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Trauma Airway Intubation Is a Team Effort

Field intubation of trauma patients should be a team effort.

Have a checklist for intubation of trauma patients, and assign your assisting colleagues a role to ensure success on the first attempt. Photo Courtesy Christopher T. Stephens, MD, MS, NREMPT-P

Greetings colleagues!

As the second part of this three-part series on the traumatic airway, we will now focus on intubating the trauma patient case that was introduced in the previous article, “Managing the Traumatic Airway.”

(Missed the first part of this three-part series? Click here to read Part I.)

Why is intubation of trauma patients being scrutinized across the nation, you ask? As an instructor of trauma airway management, I can assure you that it isn’t because you as field providers don’t know how to effectively intubate! In short, there are studies (whether sound or not) that are suggesting worse outcomes in patients who are intubated in the field.

So what, you ask? Sicker patients are sicker and need an endotracheal tube, right? Everyone agrees that there are some patients out there who just need to be intubated. Obstructed airways, vomit, blood and poor anatomy make traumatic airways challenging to manage in the field. In fact, these airways can be challenging in the trauma centers as well. Many patients simply can’t be oxygenated and ventilated effectively with a supraglottic airway—a or bag-valve mask (BVM) and oral airway for that matter, right? These are the cases that get our sympathetic nervous system going and put us in that position where “critical decision making” becomes extremely important.

The Intubation
So you have decided to intubate this trauma patient—who is 110 kg and looks like a small linebacker for your local professional football team. Here are some questions for you:

1. What help do you have?
2. What environment are you in (i.e., street, ditch or ambulance)?
3. Are you able to effectively oxygenate/ventilate this patient with basic tools as discussed previously?
4. Will you plan to do a blind nasal intubation or drug-facilitated oral intubation (rapid sequence intubation/RSI)?

These are some of the questions that must be thought about ahead of time, and a plan must have already been made so that the EMS team can be successful.

I like to teach EMTs and paramedics to think like pilots. Have a checklist and start at the top and work your way down. You will never miss anything this way. Assign your assisting colleagues a role to get the patient intubated successfully on the first attempt.

Ideally, you should have four EMS providers to intubate a trauma patient. The team leader is the one intubating. At this point, the team leader should be assisting the patient’s airway and pre-oxygenating with 100% oxygen via a BVM. Pre-oxygenation is VERY important. It will buy you more time to get that tube in the right hole. You should do this for blind nasal intubations as well. Trauma patients tend to desaturate at an alarming rate because most have been hypoventilating to this point due to pain, semiconsciousness, pneumo- or hemothoraces, etc. And remember, all trauma patients are full stomachs. Some have already aspirated prior to your arrival, which also works against you. All of these conditions make your intubation attempts less forgiving, and you must be prepared to act quickly if the patient becomes challenging and/or desaturates.

Once you have pre-oxygenated your patient for at least 60 seconds, attempt your intubation. If it’s a blind nasal intubation, you may have more time because the patient is still breathing. You also have the luxury to just assist them to the hospital if it fails. If you’re planning a drug-facilitated intubation, then all bets are off. Once you have decided to push drugs, you had better have your skills, colleagues and equipment ready for action.

During pre-oxygenation of the patient, the team leader must assign roles. The second medic will draw up and be responsible for pushing drugs, then handing supplies to the intubating team leader (i.e., endotracheal tube, suction, bougie, another blade, video laryngoscope, etc).

The third provider is responsible for removing the front of the cervical collar (yes, the front of the c-collar MUST be removed PRIOR to laryngoscopy) and holding cricoid pressure correctly. Note: Cricoid pressure needs to be learned correctly and practiced. Some protocols have done away with cricoid pressure; I feel that it’s still an important tool to be used in traumatic airways with full stomachs.

