Guidelines for Emergency Tracheal IGuidelines for Emergency Tracheal Intubation Immediately after Traumatntubation Immediately after Traumat

ic Injuryic Injury[CLINICAL MANAGEMENT UPDATE[CLINICAL MANAGEMENT UPDATE]]

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Acute postinjury respiratory system insAcute postinjury respiratory system insufficiencyufficiency

The primary concern is hypoxemic hypoxia The primary concern is hypoxemic hypoxia and subsequent hypoxic encephalopathy oand subsequent hypoxic encephalopathy or cardiac arrest. r cardiac arrest.

A secondary problem is hypercarbia, cereA secondary problem is hypercarbia, cerebral vasodilation and acidemia. bral vasodilation and acidemia.

An additional concern is aspiration, pneumAn additional concern is aspiration, pneumonia, or ARDS and acute lung injury.onia, or ARDS and acute lung injury.

The primary categories of respiratory The primary categories of respiratory system insufficiencysystem insufficiency

Airway obstruction, hypoventilation, lung injury, Airway obstruction, hypoventilation, lung injury, and impaired laryngeal reflexes and impaired laryngeal reflexes

Airway obstruction can occur with cervical spine Airway obstruction can occur with cervical spine injury, severe cognitive impairment (GCS<= 8), injury, severe cognitive impairment (GCS<= 8), severe neck injury, severe maxillofacial injury, or severe neck injury, severe maxillofacial injury, or smoke inhalation. smoke inhalation.

Hypoventilation can occur with airway Hypoventilation can occur with airway obstruction, cardiac arrest, severe cognitive obstruction, cardiac arrest, severe cognitive impairment, or cervical spinal injury. impairment, or cervical spinal injury.

Trauma patients requiring emergency tTrauma patients requiring emergency tracheal intubationracheal intubation

The mean study Injury Severity Score (ISS) is 29;The mean study Injury Severity Score (ISS) is 29; ( varies from 17 to 54). ( varies from 17 to 54).

The average study GCS score for trauma patientThe average study GCS score for trauma patients is 6.5 (3–15). s is 6.5 (3–15).

The mean study mortality rate for emergency traThe mean study mortality rate for emergency tracheal intubation in trauma patients is 41%, ( 2% cheal intubation in trauma patients is 41%, ( 2% to 100% ).to 100% ).

Substantial variation in the percentages of trSubstantial variation in the percentages of trauma patients undergoing emergency tracheauma patients undergoing emergency trache

al intubational intubation For aeromedical settings, the percentage of patiFor aeromedical settings, the percentage of pati

ents is 18.5%; ( 6% to 51% )ents is 18.5%; ( 6% to 51% ) The ground EMS studies indicate that the rate of The ground EMS studies indicate that the rate of

patients is 4.0% ( 2% to 37% )patients is 4.0% ( 2% to 37% ) For trauma center settings, the percentage of paFor trauma center settings, the percentage of pa

tients undergoing tracheal intubation is 24.5% ( tients undergoing tracheal intubation is 24.5% ( 9% to 28%) 9% to 28%)

Indications of emergency tracheal intuIndications of emergency tracheal intubation in trauma patientsbation in trauma patients

a) Airway obstructiona) Airway obstructionb) Hypoventilationb) Hypoventilationc) Severe hypoxemia (hypoxemia despite c) Severe hypoxemia (hypoxemia despite

supplemental oxygen)supplemental oxygen)d) Severe cognitive impairment d) Severe cognitive impairment (GCS score <= 8)(GCS score <= 8)e) Cardiac arreste) Cardiac arrest f) Severe hemorrhagic shockf) Severe hemorrhagic shock

