Airway Management

I. General Considerations

Ensuring adequate oxygenation, ventilation, and protection from aspiration are the cornerstones of airway management and the first priorities when treating the injured patient. Trauma patients have unique physiologic and anatomic challenges that significantly magnify the complexity of airway management. This chapter provides an overview of the basic principles of adult trauma airway management.

A

Airway management consists of both basic (e.g., bag-valve-mask ventilation) and advanced (e.g., endotracheal intubation) airway interventions. Basic airway interventions are more important than advanced interventions.

B

Airway management must follow a clear, deliberate, systematic plan, including the anticipation for and use of alternative/rescue interventions.

C

Assume all trauma patients have a cervical spine injury, head injury, and hypovolemia. All airway management interventions must be performed with cervical immobilization.

D

Most trauma patients require the use of pharmacologic agents to facilitate endotracheal intubation (ETI). Only properly trained and experienced personnel should use neuromuscular blocking agents (paralytics) to facilitate endotracheal intubation.

E

Airway procedures should be performed by the most experienced person available. No other procedures should occur during intubation or other airway management efforts.

F

Airway management of the trauma patient is a team effort. Communication between the airway manager and the trauma team leader is essential. The ultimate decision to perform endotracheal intubation or other advanced airway procedures should rest with the trauma team leader.

II. Anatomy

The key structures that are visualized during endotracheal intubation include the epiglottis, vallecula, vocal cords, and aryepiglottic folds (Fig. 11-1). A cross-sectional view of airway structures during orotracheal intubation is depicted in Fig. 11-2. Anatomical landmarks for cricothyroidotomy are depicted in Fig. 11-3.

III. Basic Airway Interventions

All patients should receive basic airway interventions. Basic airway interventions are more important than advanced interventions. All interventions must be performed with inline cervical immobilization. Two or three operators may be needed to maintain basic airway control.

A

In alert and spontaneously breathing patients, apply a non-rebreather mask with 100% oxygen (10–15 L/min).

B

In semi-conscious or obtunded patients:

• If possible, insert an oropharyngeal or nasopharyngeal airway. (Use extreme caution when inserting a nasopharyngeal airway in a patient with a suspected midface or basilar skull fracture.)
• Use the jaw-thrust maneuver to open the airway. Do not use head-tilt/chin-lift on trauma patients because of the risk of cervical spine injury.
• If the patient is spontaneously breathing, use a non-rebreather mask with 100% oxygen.
  
  

  Laryngoscopy technique for orotracheal intubation of the trauma patient. Note that the cervical spine must be maintained inline—flexion and extension of the head are contraindicated.

  Cricothyroidotomy technique. (From Trunkey DD, Guernsey JM. Cervicothoracic trauma. In: Blaisdell FM, Trunkey DD, eds. Surgical Procedures in Trauma Management. New York, NY: Thieme Inc; 1986:303, with permission.)

• If the patient is not breathing spontaneously, if respiratory effort is inadequate, or if oxygen saturation cannot be maintained >90%, use bag-valve-mask (BVM) ventilation.
  • BVM of the trauma patient requires at least two operators: one to perform a jaw thrust and seal the mask, and one to squeeze the bag.
  • Consider applying cricoid pressure (or Sellick's maneuver) to lessen the risk of gastric distention during BVM ventilation (Chapter 6).
• Use large-bore suction to keep the airway clear of blood and secretions.

IV. Advanced Airway Interventions-Endotracheal Intubation (Oro-Tracheal)

After basic airway interventions have been instituted, advanced airway management may be considered. Endotracheal intubation (ETI) is the most common method of advanced airway management. ETI is believed to protect the airway from aspiration and to facilitate controlled ventilation. Orotracheal intubation is the most common and preferred method of ETI in trauma patients. Alternate/rescue and surgical airway techniques are described in Sections VII and VIII.

