DOI: 10.33962/roneuro-2022-038 Airway management in neurotrauma care. Basic considerations Indubala Maurya, Ved Prakash Maurya, Rakesh Mishra, Luis Rafael Moscote -Salazar, Tariq Janjua, Mohd Yunus, Amit Agrawal Romanian Neurosurgery (2022) XXXVI (2): pp. 216-219 DOI: 10.33962/roneuro-2022-038 www.journals.lapub.co.uk/index.php/roneurosurgery Airway management in neurotrauma care. Basic considerations Indubala Maurya1, Ved Prakash Maurya2, Rakesh Mishra3, Luis Rafael Moscote-Salazar4, Tariq Janjua5, Mohd Yunus6, Amit Agrawal7 1 Department of Anaesthesiology, Kalyan Singh Super Specialty Cancer Institute, CG City, Lucknow, INDIA 2 Department of Neurosurgery, SGPGIMS, Lucknow, INDIA 3 Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, INDIA 4 Latin-American Council of Neurocritical Care (CLaNi), COLOMBIA 5 Department of Critical Care Medicine, Physician Regional Medical Center, Naples, FL, USA 6 Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Saket Nagar, Bhopal, INDIA 7 Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal, INDIA ABSTRACT The predictability of the airway compromise affects the decision for tracheal intubation. Associated specific injuries, clinical presentation, and expected deterioration are the deciding factors regarding the need for securing the airway. Emergent or semi-urgent intubations are straightforward in the majority of patients. Airway management in trauma patients aims to improve tissue oxygenation, ensure ventilatory exchange, stabilize other injuries and prevent aspiration. Airway management in the trauma and emergency room is challenging as the emergency team has limited time for full airway assessment unlike pre-anaesthesia check-up clinic/operative room. The airway cart must be checked routinely in the emergency room for the working condition of the equipment and its availability. All trauma patients must be considered to have cervical spine injuries unless ruled out. The airway management for trauma patients is best done using a team approach including emergency medicine physicians, anaesthesiologists, surgeons, and trained paramedical staff. Regardless of the emergency room setting, airway management of a trauma patient requires effective communication and efficient teamwork. INTRODUCTION Airway management in trauma patients aims to improve tissue oxygenation, ensure ventilatory exchange, stabilize other injury and prevent aspiration. Airway management in the trauma and emergency room is challenging as the emergency team has limited time for full Keywords neurotrauma, neurocritical care, traumatic brain injury, airway management Corresponding author: Amit Agrawal Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal, India dramitagrawal@gmail.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published June 2022 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 217 Airway management in neurotrauma care airway assessment unlike pre-anaesthesia check-up clinic/operative room. Trauma patients present a varied spectrum of injury from localized to multisystem involvement. The presence of hemodynamic instability, direct airway injury, thoracic injury, combative patient (Raised Intracranial pressure/intoxication/hypoxemia), etc. can lead to difficult airway situations. Availability of trained team, synchronized teamwork, and functional airway equipment are paramount for safe airway management. 1-3 INDICATION FOR SECURING THE AIRWAY Associated specific injuries, clinical presentation, and expected deterioration are the deciding factors regarding the need for securing the airway. Emergent or semi-urgent intubations are straightforward in the majority of patients. But in some patients, it may be less clear. The Eastern Association for the Surgery of Trauma (EAST) practice management guidelines and the Advanced Trauma Life Support (ATLS) program have given indications for intubation in trauma patients. 1, 4 In general, the indication for emergency tracheal intubation in trauma patients is the failure of oxygenation or ventilation, failure to maintain/protect the airway and anticipated deterioration of the airway. (Table 1: Indication for tracheal intubation). The trauma patients may have poor oxygenation and ventilation hypoxemia or hypoventilation due to multiple factors and may not respond to simple interventions e.g., oxygen supplementation. Adequacy of oxygenation and ventilation can be assessed clinically by pulse oximetry, respiratory effort, and associated injuries. Inability to protect the airway could be due to decreased level of consciousness secondary to traumatic brain injury or intoxication. In these cases, early intubation is typically indicated. Any patients with penetrating neck injury, inhalation injury (burns from closed space fire), hemorrhagic shock (due to complicated pelvic fracture, Liver laceration) may lose airway as natural clinical course, thus they will need intubation in anticipation. The predictability of the airway compromise affects the decision for tracheal intubation. 