Indications of emergency tracheal intuIndications of emergency tracheal intubation in smoke inhalation patientsbation in smoke inhalation patients

a) Airway obstructiona) Airway obstructionb) Severe cognitive impairment (GCS score <= 8)b) Severe cognitive impairment (GCS score <= 8)c) Major cutaneous burn (>=40%)c) Major cutaneous burn (>=40%)d) Prolonged transport timed) Prolonged transport timee) Impending airway obstruction:e) Impending airway obstruction: i. Moderate to severe facial burni. Moderate to severe facial burn ii. Moderate to severe oropharyngeal burnii. Moderate to severe oropharyngeal burn iii. Moderate to severe airway injury seen on endoiii. Moderate to severe airway injury seen on endo

scopyscopy

SCIENTIFIC FOUNDATION TO SCIENTIFIC FOUNDATION TO CHARACTERIZE PATIENTS IN CHARACTERIZE PATIENTS IN

NEED OF NEED OF EMERGENCY TRACHEAL EMERGENCY TRACHEAL

INTUBATION IMMEDIATELY INTUBATION IMMEDIATELY AFTER TRAUMATIC INJURYAFTER TRAUMATIC INJURY

Trauma Patients with Airway ObstructionTrauma Patients with Airway Obstruction

C- spine injury can have airway obstruction secoC- spine injury can have airway obstruction secondary to cervical hematoma ndary to cervical hematoma

The need for emergency tracheal intubation in pThe need for emergency tracheal intubation in patients with C-spine injury is 22%. atients with C-spine injury is 22%.

Other patients with severe cognitive impairment Other patients with severe cognitive impairment severe neck injury, laryngotracheal injury, severe neck injury, laryngotracheal injury,

severe maxillofacial injury, commonly have airwasevere maxillofacial injury, commonly have airway obstruction and associated hypoxemiay obstruction and associated hypoxemia

Level I Recommendation Level I Recommendation Trauma patients with airway obstruction need Trauma patients with airway obstruction need

emergency tracheal intubation.emergency tracheal intubation.

Trauma Patients with HypoventilationTrauma Patients with Hypoventilation

That patients with cervical spinal cord injury ofteThat patients with cervical spinal cord injury often have hypoventilation. The need for emergencn have hypoventilation. The need for emergency tracheal intubation is 22% (14–48%). y tracheal intubation is 22% (14–48%).

Other patients with severe cognitive impairment Other patients with severe cognitive impairment have abnormal breathing patterns and can have have abnormal breathing patterns and can have hypoventilation. hypoventilation.

Level I RecommendationLevel I Recommendation Trauma patients with hypoventilation need eTrauma patients with hypoventilation need e

mergency tracheal intubationmergency tracheal intubation

Trauma Patients with Severe HypoxemiaTrauma Patients with Severe Hypoxemia Severe hypoxemia is defined as persistent hypoxemia, dSevere hypoxemia is defined as persistent hypoxemia, d

espite the administration of supplemental oxygen. espite the administration of supplemental oxygen. Hypoxemia may be secondary to airway obstruction, hypHypoxemia may be secondary to airway obstruction, hyp

oventilation, lung injury, or aspiration oventilation, lung injury, or aspiration Blunt or penetrating thoracic injury can cause respiratory Blunt or penetrating thoracic injury can cause respiratory

distress and hypoxemia. distress and hypoxemia. Emergency tracheal intubation is required for 40% to 60Emergency tracheal intubation is required for 40% to 60

% of patients sustaining pulmonary contusion, chest wall % of patients sustaining pulmonary contusion, chest wall fractures, or flail chest. fractures, or flail chest.

Level I Recommendation Level I Recommendation Trauma patients with severe hypoxemia need Trauma patients with severe hypoxemia need

emergency tracheal intubation.emergency tracheal intubation.

Trauma Patients with Severe Cognitive Trauma Patients with Severe Cognitive Impairment (GCS Score <= 8)Impairment (GCS Score <= 8)

The trauma patients with severe cognitive impairThe trauma patients with severe cognitive impairment (GCS score <= 8) commonly have airway oment (GCS score <= 8) commonly have airway obstruction, hypoventilation, and hypoxia. The resbstruction, hypoventilation, and hypoxia. The respiratory system insufficiency worsens the neurolpiratory system insufficiency worsens the neurologic outcome for postinjury severe cognitive impogic outcome for postinjury severe cognitive impairmentairment

EMS ground crews may intubate a much lower pEMS ground crews may intubate a much lower percentage of patients with severe cognitive impaiercentage of patients with severe cognitive impairment (33%) as opposed to patients managed by rment (33%) as opposed to patients managed by aeromedical crews (85%). aeromedical crews (85%).