A. General considerations

• ETI of the trauma patient is difficult and should be attempted by the most qualified operator available. There is high potential for ETI failure in trauma patients, and alternative strategies should be anticipated. Alternate/rescue airway management plans must always be formulated at the earliest stages of the patient encounter.
• ETI must be performed with manual inline cervical immobilization. Flexion and extension of the head should never be used to facilitate ETI in trauma patients. Likewise, the sniffing position is contraindicated in trauma patients.
• ETI requires the coordination of multiple tasks. At least three rescuers are usually needed to accomplish ETI on a trauma patient.
• Most trauma patients will require pharmacologic agents (deep sedation or rapid-sequence intubation) to facilitate ETI (Section VI).
  P.84
  
  
• In the event of serious facial injury distorting oral or airway structures, it may be necessary to proceed directly to another advanced intervention (for example, a surgical airway).

B. Indications for ETI

These are general indications only and do not encompass all possible clinical scenarios.

• Apnea or near apnea
• Airway obstruction or respiratory compromise unrelieved with basic interventions
• Depressed consciousness from head trauma or any other cause
• Combativeness from head trauma or any other cause
• Respiratory distress (severe tachypnea, increased work of breathing, cyanosis, hypoxemia, etc.)
• Facial or neck injury with potential airway compromise
• Chest wall injury or dysfunction with respiratory compromise
• Persistent or refractory hypotension
• Need for diagnostic or therapeutic procedures in patients at risk for deterioration (e.g., computed tomography, etc.)

C. Technique for orotracheal intubation

• Prepare and test all intubation equipment prior to patient arrival.
  • For a typical 70-kilogram (kg) adult, use a curved (Macintosh no. 3 or 4) or straight (Miller no. 3) blade. Test the light.
  • Use a no. 7.0 to 7.5 endotracheal tube on average-sized adult females and no. 7.5 to 8.0 tube on males. Children may require smaller uncuffed tubes (Chapter 46). Insert a stylet, then test the cuff.
  • Prepare and test the large-bore suction.
  • Prepare the pharmacologic agents (Section VI).
  • Prepare an alternate/rescue airway plan (Sections VII and VIII).
• Oral intubation requires at least three rescuers (Fig. 11-4).
  • Rescuer 1: The most experienced provider; performs laryngoscopy and placement of endotracheal tube.
  • Rescuer 2: Performs manual cervical immobilization and applies cricoid pressure.
  • Rescuer 3: Provides pre-oxygenation, assists rescuer 1 (handing equipment to intubator, etc.), and performs post-intubation ventilation.
• Position the patient supine on the stretcher. Rescuer 2 maintains manual cervical immobilization. We recommend standing to the patient's side and facing the intubator—this gives the intubator more room while making it easier to use both hands to support the neck and jaw.
• Rescuer 3 should pre-oxygenate the patient using a non-rebreather mask or BVM ventilation (Section III). Use 100% O₂ (10–15 L/min); if possible, optimize oxygenation and ventilation (spontaneous breathing or assisted) for 3 to 4 minutes; this technique maximizes pulmonary oxygen reserves. If possible, pre-oxygenate to SaO₂ = 100%.
• Ensure a functioning intravenous catheter for drug administration.
• When directed, rescuer 2 unfastens the cervical collar while maintaining cervical stabilization and applying cricoid pressure (Sellick's maneuver; this technique minimizes gastric regurgitation and aspiration during intubation).
• Give sedative and/or paralytic drugs (Section V).
• Perform the laryngoscopy (insert the laryngoscope blade and expose the vocal cords) (Fig. 11.2).
  • With a curved (Macintosh) blade, insert the blade in the right side of the patient's mouth and sweep the tongue to the left. Insert the tip of the blade in the vallecula (the space between the tongue and the epiglottis)—pressure placed on the hyo-epiglottic ligament will lift the epiglottis and expose the vocal cords. With a straight (Miller) blade, similarly insert the blade in the right side of the patient's mouth, but directly lift the epiglottis with the tip of the blade.
  • Maintain in-line stabilization of the cervical spine. Head-tilt/extension, neck flexion, and “sniffing position” are contraindicated in trauma patients. Increased cricoid pressure (Sellick's maneuver) may be used to improve laryngoscopic view.
  • Limit the duration of each laryngoscopy attempt to 30 seconds. Stop earlier if SaO₂ drops <90%.
  • No other procedures should be performed while the laryngoscopy is being attempted.
• Insert the endotracheal tube.
  • Place the tip of the tube just past the vocal cords. In a typical 70-kg patient, the tube should be placed to a depth of 21 to 22 centimeters (cm) for adult women and 22 to 23 cm for adult men (denoted by depth markers on the tube) at the patient's teeth.
  • Hold the tube manually—do not release the tube until placement is confirmed and the assistant is prepared to secure the tube. Similarly, do not release cricoid pressure until proper tube position is confirmed.
  • Inflate the cuff with 10 mL of air, remove the stylet, and attach the bag-valve device.
  • If tube placement fails, stop and reventilate with BVM. Re-attempt ETI. If unsuccessful after three total ETI attempts, go directly to alternate/rescue airway techniques. Proceed to an alternate/rescue airway sooner if clear barriers are encountered during initial ETI attempts.
• Confirm correct tube placement. This step is essential—unrecognized tube misplacement (esophageal or hypopharyngeal) can be rapidly fatal. No singular method of monitoring or tube confirmation is infallible. Use a combination of focused examination and adjunct devices to confirm tube placement.
  • Directed physical examination. Auscultate the epigastrium—it should be quiet. Auscultate the apices and bases of both lungs; breath sounds should be present and equal, and the chest should rise normally. Each of these findings can be misleading or difficult to appreciate, particularly under resuscitation conditions.
    P.86
    
