This post and cases were written by Dr. Chris Heyd, a staff emergency physician and trauma team leader in Hamilton, Ontario and Simulation Director of McMaster University’s FRCP-EM program.
(Authors note: this post is an adjunct to a presentation I gave at the McMaster University 10:EM Conference but the cases and principles may be of interest to all emergency medicine providers.)
Trauma Airway: Resuscitate before you Intubate
Securing the airway of a severely traumatized patient is fraught with difficulties. There can be anatomic difficulties associated with facial and neck injuries. There are often physiologic difficulties from uncommon causes of shock (like pericardial tamponade). It’s not surprising that a sick trauma patient can get your heart rate up.
But emergency physicians have all the skills needed to safely handle any trauma airway!
ATLS revolutionized trauma care via a series of standard surveys (primary, secondary and tertiary) and given emergency providers tools to adopt a shared mental model. However, it has become overly prescriptive and can inhibit emergency physicians from activating their usual resuscitative skills.
When we view the Primary Survey (A-B-C-D-E) as a tool to assess the trauma patient and not as a rigid step-by-step treatment plan, ER docs can approach a trauma intubation like every other intubation and adequately resuscitate before they intubate.
My approach to intubation in the severely injured patient:
1. Use A-B-C-D-E to assess the traumatized patient in less than one minute
- Identify the need for intubation and anatomic and physiologic challenges
- Logroll can usually be deferred until intubation is complete
2. Resuscitate before you intubation. Identify causes of shock that will cause decompensation during rapid-sequence intubation. Correct these in order of physiologic priority, not in A-B-C-D-E order.
Causes of shock in traumatized patients
- Obstructive: pericardial tamponade, tension pneumothorax
- Hypovolemic: internal or external hemorrhage
- Distributive: neurogenic shock (diagnosis of exclusion)
- Medical: intoxication/withdrawal, medication-related, underlying medical issue (based on history)
3. Develop and vocalize a multi-step airway plan.
- Expect an anatomically difficult airway
- Tailor medications to your specific patient
- Prepare adjuncts and back-up plans
- Prepare for surgical airway (at minimum, mental rehearsal)
Below are three sim cases based on patients that I cared for over the past year working as a Trauma Team Leader in Hamilton, Ontario. They each provide a different challenge to airway management of the trauma patient. They can be used in the ED or sim lab and are appropriate for both Trauma Team quality improvement and for team dynamics optimization.
Case 1 – Severe chest injury
Case 2 – Facial smash
Case 3 – Uncooperative polytrauma
For further reading on this topic, please see Petrosoniak & Hicks’ excellent article in EM Clinics of North America (2018). Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock.