturation remains preoxygenation status.104”

What the sources say

• Partly supported

  The practical guide in “Limitations of this review” recommends preoxygenation before intubation and checking that end-tidal oxygen reaches 85–90%. The review also reports that apneic oxygenation can prolong time to desaturation, but it does not establish that preoxygenation status is the most important determinant of that time. Page numbers are unavailable in our copy. (LLM, conf=0.76)

  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

“With a favorable hemodynamic profile and strong analgesic effect, ketamine is quickly becoming the preferred induction agent for trauma patients.100”

What the sources say

• Partly supported

  The Introduction (Background and Importance; page unavailable) describes ketamine’s favorable hemodynamic effects and its emergence as an alternative for trauma intubation. It does not discuss a strong analgesic effect or establish that ketamine is becoming the preferred agent generally; the Background says it remains unclear which agent should be preferred, and the Discussion reports no improvement in patient-centered outcomes over etomidate. (LLM, conf=0.88)

  cites [100] Upchurch, 2017, Comparison of etomidate and ketamine for induction during rapid sequence intubation of adult trauma patients, Ann Emerg Med sourceExperimental — accuracy not yet measured

In the paper

“Patients with a shock index (defined as heart rate divided by SBP) of greater than 0.8 are at particular risk of developing significant hypotension in the postintubation period.82,95,96”

What the sources say

• ?Not checked — no full text of the sourcecites [82] Heffner, 2013, Incidence and factors associated with cardiac arrest complicating emergency airway management, Resuscitation source
• ?Not checked — no full text of the sourcecites [95] Trivedi, 2015, Evaluation of preintubation shock index and modified shock index as predictors of postintubation hypotension and other short-term outcomes, J Crit Care source
• Partly supported

  The Background says shock index is a strong predictor of postintubation hemodynamic instability in the emergency department. It does not give a >0.8 threshold or specify significant postintubation hypotension; the threshold it discusses is ≥1 for an uncompensated shock state. The Conclusions concern poor outcomes in adult trauma patients with a reverse shock index <1, not postintubation hypotension. (LLM, conf=0.85)

  cites [96] Lai, 2016, Systolic blood pressure lower than heart rate upon arrival at and departure from the Emergency Department indicates a poor outcome for adult trauma patients, Int J Environ Res Public Health sourceExperimental — accuracy not yet measured

In the paper

“Owing to the association between using etomidate and adrenal suppression, many institutions have moved to alternative induction agents.1,100”

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
• Partly supported

  The Introduction (Importance) states that etomidate causes transient adrenal suppression. The Introduction (Goals of This Investigation) says the authors’ institution switched from etomidate to ketamine because of concerns about adrenal dysfunction, but the paper does not establish that many institutions made that switch. (LLM, conf=0.88)

  cites [100] Upchurch, 2017, Comparison of etomidate and ketamine for induction during rapid sequence intubation of adult trauma patients, Ann Emerg Med sourceExperimental — accuracy not yet measured

In the paper

“By continuously replenishing the FRC oxygen stores, apneic oxygenation using conventional or specialized nasal prongs to administer high-flow oxygen (10-70 LPM) may extend the safe apnea time after an RSI.103,104”

What the sources say

• ?Not checked — no full text of the sourcecites [103] Weingart, 2012, Preoxygenation and prevention of desaturation during emergency airway management, Ann Emerg Med source
• Supported

  The Physiological mechanism of apneic oxygenation section explains that supplemental oxygen moves from the pharynx into the alveoli during apnea and may prolong the safe apneic period for intubation; this supports the claim’s description of replenishing lung oxygen stores, although the paper does not use the term FRC there. The Transnasal humidified high-flow oxygen and clinical-settings sections describe nasal-prong delivery at flows including 10 and 70 L/min, and report reduced desaturation after apneic oxygenation was added to a rapid-sequence-intubation protocol. No page numbers are available in our copy. (LLM, conf=0.87)

  cites [104] Wong, 2017, The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review, Can J Anaesth source

In the paper

“even transient drops in blood pressure are associated with adverse outcomes in trauma patients.23,[92][93][94]”