    
  • End-tidal carbon dioxide detection. If the tube is correctly placed, carbon dioxide will be present in the endotracheal tube. This is likely the most accurate method for confirming tube placement. Note that these devices may be inaccurate in cardiac arrest or severe shock.
    • The presence of expired CO₂ suggests correct tracheal placement. The absence of expired CO₂ means either incorrect placement (i.e., esophageal) or poor perfusion.
    • Colorimetric devices are widely used. These devices turn from purple to yellow in the presence of carbon dioxide. They are inaccurate when wet or exposed to air for extended periods.
    • Digital capnometers or waveform capnographers are the current standard. They are preferable because they are not susceptible to moisture and provide continuous information.
  • Esophageal detector device (bulb detector or Toomey syringe)—may be used when CO₂ measuring devices are not available or as an adjunct for additional tube placement information.
    • If using a bulb detector, squeeze the bulb and attach it to the endotracheal tube. Rapid and complete reinflation of the bulb (within 3–5 seconds) suggests correct tracheal placement.
    • If using a Toomey syringe, attach it to the endotracheal tube and aspirate quickly. Unimpeded aspiration suggests correct tracheal placement.
  • If any uncertainty exists, laryngoscopy (direct revisualization) may be performed to visually confirm the tube passing through the vocal cords. (Caution: this technique may be inaccurate, especially when airway structures are distorted from injury.)
  • Methods that should not be relied on for confirming tube placement: tube fogging (gastric contents can fog the tube), chest x-ray (identifies vertical position only, not intratracheal placement), and oxygen saturation (desat-uration may not occur for several minutes after tube misplacement).
• Secure the tube using adhesive tape, umbilical tape, or a commercial tube holder.
• Release cricoid pressure and replace the cervical immobilization collar.
• Place a nasogastric tube (oral if facial trauma is present) unless contraindicated.

D. Features suggesting difficult ETI

While the difficulty of an ETI is often relative to the experience of the operator, the following features are generally associated with ETI difficulty. The presence of multiple factors should lower the threshold for proceeding to alternate/rescue airway interventions. Note that this is not a comprehensive list of potential factors. In general, all trauma patients should be considered potentially difficult intubations.

