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Airway Tips

Control of the difficult airway in trauma
The potential for cervical spine injury makes airway management more complex in the trauma patient. A cervical spine injury should be suspected in all injury mechanisms involving blunt trauma. Patients with injury above the clavicles are at increased risk. Cervical spine injury is often present and secondary injury to the spinal cord must be avoided. The head injured patient is sometimes difficult to intubate as usually there is a gradual reduction in the GCS and the gag reflex remains. Immobilization of the cervical spine must remain in place until a complete clinical and radiological evaluation has excluded any injury to the cord.

In trauma the following categories of patients require a definitively secured airway:

  • Apnoea
    GCS < 9 or sustained seizures.
    Unstable mid-face trauma.
    Airway injuries.
    Large flail segment or respiratory failure.
    High aspiration risk.
    Inability to otherwise maintain an airway or oxygenation.
    Patients in Cardio-respiratory arrest

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Airway Management
Initially the airway should be cleared of debris, blood and secretions. It should be opened using the 'chin lift' or 'jaw thrust' or 'triple airway' manoeuvres. The 'sniffing the morning air' position for standard tracheal intubation flexes the lower cervical spine and extends the occiput on the atlas. So cervical collar application before this is essential. If you haven't got a collar to fit your patient use whatever you can which looks reasonably clean. Blankets, bags clothing and by-standers.

An oral (Guedel) or nasopharyngeal airway may be necessary to maintain patency until a definitive airway is secured. Insertion of an airway produces minimal disturbance to the cervical spine. Bag and mask ventilation also produces a significant degree of movement at zones of instability in the neck.



If a patient gags on an OP airway don't even get the ET kit ready, they will not tolerate an ET tube. In this case go with the bag and mask and keep the respiratory rate at around 10-12 per minute on high flow oxygen.


With a trauma patient who needs to be intubated try undoing the front section of a cervical collar to allow the jaw to move forwards during the push with your laryngoscope. Get your partner to manually hold the neck and 'c' spine in-line while you do this. Then after a successful intubation re-fasten the collar.

Difficult airway = Use a bougie! These are often forgotten about. A great piece of kit


Unsuccessful Intubation
Failed or difficult intubation is always a problem. It is important not to waste time with repeated attempts at intubation while the patient is desaturating (SPo2). Alternative methods of securing the airway should be used. (Bag & Mask / OP airway). Never keep an ET tube in place which you are unsure of. Get it out, oxygenate, and have another go.
Verification of Tracheal Tube Placement

It is vital that the position of the tube is confirmed. There are three things to observe. Firstly, the rise and fall of the chest. Secondly, auscultation. Listen to the chest on each push on the bag you should hear good air entry. Thirdly, if the patient has cardiac output you should be measuring the SPo2 and this reading should remain high. (Although patients with chest injuries increase the likelihood of mistakes in this area). Capnography is the measurement of expired Co2 and is usually used to verify tube position in the Emergency department. Although the first thing a receiving doctor will do is listen with a stethoscope to the chest, as you did! Capnography is now widely used to confirm positioning of ET tubes in the pre-hospital environment.


Laryngeal Mask Airway (LMA)
The LMA is gaining wider support in the management of patients with cervical spine injury. As well as maintaining the airway, a tracheal tube (size 6 or less) may be placed, either blindly or via flexible fibreoptic laryngoscopy. The LMA does not however fully protect the airway from aspiration, and by acting as a bolus in the pharynx, may actually relax the lower oesophageal sphincter and increase reflux.


Airway management in opiate overdose
This is an area any Paramedic will have come across. You know what I mean. You intubate, administer high rate O2. You administer Naloxone and the patient starts to gag and pull on the tube. He would be shouting but he can't. In suspected opiate or narcotic overdose you may find the whole situation goes better if you ventilate with the bag & mask / high O2, give your patient Naloxone at the same time and providing there is no aspiration then continue assisted ventilation until your patient comes round.

All information in this section is for guidance and advice only and is assumed to be correct at the time of publishing. Check with your local training department before carrying any of the procedures in this section. The Paramedic Resource Centre cannot be held responsible for any error or omission in any page on this site.

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