A guide to avoid inflicting further trauma during airway management

When an emergency responder arrives at an emergency scene where one or more patients have suffered physical trauma, unspoken in the goals during the moment is to not only provide effective treatment, but to avoid causing any additional trauma.

Sometimes, this is easier said than done. For example, if someone is in an especially bad car accident and their severely injured body is trapped in the vehicle, moving the body may lead to more harm until proper equipment arrives to remove them from the wreckage. In other cases, patients themselves may prove to be an obstacle, such as if they are panicked and begin to move while a responder is performing treatment.

Avoiding trauma is especially important during airway management procedures, especially suctioning, when a catheter is being used freestyle in a patient’s esophagus to clear fluids, blood, particulate and more. As our examples show, however, a steady, careful hand is necessary — particularly if the airway is already injured — but the environment will not always cooperate.

Indeed, it takes a blend of experience, technique and steely nerves to ensure you avoid inflicting trauma during treatment.

Assessment

If you’re going to avoid injuring a patient who requires airway management, you must first know what you’re working with through a respiratory assessment. These are some critical components to a good assessment:

• Look and listen: It’s easy to rely on a checklist to get through an assessment, but the objective is to comprehensively appraise the patient’s status. Don’t go by a formula; take in information in the moment. Look at the individual — what do you see? Are there obvious warning signs? Other indications? Then listen. Are they hoarse? Expressing themselves coherently?

• Know that norms vary with context: There is no single baseline for patients. While healthy adults take in 12-18 breaths per minute, infants and children breathe more rapidly, and older adults may have quicker breathing paces, as well. Further context may affect the assessment, as well, such as when patients are experiencing anxiety or neurological impairments.

• Know what’s normal for the patient: If possible, gather information from the patient or observers, such as family members who know the patient’s medical history or witnesses to the incident. For example, some patients have naturally low blood pressure, so slightly elevated blood pressure may be more of a concern than in other patients.

• Take your time: Distraction and rushing are common factors in how EMS professionals commit errors and trauma. Taking the time to carefully perform an assessment may seem contradictory — after all, emergencies are urgent, by their very nature — but taking the time to be thorough can save a lot of trouble for everyone.

Positioning

Sometimes, the best airway management technique is to have the patient manage their own airway by allowing them to assume a position of comfort and monitoring them, as long as they have not already experienced trauma. If spinal immobilization is a concern or the patient is unconscious, but their breathing appears normal following an assessment, you most likely will want to position the patient on a backboard to make sure it stays that way.

If suctioning is required, positioning is even more important, as the mouth and airway must be aligned and open. Consider elevating or turning the backboard to assist respiratory efforts, or use these techniques:

• Head-tilt/chin-lift: Most common means of opening the airway in the non-trauma patient.

• Tongue-jaw lift: Effective means of opening the airway and checking for foreign body obstruction; not used during artificial ventilation.

• Jaw thrust: Used to open the airway in suspected trauma, such as cervical spine injury.

Technique

Airway suctioning would seem simple on the surface — use a portable or traditional suctioning unit, along with a catheter that has a small enough tip for easy maneuvering, yet a large enough diameter to effectively evacuate material. Depending on patient status, age, size and many other factors, however, the job becomes more complicated.

For example, pediatric and geriatric populations require careful and cautious suctioning. These patients tend to have more delicate tissues and muscles that may require decreased suctioning power. Children, obviously, have smaller oral cavities and airways, necessitating small equipment. Older patients, meanwhile, frequently have dental hardware in place that requires a delicate touch for a different reason.

On the other hand, a more powerful approach may be required for patients who have undergone a trauma and/or are having heavy bleeding, active vomiting or copious secretions. In these situations, and in the event bone, tissue or teeth are creating blockages, more suctioning power and a wider catheter have a better chance to efficiently clear the airway.

Should intubation be required, the SALAD (Suction Assisted Laryngoscopy and Airway Decontamination) technique is a safe and effective way to prepare the airway for the procedure and maintain consistent suctioning. By constantly suctioning the upper airway while a provider intubates the patient, the technique minimizes the patient’s risk of aspiration, which can make a fraught situation worse or harm their long-term recovery.

Patient management

Sometimes during a delicate airway procedure such as suctioning or intubation, the patient’s actions can unintentionally cause further trauma, such as if they are in a panic and move during suctioning. Gaining patient trust and building rapport, if time allows, is crucial for an EMS provider, so consider:

• Speaking to the patient in layperson’s terms. Complicated medical jargon can create more distance between you and the patient.

• Delivering all observations and diagnoses with care, as rattling off technical symptoms and conditions to a colleague in front of the patient can trigger confusion or strong emotional responses.

• Being mindful not to vocalize judgments about a patient’s health issues, lifestyle or situation.

• Explaining medical interventions and steps throughout treatment to help allay anxiety and fears.

For patients who have special needs and/or may be incommunicative, attempt to interact, communicate and build rapport with a family member, if possible. Not only will they want to be informed about the situation, but they can tell you if the patient has any conditions or concerns you should be aware of before treatment.

Don’t forget to take of yourself, too. Amid a long shift, or after a particularly busy span of months, it’s easy to lose sight of one’s own physical and mental health. If those things slip, it can impact job performance — and as we’ve discussed here, there is little room for mistakes.