A priority for all trauma patients is rapid assessment and appropriate, prompt and effective management of the airway. Adequate ventilation and tissue oxygenation can prevent hypoxic injury, particularly within the central nervous system. Failure to secure the airway soon enough is a major cause of preventable death following significant injury (Ivatury and Guilford, 2008). Many controversial issues surround the management of the trauma airway including the effect of early tracheal intubation on morbidity and mortality, the variation in failed intubation rates for paramedics compared with physicians, and the use of manual in-line stabilisation and cricoid pressure during tracheal intubation. Studies have attempted to address these and other questions related to airway management in trauma patients. Unfortunately, many variables within the studies make interpretation of the results difficult. This review aims to summarise the key issues in relation to all of these controversies.
Aagbi (2009) Available at: www.aagbi.org/publications/guidelines/docs/prehospital_glossy09.pdf (accessed November 2010).
2.
Annane D. ( 2005) ICU physicians should abandon the use of etomidate!Intensive Care Med31(3): 325-326.
3.
Bloomfield R. and Noble DW ( 2006) Etomidate and fatal outcome-even a single bolus dose may be detrimental for some patients. BJA97(1): 116-117.
4.
Bochicchio GV, Ilahi O., Joshi M., et al. (2003) Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. J Trauma54: 307-311.
5.
Bredmose P., Lockey DJ, Grier G., et al. (2009) Prehospital use of ketamine for analgesia and procedural sedation. Emerg Med J26: 62-64.
6.
Brimacombe J., White A. and Berry A. ( 1993) Effect of cricoid pressure on ease of insertion of the laryngeal mask airway. BJA71: 800-802.
7.
Butler JM, Clancy M., Robinson N., et al. (2001) An observational survey of emergency department rapid sequence intubation. Emerg Med J18: 343-348.
8.
Christensen EF and Høyer CC ( 2003) Prehospital tracheal intubation in severely injured patients: a Danish observational study. BMJ327: 533-534.
9.
Cobas MA, De La Pena MA, Manning R., et al. (2009) Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg109: 489-493.
10.
Cranshaw J. and Nolan J. ( 2006) Airway management after major trauma. CEACCP6(3): 124-127.
11.
DAS (2006) Available at: www.das.uk.com/guidelines/rsi.html (accessed November 2010).
12.
Davis DP, Dunford JV, Poste JC, et al. (2004) The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma57: 1-10.
13.
Davis DP, Hoyt DB, Ochs M., et al. (2003) The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma54: 444-453.
14.
Davis DP, Paey J., Sise MJ, et al. (2005) The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. J Trauma58: 933-939.
15.
Deakin CD, King P., Thompson F., et al. (2009) Prehospital advanced airway management by ambulance technicians and paramedics: is clinical practice sufficient to maintain skills?Emerg Med J26: 888-891.
16.
Deakin C., Peters R., Tomlinson P., et al. (2005) Securing the pre-hospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics. Emerg Med J22: 64-67.
17.
Demetriades D., Charalambides K., Chahwan S., et al. (2000) Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma48: 724-727.
18.
Dunford JV, Davis DP, Ochs M., et al. (2003) Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med42: 721-728.
19.
Ellis DY, Harris T. and Zideman D. ( 2007) Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med50(6): 653-665.
20.
Fakhry SM, Scanlon JM, Robinson L., et al. (2006) Prehospital rapid sequence intubation for head trauma: conditions for a successful program. J Trauma60: 997-1001.
21.
Fenton PM and Reynolds F.(2009) Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting. Int J Obstet Anesth18(2): 106-110.
22.
Gausche M., Lewis RJ, Stratton SJ, et al. (2000) Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial . JAMA283(6): 783-790.
23.
Gobindram A. and Clarke S. ( 2008) Cricoid pressure: should we lay off the pressure ? Anaesthesia63: 1255-1267.
24.
Goldenberg IF, Campion BC, Siebold CM, et al. (1986) Esophageal gastric tube airway vs endotracheal tube in prehospital cardiopulmonary arrest. Chest90(1): 90-612.
25.
