The Journal of Emergency Medicine, Vol. 44, No. 6, pp.

11901195, 2013
Published by Elsevier Inc.
Printed in the USA
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2012.11.074

Brief
Reports

TRAUMA AIRWAY MANAGEMENT: TRANSITION FROM ANESTHESIA

TO EMERGENCY MEDICINE

Stephen Varga, MD,* Jeffrey W. Shupp, MD, Dermot Maher, MD, Ian Tuznik, MS, and Jack A. Sava, MD
*Division of Trauma and Surgical Critical Care, USC Department of Surgery, University of Southern California, LAC + USC Medical Center,
Los Angeles, California, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, and MedStar Georgetown
University Hospital, Washinton, DC
Reprint Address: Stephen Varga, MD, Division of Trauma and Surgical Critical Care, USC Department of Surgery, University of Southern
California, LAC + USC Medical Center, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA 90033

, AbstractBackground: Trauma airway management is
commonly performed by either anesthesiologists or Emer-
gency Physicians (EPs). Objective: Our aim was to evaluate
the impact of switching from one group of providers to the
other, focusing on outcomes and complications. Methods:
Medical records were used to identify all patients during
a 3-year period who were intubated emergently after trau-
matic injury. Before November 1, 2007, airway management
was supervised by anesthesiologists, after that date airways
were supervised by EPs. Complications evaluated included
failure to obtain a secure airway, multiple attempts at air-
way placement, new or worsening hypoxia or hypotension
during the peri-intubation period, bronchial intubations,
dysrhythmia, aspiration with development of infiltrate on
chest x-ray study within 48 h, and facial trauma. Results:
Of the 490 tracheal intubations, 250 were attended by EPs
and 240 were attended by anesthesiologists. The groups
were well matched with respect to age and sex, but the EP
group treated more severely injured patients on average.
Intubation was accomplished in one attempt 98.3% of
the time in the anesthesia group; those requiring multiple
attempts went on to need surgical airways 2.1% of the
time. EPs accomplished intubation in one attempt 98.4%
of the time, with an overall success rate of 96.8%; surgical
airways were needed in 3.2% of patients. The complication
rate was 18.3% for the anesthesia group and 18% for the
EP group. There were no statistically significant differences
between the EP and anesthesia groups with regard to
complication rates, although the EP patients had a higher
Injury Severity Score on average. Conclusions: EPs can
safely manage the airways of trauma patients with rates of
complication and failure comparable with those of anesthe-
siologists. Published by Elsevier Inc.
, Keywordsairway; trauma; anesthesia; Emergency
Medicine
INTRODUCTION
Injured patients present unique challenges for airway
providers. This role has historically been performed by
anesthesiologists, and many programs still utilize trauma
anesthesiologists for airway management. However, dur-
ing the past several years, some Level I Trauma Centers
have altered their practices, assigning traumatic airway
management responsibilities to Emergency Physicians
(EPs) rather than anesthesiologists. Although there is lit-
erature supporting the EPs ability to manage an airway,
there is a dearth of research comparing the abilities of an-
esthesiologists and EPs to manage the airway in trauma
patients (18).
The present study is a comparison of traumatic airway
management by EPs and anesthesiologists at a large, ur-
ban, Level I Trauma Center with 2,800 trauma admis-
sions annually. Before 2007, airway management in
trauma patients at this institution was conducted by

RECEIVED: 30 March 2012; FINAL SUBMISSION RECEIVED: 21 October 2012;

