Endotracheal Intubation Following Trauma

Level 1

There were no recommendations.

Level 2

1. A careful airway assessment should be performed before initiating efforts to secure the airway. The goals of this assessment are to identify potential markers of difficulty with the following:
   1. Bag-valve mask ventilation,
   2. Laryngoscopy, and
   3. Surgical airway.
2. The application of structured assessment tools (e.g., the LEMON law) is recommended.
3. When significant difficulty is anticipated, neuromuscular blockade should be used with caution, and airway rescue devices, including surgical airway equipment, should be immediately available.

Level 3

There were no recommendations.

Level 1

1. ETI is indicated in trauma patients with the following traits:
   1. Airway obstruction,
   2. Hypoventilation,
   3. Persistent hypoxemia (SaO₂ ≤ 90%) despite supplemental oxygen,
   4. Severe cognitive impairment (Glasgow Coma Scale [GCS] score ≤ 8),
   5. Severe hemorrhagic shock, and
   6. Cardiac arrest.
2. ETI is indicated for patients experiencing smoke inhalation with any of the following traits:

1. Airway obstruction,
2. Severe cognitive impairment (GCS score ≤ 8),
3. Major cutaneous burn (≥40%),
4. Major burns and/or smoke inhalation with an anticipated prolonged transport time to definitive care, and
5. Impending airway obstruction as follows:
   1. Moderate-to-severe facial burn;
   2. Moderate-to-severe oropharyngeal burn, and
   3. Moderate-to-severe airway injury seen on endoscopy.

Level 2

There were no recommendations.

Level 3

ETI may also be indicated in trauma patients with any of the following traits:

1. Facial or neck injury with the potential for airway obstruction,
2. Moderate cognitive impairment (GCS score > 9–12),
3. Persistent combativeness refractory to pharmacologic agents,
4. Respiratory distress (without hypoxia or hypoventilation),
5. Preoperative management (i.e., patients with painful injuries or undergoing painful procedures before nonemergent operation), and
6. Early ETI is indicated in cervical spinal cord injury with any evidence of respiratory insufficiency (complete cervical SCI or incomplete injuries C5 and above).

Level 1

1. Orotracheal intubation guided by DL is the ETI procedure of choice for trauma patients.
2. Rapid sequence intubation (RSI) should be used to facilitate orotracheal intubation unless markers of significant difficulty with intubation are present. An RSI drug regimen should be given to achieve the following clinical objectives:
   1. Adequate sedation and neuromuscular blockade,
   2. Maintenance of hemodynamic stability and CNS perfusion,
   3. Maintenance of adequate oxygenation,
   4. Prevention of increases in intracranial hypertension, and
   5. Prevention of vomiting and aspiration.
      
      There are no recommendations regarding the use of specific induction agents used for RSI in trauma. Succinylcholine is the recommended agent of choice for neuromuscular blockade, in the absence of any contraindications to its use.
3. Enhancements for safe and effective ETI in trauma patients include the following:
   1. Availability of experienced personnel,
   2. Pulse-oximetry monitoring,
   3. Maintenance of cervical neutrality,
   4. Confirmation of tube placement using auscultation of bilateral breath sounds and end-tidal CO₂ detection, and
   5. Continuous end-tidal CO₂ monitoring for patients with severe traumatic brain injury.
4. Cricothyroidostomy is appropriate when emergent/urgent tracheal intubation is needed and cannot be achieved rapidly with DL or with the use of alternative airway techniques and devices.

Level 2

1. When ETI cannot be achieved rapidly with DL, a number of airway rescue devices may be used as follows:
   1. Blind-insertion supraglottic devices (i.e., LMA, Combitube, and King Airway),
   2. Gum-elastic bougie,
   3. Video laryngoscopy, and
   4. Surgical cricothyroidostomy. 

Decisions regarding the most appropriate rescue technique should be guided by the clinical scenario at hand, resource availability, and the skill and experience of the treating clinician.

Level 3

1. Video laryngoscopy may offer significant advantages over DL, including the following:
   1. Superior views of the glottis (Cormack-Lehane I/II);
   2. Higher intubation success rates for patients with anatomically difficult airways, in obese patients, and in those with the cervical spine held in-line; and
   3. Higher intubation success rates by inexperienced airway providers.