Airway Management in Major Trauma

Reviewed and revised 21 November 2014


  • airway obstruction or disruption is an important cause of death and morbidity in major trauma, although intubation may be indicate for a number of other reasons
  • airway management must take into account the risk of coexistent cervical spine injury, the mantra being “airway management with cervical spine stabilisation”
    • 2-12% risk of cervical spine injury in major trauma, and 7-14% of these are unstable
    • 10% of comatose trauma patients have a cervical spine injury


Mechanisms include:

  • loss of pharyngeal tone due to loss of consciousness from TBI or shock (most common cause)
  • Posteroinferior displacement of a fractured maxilla parallel to the inclined plane of the skull base may block the nasopharyngeal airway
  • A bilateral fracture of the anterior mandible may cause the fractured symphysis to slide posteriorly along with the tongue attached to it via its anterior insertion causing oropharyngeal obstruction in the supine patient
  • Fractured or exfoliated teeth, bone fragments, vomitus and blood as well as foreign bodies may cause airway obstruction
  • Hemorrhage ( distinct vessels in open wounds or severe nasal bleeding) may cause airway obstruction
  • Soft tissue swelling and edema may cause delayed airway compromise
  • Trauma to the larynx and trachea may cause swelling and displacement of structures, such as the epiglottis, arytenoid cartilages and vocal cords, causing cervical airway obstruction


Indications include:

  • facilitate oxygenation and ventilation
  • airway protection
  • prevent impending, or overcome, airway obstruction
  • humanitarian reasons (e.g. provide analgesia and anaesthesia for procedures)
  • neuroprotection (e.g. targeted PCO2 management)
  • allow safe transfer


Issues complicating airway management in major trauma include:

  • may be a time critical emergency due to hypoxia and/or airway obstruction
  • full stomach and aspiration risk
    • cricoid pressure is controversial – it is contra-indicated in laryngeal trauma and may worsen laryngeal visualisation or cause airway obstruction
  • manual in-line stabilisation (MILS) of the cervical spine should be maintained in unconscious patients
  • jaw thrust is the preferred airway opening manoeuvre
    • head-tilt chin lift is not performed due to risk of cervical spine instability
  • suspected base of skull fracture is a relative contra-indication to nasopharyngeal airway insertion
  • difficult ventilation e.g. poorly fitting mask in facial trauma, traumatic airway leak, poor compliance in chest trauma
  • endotracheal intubation via the oral route may be impossible due to mechanical trismus or airway trauma
  • many trauma airway experts advise use of a bougie or stylet as direct laryngoscopy and intubation is more difficult, due to:
    • local swelling and deformity
    • impaired visualisation due to deformity and debris (haemorrhage may obscure video laryngoscopy)
    • restricted movement of the neck during MILS
  • emergency surgical airways are more difficult, due to:
    • local swelling and deformity
    • an inability to extend the neck during MILS
  • suxamethonium is contra-indicated >48 hours after burns or spinal injury (due to risk of hyperkalaemia)
  • haemodynamic instability may occur post-intubation
    • a vagal response in neurogenic shock may result in severe bradycardia or asystole (treat with atropine)
    • hypotension may result from induction agents, haemorrhagic shock or neurogenic shock


Cervical spine protection is indicated in the following trauma settings:

  • Neck pain or neurological symptoms
  • Altered level of consciousness
  • Significant blunt injury above the level of the clavicles

MILS is performed by an assistant during airway management to maintain a neural position and prevent inadvertent movement of the head and neck, by either:

  • crouching beside the intubator with hands placed on the patient’s trapezius muscles and forearms along the sides of the patient’s head
  • standing beside the patient in front of the intubator with hands placed on the sides of the patient’s head and forearms resting on the patient’s chest
  • traction is not applied

MILS is replaced by a cervical collar, lateral blocks/ sand bags, and head and chin straps once the airway is secure

References and Links


  • Rapid Sequence Intubation (RSI) in Traumatic Brain Injury
  • Airway management in maxillo-facial trauma
  • Airway management in cervical spine injury
  • Airway and neck trauma

Journal articles

  • Cranshaw J, Nolan J. Airway management after major trauma. Contin Educ Anaesth Crit Care Pain(2006) 6 (3): 124-127.doi: 10.1093/bjaceaccp/mkl015
  • Dupanovic M, Fox H, Kovac A. Management of the airway in multitrauma. Curr Opin Anaesthesiol. 2010 Apr;23(2):276-82. PMID: 20042974.
  • Langeron O, Birenbaum A, Amour J. Airway management in trauma. Minerva Anestesiol. 2009 May;75(5):307-11. PMID: 19412149. [Free Full Text]
  • Walls RM. Management of the difficult airway in the trauma patient. Emerg Med Clin North Am. 1998 Feb;16(1):45-61. PMID: 9496314.

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.