5, 6 Table 1: Indication for tracheal intubation Eastern Association for the Surgery of Trauma (EAST) ● Hypoventilation ● Persistent hypoxemia ● Decreased level of consciousness (GCS≤ 8) ● Cardiac arrest ● Hemorrhagic shock ● Airway obstruction ● Inhalation injury ● Facial injury Advanced trauma life support (ATLS) ● Poor Respiratory efforts ● Hypoxia ● Hypercarbia ● Cyanosis ● Neurological deterioration (GCS≤ 8) ● Apnea ● Severe facial injury ● Direct airway injury ● Inhalational injury ● Unconscious patients PREPAREDNESS A preparedness and coordinated approach to airway management is the key step. 7, 8 The airway cart must be checked routinely in the emergency room for the working condition of equipment and its availability. The intuitional/local practice best determines the timing but checking after every shift is recommended. Standard airway equipment should be there in the airway cart. 9 The cart should have different sizes/types of facemasks, laryngoscopes, endotracheal tubes, oral airway, nasal airway, bougies, invasive airway equipment, etc. (Table 2: Difficult airway cart). Table 2: Difficult airway cart ● Manual Resuscitator with oxygen reservoir ● Oral and nasal airways (various sizes) ● Rescue airways device: Combi tube, Laryngeal mask airway ● Endotracheal tube introducer (Gum elastic bougie) ● Semi-rigid stylet ● Endotracheal tubes (Range of sizes) ● Laryngoscope blades of shorted design and size ● Laryngoscope handle with battery (check for functionality) ● Syringes, Lubricant, Tube ties ● Video laryngoscope ● Cricothyrotomy kit Always ensure that oxygen source and suction equipment are available in the functional stage. The emergency drug tray must have induction agents (e.g., etomidate, ketamine, propofol, etc.) and muscle relaxants (e.g., Succinylcholine, Rocuronium, etc.) 218 Indubala Maurya, Ved Prakash Maurya, Rakesh Mishra et al. beside emergency drugs. 2, 3, 10 Regardless of the emergency room setting, airway management of a trauma patient requires effective communication and efficient teamwork. The airway management for trauma patients is best done using a team approach including emergency medicine physicians, anaesthesiologist’s, surgeons, and trained paramedical staff. 11-13 Emergency intubation in the emergency room requires additional assistance to administer drugs, to ventilate the patient, to give cricoid pressure, and manual in-line stabilization (MILS) of the cervical spine if indicated. Even extra assistance is needed to control agitated patients due to head injury/intoxication. UNCOOPERATIVE/AGITATED PATIENTS The agitated patients can injure themselves. The trauma patients may be violent or agitated due to various reasons such as alcohol/drugs intoxication, hypoxia, hypercarbia, head injury, hypoglycemia, severe pain, etc. These factors should be addressed along with airway intervention. As per EAST guidelines, if the severity of agitation hinders assessment and resuscitation, intubation can be considered. 4 CRANIOFACIAL TRAUMA A significant proportion of individuals with severe maxillofacial injury, more so with pan-facial involvement, have associated traumatic brain and spine injury; therefore, spine stabilization and preventing airway compromise are challenging in these patients. The mechanisms attributed to airway compromise in maxillo-facial trauma are primarily due to tongue fall secondary to bilateral mandible fracture, displacement of the fractured maxilla, hematoma, soft-tissue oedema, foreign body, or direct laryngeal trauma. The patient should be placed in a lateral position for mid-facial trauma with the potential risk of haemorrhage and the mandible pulled forward. This technique would help remove the blood and secretion, and the airway can be easily kept patient. Oropharyngeal airway and nasopharyngeal airway devices are used in these cases because traditional manoeuvres of jaw thrust, chin lift, and head tilt may not be possible due to associated oedema or C-spine injury. While intubating, a rigid high suction device may be kept alongside the laryngoscope to prevent soiling of the airway. 14 The available options are orotracheal intubation, nasotracheal intubation, cricothyroidotomy, and tracheostomy. DIRECT AIRWAY TRAUMA In patients with direct trauma, the airway is a challenging situation for the emergency team. Direct trauma to the airway can be due to blunt or penetrating injury. Airway injury can occur at multiple levels and may be associated with a cervical spine injury, injury to the aerodigestive tract, etc. It can result in immediate or delayed airway obstruction. 5, 15, 16 General principles for the management of direct airway trauma include repeated clinical assessment because the airway can compromise due to tissue oedema or hematoma over time. Even if the patient appears clinically stable, airway management is required given anticipated deterioration. Swallowing of blood from a facial fracture can cause gastric distention and irritation thus it may increase the risk of regurgitation. The emergency team should assess the possibility of difficulty with bag-mask ventilation, endotracheal intubation, supraglottic device placement, and even with the surgical airway. A large-bore catheter suction should be used. If a difficult BMV is anticipated, an awake approach instead of RSII is safer. During bag-mask ventilation, airway obstruction can increase further due to pressure on the mandible and displacement of fractured segments. Airway disruption and bleeding make laryngoscopy and intubation challenging. Placement of supraglottic airways devices can be difficult due to distorted airway anatomy and limited mouth opening. If initial attempts to laryngoscopy fail, the surgical airway is indicated. In selected patients, the surgical airway may be the most appropriate initial approach to airway intervention. CONCLUSION All trauma patients must be considered to have cervical spine injury unless rules out. The selection of induction drugs should be based on the type/severity of the injury and the patient's hemodynamic status. A variety of effective rescue airway devices are available for use in trauma patients. 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