Airway Management in Trauma 
Gregory Sund, Matthew Kynes, Phil Yao 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Editor’s Note: This chapter builds on Airway 
Management and Endotracheal Intubation, which 
discusses the basics of  airway management, specific 
equipment, medications, and management of difficult 
situations. The reader will be well served by starting 
with that chapter before reading this one.  
 
Airway management for trauma victims can 
be challenging for a variety of reasons. These include 
distortion of airway anatomy, obscured visualization 
from blood, emesis or other material, and the need to 
maintain the head in a neutral position when a 
cervical spine injury is suspected. It is important to 
understand the particularities of each situation and 
how to evaluate and to safely manage the airway in 
such patients. 
Before the airway can be managed, it must be 
assessed. The steps in the evaluation of airway 
patency and adequacy of breathing will not be 
discussed in this chapter. The reader instead is 
referred to Basic Life Support (BLS) and Advanced 
Cardiac Life Support (ACLS) for further explanation 
of these steps. But it is important to understand that 
hypoxia and hypoventilation need to be recognized 
and acted upon quickly, as these can be signs of life-
threatening injuries and can worsen the level of 
consciousness and brain injury in head-injured 
patients. Some of the particularities of airway 
management in trauma victims are discussed below. 
 
Cervical spine injury 
Most trauma patients are assumed to have a 
cervical spine injury until it is ruled out either by 
physical exam or imaging. Until such an injury has 
been ruled out the patient’s neck must remain in a 
neutral position at all times using a properly placed 
cervical collar or manual in-line stabilization. This 
can make intubation difficult or sometimes 
impossible. Therefore, it is important to be prepared 
with back-up airway equipment (e.g., bougie, 
videolaryngoscope, cricothyroidotomy kit) before 
attempting intubation. If intubation fails the operator 
should also be prepared to insert a rescue airway 
device such as a laryngeal mask airway. The 
esophageal-tracheal 
Combitube 
or 
King 
supralaryngeal device may be available at some 
hospitals and can be lifesaving in these situations. 
While these devices are not a permanent solution, 
they can provide oxygenation and ventilation until a 
more permanent airway can be established. 
 
Proper technique for cervical spine stabilization during 
intubation when cervical spine injury has not been ruled out. 
The assistant (left side of the picture) uses the “earmuff” 
technique, which allows the mandible to move downwards. 
During insertion of the tube, the assistant and the intubator will 
be working “against” each other, as one tries to see the vocal 
cords as well as possible and the other tries to limit movement 
of the neck. Source: Kovacs G et al. 
https://doi.org/10.1016/j.emc.2017.08.006  
 
Risk of pulmonary aspiration 
All trauma patients are considered “full 
stomach” and therefore at increased risk of aspiration 
of gastric contents. This is one reason why securing 
the airway is so critical whenever the patient’s level 
of consciousness is depressed (Glasgow Coma Scale 
[GCS] less than 8). Intubation should be performed 
with rapid sequence induction in order to secure the 
airway as quickly as possible and protect the lungs 
from aspiration of gastric contents. This technique is 
outlined in the chapter on endotracheal intubation.  
In our institution, we use cricoid pressure in 
all rapid sequence inductions. In theory, this 
maneuver serves to occlude the esophagus and 
prevent aspiration of gastric contents. However, 
studies have questioned whether cricoid pressure 
actually achieves this effect. If used, this technique 
Airway Management in Trauma 
Gregory Sund, Matthew Kynes, Phil Yao 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
should be applied as soon as the patient loses 
consciousness and released once endotracheal 
intubation is confirmed. The recommended pressure 
to be used is 3 to 4 kg at most. Excessive cricoid 
pressure can cause further trauma to the airways. 
Cricoid pressure can also obscure the view of the 
vocal cords, so ask the assistant to apply less pressure 
if you are having difficulty.  
 
Inhalational burns 
Exposure to fire and smoke in an enclosed 
space can cause inhalational injury to the airway 
resulting in progressive edema and airway closure. In 
patients 
with 
suspected 
inhalational 
injury, 
endotracheal intubation should be performed early 
before significant airway edema occurs. Inhalational 
injury should be suspected in any patient who was 
exposed to a fire in an enclosed space, those with 
singed or soot-covered nostrils or mouth, and those 
displaying signs such as hoarseness, dyspnea, 
tachypnea or altered level of consciousness not 
explained by head injury. While succinylcholine can 
be used safely in patients within 48 hours of burn 
injury, those outside of this time window are at 
increased risk of hyperkalemia when given this 
medication. In these situations, it is better to use a 
non-depolarizing muscle relaxant.  
Patients with severe burn injuries or those 
which occurred in enclosed spaces should also be 
considered at risk for carbon monoxide poisoning. 
Carbon monoxide binds to hemoglobin with an 
affinity approximately 250 times that of oxygen. 
This results in a left-ward shift of the oxy-
hemoglobin 
dissociation 
curve 
and 
impaired 
availability of oxygen at the level of the tissues. 
Because standard pulse oximetry cannot distinguish 
between oxyhemoglobin and carboxyhemoglobin, 
this tool will display a falsely elevated oxygen 
saturation in a patient with carbon monoxide 
poisoning. In patients with carboxyhemoglobin 
levels of 20% or greater (measured by arterial or 
venous 
blood 
gas 
analysis) 
intubation 
and 
mechanical ventilation will be necessary to improve 
oxygenation and enhance carbon dioxide clearance 
by the body. 
 
