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Managing the Traumatic Airway

When considering airway management techniques for trauma patients, EMS providers should consider their resources.

Greetings colleagues,

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?

[poll id=”3″]

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?

[poll id=”4″]

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.

[poll id=”5″]

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.

[poll id=”6″]

–Dr. Stephens


  1. good review would enjoy more of these.

  2. Good article, very thought provoking. These are always tough calls. Looking forward to the next articles.

  3. Good information. I’m a program director for teaching EMS and was curious to know what everyone else was thinking. Very Interesting!

  4. Good scenario. Firm believer in intubation, but also in ventilation. It’s a shame veterans EMS providers are not proficient in their skills. We forget the new kids are going to be taking care of us one day. Start caring, MASTER your skills again.Take care of that patient. Teach our new. Airway is just the beginning.

  5. Great article!! I look forward to the series…

  6. Excellent case review, I really enjoyed this so far !

  7. I like this article and the questions in between. Glad to have a Doctor/Anesthesiologist on the side of EMT’s and Paramedics. Realizing that we are more than just ambulance drivers. Keep this going I enjoy the information.

  8. I took a patient in recently, the situation doesnt matter, however this is what the 3rd year resident said to me(he was a practicing medic before going to med school)….he said it doesnt matter wether or not we get the tube….our job as paramedics is to get the airway. The most important thing is to think whats the best airway for our patient, not “get the tube so I can be thought of as a good medic.”

    This article was great Im looking forward to the next two.

  9. I would love for you to post more of these. They are very thought provocative. As a former Paramedic I am at a loss for all the debate over airway management these days. I first became a Paramedic in 1987 and worked untill the mid 90’s. I attended BTLS and ACLS classes on a regular basis. The main theme was always to provide optimal care at the scene of an accident or illness and during transport. You can only do this if you can maintain a patient airway. Without it your patient can not survive. Paramedics have been doing Intubation and advanced airway management techniques in the field for several decades now and have proven that maintaining a patent airway improves the chance of survival. I believe where we go wrong is realizing that if you can not rapidly provide a patient airway, you should immediately transport without delay. I have seen a lot of medics stay on scene to long attempting to intubate when they should have just transported. We all need to remember BLS before ALS and transport without delay!

  10. Outstanding, article all EMS providers from emt’s and above should use these Airway options as one of Many tools

  11. Great article! I would like to see more like it with different scenarios.

  12. These type of scenarios happen in real life every day. Providing this type of educational platform brings awareness and importance of continung education for all of us. Thanks doc

  13. I’d like to echo the comments made by Ronda P. above. I, too, believe that intubation is a crucial skill that needs to remain in the paramedic skill-set. My own opinion in the tube/don’t tube debate is that we as a group are not managing the tube very well. Either we take to long to insert it or we do a lousy job of maintaining it once it’s in, or both. The stats are there; we have to decide what we are going to do about it. As Ronda says, mastery is the key and that only comes from training and re-training. Perhaps we don’t need to intubate every unconscious patient but there will always be that one airway that is either swelling shut or continues to fill with blood or vomit and there is no OPA or SGA that is going to help you protect it. THAT patient will need intubation and he will need you to be good at it!

  14. Have to agree with Mike Holley. It’s great to have articles like this written/taught by someone who has been where we are. Hope this is just the beginning. Makes re-cert studying more interesting. Thanks again.

  15. interestig article. had a similiar case @ 4 years ago where it took the paramedic from MERCY FLIGHT @10 minutes to finally intubate the pat. with a KING TUBE after several failed attempts. we kept using the BVM on pat. in between attempts. and just so you know, the pat. made it ok.

  16. GET OR time!!! Do at least 150 intubations before you go out to the street and try to get at least 50 intubations at the OR / year…..we would not have all the discussions if we would get more OR time…

  17. Very interesting article. I would love to read more.

  18. Very interesting article and I am looking forward to the next article.

    On the paramedics intubating or not allowed to intubate; I’m old enough to remember when Emergency Medicine was in its infancy, only anesthesiologist were allowed to intubate. Honestly in large teaching hospitals most of the intubation is done by residents, so I’d like to see a true study on the success of veteran EM physicians that intubate once or twice a month. But that is another story. I think as long as the paramedic can maintain their skills there shouldn’t be a problem. I do think we need to have multiple other options such as: retrograde intubation, RSI, King airway devices, LMA, surgical airway, etc, etc. The more skilled you are and the more options you have the more comfortable you are and less likely you may have to intubate someone.

