Surgical Critical Care,  Trauma Surgery

The Five Letters on Which Trauma Stands – Part 3

Letter A – Airway Maintenance with Restriction of C-Spine Motion

We always have to start with the evaluation of the airway because if they are not controlled (obstructed completely or partially) they will kill our patient in a very short time. 

You have to use all your senses and semeiotic experience to properly evaluate the patency of your patient airways. 

How to use them:

  1. Sight: look at the patient and inside his/her mouth. Do you see any possible cause of airway obstruction (e.g. foreign body inside the mouth)? Is he/she in respiratory distress? Is he/she vomiting? Has he/she blood inside his/her mouth? Is there an injury to his/her neck and/or face? Is there a massive hemorrhage? Signs of smoke inhalation?
  2. Hearing: listen to how he/she’s breathing. Is there stridor? Hoarseness?
  3. Touch: palpate his/her neck (anteriorly and posteriorly), checking the C-spine as well. Is the trachea broken or deviated? Is there subcutaneous emphysema? Does the evaluation of the C-spine cause pain? Are there hematomas?
  4. Taste: (not really a sense this time) talk to him/her, ask if he/she remembers what’s happened or if he/she has pain, and things like these… Is he/she able to answer? Is there a smell of something (vomit, alcohol, blood)?

The first thing to do is to introduce yourself and ask the patients how they feel. This must be done not for good manners, but because you’ll see how they will respond to your stimuli. If they will answer correctly, with a good and strong voice and oriented, you immediately know the airways are open, the lungs can pump enough air to produce voice, blood pressure is enough to perfuse the brain and it works properly (ABCD checked in one shot!).

You: “Hello, my name is… and I am your surgeon, what happened?”

Pt: “Hi, my name is Kenny, I’ve been involved in a motorcycle crash against a car. I feel pain on my right leg.”

This rapid evaluation should calm you down, but just a bit! However, if you don’t get a complete answer like this, you have to find where the problem sets.

When you speak to your patients don’t do it from the distance, but go literally on them! Talking from the distance will cause the patients to search for your eyes, meaning they will try to turn the head… not a good idea for the C-spine control!

Going back to the airways, they can be obstructed by liquids (blood or vomit) or objects, so you have to check the mouth for them, be prepared with suction to solve the problem. 

The second thing that can happen is the soft palate to fall back occluding the air passage. This will occur when the level of consciousness decreases (low saturation? low blood pressure? brain damage?), and you have to rapidly deal with it reopening the airways. 

The maneuvers you can do are from the simplest to the most complex (from jaw-thrust to surgical airway):

ManeuverAirway ProtectionProblems
Jaw-thrust or chin-lift maneuver + self-inflating bag oxygenation with/without oropharyngeal cannulaNoOne person must continue ventilating the patient
Laryngeal maskNoIt does not exclude the esophagus, thus not protecting the airway. It’s less stable than a tube
Endotracheal tubeYesIntubation can be very challenging in certain situations (e.g. unstable C-spine fracture, massive facial fractures, severe upper airway injury…)
CricothyroidotomyYesIt may be difficult in obese patients

The description of the different maneuvers is beyond this post, we will explain them in the future.

The definition of “Definitive Airway” is a “cuffed tube in the trachea beyond the vocal cords”. This means that the trachea is excluded from the oesophagus, protecting it from the possible vomiting. 

But, when do you actually need a definitive airway?

Situations that may warrant to secure the airways are:

  • Injury to the larynx and/or trachea
  • Severe facial fractures
  • Massive neck hematoma
  • Incoercible vomiting
  • Massive bleeding from the mouth
  • Head injury with Glasgow Coma Scale ≤8
  • Hemorrhagic shock
  • Unstable C-spine fracture
  • Respiratory distress

If you have any suspect for your patient airways, double-check them, and ask for senior support. If you decide to tube the patient, please, make sure you know exactly what you are facing or call for help! It is a sign of wisdom and not of weakness. 

When you’re checking for A also try to understand the patient’s level of consciousness. We are not saying to calculate the GCS now (even though if you can, it would be best) but at least to have a fairly good idea of it. Use the AVPU scale is of great help:

  • A – Alert: the patient has open eyes and speaks;
  • V – Verbal: the patient has closed eyes but will answer to your call;
  • P – Pain: the patient will only respond to pain stimuli;
  • U – Unconscious: the patient won’t respond to the pain stimuli.

With this, you can already have an idea of the GCS and, consequently, if the patient will need the airway secured (would you prepare to intubate a patient with a V level of consciousness?).

Remember to ALWAYS protect the C-spine of your patient (you can decide not to only in very selected cases)! The patient usually arrives at you with already a Philadelphia Collar and/or the cervical blocks. Make sure that your patient has a proper restriction of the cervical movements so that he/she won’t risk any more damages to it. 

Letter B – Breathing and Ventilation

The second letter involves everything that concerns the thoracic cavity. As pointed out earlier, the aim of this evaluation is to identify and manage immediate life-threatening injuries. Possible conditions posing the patient in direct life danger are tracheal or bronchial injuries, tension pneumothorax, open pneumothorax, massive hemothorax, fail chest, massive pulmonary contusions, and cardiac tamponade.