What the sources say

• Partly supported

  The Introduction (Background and Significance) says that a single episode of hypotension doubles mortality, supporting the point about transient blood-pressure drops. The paper addresses patients with major traumatic brain injury, however, not trauma patients generally; no page number is provided in our copy. (LLM, conf=0.85)

  cites [23] Spaite, 2017, The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury, Ann Emerg Med sourceExperimental — accuracy not yet measured
• Partly supported

  The Results report higher unadjusted mortality among ED patients with postintubation hypotension, and Table 6 reports deaths among patients with transient hypotension. But the paper does not establish an adverse-outcome association specifically for transient drops in trauma patients; its discussion says the overall mortality association was not present after adjustment and identifies sustained hypotension as associated with increased mortality. (LLM, conf=0.85)

  cites [92] Green, 2012, Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability, CJEM sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [93] Green, 2015, Postintubation hypotension in intensive care unit patients: a multicenter cohort study, J Crit Care source
• ?Not checked — no full text of the sourcecites [94] Heffner, 2012, The frequency and significance of postintubation hypotension during emergency airway management, J Crit Care source

In the paper

“No specific oxygen saturation level should be used as a trigger to perform FONA, recognizing that a failed oxygenation situation is dynamic and characterized by a rapidly falling oxygen saturation despite maximal efforts to reoxygenate the patient.111”

What the sources say

• Supported

  The “Failed oxygenation during attempted tracheal intubation: the emergency strategy” section (page not provided) declines to recommend a specific oxygen-saturation trigger and describes rapidly declining saturation despite maximum attempts at oxygenation as an indication for cricothyrotomy. This supports both parts of the citing sentence. (LLM, conf=0.94)

  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

“RSI in underresuscitated patients may result in unintended poor outcomes, including critical hypoxemia and circulatory collapse.82,83”

What the sources say

• ?Not checked — no full text of the sourcecites [82] Heffner, 2013, Incidence and factors associated with cardiac arrest complicating emergency airway management, Resuscitation source
• Partly supported

  The Results report desaturation during intubation, and the Discussion addresses severe cardiovascular collapse after intubation. The Discussion also describes possible hypovolemia before induction, but it does not establish that underresuscitation specifically increases the risk of either outcome during rapid sequence intubation. The paper gives no page numbers for these passages. (LLM, conf=0.82)

  cites [83] Perbet, 2015, Incidence of and risk factors for severe cardiovascular collapse after endotracheal intubation in the ICU: a multicenter observational study, Crit Care sourceExperimental — accuracy not yet measured

In the paper

“The incidence of post intubation hypotension is high in patients requiring emergency airway management (23%-46%)”

What the sources say

• ?Could not verify

  The Introduction describes hypotension as common early in the care of traumatic brain injury, but gives no post-intubation incidence. The Limitations section says the study did not analyze the timing of low blood-pressure readings or evaluate interventions. Searches for post-intubation hypotension and emergency airway management found no support for the claimed 23%–46% range. (LLM, conf=0.76)

  cites [23] Spaite, 2017, The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury, Ann Emerg Med sourceExperimental — accuracy not yet measured
• Partly supported

  The Results (Abstract) report postintubation hemodynamic instability in 44% of 218 emergency-department patients, supporting the claim that it is common. The paper does not report a 23%–46% incidence range; its Discussion gives 0%–38.6% for previous studies. (LLM, conf=0.88)

  cites [92] Green, 2012, Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability, CJEM sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [93] Green, 2015, Postintubation hypotension in intensive care unit patients: a multicenter cohort study, J Crit Care source
• ?Not checked — no full text of the sourcecites [94] Heffner, 2012, The frequency and significance of postintubation hypotension during emergency airway management, J Crit Care source

In the paper

“A study comparing standard full-dose ketamine with etomidate in trauma patients showed no survival benefit of one agent over the other.100”

