Trauma airway with a full stomach and suspected cervical injury
A 34-year-old man is brought to the emergency department 45 minutes after a high-speed motorcycle crash. He weighs 110 kg, has a Glasgow Coma Scale of 9 (E2 V2 M5), and is in a rigid cervical collar. He has vomited once in the ambulance and has facial lacerations with blood in the oropharynx. SpO2 is 91% on a 15 L/min non-rebreather, respiratory rate 28, and he is making gurgling sounds. Blood pressure is 88/50 mmHg, heart rate 132. A CT scan shows a small frontal contusion and a suspected C5-C6 ligamentous injury. The trauma team wants to intubate before transfer to CT. The ED has video laryngoscopy, a fibreoptic scope, a size 5 intubating LMA, and a surgeon scrubbed and available for an emergency front-of-neck airway.
1. Outline your airway plan and justify each decision against the competing risks in this patient.
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Competing risks: aspiration (recent emesis, blood in airway), hypoxaemia (SpO2 91%), haemodynamic instability (shock), and cervical spine instability. There is no time for a controlled awake fibreoptic intubation, and topicalisation in a bleeding, vomiting airway is unsafe.
Plan (physiologically and anatomically staged):
- Optimise before induction: Sit up if tolerated, suction continuously, apply high-flow nasal oxygen during preoxygenation, and correct shock concurrently (blood products, vasopressor if needed). Preoxygenation may be limited; accept that desaturation will be rapid.
- First attempt = video laryngoscopy with manual in-line stabilisation. Video laryngoscopy improves glottic view in a bloody airway and allows a better angle with limited mouth opening. Use a tracheal tube with a stylet and a bougie immediately available. Do not use cricoid pressure as routine (it worsens the view).
- RSI with a haemodynamically neutral induction: Ketamine or etomidate, with rocuronium 1.2 mg/kg (or suxamethonium if no contraindication). Assume full stomach and difficult mask ventilation; avoid a second dose of suxamethonium.
- Declare a failed-attempt algorithm: Limit to a maximum of 2-3 optimised attempts by the most experienced operator. Between attempts, reoxygenate with a two-person mask technique or a second-generation supraglottic airway as a conduit for oxygenation (not as a definitive airway).
- Front-of-neck access: If 'cannot intubate, cannot oxygenate' occurs, proceed immediately to a scalpel-bougie-tube cricothyroidotomy, since a surgeon is present but should not delay the anaesthetist's own rescue.
- After intubation: Confirm with capnography, secure the tube, and maintain in-line stabilisation until imaging clears the spine.
2. The first video laryngoscopy attempt fails with a Cormack-Lehane grade 3 view and SpO2 falls to 78%. What is your immediate sequence of actions, and what makes this different from a routine difficult airway?
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Immediate sequence:
- Stop and oxygenate: Withdraw the blade, perform a two-person mask ventilation with an oral airway and suction, and consider inserting a second-generation supraglottic airway if mask ventilation is inadequate. Do not persist with laryngoscopy while desaturating.
- Optimise the next attempt: Reposition (ramp, head-up), suction blood, consider a bougie first-pass technique, and ensure the most experienced operator takes over. Limit to one further attempt.
- Reassess the 'can oxygenate' status: If SpO2 remains below 85-90% despite best efforts, declare CICO and move to front-of-neck access without delay.
Why this differs from a routine difficult airway: In a routine case, the priority is a controlled awake technique or repeated attempts with full preoxygenation. Here, preoxygenation reserve is minimal (shock, aspiration, contusion), the airway is soiled, and the cervical spine limits positioning. The safe apnoea time is short, so the decision threshold for surgical airway is much lower and the attempt limit is stricter. The presence of a surgeon does not change the anaesthetist's responsibility to perform an immediate cricothyroidotomy if needed.