ACCEPTED: 18 November 2012

1190
Trauma Airway Management
anesthesiologists. In response to the addition of an EP res-
idency program, and to allow EP residents more experi-
ence managing the airway in trauma patients, the policy
was changed in 2007, making EPs responsible for the air-
way. The present study compares treatment outcomes
and complications between traumatic airway patients
managed by EPs and anesthesiologists to determine the
impact of this change in policy.
METHODS
After approval by the Institutional Review Board, the
trauma registry of a large, urban, Level I Trauma Center
was used to identify all trauma intubations performed by
anesthesiologists from January 1, 2006 until October 29,
2007 and all trauma intubation performed by EPs from
November 1, 2007 until July 20, 2009. All patients intu-
bated in the trauma bay were included in the study and
any patient that arrived already intubated was excluded.
Before 2007, high-level trauma activations were re-
ceived by the trauma team as well as an attending anes-
thesiologist accompanied by either an anesthesia
resident or a Certified Registered Nurse Anesthetist. If
no airway concerns were noted, the trauma team leader
or attending Trauma Surgeon would dismiss the anesthe-
sia team. If an intubation was needed, the anesthesia res-
ident, Certified Registered Nurse Anesthetist, or trauma
flight nurse would complete the intubation with attending
supervision. Flight nurses are trained in advanced airway
management, perform field intubation, and undergo
yearly mandatory evaluation, including in-hospital intu-
bation under physician supervision. Choice of medication
for the intubation was made by the attending anesthesiol-
ogist.
Beginning in November 2007, responsibility for
trauma airway management was switched to EPs, includ-
ing response to activations and intubation when needed.
EP attendings have discretion to either intubate patients
themselves or supervise intubation by residents or trauma
flight nurses. If no airway issues were identified, the EP
team was dismissed by the trauma team leader or trauma
surgeon. The choice of medication for the intubation was
made by the EP.
Airway equipment available for intubations included
straight and curved blade laryngoscopes, a Glide Scope,
nasotracheal and endotracheal tubes, and a cricothyroi-
dotomy set, if needed. The majority of patients underwent
rapid sequence intubation with etomidate for sedation
and succinylcholine for neuromuscular blockade. All
patients were placed on a cardiac and noninvasive blood
pressure monitor with a pulse oximeter. They were rou-
tinely preoxygenated before intubation attempts. Occa-
sionally, cricoid pressure was applied to minimize
passive regurgitation in patients requiring intubation or
1191
need for better visualization. For all blunt trauma pa-
tients, in-line cervical stabilization was maintained
throughout the entire intubation. Intubation was typically
confirmed by colorimetric end-tidal carbon dioxide de-
tection and auscultation of the chest and position was
confirmed by chest x-ray study. After intubation, the phy-
sician performing or supervising the intubation wrote
a detailed note about the event, indicating any difficulties
or complication. The nursing staff also independently re-
corded the events and all vital signs throughout the
patients time in the trauma bay.
The chart review included event notes from anesthe-
sia and EP attendings or residents, nursing notes, re-
corded vital signs, and radiographic images. Data
reviewed included demographics, indications for intuba-
tion, peri-intubation vital signs, intubation medications
used, complication of the intubation, need for surgical
airway, number of attempts at endotracheal (ET) tube
placement, and positioning of the ET tube. Complica-
tions of intubation noted during chart reviews included
failure to obtain a secure airway requiring cricothyroi-
dotomy, failure to place ET tube with first try, hypoxia
or hypotension during the peri-intubation period, bron-
chial intubations, dysrhythmia, aspiration with develop-
ment of infiltrate on chest x-ray study within 48 h, and
facial trauma from placing the ET.
Hypoxemia was defined as any oxygen saturation
<90% within 1 min after an induction agent was given
or immediately after intubation that could not be attrib-
uted to the trauma itself. Hypotension was defined as
systolic blood pressure <100 mm Hg within 1 min after
induction agents were given that could not be attributed
to shock. If patients presented to the trauma bay already
hypoxic or in shock, or if they became hypoxic or hypo-
tensive secondary to their injuries, they were not in-
cluded with the complications. If these events occurred
within 1 min after induction medication was given or
during attempts at intubation, they were presumed to
be a complication of the intubation and not the trauma
itself. Aspiration in this study was defined as the pres-
ence of gastric contents or blood in the patients orophar-
ynx, or if gastric contents of blood were seen in the
endotracheal tube. If a patient required intubation and
had a chest x-ray study 48 h after intubation, we exam-
ined those x-ray studies for evidence of infiltrate that
was not present on initial chest x-ray study and could
not be explained by the trauma or any infectious process;
consequently, this infiltrate was presumed to be from as-
piration during intubation (4). Bronchial intubation was
documented by immediate post-intubation chest x-ray
study. Dysrhythmia was defined as evidence of any dys-
rhythmia within 1 min after induction agents were given
where the dysrhythmia could not be attributed to the
trauma itself.
1192 S. Varga et al.

