25.3.1 What Are the Airway Management Considerations One Needs to Be Aware of?
The initial plan should anticipate both difficult laryngoscopy and difficult BMV. This is at least in part related to the potential for an unstable cervical spine prohibiting proper positioning of the airway by neck flexion or extension with the potential for spinal cord injury. The practitioner should also consider how the patient ought to be positioned for laryngoscopy, as the volume of bleeding and the mechanical stability of the airway might preclude lying the patient flat. An induction with full paralysis might be desirable, although it must be recognized that failure of both intubation and BMV is a significant possibility in this patient. In such a circumstance, the efficacy of many of the common alternative devices would also be compromised. Transillumination with the lightwand (eg, Trachlight™) could be problematic. The intubating laryngeal mask airway might be difficult to place. Vision with the Bullard™ laryngoscope, GlideScope®, or bronchoscope would be clouded in the presence of blood. Basic backups, such as the Combitube™, or surgical airway, would have to be available.
25.3.2 What Procedure Should Be Used to Intubate the Trachea of This Patient?
Timing of positioning in anticipation of airway management is an important consideration. Upon arrival, the patient is able to maintain his airway as he is sitting up. This positioning allows blood and bone fragments to be somewhat displaced away from the airway. However, immediately placing the patient in a supine position strictly for concern of his cervical spine places his tenuous airway at undue risk. Given his mental status and host of injuries, one would anticipate that he would begin to obstruct his airway upon supine positioning. As such, consider denitrogenation in his original position of comfort. Manual in-line cervical immobilization can be quickly initiated in the sitting position. Once all preparations for the difficult airway have been made, the patient should be placed supine immediately preceding laryngoscopy.
With a deteriorating neurological status and a possible increase in ICP, Plan A is a standard approach to rapid-sequence intubation (RSI) with in-line cervical spine stabilization. Alternatively, if the airway is determined to be too difficult to proceed with RSI, an awake look may be employed as Plan A, realizing that the topical anesthesia will most likely fail due to the amount of blood in the airway. Paralysis and intubation would be indicated upon viewing glottic structures. Plan B would be an EGD and Plan C a surgical airway—in other words a "triple setup." Preparation begins by assembling standard intubating equipment, alternative airway devices, and a surgical airway kit. Denitrogenation with a non-rebreather oxygen mask should be initiated well in advance of induction. Uncontrolled epistaxis may impede this process, can lead to aspiration, and may require immediate packing, or cauterization. Adequate suctioning is essential.
Pretreatment with lidocaine, and an opioid should be given 3 minutes prior to intubation, time permitting. RSI will ordinarily include propofol or etomidate, followed by succinylcholine. Anti-aspiration maneuvers, such as Sellick maneuver, ought to be employed, although cautiously to avoid internal jugular vein compression and impeded venous return from the cranial vault. Dosages of the opioids and the induction agents should be moderated to avoid hypotension, particularly in the face of substantial sympathetic nervous system activation.
A sequence of predetermined steps should be employed if failure with laryngoscopy or oxygenation occurs. The alternative airway device of choice should be the one with which the practitioner has the most experience. An intubating LMA has particular advantage, as it may circumvent the problem of a traditional mask seal on top of a mobile maxilla. It can also be manipulated by the guiding handle to best fit the hypopharynx. As an additional backup, the patient's neck should be prepped, and cricothyrotomy equipment should be opened and ready for use, in the event that the preceding steps fail to secure the airway.