Synopsis
Recognise a failing traumatic airway, maintain oxygenation while limiting spinal movement, deliver a planned definitive airway, and confirm continuously that ventilation remains effective.
- Ask the patient to speak while observing work of breathing; a clear answer supports current patency but does not predict whether swelling, bleeding or fatigue will worsen.
- Open with jaw thrust, suction under direct vision and remove visible loose material; use an oropharyngeal airway only without a gag reflex and a nasopharyngeal airway cautiously when midface or skull-base injury is suspected.
- Give high-concentration oxygen during critical illness, pre-oxygenate with the best tolerated technique and preserve spontaneous ventilation until the definitive plan is ready when anatomy is concerning.
- Manual in-line stabilisation supports the head during airway work; remove or open the anterior collar section if it limits mouth opening, then reapply movement restriction after securing the airway.
- Trauma rapid-sequence induction requires a named intubator, optimised position, suction, bougie or stylet, videolaryngoscope when available, rescue supraglottic airway and prepared front-of-neck kit.
- Confirm tracheal placement with a sustained waveform capnography trace, chest movement and clinical assessment; colour change or misting alone is inadequate.
- Use lung-protective ventilation, avoid routine hyperventilation and target oxygen and carbon dioxide to the clinical context, with particular care in traumatic brain injury.
- Recheck tube depth, waveform, oxygen saturation and chest findings after every move because CT transfer, log roll and handover are common moments of displacement.
Key red flags
Stridor, gurgling, inability to speak, expanding neck swelling, severe facial disruption, soot or progressive hoarseness indicates a threatened airway requiring early expert control.
Apnoea, exhaustion, cyanosis, severe hypoxaemia, a falling GCS or loss of protective reflexes makes airway intervention time-critical even if initial anatomy appears normal.
Absent sustained waveform capnography after intubation, sudden desaturation, high airway pressure or loss of chest movement requires immediate exclusion of oesophageal placement, displacement, obstruction and pneumothorax.
Investigation priorities
Confirm and continuously monitor tracheal ventilation.
Identify clinically significant fracture or instability.
Management branches
Noisy, obstructed or inadequately ventilated traumatic airway.
- Call for anaesthetic and trauma help, maintain manual in-line stabilisation, apply jaw thrust and clear blood, vomit or visible foreign material with effective suction.
- Give high-concentration oxygen and use correctly sized airway adjuncts; assist ventilation with a two-person bag-mask technique if spontaneous breathing is inadequate.
- Treat concurrent chest causes of failed oxygenation, optimise circulation with blood where haemorrhage is present and prepare the definitive airway before reserve is exhausted.
- Reassess speech, chest movement, saturation, waveform carbon dioxide when ventilating, mental state and haemodynamics after every manoeuvre.
The tube and physiology are currently stable enough for imaging or definitive care.
- Record tube type, depth, grade, waveform, drugs, complications and cervical precautions, and assign one clinician to airway observations during every movement.
- Reconfirm capnography, saturation, pressure, tube depth and chest findings immediately after trolley transfer, CT movement or patient repositioning.
- Complete cervical-spine assessment and imaging, replacing indiscriminate prolonged collar use with an individual clearance or protection plan.