What the sources say

• Supported

  The Limitations section states that nearly all patients received full induction doses of ketamine or etomidate. The Discussion reports that ketamine was not associated with improved hospital mortality compared with etomidate in adult trauma patients. Page numbers were not provided in the copy. (LLM, conf=0.94)

  cites [100] Upchurch, 2017, Comparison of etomidate and ketamine for induction during rapid sequence intubation of adult trauma patients, Ann Emerg Med source

In the paper

“In the hospital setting, delayed intubation is associated with increased mortality in noncritically injured trauma patients.11”

What the sources say

• ?Not checked — no full text of the sourcecites [11] Miraflor, 2011, Timing is everything: delayed intubation is associated with increased mortality in initially stable trauma patients, J Surg Res source

In the paper

“No conclusion could be reached regarding prehospital intubation for patients with traumatic brain injury, with or without RSI [rapid sequence 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

“More recent data suggest that when performed by skilled emergency medical services (EMS) providers, advanced airway management is associated with a significant decrease in mortality.9,10”

What the sources say

• ?Not checked — no full text of the sourcecites [9] Meizoso, 2015, Decreased mortality after prehospital interventions in severely injured trauma patients, J Trauma Acute Care Surg source
• ?Not checked — no full text of the sourcecites [10] Lockey, 2014, Advanced airway management is necessary in prehospital trauma patients, Br J Anaesth source

In the paper

“IBA from head trauma results in a primary respiratory arrest without significant parenchymal injury to the brain.27”

What the sources say

• ?Not checked — no full text of the sourcecites [27] Wilson, 2016, Impact brain apnoea–a forgotten cause of cardiovascular collapse in trauma, Resuscitation source

In the paper

“This observation in part explains the comparatively poor survival rates for trauma patients who are intubated in the prehospital setting.”

In the paper

“there is evidence to support the argument that advanced airway management can be performed in the prehospital setting without delaying transfer to a trauma center.8,9”

What the sources say

• ?Not checked — no full text of the sourcecites [8] Eckstein, 2000, Effect of prehospital advanced life support on outcomes of major trauma patients, J Trauma source
• ?Not checked — no full text of the sourcecites [9] Meizoso, 2015, Decreased mortality after prehospital interventions in severely injured trauma patients, J Trauma Acute Care Surg source

In the paper

“In one series, 30% to 40% of patients are assessed as having partial or complete airway obstruction on EMS arrival.10”

What the sources say

• ?Not checked — no full text of the sourcecites [10] Lockey, 2014, Advanced airway management is necessary in prehospital trauma patients, Br J Anaesth source

In the paper

“Head-injured patients with a decreased level of consciousness frequently receive prehospital advanced airway management.10”

What the sources say

• ?Not checked — no full text of the sourcecites [10] Lockey, 2014, Advanced airway management is necessary in prehospital trauma patients, Br J Anaesth source

In the paper

“With appropriate treatment, prognosis is generally good.”

In the paper

“The presence of airway contamination with either blood or vomitus has been shown to decrease the rate of first-attempt intubation success, regardless of the device used.54”

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

“Primary airway trauma is relatively uncommon in the civilian urban setting, with a reported incidence of less than 1% (0.4% for blunt and 4.5% for penetrating injuries).67”

What the sources say

• ?Not checked — no full text of the sourcecites [67] Kummer, 2007, A review of traumatic airway injuries: potential implications for airway assessment and management, Injury source

In the paper

“there was no significant difference in complications associated with acute airway management in patients intubated for discretionary indications, as compared with those intubated for higher acuity reasons.59”

What the sources say

• ?Not checked — no full text of the sourcecites [59] Sise, 2009, Early intubation in the management of trauma patients: indications and outcomes in 1,000 consecutive patients, J Trauma Inj Infect Crit Care source

In the paper

“The combination of altered levels of consciousness, diminished protective airway reflexes, delayed gastric emptying, and full stomachs place trauma patients at high risk of vomiting and aspiration during airway management.”