• Anatomic features associated with ETI difficulty
  • Obesity
  • Short neck
  • Small mouth
  • Overbite or underbite
  • Limited neck mobility
  • Airway trauma or injury
• Clinical scenarios associated with ETI difficulty
  • Head trauma or other major injury
  • Hypotension
  • Intoxicated or combative patient

E. Managing failed ETI efforts

ETI of the trauma patient is difficult. A common mistake is failing to recognize futile intubation attempts and failing to move immediately to alternate/rescue airway interventions.

• Assume all attempts at intubation will fail. Establish a clear alternate/ rescue airway plan prior to the first ETI attempt.
• Reassess, oxygenate, and ventilate prior to each successive attempt.
• Change the ETI equipment, technique, or operator with each intubation effort—avoid repeating the same unsuccessful approach.
  P.87
  
  
• Perform no more than three total laryngoscopy attempts (regardless of the number of operators). If unsuccessful after three attempts, go directly to an alternate/rescue airway plan.

V. Pharmacologic Assistance During Intubation

A. General considerations

• While deeply comatose or cardiac arrest patients can be intubated without drugs, most trauma patients are awake, combative, or unrelaxed and must receive sedative and neuromuscular blocking agents to facilitate safe and rapid ETI. A secondary purpose of pharmacologic assistance is to minimize hemodynamic response (e.g., blood pressure and intracranial pressure) to ETI, which can be stressful on a patient who is already in physiologic compromise from injury. The decision to use pharmacologic agents should be made on a case-by-case basis.
• When choosing a drug regimen for the trauma patient, it is best to assume that both hypovolemia and traumatic brain injury exist. Although these conditions are often not present, this approach allows for a greater margin of safety because either condition can be difficult to exclude in the first minutes after patient arrival. Short-acting agents should be used to facilitate rapid recovery if ETI efforts fail.
• The use of neuromuscular blocking agents (NMB) (rapid-sequence intubation, or RSI) is a helpful advanced technique but contains potential risks. A pharmacologically paralyzed patient has no airway tone or respiratory effort; if ETI cannot be readily accomplished, this condition can rapidly lead to death. NMB agents should be used only by the most advanced and properly trained personnel.

B. Preferred regimen—etomidate + succinylcholine

The combination of short-acting sedative/inductive and neuromuscular blocking agents is preferred for injured patients. This will optimize intubation conditions while allowing for rapid recovery if ETI failure occurs. Based on this consideration, while there are many potential drug regimens, we recommend the drug combination etomidate + succinylcholine. Give both agents consecutively and in rapid sequence (IV over 3–5 seconds for each drug).

• Etomidate (0.2–0.3 mg/kg IV; 15–20 mg in a 70-kg adult) facilitates deep sedation and has minimal side effects at these doses. Onset of action is 30 to 60 seconds, and duration is <10 minutes. Hypotension can occur with etomidate, particularly if severe hypovolemia is present, but is usually less frequent and profound than other agents. Etomidate is believed to be cerebroprotective.
  • Ketamine (1–2 mg/kg IV; 70–140 mg in a 70-kg adult), a dissociative agent, is an alternative agent. Onset of action is 30 to 60 seconds, and duration of action is 5 minutes. Because it can raise intracranial pressure in head-injured patients, some authors discourage the use of ketamine in the presence of a head injury. Emergence reactions can occur with ketamine, but this side effect is of limited concern in the context of trauma resuscitation.
  • Fentanyl (2–5 micrograms per kilogram [µg/kg] IV; 150–350 µg in a 70-kg adult), an opioid, is not an induction agent but may be used as an alternate for this role. Onset of action is 1 to 2 minutes, duration of action is 30 to 40 minutes. Fentanyl does not cause as much histamine release as other opioids and therefore is less likely to cause hypotension. Fentanyl can cause chest wall rigidity, but this effect is rare and has uncertain clinical significance in the setting of trauma resuscitation. Note that fentanyl provides no amnestic effect.
  • Barbiturates can also be used for induction of isolated head injured patients; for example, thiopental (3–5 mg/kg IV; 210–350 mg in a 70-kg adult) or methohexital (1–3 mg/kg IV; 70–210 mg in a 70-kg adult). These agents have rapid onset (<1 minute) and short duration (thiopental, 5–10 minutes; methohexital, 4–6 minutes). We urge caution with this class of

