The correct answer is:

Perform immediate cricothyroidotomy.

Educational Objective:

List indications for cricothyroidotomy in trauma resuscitation.

Key Point:

A surgical airway is indicated when a definitive airway is emergently required in a trauma patient failing to maintain oxygenation despite bag-valve mask ventilation and when an endotracheal tube cannot be placed through the vocal cords.

Explanation:

The inability to intubate the trachea is a clear indication for an alternate airway plan, including laryngeal mask airway, laryngeal tube airway, or surgical airway. The choice between these methods is dictated by the situation.

A surgical airway (ie, cricothyroidotomy, tracheostomy) is indicated in the trauma patient who is unable to oxygenate (failed airway) in the presence of edema of the glottis, fracture of the larynx, severe oropharyngeal hemorrhage that obstructs the airway, or when it is not possible to place an endotracheal tube through the vocal cords.

Surgical cricothyroidotomy is preferable to tracheostomy for most patients who require an emergency surgical airway because it is easier to perform, is associated with less bleeding, and requires less time to perform than emergency tracheostomy.

If orotracheal intubation fails but the patient can be oxygenated, then this is a difficult rather than failed airway, and other options are available.

The Advanced Trauma Life Support airway decision scheme is generalized (see Figure); when available, more specific institutional protocols should be followed.

Blind nasotracheal intubation should only be performed in patients who are spontaneously breathing; it is relatively contraindicated in facial trauma. In the real-world setting, this method is rarely used in the emergency department.

Nasotracheal intubation continues to be a recommended option. In a spontaneously breathing patient in whom the clinician is not forced to act within seconds and in whom an awake technique has failed, the difficult airway algorithm lists 5 final options (see Figure):

• Intubating laryngeal mask airway
• Flexible endoscopy
• Video-assisted laryngoscopy
• Cricothyroidotomy
• Blind nasotracheal intubation

If any of these options fail, then the clinician must switch to the failed airway algorithm.

However, none of these scenarios apply to this patient because he has a failed airway, not a difficult airway.

References:

American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed., 2018.

Brown CA, Walls RM. Airway (chapter 1). In: Wall R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:3-24.