Head and neck trauma 
Any patient with severe head and neck 
trauma can have significant airway distortion which 
can make direct laryngoscopy and endotracheal 
intubation difficult or impossible. Blood in the 
mouth and oropharynx is often encountered. 
Adequate suction should be immediately available 
before 
attempts 
at 
laryngoscopy 
are 
made. 
Hematoma formation in the mouth or neck can also 
distort 
anatomy 
making 
visualization 
more 
challenging. In some cases, patients may have direct 
injury to the glottic opening and/or the trachea. For 
such patients, a head and neck surgeon should be 
consulted as soon as possible. It may be necessary to 
proceed directly with cricothyroidotomy or awake 
tracheostomy depending on the urgency of the 
situation.  
 
Left neck hematoma after stab wound to the neck. A hematoma 
like this has the potential to deviate the airway significantly and 
make safe orotracheal intubation difficult or impossible. Photo 
courtesy of Dr. Demetrios Demetriades. 
 
Traumatic Brain Injury 
As mentioned above, most patients with a 
GCS less than 8 from traumatic brain injury (TBI) 
are unable to effectively protect their airways or 
maintain ventilation.  Hypoventilation will lead to 
hypoxia and hypercarbia, both of which can further 
depress consciousness and lead to secondary brain 
injury. Most TBI patients should be administered 
100% oxygen by non-rebreather mask if GCS is 
greater than 8 and ventilation appears adequate. If 
not, the decision should be made earlier rather than 
Airway Management in Trauma 
Gregory Sund, Matthew Kynes, Phil Yao 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
later to secure the airway with intubation and place 
the patient on controlled ventilation. TBI can take 
different forms, including diffuse axonal injury, 
subdural hematoma, epidural hematoma, and others. 
The major concern for TBI is maintaining adequate 
cerebral perfusion in the setting of elevated 
intracranial pressure (ICP). Airway manipulation can 
cause tachycardia and acute hypertension which may 
worsen ICP and reduce cerebral perfusion. Induction 
medications should maintain stable hemodynamics. 
Intubation should be performed only when adequate 
anesthetic depth is obtained. After intubation, mild 
hyperventilation may be initiated to reduce ICP until 
definitive therapy can be provided.  
Succinylcholine  can raise intracranial  
pressure so it should be used with caution in a patient 
with a head injury. However, it has the most rapid 
onset of all the paralytics, so the decision to avoid it 
must be balanced with the need for rapid and safe 
airway control in a trauma patient with multiple 
injuries.  
 
Endotracheal Intubation of a Trauma Patient:  
 
Both the patient’s cervical spine and airway 
are at risk during this maneuver- it is crucial to have 
adequate, experienced help available. All people 
involved 
must 
be 
committed 
to 
avoiding 
hyperextension of the neck. Providers with advanced 
video-endoscopic airway equipment may make a 
first attempt at intubation without removing the 
cervical collar- this depends on your experience and 
comfort with this technique.  
 
Preparation: 
1. Airway equipment:  
● Endotracheal tube of appropriate size with stylet 
and syringe: check balloon cuff 
● Laryngoscope blade: choose whichever is most 
familiar; most common is Miller 2, Macintosh 3, 
or Macintosh 4 
● Video laryngoscopy: if available 
● Bougie 
● Laryngeal Mask Airway 
● Capnometry or End Tidal CO2 detector 
 
2. Medications:  
● Does the patient need a hypnotic agent like 
propofol, 
etomidate, 
ketamine, 
and/or 
midazolam? What is their volume status and will 
they tolerate vasodilation? 
● Rapid-acting 
neuromuscular 
blockade: 
succinylcholine at 1 mg/kg or rocuronium at 1.2 
mg/kg 
 
Commonly used sedation agents for intubation and some of 
their side effects 
 
 
Commonly used paralytics and their duration of onset. Recall 
that during the time of onset, the patient may not be able to 
breathe but may not be paralyzed enough to intubate, so a 
shorter onset is almost always preferable.  
 