    NOW, you mentioned placing a NPA orally. I’ve been a paramedic for many years (to many to mention) and I have never seen this procedures. Can you describe it to me? Are you just placing it in the mouth? I would think that would cause the patient to gag also.

  19. My 18 year old daughter was killed by a paramedic who intubated her esophagus in the field. He failed to use the capnography even though it was available on his helicopter. He failed to respond when two other medics on scene told him the tube was in the wrong place. He failed to respond to his own documented observations that my daughters abdomen became immediately distended and she turned “dusky”. He documented that he heard gurgling over the epigastrum and still didn’t pull the tube. He paralyzed her because she reached up and pulled out the nasal trumpet he put in labeling that as combative. When she coded 7 minutes after intubation he still didn’t take it out. When he reached the hospital 22 minutes later with my now dead daughter he still didn’t take it out. My daughter was revived at the ER because she had a young strong heart and once she was correctly tubed they were able to get a heart beat and bp for long enough for her to be an organ donor. Her brain death was not caused by her accident it was caused by a rogue paramedic who’s only goal was intubation not ventilation. It will be 2 years on May 3 and the lawsuit is still pending. He had his license suspended by the state of Texas for 18 months so watch out because he could be working in your town now. I intend to use every penny from the lawsuit to make sure that ETTubes are removed from the hands of paramedics. They are unsupervised and undertrained and they cause more deaths than are reported. LMA’s and EOA’s always seem to work quite well and can be placed by a trained monkey. The girl in this picture was my daughter. Her death was caused directly by a paramedic with a lethal weapon/ an ETT. Think of her the next time you teach airway management. I know I will

    • First, Mr. Gilbreath, my condolences for your loss.

      I respectfully disagree with your position on paramedics’ use of intubation. While the paramedic ‘treating’ your daughter obviously screwed up, this result is not limited to paramedics. As an EMT-Basic for six years and now as a new paramedic, I have watched coworkers take too long to perform the intubation and perform multiple attempts wasting valuable time. That said, I can recall at least six or more times, just in my short time in EMS, that I have taken a patient to our local ER and watched the ER physicians spend too much time with their attempt, attempt multiple times, and even unsuccessfully RSI a pediatric patient and yet continue the intubation almost shoving the tube into place. If the families of those patients knew what was happening, I am sure they would agree with you. If it were my family, there are certain employees that, if they showed up, I would tell them that I am intubating because, although I only have five intubations behind me, all were successful on the first attempt (one of these was a ‘difficult’ patient that two other medics had tried to intubate). Why? Because I am that good? No! It is because I try to pay attention to the detail and mechanics of placing a tube. I get nervous every time I go to intubate because I do not have the skill level that I would like; and there are no training options available unless I purchase my own manikin.

      If we take away intubation from all paramedics because some are incompetent, we also must remove this and other skills from paramedics and other practitioners such as doctors. Instead of removing these skills, as others have said, we need continuous training and when a medic cannot successfully perform a skill, they should be suspended until they can. Quality assurance has to become more than talk, and this goes for tracking skills other than intubation. QA needs to become commonplace and medics need to learn that there are consequences for their actions…that will be handed down.

      It is my personal belief that EMS, in general needs to stop being complacent and strive to be, and act like, professionals. Maybe you are right; maybe skills DO need pulled from paramedics…until they get it in their head to take the job serious and not settle for substandard care. If we resort to only doing skills that monkeys can do, maybe we should hire monkeys for patient care and only have human drivers…wage expense would be much lower. As for the use of LMAs and EOAs, the ONLY airway that I have seen that completely isolates the trachea and prevents aspiration and gastric distention is the endotracheal tube.

      With all that said, I would ask that you not focus your efforts on further limiting paramedic skills but work to have more stringent requirements placed on paramedic candidates and for those such as the one your daughter had, seek strict remedial training with a probationary period. If paramedics are unable to consistently and effectively do their required job, they do not need fewer skills, they need to find a new job where they are not responsible for someone’s life.

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