Airway management seems to be at the forefront of “hot EMS topics” these days. I’ve had the pleasure of discussing this topic amongst the brightest and most experienced in our field. These discussions certainly stimulate our sympathetic nervous system and cause arguments, debates, tachycardia and for some, even hypertensive crisis!
So what has come of these debates and arguments? One thing is for certain: There are many critics out there discussing airway management in the field and what is and isn’t appropriate. Many of these folks believe that airway management by EMS providers should be limited to a bag-valve mask (BVM) and oral airway or a supraglottic device.
As a former paramedic turned anesthesiologist, I think that we shouldn’t limit ourselves to certain techniques. Rather, we should educate, train and arm our field providers with the very best that airway tools have to offer. In this next series of articles, we’re going to explore the concept of managing the traumatic airway.
I’ll begin with a case study so you can envision what’s going on with a patient you’ve likely cared for in the past or will definitely care for in the future as you progress through your EMS career. As you read the case, consider how you would assess the patient. Also picture when, during the primary and secondary survey, you might pause to treat the patient and what that treatment would include.
We will progress through the cycle of managing the trauma airway over the next several articles. In addition, you will see some polls along the way that we will ask use to determine your thought process and hopefully stimulate some good discussion and opinions. So let’s get started.
You’re called to the scene of a 30-year-old male involved in a high-speed motorcycle crash. On arrival, witnesses state that the patient was just seizing but has stopped. You take a quick look at the patient and see a male (approximately 110 kilograms) lying on the street supine without a helmet. When you reach the patient’s side, he is breathing with gurgling respirations. There are no obvious external signs of bleeding or trauma. The patient is moaning with a GCS of 9. What will your initial management steps consist of?
Most of us have cared for this exact patient. Did you intubate them on scene? Scoop and run? Intubate during transport? Assist respirations with just a BVM and possibly oral or nasal airways? I’m sure that we would get a lot of conflicting answers on this one! But why? Haven’t we all taken basic trauma life support or an equivalent course as EMTs and medics? Is there really an airway protocol that we can follow for all trauma patients? What does your system use for airway/rapid sequence intubation protocols? Do you have a quality assurance/improvement process for all intubations or airway techniques provided in the field? Are all medics in your system allowed to intubate, or is this practiced only by veterans and supervisors?
Now, back to our case! Let’s say you have elected not to intubate at this point. What are your priorities with this patient? This is a difficult question to answer because you have several priorities at this point. They include providing and maintaining a patent airway, packaging the patient and transporting to a designated trauma center. Seems simple enough but there are many things to consider.
Let’s start with the big question: How can we clear and maintain a patent airway in this patient? First off, call for help! The first thing I do at the trauma center is make sure I have plenty of sets of hands around to assist me with managing a traumatic airway that comes in. You should do the same thing. Hopefully you at least have one partner with you on the scene as first responders. Have your partner set up the suction and take out the airway equipment while you open the patient’s airway with a jaw thrust maneuver, which, by the way, takes a lot of practice to gain proficiency. Hopefully more help is on the way at this point, especially if you plan to intubate this patient.
Simple jaw thrust in trauma patients can usually get the airway open enough to exchange air if the patient is still breathing spontaneously. There are two good techniques to do at this point that are fast and effective. First off, make sure that you suction the patient’s oropharynx extensively, and try to get back to the posterior oropharynx where lots of pooled secretions and blood like to hang out. Next, attempt to place an oropharyngeal airway and see if the patient will tolerate it. If they gag or bite down, go with a nasopharyngeal airway that is much less stimulating and quite safe to use.
If the patient has multiple facial fractures or has evidence of a basilar skull fracture, I like to place a nasopharyngeal airway orally; it’s soft and less stimulating than an oral airway. This is a nice technique that most semi-conscious patients will tolerate. Now you can use your clinical judgment to determine if the airway placement is allowing enough gas exchange to place a non-rebreather face mask on the patient, or if you need to assist the ventilations with a bag-valve-mask (BVM). Assisting ventilations with a BVM is a lost art with all of our technology these days, including intubation and non-invasive techniques, such as continuous positive airway pressure and bilevel positive airway pressure. When I’m teaching veteran EMTs and paramedics in the operating room, I notice how many of them struggle to hand-ventilate patients with a BVM. This, too, is a very difficult technique to master as prehospital providers. We can all mask a mannequin without a problem, but patients come in all shapes and sizes and many with facial hair and blood/vomit to boot! All of this makes it more challenging to handle the traumatic airway.
Returning to our case, has your help arrived yet? If so, you have a much higher chance of success managing this challenging airway. If you’re struggling to assist your patient’s ventilations, you need to do a two-handed technique, grasping the mandible using c-clamps with both hands to effectively “pull” the patient’s face into the face mask and have your partner squeeze the bag just enough to get the chest to rise. Remember that aggressive “bagging” of patients can be bad for many reasons, including gastric insufflation, vomiting, hypocapnea and altered cerebral perfusion, and worsening of pneumothoraces if present.
Now, if you’re successful at maintaining a patent airway at this point, you have the option to continue doing this while packaging the patient and transporting. If you still are unable to ventilate your patient, then you should consider intubation or use of alternate airways, such as a supraglottic device. Intubation attempts will be covered in the next article so stay tuned! If your patient is unconscious and breathing, you should be able to maintain the airway throughout transport. If indicated, use of a supraglottic airway is a good option if your protocol allows you to do so.
Most EMS systems carry a Combitube, Easytube or King airway device. Some carry a laryngeal mask airway. Whichever device is at your disposal, it’s imperative that you train with it regularly to be comfortable using it. Put the device in mannequin heads, simulators and, better yet, in cardiac arrest patients on operating room training days! Many protocols are moving away from intubation in cardiac arrest patients, so this is a good population to practice using both a BVM with an oral airway, or a supraglottic airway if your protocol allows.
So now your patient has a patent airway, is packaged and is off to the trauma center! Don’t forget to monitor your patient carefully while en route and reassess your patient’s airway and assisted ventilations. We will cover more of how to approach the intubated trauma patient in the next two articles.