In the paper

“Concerns that ketamine may raise intracranial pressure and worsen outcomes in TBI is not supported by evidence.61,62”

What the sources say

• ?Not checked — no full text of the sourcecites [61] Cohen, 2015, The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review, Ann Emerg Med source
• ?Not checked — no full text of the sourcecites [62] Zeiler, 2014, The ketamine effect on ICP in traumatic brain injury, Neurocrit Care source

In the paper

“Massive subcutaneous emphysema can distort airway anatomy, further complicating management.”

In the paper

“the primary benefit of a rigid cervical collar is to serve as a reminder about the potential existence of an unstable c-spine injury.”

What the sources say

• ?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
• ?Not checked — no full text of the sourcecites [53] Aprahamian, 1984, Experimental cervical spine injury model: evaluation of airway management and splinting techniques, Ann Emerg Med source

In the paper

“If given slowly, a dissociative intravenous dose of 1 to 1.5 mg/kg poses little risk of respiratory depression.”

In the paper

“Sise and colleagues 59 reviewed 1078 trauma patients intubated for discretionary indications (eg, agitation, alcohol intoxication) and found that 62% of patients, once investigated, had a significant head injury.”

What the sources say

• ?Not checked — no full text of the sourcecites [59] Sise, 2009, Early intubation in the management of trauma patients: indications and outcomes in 1,000 consecutive patients, J Trauma Inj Infect Crit Care source

In the paper

“the chances that movement occurring during controlled airway management will result in cord injury is extremely low.”

In the paper

“Blood and vomit in the airway can lead to early and late complications related to difficult airway management and/or aspiration.”

In the paper

“PPV in the setting of airway disruption can create or worsen pneumothorax, pneumomediastinum, or subcutaneous emphysema.”

In the paper

“Patients rendered apneic as part of an RSI without adequate preoxygenation are at high risk of desaturation.”

In the paper

“it is unclear whether or not this results in any important differences in clinical outcomes.34”

What the sources say

• ?Not checked — no full text of the sourcecites [34] Kill, 2013, Videolaryngoscopy with glidescope reduces cervical spine movement in patients with unsecured cervical spine, J Emerg Med source

In the paper

“Dosage recommendations for RSI induction agents are largely based on patients without hemodynamic instability.”

In the paper

“Patients with preintubation oxygen saturations of less than 95% are at risk of abrupt desaturation within 90 seconds of the onset of apnea.103”

What the sources say

• ?Not checked — no full text of the sourcecites [103] Weingart, 2012, Preoxygenation and prevention of desaturation during emergency airway management, Ann Emerg Med source

In the paper

“By the time peripheral oxygen saturation begins to fall, cerebral hypoxemia has already occurred, a phenomenon known as “pulse-ox lag.” 103”

What the sources say

• ?Not checked — no full text of the sourcecites [103] Weingart, 2012, Preoxygenation and prevention of desaturation during emergency airway management, Ann Emerg Med source

In the paper

“Success for high-acuity, low-opportunity events like this requires frequent, deliberate practice using simulation.118”

What the sources say

• ?Not checked — no full text of the sourcecites [118] Petrosoniak, 2013, Beyond crisis resource management, Curr Opin Anaesthesiol source

In the paper

“The transition to PPV, either through a closed system BVM with an attached with positive end-expiratory pressure (PEEP) valve or with mechanical ventilation once intubated, abruptly increases the intrathoracic pressure, further shifting this gradient.”

In the paper

“it is probably true to suggest that the dose of the drug is more important than the choice of drug.”

In the paper

“In rare situations, FONA may be the first and only invasive airway technique attempted, even in the setting of normal oxygen saturation; for example, massive facial trauma disrupting all recognizable airway landmarks.”

In the paper

“All commonly used induction agents will cause hypotension, particularly when a full dose is administered to a volume-constricted patient.”

In the paper

“Delivery of close to 100% oxygen for approximately 4 minutes is required to denitrogenate normal lungs and may be most easily accomplished with high-flow, “flush-rate” (40 LPM) oxygen using a conventional non-rebreather mask.105”

What the sources say

• ?Not checked — no full text of the sourcecites [105] Driver, 2017, Flush rate oxygen for emergency airway preoxygenation, Ann Emerg Med source