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Trauma is the third leading cause of death of all ages in the United States and accounts annually for millions of nonfatal injuries, as well. Effective multidisciplinary team-based care is a hallmark of optimal advanced trauma life support (ATLS), and the anesthesiologist is often involved in the initial assessment and resuscitation. The approach to the trauma patient is generally divided into a primary survey (Airway, Breathing, Circulation, Disability, and Exposures [ABCDEs]) focused on identifying immediate life-threatening injuries, followed by a more detailed secondary survey focused on recognizing and addressing the remaining injuries. Although a detailed exam is eventually necessary, diagnostic testing and examination should never prevent early surgical intervention in a hemodynamically unstable patient.
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Airway mismanagement is a leading cause of prehospital mortality in trauma patients, resulting from failure to recognize the need for airway intervention, unrecognized misplacement of airway devices, or aspiration of gastric contents. Airway obstruction is common, and simple jaw-thrust maneuvers may prove lifesaving. The quickest way to establish a patent airway is to have the patient speak. It is important to perform an appropriate airway examination early in the evaluation, with particular attention to dentition, blood in the airway, swelling, tracheal deviation, and facial or cervical fractures. If there is any concern for trauma to the airway, impending airway compromise as in inhalational injuries, or a decompensated level of consciousness, then one should establish a definitive airway as soon as possible. It will likely be necessary to maintain cervical spine precautions, and video laryngoscopy may assist in minimizing manipulation to the spine. Video laryngoscopy has now also been advocated in prehospital and emergency department domains as a useful adjunct in specific cases by experienced providers. For pediatric patients, the use of cuffed endotracheal tubes is suggested for all children infants <1 year of age.
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If the patient presents with a “semidefinitive” airway device placed in the field, the anesthesiologist is often responsible for deciding when and how a definitive airway should be secured. Such airway devices include:
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Laryngeal Mask Airway (LMA)—This is a supraglottic device that requires appropriate training for correct placement. ATLS recommends that patients presenting with this device, or any other supraglottic device, have a definitive airway established as soon as possible. A similar device known as the intubating LMA is designed to allow an endotracheal tube to be passed blindly through the device to establish a definitive airway. A fiberoptic bronchoscope can be passed through this device to facilitate placement of an endotracheal tube.
Laryngeal Tube (LT)—Like the LMA, the LT is placed without direct visualization of the vocal cords, and it does not require significant manipulation of the head and neck. This device offers greater rate of successful insertion as well as a decreased time for insertion when compared to the combitube and endotracheal intubation.
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