 
3. Other considerations:  
● Equipment for suction  
● Personal 
protective 
equipment 
(especially 
eyewear)  
● Stethoscope  
● Appropriate vascular access  
● Breathing circuit with oxygen cylinder 
● Available provider with skills and equipment for 
surgical airway 
 
Procedure:  
1. Assign 
roles 
for 
intubating, 
injecting 
medications, holding cricoid pressure, and 
providing manual in-line stabilization. All blunt 
trauma patients are assumed to have cervical 
spine injury until proven otherwise. 
2. Discuss any concerns with airway management 
(blood, vomit, abnormal anatomy from trauma 
and/or masses) 
3. Preoxygenate (if able) 
Airway Management in Trauma 
Gregory Sund, Matthew Kynes, Phil Yao 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The cervical collar has been opened but not removed from the 
patient. The assistant provides cervical stabilization using the 
“earmuff” technique. The laryngeal mask airway is held in 
place using the one handed “EC” hold.  
 
4. After all teams have expressed readiness, give 
neuromuscular blocking agent +/- hypnotic 
5. Open the cervical collar and move the anterior 
part to the side, without fully removing the collar. 
Another assistant applies cricoid pressure (see 
“Risk of Pulmonary Aspiration” above.)  
6. Perform laryngoscopy and intubation without 
hyperextending the neck. Adjuncts include 
intubating bougie and video laryngoscope.  
 
As the assistant maintains cervical stabilization, another assistant 
provides cricoid pressure. Note that the intubator, whose main 
concern is seeing the vocal cords, is working “against” the one 
stabilizing the airway.  
 
7. Attach breathing circuit and auscultate for 
bilateral breath sounds. Have the assistant 
maintain cricoid pressure, if applied, until 
intubation is confirmed.  
 
After intubation has been confirmed, release cricoid pressure 
and replace the cervical collar. Secure the airway.  
 
8. If initial attempt unsuccessful and patient has not 
desaturated <90%, reattempt with different 
laryngoscopy technique or have a different 
person intubate 
9. If attempts have been unsuccessful and the 
patient is desaturating, provide gentle mask 
ventilation while holding cricoid pressure. See 
“Pitfalls” below for further management.  
 
Pitfalls:  
 
The dreaded “Can not intubate, can not 
ventilate” situation must be foreseen and avoided if 
possible. An experienced operator will recognize 
situations, described above, that make this situation 
more likely. Proceed with great care!  
● Avoid airway trauma by reducing the number of 
intubation attempts. In a teaching situation, you 
must balance the needs of the learner with the 
needs of the patient.  
● If you are unable to intubate and the patient is 
chemically paralyzed, consider placing a 
laryngeal mask airway (LMA) rather than 
attempting intubation again and traumatizing the 
airway further. Wait for the paralytic to wear off 
and for the patient to breathe spontaneously again 
(without fully awakening.) This buys you more 
Airway Management in Trauma 
Gregory Sund, Matthew Kynes, Phil Yao 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
time as you plan the next approach, rather than 
trapping you in futile repeated attempts as the 
patient becomes progressively hypoxic. 
● Your next attempt may involve different 
equipment (including fiber optic or video 
equipment,) a smaller endotracheal tube, or a 
more experienced operator. It is important to 
make the best arrangements in a calm and 
unhurried manner, rather than frantically as the 
patient is desaturating. Using the LMA until the 
patient can breathe spontaneously allows you to 
take this approach.  
 
An intubating bougie with endotracheal tube loaded. The end 
on the left is passed through the vocal cords. As the tip passes 
over the tracheal rings, the operator feels this feedback and 
tracheal position is confirmed. The endotracheal tube is then 
advanced over the bougie into the trachea. Source: Baker JB et 
al, DOI: 10.5811/WESTJEM.2015.4.22857  
 
 
Intubation using a fiberoptic glidescope. Note that the 
anesthetist is holding the blade with her left hand and an 
endotracheal tube with a stylet in the right hand, watching the 
screen preparing to insert the tip of the tube between the vocal 
cords as seen on the screen (Red arrow.) 
 
● If you are unable to ventilate through LMA after 
paralysis in the above situation, your only option 
is a surgical airway. Again, this situation should 
be foreseen in the high-risk situations described 
above. Have an experienced operator with the 
necessary equipment standing by.  
 
Conclusion 
Airway management in trauma victims is 
often required to ensure a positive outcome but can 
be challenging. Therefore, it is important to 
understand the particularities of different types of 
trauma as discussed above and to have a plan in place 
for managing the airway in each situation. As with 
any critical situation that occurs in the hospital, 
communication and teamwork will be the most 
important tools at your disposal. Calling for help 
early, using closed-loop communication, and 
preparing beforehand for such situations may make 
the difference between a secure and safe airway and 
a post-traumatic mortality. 
 
Gregory Sund, MD 
AIC Kijabe Hospital  
Kenya 
 
Matthew Kynes, MD 
AIC Kijabe Hospital 
Kenya 
 
Phil Yao, MD 
University of California, San Diego 
California, USA 
 
November 2022 