The fourth provider will hold in-line manual stabilization of the cervical spine throughout the intubation. When the team leader states that they’re ready, the second medic should push the appropriate drugs and appropriate doses. This is a decision that has to be made correctly and using expert paramedic critical decision techniques. Understanding the physiology/pharmacology of rapid sequence intubation (RSI) is as important as the skill itself. How sick is the patient? What are their vital signs prior to pushing drugs? Do they have pulses (central or peripheral?) Are they in shock? Do they have signs of a head injury?

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These are questions that must be answered during a rapid primary and secondary survey while preparing to intubate the patient. Is the patient combative due to shock, head injury, alcohol/drugs, or all of the above? If able, try and get a baseline set of vital signs prior to pushing drugs. This will help guide your drug choice and dosing. Drug selection and dosing is an EXTREMELY important topic for trauma patients and should be discussed at length with your medical director and training supervisors. Anesthetic agents are powerful and can make patients worse if used incorrectly.

There are many issues to think about when dealing with a traumatic airway, and hopefully you will have some time to work through a good plan of action so if things start to go wrong, your checklist and plan will be there for you to fall back on.

Once the patient has been relaxed with succinylcholine or an alternative paralytic agent, the team leader should perform their laryngoscopy with the blade they’re most comfortable using. Remember, your first shot is always your best shot! I teach trauma airways with a Macintosh 3 blade for most adults because I find it easier for medics and trainees to keep the tongue out of the way with the wider Macintosh blade.

As an alternative, you may also use a video laryngoscope, such as the Glidescope Ranger, for your intubation. The Glidescope Ranger has been useful for managing traumatic airways. It allows everyone assisting to see what the team leader is seeing, which can therefore help them anticipate what the team leader may need to get the job done, such as suction, bougie or a smaller endotracheal tube. As with any piece of airway equipment, there’s a learning curve with video laryngoscopy. You must practice it on mannequins, cadavers in airway labs and on live patients in the operating room, if possible.

I want to say a few words about the intubating stylet or bougie. Since I manage traumatic airways for a living, in my opinion, the bougie is the single most important piece of intubating equipment. This little flexible styllete has been my savior during many a difficult airway in the trauma center. That being said, a bougie and video laryngoscope is a VERY effective combination of equipment to intubate the trauma patient. I encourage each of you to grab an airway mannequin, a bougie and a demo Glidescope Ranger and practice this technique. This is going to be the wave of the future for airway management, especially in the uncontrolled field environment, where help can be lacking.

If you can’t see a view of the vocal cords or confirm the tube to be in the esophagus, you must go to Plan B. This may include changing blades, switching to a video laryngoscope, or perhaps allowing another, more-experienced airway operator to assist. Do NOT forget to attempt oxygenating and ventilating the patient with an oral/nasal airway and BVM between intubation attempts. Do your best to get the patient as close to 100% oxygen saturation as possible prior to your next intubation attempt.

If the second attempt fails, consider either placing a supraglottic airway device or simply performing BVM assisted ventilations with an oral/nasal airway throughout transport. Remember, this technique sometimes requires two rescuers to perform adequately. If you can’t intubate and can’t ventilate the patient, you must proceed to a surgical airway—either a needle or open surgical cricothyroidotomy. We will discuss this in the next article.

The Confirmation
Once the endotracheal tube is placed, it’s important for tube confirmation to be established. This can be done in many ways. Chest rise and bilateral breath sounds are important but can sometimes be misleading. If the patient is warm and still perfusing, tube fogging should be noted, as well as end-tidal carbon dioxide (ETCO2). Either an easy cap (calorimetric) ETCO2 or continuous waveform capnography should be employed as the gold standard for tube confirmation. Continuous waveform capnography ideally should be used by every medic unit that’s intubating patients in the field. This will be discussed further in the next article.