    P.88

    
    agents due to their hypotensive effects and do not use them in our trauma resuscitation area.
• Succinylcholine (1–2 mg/kg IV; 70–140 mg in a 70-kg adult) is the preferred neuromuscular blocking agent for trauma airway management because of its rapid onset (1 minute) and short duration (5–7 minutes). Succinylcholine is a depolarizing paralytic; it causes transient muscle fasciculations prior to onset of paralysis. An important side effect of succinylcholine is hyperkalemia, which may cause cardiac arrest. While usually subclinical, this effect may be significant in renal failure patients, patients with burns >24 to 48 hours old, and patients with >1 week of paresis or motor dysfunction (e.g., CVA, spinal cord injury, etc.). Other relative contraindications to succinylcholine include globe (eye) injury and impending cerebral herniation.
  • A variety of nondepolarizing neuromuscular blocking agents may be used where there are contraindications to succinylcholine. Note that these agents all have slower onset and longer duration of action. Two good choices are vecuronium (0.08–0.10 mg/kg IV; 5–7 mg in a 70-kg adult; onset 2–3 minutes, duration 30–35 minutes) and rocuronium (0.6–1.2 mg/kg IV; 45–85 mg in a 70-kg adult; onset 1.0–1.5 minutes, duration >30 minutes).

C.

Pretreatment with other drug agents is often listed in RSI protocols but has unproven value.

• Intravenous lidocaine may blunt physiologic and intracranial response to ETI, but the benefit of this technique in trauma patients has not been demonstrated.
• Pretreatment with a nondepolarizing neuromuscular blocking agent may prevent succinylcholine fasciculations but offers little practical benefit.
• Atropine can help offset paralytic agent-associated bradycardia in pediatric patients (Chapter 46).

D. Postintubation paralysis and sedation

• Maintenance of paralysis may be required after intubation and may be accomplished by any conventional nondepolarizing agent. An initial dose of vecuronium (0.08–0.10 mg/kg IV; 5–7 mg in a 70-kg adult) will provide 30 to 35 minutes of paralysis. Repeating lower doses (0.01–0.02 mg/kg IV; 0.7–1.4 mg in a 70-kg adult) will provide an additional 12 to 15 minutes of paralysis. (Caution: The effects of neuromuscular blocking agents are often cumulative, and repetitive dosages may cause prolonged paralysis.)
• Provide concurrent sedation with a benzodiazepine such as lorazepam (0.025–0.05 mg/kg IV; 2–4 mg in a 70-kg adult) or diazepam (5–10 mg IV). Propofol (5–50 µg/kg/min constant infusion, adjusted as needed) may also be used.

E. Discouraged techniques

• Except for patients that are comatose, obtunded, or in cardiac arrest, we discourage intubation of trauma patients without drugs. Not only is this cruel, but it is technically difficult, is less likely to result in successful intubation, and may be hemodynamically stressful on a patient who is already in tenuous condition. We discourage the sole use of topical anesthetics (e.g., lidocaine, tetra-caine, cetacaine) for the same reasons.
• We discourage “light sedation” only to facilitate ETI; for example, benzodi-azepines (midazolam, lorazepam, or diazepam) or opioids (morphine, meperi-dine, hydromorphone). At conventional sedative doses, these agents have slow and unpredictable onset and often do not provide adequate intubating conditions. At higher deep sedation dosages, these agents can cause significant hypotension.
• It is important to recognize the patient who represents an anticipated difficult airway and high likelihood of failure of intubation with RSI. Examples are spontaneously breathing patients with major facial injuries and/or patients with significant bleeding into the airway. RSI in this setting, making a spontaneously breathing patient an apneic patient, converts a difficult situation to a catastrophe. In these situations, neuromuscular