Grier G., Bredmose P., et al. (2009) Introduction and use of the ProSealTM laryngeal mask airway as a rescue device in a pre-hospital trauma anaesthesia algorithm. Resuscitation80: 138-141.
26.
Hanif MA, Kaji AH and Niemann JT (2010) Advanced airway management does not improve outcome of out-of-hospital cardiac arrest. Acad Emerg Med17: 926-931.
27.
Harris T., Davenport R., Hurst T., Jones J. ( 2010) Improving outcome in severe trauma: trauma systems and initial management-intubation, ventilation and resuscitation. Postgrad Med J. Epub ahead of print.
28.
Helm M., Hossfeld B., Schafer S., et al. (2006) Factors influencing emergency intubation in the pre-hospital setting-a multicentre study in the German Helicopter Emergency Medical Service. BJA96(1): 67-71.
29.
Herff H., Wenzel Lockey V., et al. (2009) Prehospital intubation: the right tools in the right hands at the right time. Anesth and Analg109(2): 303-305.
30.
Hildreth AN, Mejia VA, Maxwell RA, et al. (2008) Adrenal suppression following a single dose of etomidate for rapid sequence induction: a prospective randomized study . J Trauma65: 573-579.
31.
Hodges RJH, Bennett JR, Tunstall ME and Knight RF ( 1959) General anaesthesia for operative obstetrics. BJA31: 152-163.
32.
Holh CM, Kelly-Smith CH, Yeung TC, et al. (2010) The effect of a bolus dose of etomidate on cortisol levels, mortality, and health services utilization: a systematic review. Ann Emerg Med56: 105-113.
33.
Ivatury RR and Guilford K. ( 2008) Patient safety in trauma: maximal impact management errors at a level I trauma center. J Trauma64: 265-272.
34.
Jabre P., Combes X., Lapostolle F., et al. (2009) Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre trial. Lancet25374(9686): 293-300.
35.
Jacoby J., Heller M., Nicholas J., et al. (2006) Etomidate versus midazolam for out-of-hospital intubation: A prospective, randomized trial. Ann Emerg Med47(6): 525-530.
36.
Kwan I. and Bunn F. ( 2005) Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehosp Disast Med20(1): 47-53.
37.
Kwan I., Bunn F. and Roberts IG ( 2001) Spinal immobilisation for trauma patients. Cochrane Database of Systematic Reviews, reassessed 2007.
38.
Lecky F., Bryden D., Little R., et al. (2008) Emergency intubation for acutely ill and injured patients. Cochrane Database of Systematic Reviews , Issue 2.
39.
Lockey D., Coats T., Parr MJ, et al. (1999) Aspiration in severe trauma: a prospective study. Anaesthesia54: 1097-1109.
40.
Lockey D., Davies G. and Coats T. ( 2001) Survival of trauma patients who have prehospital tracheal intubation without anaesthesia or muscle relaxants: observational study. BMJ323: 141.
41.
Mackay A., Terris J. and Coats TJ ( 2001) Prehospital rapid sequence induction by emergency physicians: is it safe? Emerg Med J18: 20-24.
42.
Mendelson CL ( 1946) The aspiration of stomach contents into the lungs during obstetric anaesthesia. Am J Obstet Gynecol52: 191-205.
43.
Morris C. and McAllister C. ( 2005) Etomidate for emergency anaesthesia: mad, bad and dangerous to know?Anaesthesia60: 737-739.
44.
Mort TC ( 2004) Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg99: 607-613.
45.
Mort TC ( 2005) Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit Care Med33: 2672-2675.
46.
Muckart DJJ, Bhagwanjee S. and van der Merwe R. ( 1997) Spinal cord injury as a result of endotracheal intubation in patients with undiagnosed cervical spine fractures. Anesthesiology87: 418-420.
47.
Ncepod (2007) Available at: www.ncepod.org.uk (accessed November 2010).
48.
Neilipovitz DT and Crosby ET ( 2007) No evidence for decreased incidence of aspiration after rapid sequence induction. Can J Anesth54(9): 748-764.
49.
Nolan JP ( 1993) Orotracheal intubation in patients with potential cervical spine injuries. Anaesthesia48: 630-633.
50.