Once the correct tube location is confirmed, be certain that the tube is secured well, the cervical collar is replaced, and the tube location is reassessed after securing because tubes sometimes migrate into the right mainstem bronchus when being secured. At this point, you’re still not out of the woods! Now that you have successfully intubated the patient, you must worry about their physiology while transporting. This is a point that many field providers dismiss when managing airways in the field and a topic that may prevent medical directors from removing intubation from protocols around the nation. So there you have it—four providers ideally to get the task done correctly!

Stay tuned for the final article in this series of managing the traumatic airway.

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  1. This article is GREAT!! I work at a Level One Peds Trauma Center and we have the GlideScope and the bougies. Both are rarely pulled out. There has been more of a push towards the doctors to use the GlideScope (mostly by the medics that work in the ED) because of the ability for the whole team to be able to anticipate what will be needed next. Although it is sometimes a hinderance because too many people trying to give their “two cents” on the intubation can go horribly wrong. There is not a lot of use of the bougie here but I have seen it once or twice. Again, I wish they would use it more especially when they have tried 3 or 4 times to get a tube.

    One thing that was not mentioned is the setup of the equipment and what is setup. I have setup for many intubations in the ER and I think a good rule of thumb is to get out three tubes, the one the person intubating needs and one bigger and one smaller. This ensures you will be ready in case of a difficult intubation or a bigger than expected airway…but thats just my “two cents”

  2. I like this article, like the thought process, and written well. I look forward to reading the next one. I’ve seen, read, and lived this all over and over again, but the aurthor’s veiwpoint held my interest. Simple article, but very true and realistic.

  3. As a provider that has participated as the lead in many intubations I would like to say that this series of articles are great. The information provided is both helpful and useful. You mention the Glide Scope as a useful tool, and I will agree. But there are similiar alternatives out there that greatly enhance the intubation process for EMS providers. One of them is the AirTraq by King. This device is both extremely functional as well as affordable for small agencies. Another product that I am excited to see (when it becomes available) is the CoPilot. With devices such as these, that allow better visualization once in the airway, provider confidence is greatly enhanced.

  4. Great series. I am presenting better intubation techniques and difficult airway at our divisions recerts this month. I am going to post this series for them all to reference. Looking forward to Part 3.

  5. Thank you so much for taking the time to write this informative article.I appreciate your clear systematic approach to critical decision making. This is a great example of how EMS providers should function in the field.

  6. Check out this great article. Talks about using a Nasal Cannula at 15 lpm during pre-ox and intubation attempts to prevent desaturation.


  7. Time to let go of the EMT-P credential if you are a doctor. Surely you have been boarded in your profession that might lend credibility to your article.

    • “Time to let go of the EMT-P credential if you are a doctor. Surely you have been boarded in your profession that might lend credibility to your article.”

      You have GOT to be kidding. Anyone who thinks “MD” signifies proficiency in the knowledge/skill set of which the EMT-P is expert clearly knows little about paramedics and pre-hospital care. Keeping the NREMT-P (and do not forget the “N” since it tells its own story) after his name immediately informs the reader that you have an anesthesiologist that understands pre-hospital care, has lived it, speaks the same language, and can understand his trauma patients in a way no non-EMS experience[physician can.

      Lend credibility to his article? By citing his board certification? I have know board certified physicians whose clinical credibility was non-existent. I don’t care how many ‘board certifications’ you recite, you will NOT attain the level of credibility contained in: “Trauma Anesthesiology Fellowship – University of Maryland Shock Trauma Center Currently Assistant Professor of Anesthesiology at University of Maryland School of Medicine and Attending Trauma Anesthesiologist – R Adams Cowley Shock Trauma Center, Baltimore, MD. Director of Education, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Medical Director, Maryland Fire&Rescue Institute. Instructor for Maryland State Police Aviation Command; Flight Physician, Tactical Physician”.

      Shame on you for looking down your nose at paramedics. And “surely you have been boarded in your profession that might lend credibility to your article” is just plain ridiculous.

  8. Practice, practice, practice, I can’t agree more. Your training institution does not advocate this theory. If they did we would have much better results and improved patient care!

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