Scientific EvidenceScientific Evidence Winchell and Hoyt found a significant reduction in Winchell and Hoyt found a significant reduction in

mortality with prehospital tracheal intubation.mortality with prehospital tracheal intubation.With severe brain injury and extracranial trauma With severe brain injury and extracranial trauma : 35.6% VS 57.4% : 35.6% VS 57.4% Isolated severe brain injury: 22.8% VS 49.6% Isolated severe brain injury: 22.8% VS 49.6% Cooper and Boswell showed a decrease in injury-Cooper and Boswell showed a decrease in injury-

related complications related complications Hicks et al. demonstrated a reduction in hypoxemiHicks et al. demonstrated a reduction in hypoxemi

a during transfer to a trauma center a during transfer to a trauma center Level I RecommendationLevel I Recommendation Trauma patients with severe cognitive impairmTrauma patients with severe cognitive impairm

ent (GCS score <= 8) need emergency tracheal ent (GCS score <= 8) need emergency tracheal intubation.intubation.

Trauma Patients with Cardiac ArrestTrauma Patients with Cardiac Arrest 10 studies of trauma patients (3567 patients ) un10 studies of trauma patients (3567 patients ) un

dergoing emergency tracheal intubation provide dergoing emergency tracheal intubation provide evidence that patients with cardiac arrest need trevidence that patients with cardiac arrest need tracheal intubation.acheal intubation.

Level I Recommendation Level I Recommendation Trauma patients in cardiac arrest need emergeTrauma patients in cardiac arrest need emerge

ncy tracheal intubation.ncy tracheal intubation.

Trauma Patients with Severe Trauma Patients with Severe Hemorrhagic ShockHemorrhagic Shock

10 studies of trauma patients (5633) undergoing 10 studies of trauma patients (5633) undergoing emergency tracheal intubation provide evidence emergency tracheal intubation provide evidence that patients with severe hemorrhagic shock neethat patients with severe hemorrhagic shock need tracheal intubationd tracheal intubation

Level I RecommendationLevel I Recommendation

Emergency tracheal intubation is needed for sEmergency tracheal intubation is needed for severe hemorrhagic shock in trauma patients evere hemorrhagic shock in trauma patients and is essential when emergency thoracotoand is essential when emergency thoracotomy or celiotomy is requiredmy or celiotomy is required..

Patients with Smoke InhalationPatients with Smoke Inhalation Acute respiratory system insufficiency can be caAcute respiratory system insufficiency can be ca

used by CO toxicity and thermal or combustion-pused by CO toxicity and thermal or combustion-product tissue injury roduct tissue injury

Typical acute manifestations of smoke inhalation Typical acute manifestations of smoke inhalation are airway obstruction, hypoventilation, and seveare airway obstruction, hypoventilation, and severe cognitive impairment. re cognitive impairment.

Although severe hypoxemia is not typical, it can Although severe hypoxemia is not typical, it can occur if there has been pulmonary aspiration or troccur if there has been pulmonary aspiration or traumatic lung contusion. aumatic lung contusion.

Tracheal intubation is needed in 16.6% of burn pTracheal intubation is needed in 16.6% of burn patients. The incidence of smoke inhalation injury atients. The incidence of smoke inhalation injury for patients who have burn injury is 10.7%for patients who have burn injury is 10.7%

Clinical indicators of smoke inhalationClinical indicators of smoke inhalation* Closed-space injury * Closed-space injury * Facial burns * Facial burns * Singed nasal vibrissae * Singed nasal vibrissae * Soot in oropharynx * Soot in oropharynx * Oropharyngeal burns* Oropharyngeal burns* Hoarseness * Hoarseness * Airway obstruction * Airway obstruction * Wheezing * Wheezing * Carbonaceous sputum * Carbonaceous sputum * Uunconsciousness * Uunconsciousness

Scientific Evidence Scientific Evidence Investigators have described 16 groups of smoke inhalatiInvestigators have described 16 groups of smoke inhalati

on patients who needed tracheal intubation. The overall on patients who needed tracheal intubation. The overall rate of emergency tracheal intubation was 62.2% (605 of rate of emergency tracheal intubation was 62.2% (605 of 972). 972).

