Blood in the Airway: RSI in a Hypoperfusing Trauma Patient

Why this is difficult

• Physiology: SpO2 88% on a high-flow mask means little oxygen reserve; apnea time will be short.
• Anatomy: midface instability, blood, vomitus, and a clenched jaw make bag-mask ventilation and laryngoscopy unreliable.
• Hemodynamics: BP 84/48 and HR 132 mean induction drugs can precipitate cardiovascular collapse.

Plan

1. Suction immediately and repeatedly; use the rigid catheter for large clots and keep a second suction ready.
2. Position for laryngoscopy: head-up/ramped if tolerated, with manual in-line stabilization if c-spine injury is possible.
3. Preoxygenate with a tight-seal bag-mask and PEEP while preparing equipment; add nasal cannula apneic oxygenation at 15 L/min.
4. Insert an oral airway if tolerated; avoid blind nasal passage because of midface trauma.
5. Prepare video laryngoscopy, a bougie, a supraglottic airway, and a surgical airway kit before the first attempt.
6. Limit attempts to two by the most experienced operator; each attempt should be brief and followed by reoxygenation.

Reasoning The greatest threat is desaturation during a bloody, anatomically distorted intubation. The plan should maximize oxygen before the attempt and minimize the time spent with the airway unsecured. A supraglottic airway is a bridge, not a definitive solution, and a surgical airway must be anticipated early because the patient may be difficult to bag and difficult to intubate.

Induction

• Ketamine 1–1.5 mg/kg IV is a reasonable choice in hemorrhagic shock because it preserves sympathetic tone better than propofol, but reduce the dose (0.5–1 mg/kg) in severe shock and have a pressor ready.
• Etomidate 0.2–0.3 mg/kg is hemodynamically neutral but may suppress adrenal function, which matters in septic or prolonged shock.
• Avoid propofol and large-dose benzodiazepines in this pressure.

Paralysis

• Rocuronium 1.2 mg/kg provides rapid, reliable intubating conditions and avoids the hyperkalemia risk of succinylcholine if there is crush injury, prolonged immobility, or denervation.
• Succinylcholine 1–1.5 mg/kg is acceptable in acute trauma without those risks, but rocuronium is the safer default here because the mechanism could involve a crush component.

Supporting measures

• Give a 500-mL isotonic fluid bolus or blood products if available while preparing.
• Draw up push-dose epinephrine (10 mcg/mL) or phenylephrine before induction.
• Titrate to effect and reassess BP immediately after induction.

Reasoning The goal is to blunt awareness and sympathetic response without worsening the existing shock. Drug doses should be reduced in shock, and the paralytic should be dosed for reliable first-attempt success rather than for convenience. Hemodynamic support should be prepared before the drug is pushed, not after the pressure falls.

Immediate action

1. Stop the attempt, withdraw the blade, and suction aggressively.
2. Resume bag-mask ventilation with an oral airway and two-person technique; add PEEP and 100% oxygen.
3. If bag-mask ventilation is ineffective, place a supraglottic airway as a rescue bridge.
4. Reposition, suction again, and allow one final attempt by the most experienced operator using video laryngoscopy and a bougie.

Surgical airway criteria

• Cannot intubate and cannot oxygenate despite suction, positioning, and a supraglottic airway.
• SpO2 continues to fall below 80% with no improvement.
• Blood or anatomy prevents any effective ventilation.
• The patient is peri-arrest from hypoxia.

Procedure choice Perform a surgical cricothyrotomy if the anatomy allows; in a patient with midface trauma, cricothyrotomy is preferred over blind nasal or further oral attempts.

Reasoning The first priority after a failed attempt is oxygen, not another look. Repeated attempts in a bloody airway cause trauma, swelling, and worsening hypoxia. The decision to cut should be made early, based on the inability to oxygenate, rather than after the patient has arrested.