Remember that all of them MUST be diagnosed using signs and symptoms the patient is giving you. eFAST is awesome, but you won’t always have it and you cannot be dependent on an ultrasound machine! It will come and help you in a second time (we set it inside the adjuncts on purpose).

As for A, also in B, you must use all your senses in order to evaluate the chest. Look if it expands equally, touch it to feel for subcutaneous emphysema and to evoke pain, listen to the lungs sounds (present or not, and how), beat it to listen to a dull sound or a hyper-tympanic one.

Remember that signs of tension pneumothorax or massive hemothorax are jugular distension and tracheal deviation. Therefore, look for them while you are assessing the “letter B” (best thing is to evaluate the neck completely during the “point A”).

Each one of the six clinical threatening conditions you are searching for has a distinguished set of signs you have to find!

Let’s imagine them one by one:

  • Tracheal or Bronchial Injuries: they usually present with penetrating injuries or decelerating mechanism. Massive subcutaneous emphysema is characteristic and often associated with a (tension) pneumothorax (PNX). The patient voice may be abnormal (hoarsening or stridor), listen to it! Most of the time the diagnosis comes after the initial management. You diagnose a pneumothorax, you set up a nice intercostal drain (ICD) and it bubbles, a bit too much. So you go for a second one to better drain the pneumothorax, and now they both bubbles… Please think about a bronchial injury!  You’ll need a bronchoscopy for its confirmation. The urgency of its treatment and repair is correlated with the possibility of ventilating the patient. Massive destruction of the main bronchus with major air leak could make it impossible to ventilate the lung, it needs a quick solution. 
  • Tension Pneumothorax: this is a REAL emergency! If you diagnose it with the ultrasound or with an X-ray you got it all wrong! If the patient is awake he will be anxious and agitated (missing in the unconscious ones), no breath sounds on the injured side and hyper-tympanic tone to percussion. You have to drain it ASAP! The goal is to create an open pneumothorax! You may use a long and thick needle, but it may kink and not function properly. Thus, finger thoracostomy is the gold standard now. Pay attention that also an intubated patient where the tube is in the main bronchus can mimic a PNX!
  • Open Pneumothorax: an open connection with the pleura must be there, the signs are similar to the tension PNX. The treatment is to insert an ICD, and AFTER that to close the wound. If you close the wound before inserting the ICD, you’ll create a tensioning mechanism. If you don’t have an ICD you should use a partial occlusive dressing (closed on three sides out of four) in order to let the air been pushed out from the pleura and not let it in. Remember, do NOT insert the ICD in the patient wound, it is dirty and you’ll create an infection for sure.
  • Massive Hemothorax: we are speaking of at least 1.5 L of fresh blood in the thorax (or output of at least 200 mL for more than 4 consecutive hrs). If this is what your patient has, you need to take him to the operating room, fast! Clinically you’ll find reduced or absent breath sounds and dullness to percussion. You may use the ultrasound to confirm it. Prepare not to panic, because a blood fall may pour on your pants while inserting the ICD. If the patient is unstable, you’ll need blood products, quickly. If you don’t have them ready, you can always re-infuse the patient’s own blood: prepare sterile saline 0.9% (usually around 500 mL) with 1 cc of heparin (5000 UI) in your Bouleau before inserting the ICD, this will allow you to reinfuse the blood straight into your unstable patient. Please, do this ONLY in extreme situations, not as routine!
  • Flail Chest: the main problem is the patient’s inability to properly ventilate. This will lead to muscular fatigue and hypo-oxygenation. Prevent it is the key. When the ventilation is prevented by the flailed ribs, the patient needs to be intubated. To diagnose this you have to look at the chest movements and to palpate the thorax. It is always correlated with pulmonary contusions.
  • Massive Pulmonary Contusions: the clinical setting in very similar to the fail chest. The only difference is the absence of uncoordinated thorax movements. You’ll find pulmonary contusions in basically every blunt thoracic trauma. These must be treated with painkillers and respiratory physiotherapy before they become over-infected. A great help will come from keeping patients “dry”. Do NOT overload them with fluids, they will extravasate where the contusions are.
  • Cardiac Tamponade: the clinical suspect is the goal to diagnose it! You may find symptoms and sings (the Beck’s triad), but they may be absent. A distended neck vein may be flat if the patient is hypovolemic. Highly suspect it in penetrating traumas inside the heart box (check for injuries on the pt’s front and back). To be sure about your diagnosis, the use of ultrasound is mandatory. If the patient is unstable, it would be better to release the tamponade surgically (call for help!). Needle release (pericardiocentesis) of it is not so easy as it seems in the emergency setting, and it is often correlated to collateral damages.

Now that we scared you a bit we leave you with good news: the concept of these life-threatening injuries is that the first-line treatment is the same for most of them: tube thoracostomy (put in an ICD). So, when in doubt, place a tube. The difficult will come in managing that drain…

See you next time… Namasté!

  1. Advanced Trauma Life Support: Student Course Manual. 10th Ed. Chicago, IL: American College of Surgeons; 2018.
  2. Peitzman AB, et al. The Trauma Manual: trauma and acute care surgery; 4th Ed. Philadelphia, PA: Lippincott; 2013.
How to Cite This Post

Marrano E, Bellio G. The Five Letters on Which Trauma Stands – Airways & Breathing. Surgical Pizza. Published on July 12, 2020. Accessed on October 23, 2021. Available at [].


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