Trauma Airway Management: Considerations and Techniques

It’s 2 am and you have just finished an emergency appendectomy when you get “that” call. Your friend down in the emergency department (ED) has a patient arriving in a few minutes who was assaulted in a local prison | Anesthesiology News

After asking for your potential assistance with his airway and mumbling something about a knife, he hangs up. You’ve been working nonstop since yesterday morning, so the only thing on your mind involves a pillow and the supine position. Nevertheless, you make your way down to the ED and arrive just as the medics roll in with their patient. He is awake and yelling as they roll him by you into the trauma bay. The emergency medical technician is applying pressure to the side of the patient’s neck and there is a large knife sticking out of the middle of the patient’s face (Figure 1). Your friend takes one look and asks you to help by managing the airway while he coordinates the rest of the trauma resuscitation. It looks like your night is about to get a lot more interesting!

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Airway management for Cesarean delivery performed under general anesthesia

Rajagopalan S, et al. (2017) International Journal of Obstetric Anesthesia. 29(3) pp. 64-9

Introduction: With the increasing popularity of neuraxial anaesthesia, there has been a decline in the use of general anaesthesia for Caesarean delivery. These authors sought to examine the incidence, outcome and characteristics associated with a failed airway in patients undergoing Caesarean delivery under general anaesthesia.

Conclusions: The authors conclude that advances in adjunct airway equipment, availability of an experienced anaesthetist and simulation-based teaching of failed airway management in obstetrics may have contributed to their improved maternal outcomes in patients undergoing Caesarean delivery under general anaesthesia.

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Alternative techniques for tracheal intubation

McCluskey, K. & Stephens, M.  Anaesthesia and intensive care medicine | Published online: 4 March 2017

Conventional direct laryngoscopy with the curved Macintosh blade is a fundamental skill for all anaesthetists and has been the cornerstone of airway management for many years. This technique relies on the operator aligning the oro-pharyngo-laryngeal structures and inserting an endotracheal tube into the trachea under direct vision. There is a recognized failure rate with this technique and thus alternative techniques for tracheal intubation should be available for use in difficult situations.

Awake fibreoptic intubation (AFOI) remains the ‘gold standard’ method for securing the airway in an anticipated difficult intubation. Advances in optical technology over recent years have lead to the development of several rigid indirect devices, which improve glottic visualization by enabling the operator to ‘see around the corner’. With improved views at laryngoscopy these videolaryngoscopes are emerging as important tools in airway management and useful teaching and training aids.

Read the abstract here

Rapid Sequence Intubation With Video Laryngoscopy Common for Difficult Airways in ED

Predicted difficult airways in one emergency department are managed most often using rapid sequence intubation (RSI) and video laryngoscopy (VL), a recent study has found | Anesthesiology News

Although difficult airways occur frequently in emergency medicine, few studies have investigated the incidence, management and outcomes of these patients, according to the investigators.

“We’ve been collecting airway data at our institution for many years, and this past year we decided to focus on the difficult airway,” said John C. Sakles, MD, professor of emergency medicine at the University of Arizona College of Medicine, in Tucson. Dr. Sakles presented the study at the 2016 annual meeting of the Society for Airway Management.

The study examined 348 nonarrest intubations between July 1, 2015, and March 31, 2016, at Banner University Medical Center, in Tucson. Operators performed a difficult airway assessment and classified the airway into one of three categories: routine, challenging or difficult.

Read the full research overview here

Rethinking training in airway management

Marshall, S. D. & Chrimes, N. Time for a breath of fresh air: Rethinking training in airway management. Anaesthesia. published online 28 September 2016.

In this editorial, Marshall and Chrimes  suggest that the way in which anaesthetists  conceptualise ‘airway education’ needs to change. They go on to say that while the last two decades of anaesthetic practice have seen a the proliferation of airway devices and techniques, training and maintaining skills in airway management have not necessarily kept pace.

In summary, they write that if anaesthetists are to continue to be regarded as airway management experts, a fundamental shift must occur in both the way they train and retain their skills.

This editorial accompanies an article by Lindkær-Jensen et al., Anaesthesia 2016; 71: doi: 10.1111/anae.13567, A national survey of practical airway training in UK anaesthetic departments. Time for a national policy?

Multimodal Airway Management: Combining Advanced Airway Techniques Can Be Better

Vlassakov, K. Anesthesiology News | Published online: 12th August 2016


Multimodal airway approaches are being designed as a response to unusual difficult airway cases. Perhaps it is time to consider including these approaches in difficult airway algorithms as a final step before resorting to surgical access.

Huge technological advances, an overwhelming plethora of devices with competitive costs, and their increased availability around the world have all enhanced the ability to manage the difficult airway, but have not eliminated the risk for failure. In fact, at times the gains seem modest compared with the effort and cost. Increased acuity, complex comorbidities, and improved survival of patients with challenging congenital or acquired airway anatomy all play important roles in assessing airway success.

In the 1980s and 1990s, the introduction to mass clinical practice of steadily improving flexible fiber-optic equipment resulted in significant advances in safety and likely decreased the need for surgical airway access. However, some limitations in the ability to intubate the trachea despite adequate visualization of the glottis were quickly described and conceptualized, with prescribed maneuvers to address the problem. Soon, combining supraglottic airway devices with flexible fiber-optic devices became a preferred method for difficult (asleep and awake) airway management techniques. The present variety of video-enhanced airway devices, such as video laryngoscopes and video stylets with fiber-optic and CCD (charge coupled device) and CMOS (complementary metal oxide semiconductor) image sensor technology, has brought further improvements in glottic visualization, but still cannot always guarantee successful passage of the endotracheal tube.

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Prediction in airway management: what is worthwhile, what is a waste of time and what about the future?

Teoh, W.H. & Kristensen, M.S. British Journal of Anaesthesia (2016) 117 (1): 1-3.

Nørskov and colleagues1 randomized Danish anaesthesia departments in two groups, in order to investigate the effect of a structured airway examination on the ability to predict difficult intubation by direct laryngoscopy. The departments either continued with the pre-anaesthetic airway evaluation that they were used to, or applied the structured evaluation that consisted of five parameters (mouth opening, thyromental distance, Mallampati classification, neck movement and ability to prognath) and two questions (weight, previous difficult intubation) that culminated in the calculation of the Simplified Airway Risk Index (SARI).2This study found that clinicians were able to predict between nine and 50% of the patients where intubation with direct laryngoscopy was or would have been difficult. This success-rate in prediction difficulty was NOT different between the departments that continued with business-as-usual, and the departments where the evaluation of the seven predictive parameters was implemented.

Read the abstract here

Read the cited Nørskov et al. article abstract here