  P.89

  
  blocking agents are contraindicated (e.g., anticipated very difficult intubation, or the absence of personnel experienced with RSI), and we recommend the cautious use of deep sedation (anesthesia induction level) using etomidate (0.15–0.3 mg/kg IV; 10–20 mg in a 70-kg adult). Intubation must be by the team member with the most experience with difficult airways. The patient must be prepped and instrument trays open for immediate surgical airway if the attempt at awake (with sedation) fails. We discourage the routine use of this technique in trauma patients. However, patients who present with such tenuous airways must be recognized and managed appropriately.

VI. Alternatives to Orotracheal Intubation (Alternate/Rescue Airways)

As previously described, orotracheal intubation is the preferred method for ETI of trauma patients. In the event of failed ETI efforts, alternate or rescue airway techniques may be needed. Surgical airways are also considered forms of alternate/ rescue airways and are described in Section VIII.

A.

Combitube and laryngeal mask airway (King Airway and LMA) are alternatives to ETI. These devices are relatively easy to insert and are believed to ventilate almost as well as an endotracheal tube. (These alternatives are discussed in detail in Chapter 8.) Both devices may provide an adequate “bridge” airway until the execution of alternate ETI techniques or placement of a surgical airway.

B.

Nasotracheal (nasal) intubation is usually performed in a “blind” fashion in patients who are spontaneously breathing. Although possible in many trauma patients, nasotracheal intubation is technically more difficult than orotracheal intubation, can cause significant airway trauma, and offers little advantage over oral intubation. Nasotracheal intubation is contraindicated in apneic patients or those with midface, nasal, or basilar skull fractures. A nasotracheal tube may cause significant sinusitis after 48 hours. Nasotracheal intubation requires the use of smaller diameter endotracheal tubes which may complicate ventilator management. Conversion of a nasotracheal to an orotracheal tube should be considered after the patient is stabilized; this may require specialized assistance from an anesthesiologist.

C. Other ETI techniques

There are a variety of alternate approaches to ETI; for example, tactile (digital) ETI, and lighted-stylet (transillumination) ETI. These approaches require specialized equipment or skill and may not be practical in the injured patient. Intubation over a flexible bronchoscope (fiberoptic intubation) requires special equipment and skill and is best left to specially trained operators (anesthesiologists who are facile with this technique). This technique is rarely appropriate in the trauma resuscitation area.

VII. Surgical Airways

Surgical airways are required when basic interventions and ETI efforts are not likely to succeed or have failed. The equipment for these techniques is specialized and should be readily available in the resuscitation suite. Landmarks for these techniques are depicted in Fig. 11-3.

A. Percutaneous translaryngeal catheter insufflation (“needle cric” or “jet ventilation”)

• Technique
  • Identify the cricothyroid membrane between the shield-shaped thyroid cartilage and the interiorly located, ring-shaped cricoid cartilage.
  • Insert a large-bore over-the-needle catheter (12–14 gauge, preferably one with side holes specially designed for this procedure) with an attached syringe. Direct the needle caudad, penetrating the skin and cricothyroid membrane until air is aspirated.
  • Thread the catheter into the airway and reaspirate to confirm intratracheal placement (evidenced by free gas withdrawal or “bubbles” if fluid is in the syringe).
  • Attach a special jet insufflating device to the catheter. This device delivers high-flow oxygen at approximately 40 to 50 pounds per square inch (psi) (1 psi = 70 cm H₂O). This device can be a simple manually triggered one-way

    P.90

    
    valve or a more elaborate ventilator with multiple control settings. The hardware needed for jet insufflation is complex and must be identified and ready for use before the anticipated procedure, not improvised.
• The trachea is used as a passive port for exhalation. Thus, the only absolute contraindication to jet ventilation is complete airway obstruction. Using the special jet ventilation device, tidal volumes of 700 to 1,000 mL can be achieved.
• Contrary to popular misconceptions, correct jet ventilation can be used for unlimited periods of time, if used with the proper high-pressure source (40–50 psi) at an inspiration:expiration rate of 1:3 seconds.
• Complications of jet ventilation include barotrauma, local hemorrhage, hypotension from overventilation and decreased venous return, inadvertent placement with resulting subcutaneous or mediastinal emphysema, hypoxia, hypercarbia, and dysrhythmias from prolonged attempts.
• A transtracheal catheter can be easily converted to a conventional cricothy-roidotomy. We recommend leaving the catheter in place and using it as a guide for identifying the cricoid membrane. A Seldinger-type guidewire can also be passed through the catheter to provide similar guidance.

B.

Cricothyroidotomy (“open cric”) is preferred to jet insufflation because of the simpler equipment, and the ability to provide optimal protection from aspiration and to place a large-bore airway for suctioning. Most clinicians are more familiar with this technique.

• Technique (Fig. 11-3)
  • Palpate the thyroid cartilage—identify the depressed cricothyroid membrane immediately caudad.
  • Make a 3-cm midline, longitudinal incision over the membrane. In a thin neck with clear landmarks, it is acceptable to perform a transverse skin incision.
  • Spread the skin with fingers or retractors and identify key landmarks by palpation (thyroid cartilage, cricothyroid membrane). This procedure is performed by palpation, not visualization.
  • Make a transverse incision (1.5–2.0 cm) through the cricoid membrane. The procedure is essentially performed using tactile input; if the membrane cannot be seen, incise where the soft membrane is palpated. Do not fracture the cricoid cartilage during the procedure. Gain access through transverse spreading, not vertical.
  • Insert a no. 5 or 6 Shiley tracheostomy tube or a no. 5.5 or 6 endotracheal tube and inflate the cuff.
  • Attach a bag-valve device and confirm tube placement.
• Complications include hemorrhage (avoid by limiting the size of incision and controlling bleeding with local pressure), misplacement, hypoxia secondary to prolonged procedure time, esophageal perforation, laryngeal fracture, and subcutaneous emphysema. Stenosis is often a problem if left in place for extended periods because of the narrow and contained diameter of the cricoid area; a cricothryoidotomy should be converted to a tracheostomy after the patient is stabilized.
• Relative contraindications to cricothyroidotomy include laryngeal trauma or pediatric patients (age <10 to 12 years). Only needle techniques (jet ventilation) should be used on pediatric patients because the cricoid membrane is delicate and can be easily transected.
• Percutaneous dilator-based cricothyroidotomy kits are available. These kits use a Seldinger guidewire technique with a series of dilators. These kits may be easier to insert by less experienced operators. However, familiarity with any technique is essential prior to the need to urgently attempt it.

C.

Tracheostomy is generally reserved for nonemergent situations. A possible exception is the presence of laryngeal fracture or where the cricoid membrane integrity is compromised.

P.91

Axioms

• Basic airway interventions (e.g., bag-valve-mask ventilation) are more important than advanced interventions (e.g., endotracheal intubation).
• Airway management must follow a clear, deliberate, systematic plan, including the anticipation for and use of alternative/rescue interventions.
• Assume all trauma patients have a cervical spine injury, head injury, and hypovolemia. All airway management interventions must be performed with cervical immobilization.
• Most trauma patients require the use of pharmacologic agents to facilitate endotracheal intubation. Only properly trained and experienced personnel should use neuromuscular blocking agents (paralytics) to facilitate endotracheal intubation.
• Airway procedures should be performed by the most experienced person available. No other procedures should occur during intubation or other airway management efforts.
• Airway management of the trauma patient is a team effort. Communication between the airway manager and the trauma team leader is essential. The ultimate decision to perform endotracheal intubation or other advanced airway procedures should rest with the trauma team leader.