Table 2

 In the trauma adult requiring emergency control of the airway, what is the best treatment algorithm to follow for management of a difficult airway? Evidence from systematic reviews of the literature

Author/yearLevel of evidence (bias code)Study designSummary
ED, emergency department; EMT, emergency medical technician; ETT, endotracheal tube; iLMA, intubating laryngeal mask airway; LMA, laryngeal mask airway; MILS, manual in-line stabilisation; NMB, neuromuscular blockade; RSI, rapid sequence induction and intubation.
ASA 200330I (a)Practice guidelines for management of the difficult airway tailored for use by anaesthesiologists and those “under direct supervision”. Some options not applicable to ED and with the facilities expected to be available during a trauma resuscitation. Complicated algorithmPractice guideline produced
EAST 200218I (a)Airway guidelines for trauma patients. Systematic review to identify who should be intubated and what the equipment/adjuncts are. Limited search to Medline and English languageRecommendations for when and how to intubate the trauma patient; algorithm produced
Crosby 199831I (a)Systematic review (details are not listed) Guideline produced, defines difficult airway, pre-operative assessment, and equipment options, also covers paediatrics and obstetrics. Limited to MedlineDevices, such as LMA, fiberscope, and lighted stylet, have a role as alternatives to face mask ventilation or ETT when these techniques fail. Management algorithm produced
Fan 200058II (a)Pseudo-randomised clinical trial. 172 patients randomised to iLMA or iLMA plus light wand. Elective pts, difficult airways excludedBlind intubation with iLMA 76% success. When light wand used as adjunct success rate of 95%
Carley 200232II (b1)Sensible guideline produced for ED RSI. No systematic review of the evidence demonstrated and no evidence that they used a wide consensus of local opinion. Not aimed specifically at traumaRecommendations and algorithm produced for management of the airway
European Resuscitation Council 199668II (b1)Review and guideline for basic management of airway and ventilation. Relevant for the initial assessment phase of the airway management. Not systematic and no critical appraisal or levels of evidence usedRecommendations produced
European Resuscitation Council 199669II (b1)Review and guideline for advanced management of airway and ventilation during resuscitation. Not directed at trauma/ED; mostly medical patients. Not a systematic review, no study critical appraisal or levels of evidence usedRecommendations produced
Kihara 200059III-1 (a)Prospective clinical trial; 120 patients for elective operation. Intubated blindly via iLMA or with aid of light wand. Not clear how patients were randomised. Not trauma or emergency cases, no mention of any patients with a difficult airwayLight wand group were intubated faster and with fewer adjustive manoeuvres. All failures to intubate (3%) were in the blind iLMA group
Asai 200060III-1 (b1)Prospective clinical trial; 40 elective patients managed with MILS and intubated either with ETT/bougie, or fibreoptic scope and iLMA. Not clear who did the intubations. Randomised to groups in blocks of 10 introduces bias potentialFibrescope and iLMA was faster, easier, and more successful 85% v 55% than ETT
Pepe 199361III-1 (b1)Review. Search strategy not given but appears to be thorough and appraises the papers found then provides evidence tables. Compares equipment availableFinds no advantage to ETT and most alternatives have training issues. Combitube has potential but more studies needed
Graham 200394III2 (b1)Prospective observational study in 7 hospitals. Data on patients in ED who needed RSI (735) intubated by either anaesthetics (355) or ED physician (377) and observed. Not randomised into groups, 40% traumaAnaesthetists got better views and more first pass intubations (91.8% v 83.8%) but on less sick patients and they were slower to intervene. Complications not significantly different
Staudinger 199362III-2 (b1)Prospective clinical trial; 37 cardiac arrest patients on ICU either nurse combitube (17) or doctor ETT (20) and time to placement/success documentedSimilar success rates at placement but combitube was faster. No apparent complications
Blostein 199863IV (a)Observational study; 10 patients failed RSI pre-hospital by flight nurses then used combitube. 100% success rate at insertion. Note the 80% success rate of RSI. Small numbers and high failure rate of RSI not commented onCombitube easy and good for failed RSI
Dufour 199520IV (b1)Prospective observational study on 219 ED patients using RSI to intubate. Looked at complication rate. Mostly medical patients (15% trauma)100% success rate intubating by emergency physician. 10% hypotension (using midazolam 0.1 mg/kg); 15% complications overall including these.
Hawkins 199596IV (b1)Retrospective database review of 5603 trauma patients, 1989–93. Showed 9.3% of trauma patients need ETT. 12.4% of these had cricothyroidotomy (n = 66) with failure in 2—that is, 1.1% of all admissions had cricothyroidotomyCricothyroidotomy feasible and safe with risk of minor complications
Jones 200233IV (b1)Observational study review of all intubations in ED before and after introduction of an airway management protocol. Missing data over a 5 month period of the 31/2 year collection periodReduction in time and increase in success rate of first time intubations after the protocol was introduced
Sakles 199821IV (b1)Observational study; 610 patients needing intubation by ED. Trauma patients 47.7%. 88% of data collected prospectively, the rest retrospective from case notes1% overall needed intubation; success rate 98.9% with 81.4% intubated 1st attempt; 1.1% failed and had cricothyroidotomy; 9.3% complication rate
Vijayakumar 199866IV (b1)Retrospective observational study of 160 patients from trauma registry intubated in ED compared for use of NMB and presence of airway injury97% success rate intubation but high rate difficult intubations noted (15%) not associated with potential airway or c-spine injury nor use of NMB. 3% needed cricothyroidotomy
DeLaurier 199070IV (b2)Retrospective observational study of complication rate of emergency cricothyroidotomy in 34 patients, 1984–1988. Small numbers. Tended to keep cricothyroidotomy for several daysComplication rate attributable directly to the cricothyroidotomy of about 30%, all minor
Hunt 198964IV (b2)Observational study. 32 paramedics/EMTs trained with pharyngeal tracheal airway then tested at 6 weeks for competence. 19 tested, up to 21% couldn’t tell where tube placed and 50% failed to auscultate chest to confirm placement. Small numbers but shows need for substantial trainingCombitube not necessarily straight forward to use
Minek 199065IV (b2)Retrospective case note review of 35 intubations aided by fibreoptic bronchoscope over 30 months, 1985–87. 6 failed so ETT or 1× cricothyroidotomy used. Medical and trauma patients. Small numbers. Trauma was only 11% total. Success rate (83%) and time (2–3++ mins) longer to intubate in the trauma patients compared with the medical patientsFibreoptic bronchoscope is an option as an adjunct but disadvantages in ED with training issues and time taken to intubate
Salvino CK 199367IV (b2)Retrospective case note review over 36 months. Did 30 cricothyroidotomies (2.4% of trauma admissions). Looked at indications and complications, 1989–91.No major complications; 13.3% minor complication rate 7 done as primary procedure. 10 were pre-hospital