Ochs M., Davis D., Hoyt D., et al. (2002) Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med40: 159-167.
51.
Ollerton JE, Parr MJA, Harrison K., et al. (2006) Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department-a systematic review. Emerg Med J23: 3-11.
52.
Rabitsch W., Schellongowski P., Staudinger T., et al. (2003) Comparison of a conventional tracheal airway with the Combitube in an urban emergency medical services system run by physicians . Resuscitation57(1): 27-32.
53.
Santoni BG, Hindman BJ, Puttlitz CM, et al. (2009) Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation . Anesthesiology110: 24-31.
54.
Schmid M., Mang K., Ey K and Schüttler J (2009) Prehospital airway management on rescue helicopters in the United Kingdom. Anaesthesia64: 625-631.
55.
Schwartz DE and Cohen NH ( 1995) Questionable effectiveness of cricoid pressure in preventing aspiration [letter]. Anaesthesiology83: 432.
56.
Sellick BA ( 1961) Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet2: 404-406.
57.
Sellick BA ( 1962) The prevention of regurgitation during induction of anaesthesia . First Eur Congress Anaesthesiol89: 1-4.
58.
Sibley A., Mackenzie M., Bawden J., et al. (2010) A prospective review of the use of ketamine to facilitate endotracheal intubation in the helicopter emergency medical services (HEMS) setting. Emerg Med J; published online first 6 Oct 2010
59.
Silvestri S., Ralls GA, Krauss B., et al. (2005) The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional Emergency Medical Services system. Ann Emerg Med45(5): 497-503.
60.
Simpson JY(1848) The alleged case of death from the action of chloroform. Lancet1: 175-176.
61.
Sise MJ, Shackford SR, Sise CB, et al. (2009) Early intubation in the management of trauma patients: indications and outcomes in 1,000 consecutive patients . J Trauma66: 32-40.
62.
Smith KJ, Dobranowski J., Yip G., et al. (2003) Cricoid pressure displaces the oesophagus: an observational study using magnetic resonance imaging. Anaesthesiology99: 60-64.
63.
Smith KJ, Ladak S., Choi PT, et al. (2002) The cricoid cartilage and the oesophagus are not aligned in close to half of adult patients. Can J Anaesth49: 503-507.
64.
Snow RG and Nunn JF ( 1959) Induction of anaesthesia in the foot-down position for patients with a full stomach. BJA31: 493-497.
65.
Sollid SJM, Lockey D., Lossius HM, et al. (2009) A consensus-based template for uniform reporting of data from pre-hospital advanced airway management. SJTREM17(1): 58.
66.
Steill IG, Nesbitt LP, Pickett W., et al. (2008) The OPALS major trauma study: impact of advanced life-support on survival and morbidity. CMAJ178: 1141-1452.
67.
Studnek JR, Thestrup L., Vandeventer S., et al. (2010) The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients. Acad Emerg Med17: 918-925.
68.
Suominen P., Baillie C., Kivioja A., et al. (2000) Intubation and survival in severe paediatric blunt head injury. Eur J Emerg Med7(1): 3-7.
69.
Svenson JE and Abernathy MK ( 2007) Ketamine for prehospital use: new look at an old drug . Am J Emerg Med25: 977-980.
70.
Thibodeau LG, Verdile VP and Bartfield JM ( 1997) Incidence of aspiration after urgent intubation . Am J Emerg Med15: 562-565.
71.
Timmerman A., Russo SG, Eich C., et al. (2007) The out-of-hospital esophageal and endobronchial Intubations performed by emergency physicians. Crit Care Trauma104(3): 619-623.
72.
Trauma.org (2006) Airway management of the trauma victim. Available at: www.trauma.org (accessed November 2010).
73.
Vanner R. ( 2009) Cricoid pressure. Int J Obstetric Anaes18: 103-105.
74.
Wang HE, Peitzman AB, Cassidy LD, et al. (2004) Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med44: 439-450.
75.
Winchell RJ and Hoyt DB ( 1997) Endotracheal intubation in the field improves survival in patients with severe head injury. Trauma Research and Education Foundation of San Diego. Arch Surg132(6): 592-597.