The American College of Surgeons Committee on TraumThe American College of Surgeons Committee on Trauma lists the following as indicators of smoke inhalation inja lists the following as indicators of smoke inhalation injury: facial burns, singeing of the eyebrows and nasal vibury: facial burns, singeing of the eyebrows and nasal vibrissae, carbon deposits and acute inflammatory changes rissae, carbon deposits and acute inflammatory changes in the oropharynx, carbonaceous sputum, history of impin the oropharynx, carbonaceous sputum, history of impaired mentation and/or confinement in a burning enviroaired mentation and/or confinement in a burning environment, explosion with burns to head and torso, and carbnment, explosion with burns to head and torso, and carboxyhemoglobin level greater than 10% if the patient is inoxyhemoglobin level greater than 10% if the patient is involved in a fire. 149 The College endorses tracheal intubvolved in a fire. 149 The College endorses tracheal intubation in smoke inhalation patients with a prolonged tranation in smoke inhalation patients with a prolonged transport time or stridor.sport time or stridor.

The National Association of Emergency Medical The National Association of Emergency Medical Technicians recommends intubation when the pTechnicians recommends intubation when the potential for losing the airway exists because of protential for losing the airway exists because of progressive edema. ogressive edema.

The American College of Emergency PhysicianThe American College of Emergency Physicians and the National Association of EMS Physicians and the National Association of EMS Physicians advocate tracheal intubation for (1) patients res advocate tracheal intubation for (1) patients requiring secondary transport to a burn center and quiring secondary transport to a burn center and receiving large-volume fluid infusion, (2) stridor, receiving large-volume fluid infusion, (2) stridor, or (3) unconsciousness. or (3) unconsciousness.

Level I RecommendationLevel I Recommendation

Smoke inhalation patients with the following conditions nSmoke inhalation patients with the following conditions need emergency tracheal intubation:eed emergency tracheal intubation:

1. airway obstruction1. airway obstruction 2. severe cognitive impairment (GCS score <= 8)2. severe cognitive impairment (GCS score <= 8) 3. a major cutaneous burn (>=40%)3. a major cutaneous burn (>=40%) 4. impending airway obstruction:4. impending airway obstruction: a) moderate to severe facial burna) moderate to severe facial burn b) moderate to severe oropharyngeal burn b) moderate to severe oropharyngeal burn c) moderate to severe airway injury seen on endoscopc) moderate to severe airway injury seen on endoscop

yy 5. a prolonged transport time5. a prolonged transport time

RECOMMENDATIONS RECOMMENDATIONS FOR PROCEDURAL FOR PROCEDURAL

OPTIONS IN TRAUMA OPTIONS IN TRAUMA PATIENTS UNDERGOING PATIENTS UNDERGOING EMERGENCY TRACHEAL EMERGENCY TRACHEAL

INTUBATIONINTUBATION

1. 1. Orotracheal intubation guided by direct laryngosOrotracheal intubation guided by direct laryngoscopy is the emergency tracheal intubation procecopy is the emergency tracheal intubation procedure of choice for trauma patients.dure of choice for trauma patients.

2. When the patient’s jaws are not flaccid and OTI i2. When the patient’s jaws are not flaccid and OTI is needed, a drug regimen should be given to acs needed, a drug regimen should be given to achieve the following clinical objectives:hieve the following clinical objectives:

a) neuromuscular paralysisa) neuromuscular paralysis b) sedation, as neededb) sedation, as needed c) maintain hemodynamic stabilityc) maintain hemodynamic stability d) prevent intracranial hypertensiond) prevent intracranial hypertension e) prevent vomitinge) prevent vomiting f) prevent intraocular content extrusionf) prevent intraocular content extrusion

3. Enhancements for safe and effective emergenc3. Enhancements for safe and effective emergency tracheal intubation include:y tracheal intubation include:

a) availability of experienced personnela) availability of experienced personnel b) pulse oximetry monitoringb) pulse oximetry monitoring c) maintenance of cervical spine neutralityc) maintenance of cervical spine neutrality d) application of cricoid pressured) application of cricoid pressure e) carbon dioxide monitoringe) carbon dioxide monitoring4. Cricothyrostomy is appropriate when emergenc4. Cricothyrostomy is appropriate when emergenc

y tracheal intubation is needed and the vocal coy tracheal intubation is needed and the vocal cords cannot be visualized during laryngoscopy or rds cannot be visualized during laryngoscopy or the pharynx is obscured by copious amounts of the pharynx is obscured by copious amounts of blood or vomitus.blood or vomitus.

Emergency Orotracheal Intubation in TrEmergency Orotracheal Intubation in Trauma Patientsauma Patients

The overall failure-to-intubate rate for OTI withouThe overall failure-to-intubate rate for OTI without drug-assistance was 20.8%t drug-assistance was 20.8%

The overall intubation success rate for OTI with The overall intubation success rate for OTI with drug-assistance was 96.3%drug-assistance was 96.3%

The overall complication rate for OTI with drug-aThe overall complication rate for OTI with drug-assistance was calculated to be 3.6% ssistance was calculated to be 3.6%

The typical indication for drug-assisted OTI isThe typical indication for drug-assisted OTI isjaw rigidityjaw rigidity A drug regimen used to enhance OTI successA drug regimen used to enhance OTI success should consider the need for patient sedation, anshould consider the need for patient sedation, an

d patient-induced paralysis d patient-induced paralysis

Emergency Nasotracheal Intubation in TEmergency Nasotracheal Intubation in Trauma Patientsrauma Patients

The overall intubation success rate was 76.8%The overall intubation success rate was 76.8% NTI is likely to fail in a significant percentage of tNTI is likely to fail in a significant percentage of t

rauma patients rauma patients The principle indications for emergent NTI in trauThe principle indications for emergent NTI in trau

ma patients were jaw rigidity and cervical spine ima patients were jaw rigidity and cervical spine injury njury

Emergency Fibroptic Tracheal IntubatioEmergency Fibroptic Tracheal Intubation in Trauma Patientsn in Trauma Patients

During the past 22 years, attempts at emergency During the past 22 years, attempts at emergency tracheal intubation with fiberoptic assistance havtracheal intubation with fiberoptic assistance have been described in 42 trauma patients and was e been described in 42 trauma patients and was successful in 35 patientssuccessful in 35 patients

Indications for emergency fiberoptic-assisted traIndications for emergency fiberoptic-assisted tracheal intubation were rigid jaws, cervical spine incheal intubation were rigid jaws, cervical spine injury, laryngotracheal injury,and obscured pharynjury, laryngotracheal injury,and obscured pharynx from blood or vomitusx from blood or vomitus

Comparing Emergency Tracheal IntubatComparing Emergency Tracheal Intubation Procedures in Traumaion Procedures in Trauma

PatientsPatients OTI was the most common method for emergenOTI was the most common method for emergen

cy tracheal intubationcy tracheal intubation Emergency intubation procedure success rates Emergency intubation procedure success rates

were OTI without drug-assistance, 79.2% ; OTI were OTI without drug-assistance, 79.2% ; OTI with drug-assistance, 96.3%; NTI, 76.8%; and criwith drug-assistance, 96.3%; NTI, 76.8%; and cricothyrostomy, 95.7%cothyrostomy, 95.7%

Emergency intubation failure rates were OTI withEmergency intubation failure rates were OTI without drug-assistance, 20.8% ; OTI with drug-assisout drug-assistance, 20.8% ; OTI with drug-assistance, 3.7% ; NTI, 23.2% ; and cricothyrostomy, tance, 3.7% ; NTI, 23.2% ; and cricothyrostomy, 4.3%4.3%

Level I RecommendationsLevel I Recommendations* neuromuscular paralysis* neuromuscular paralysis* sedation, as needed* sedation, as needed* maintain hemodynamic stability* maintain hemodynamic stability* prevent intracranial hypertension* prevent intracranial hypertension* prevent vomiting* prevent vomiting* prevent intraocular content extrusion* prevent intraocular content extrusionEnhancements for safe and effective emergency tracheEnhancements for safe and effective emergency trache

al intubation in trauma patients include the followingal intubation in trauma patients include the following* availability of experienced personnel* availability of experienced personnel* pulse oximetry monitoring* pulse oximetry monitoring* maintenance of cervical spine neutrality* maintenance of cervical spine neutrality* application of cricoid pressure* application of cricoid pressure* carbon dioxide monitoring* carbon dioxide monitoring

Emergency Cricothyrostomy and TrachEmergency Cricothyrostomy and Tracheostomy in Trauma Patientseostomy in Trauma Patients

An overall emergency cricothyrostomy intubation An overall emergency cricothyrostomy intubation success rate of 95.8%success rate of 95.8%

The overall complication rate for emergency cricThe overall complication rate for emergency cricothyrostomy was 9.6%othyrostomy was 9.6%

Fiberoptic tracheal intubation versus emFiberoptic tracheal intubation versus emergency department cricothyrostomy.ergency department cricothyrostomy.

When the vocal cords cannot be visualizedWhen the vocal cords cannot be visualized The fiberoptic intubation success rate described The fiberoptic intubation success rate described

in the literature was 83.3% ( 42 patients )in the literature was 83.3% ( 42 patients ) A reliable rate for emergency department cricothA reliable rate for emergency department cricoth

yrostomy success is not availableyrostomy success is not available Future trauma patient investigations are necessaFuture trauma patient investigations are necessa

ry to delineate the precise roles for fiberoptic intury to delineate the precise roles for fiberoptic intubation and cricothyrostomybation and cricothyrostomy

Emergency Tracheostomy in Trauma PaEmergency Tracheostomy in Trauma Patientstients

16 studies have described the performance of e16 studies have described the performance of emergency tracheostomy in 135 trauma patientsmergency tracheostomy in 135 trauma patients

Primary reason for emergency tracheostomyPrimary reason for emergency tracheostomy

was laryngotracheal injury.was laryngotracheal injury.

Level I RecommendationLevel I Recommendation

Cricothyrostomy is appropriate when emergency Cricothyrostomy is appropriate when emergency tracheal intubation is needed andtracheal intubation is needed and

the vocal cords cannot be visualized during larynthe vocal cords cannot be visualized during laryngoscopy or the pharynx isgoscopy or the pharynx is

obscured by copious amounts of blood or vomituobscured by copious amounts of blood or vomitus.s.

Emergency Combitube and Laryngeal MEmergency Combitube and Laryngeal Mask Airway in Trauma Patientsask Airway in Trauma Patients

Emergency Combitube in trauma patientsEmergency Combitube in trauma patientsIndications: obscured pharynx from blood or vomitIndications: obscured pharynx from blood or vomit

us and nonvisualized vocal cordsus and nonvisualized vocal cords Patients undergoing emergency Combitube placPatients undergoing emergency Combitube plac

ement typically had a GCS score of 3 after rapid-ement typically had a GCS score of 3 after rapid-sequencedrug administration with failed OTI or csequencedrug administration with failed OTI or cardiac arrestardiac arrest

The success rate in five studies was 90.9%The success rate in five studies was 90.9%

Emergency Laryngeal Mask Airway in Emergency Laryngeal Mask Airway in Trauma PatientsTrauma Patients

Patients undergoing emergency LMA placement Patients undergoing emergency LMA placement typically had a GCS score of 3 after rapid-sequetypically had a GCS score of 3 after rapid-sequence drug administration with failed OTInce drug administration with failed OTI

The indication was failed drug-assisted OTI secThe indication was failed drug-assisted OTI secondary to nonvisualized vocal cords, obscured pondary to nonvisualized vocal cords, obscured pharynx from blood or vomitus, and cervical spine harynx from blood or vomitus, and cervical spine injury.injury.

The published data describing emergencyThe published data describing emergency

Combitube and LMA placement in trauma patientCombitube and LMA placement in trauma patients is limited.s is limited.

The American College of Emergency Physicians The American College of Emergency Physicians and the National Association of EMS Physicians and the National Association of EMS Physicians recommend the Combitube and LMA for endotrarecommend the Combitube and LMA for endotracheal intubation failure in trauma pt’s.cheal intubation failure in trauma pt’s.

as a short-term airway until endotracheal or surgias a short-term airway until endotracheal or surgical airway access can be obtainedcal airway access can be obtained

SUMMARYSUMMARY

Emergency tracheal intubation is needeEmergency tracheal intubation is needed in trauma patientsd in trauma patients

a) airway obstructiona) airway obstruction

b) hypoventilationb) hypoventilation

c) severe hypoxemia (hypoxemia despite c) severe hypoxemia (hypoxemia despite supplemental oxygen)supplemental oxygen)

d) severe cognitive impairment (GCS score d) severe cognitive impairment (GCS score <= 8)<= 8)

e) cardiac arreste) cardiac arrest

f) severe hemorrhagic shockf) severe hemorrhagic shock

Emergency tracheal intubation in SmoEmergency tracheal intubation in Smoke inhalation patientske inhalation patients

airway obstructionairway obstruction severe cognitive impairment (GCS score <= 8)severe cognitive impairment (GCS score <= 8) a major cutaneous burn (>=40%)a major cutaneous burn (>=40%) impending airway obstruction:impending airway obstruction: a) moderate to severe facial burna) moderate to severe facial burn b) moderate to severe oropharyngeal burn b) moderate to severe oropharyngeal burn c) moderate to severe airway injury seen on endoc) moderate to severe airway injury seen on endo

scopyscopy prolonged transport timeprolonged transport time

1. Orotracheal intubation guided by direct laryngoscopy is the emergenc1. Orotracheal intubation guided by direct laryngoscopy is the emergency tracheal intubation procedure of choice for trauma patients.y tracheal intubation procedure of choice for trauma patients.

2. When the patient’s jaws are not flaccid and OTI is needed, a drug reg2. When the patient’s jaws are not flaccid and OTI is needed, a drug regimen should be given to achieve the following clinical objectives:imen should be given to achieve the following clinical objectives:

a) neuromuscular paralysisa) neuromuscular paralysis b) sedation, as neededb) sedation, as needed c) maintain hemodynamic stabilityc) maintain hemodynamic stability d) prevent intracranial hypertensiond) prevent intracranial hypertension VII. e) prevent vomitingVII. e) prevent vomiting VIII. f) prevent intraocular content extrusionVIII. f) prevent intraocular content extrusion IX. 3. Enhancements for safe and effective emergency tracheal intubIX. 3. Enhancements for safe and effective emergency tracheal intub

ation in trauma patients include:ation in trauma patients include: X. a) availability of experienced personnelX. a) availability of experienced personnel XI. b) pulse oximetry monitoringXI. b) pulse oximetry monitoring XII. c) maintenance of cervical spine neutralityXII. c) maintenance of cervical spine neutrality XIII. d) application of cricoid pressureXIII. d) application of cricoid pressure XIV. e) carbon dioxide monitoringXIV. e) carbon dioxide monitoring XV. 4. Cricothyrostomy is appropriate when emergency tracheal intuXV. 4. Cricothyrostomy is appropriate when emergency tracheal intu

bation is needed and the vocal cords cannot be visualized during larybation is needed and the vocal cords cannot be visualized during laryngoscopy or the pharynx is obscured by copious amounts of blood or ngoscopy or the pharynx is obscured by copious amounts of blood or vomitus.vomitus.