Data Analysis Table 2. Patient Demographics

Emergency
A series of univariate tests of association between various Demographics Anesthesiology Medicine p Value
confounding factors were performed. All statistical cal-
culations were performed using SPSS software version Total patients, n 240 250
Male, n (%) 205 (85.4) 209 (83.6) 0.619
13 (SPSS Inc) and R software version 2.10.1. Data were Female, n (%) 35 (14.6) 41 (16.4) 0.619
analyzed to determine the association between type of Age (y), mean 6 35.35 6 16.9 37 6 18.5 0.304
physician (anesthesiologist or EP) and overall complica- SD
ISS, mean 6 SD 18.5 6 14.6 23.2 6 17.7 0.001
tion rate, while simultaneously taking into account con-
founding factors (Table 1). Contingency table analysis ISS = Injury Severity Score; SD = standard deviation.
was used to cross-tab each possible confounding variable The p values are from Fishers exact test (for sex) and Students
t-test (for age and ISS).
against type of physician and the occurrence of complica-
tions. Specifically, Fishers exact test was used to deter- for airway protection and 29 (12.1%; 95% CI 8.2%
mine statistical differences between groups (no 16.9%) for combativeness. EP performed 239 intubations
complication vs. complication), as this type of statistical (95.6%; 95% CI 92.3%97.8%) for airway protection and
procedure is robust when dealing with imbalanced data. 11 (4.4%; 95% CI 2.2%7.7%) for combativeness. Eto-
midate and succinylcholine were used by anesthesia
RESULTS 75.8% (95% CI 69.9%81.1%) and EP 78.8% (95% CI
73.2%83.7%) of the time for rapid sequence intubation.
During the retrospective study period, 490 tracheal intu- No medication was used for 51 (21.3%; 95% CI 16.2%
bations were performed in the trauma bay and are in- 27.0%) patients in the anesthesia group and 53 (21.2%;
cluded in the present study. There were 250 patients in 95% CI 16.3%26.8%) patients in the EP group.
the EP group and 240 patients in the anesthesiology Intubation was accomplished in one attempt 98.3% (95%
group. The groups were well matched with respect to CI 95.8%99.5%) of the time in the anesthesia group.
age and sex, but the EP group treated more severely in- Four patients required multiple attempts and all four
jured patients on average, based on the difference in went on to need surgical airways. The overall incidence
Injury Severity Score, as presented in Table 2. of surgical airways in the anesthesia group is 2.1%. EP
Results of the present study demonstrated no differ- accomplished intubation in one attempt 98.4% (95% CI
ences between anesthesiologists and EPs either for the 96.0%99.6%) of the time and had an overall success
presence of any complication (p = 0.709, Fishers exact rate of 96.8%; four patients had multiple attempts and
test) or in the number of complications (p = 0.476, eight patients required surgical airways with the overall
Fishers exact test). The indication for intubation fell need for surgical airway in the EP group of 3.2%.
into two groups, either airway protection or patient com- Complications are presented in Table 1. Overall com-
bativeness. Anesthesiologists performed 211 intubations plication rate was 18.3% (95% CI 13.6%23.8%) for the
(87.9%; 95% confidence interval [CI] 83.1%91.8%) anesthesia group and 18.0% (95% CI 13.4%23.3%) for
the EP group. There were no significant differences in
Table 1. Complications specific complication rates between anesthesiologists
Emergency and EPs. Results suggested that when certain complica-
Complications Anesthesiology Medicine p Value tions occurred (including hypoxia, hypotension, bron-
chial intubation, infiltrate at 48 h, aspiration/vomiting,
Multiple 4 (1.7) [0.54.2] 4 (1.6) [0.44.0] 1.00
attempts and need for surgical airway or esophageal intubation),
Aspiration 10 (4.2) [2.07.5] 12 (4.8) [2.58.2] 0.829 the patient was more likely than patients without any
Bronchial 9 (3.8) [1.77.0] 9 (3.6) [1.76.7] 1.000 complications to suffer more than one complication.
intubation
Hypotension 9 (3.8) [1.77.0] 4 (1.6) [0.44.0] 0.167
Surgical airway 5 (2.1) [0.74.8] 8 (3.2) [1.46.2] 0.577 DISCUSSION
Hypoxemia 4 (1.7) [0.54.2] 3 (1.2) [0.23.5] 0.720
Infiltrate on CXR 2 (0.8) [0.13.0] 4 (1.6) [0.44.0] 0.686
at 48 h The goals of this study were to analyze the change in policy
Facial or dental 1 (0.4) [0.02.3] 0 (0.0) [01.5] 0.490 at a Level I Trauma Center from anesthesiologist-directed
trauma to EP-directed airway management of trauma patients by
Dysrhythmia 0 (0.0) [0.01.5] 1 (0.4) [0.02.2] 1.000
comparing the success and failure rates of each department
CXR = chest-x ray. before and after the policy change and to demonstrate that
Values are n (%) and exact (Clopper-Pearson) 95% confidence EPs can manage difficult airways in trauma patients as
intervals around the complication rate percentage in brackets.
None of the complication rates were significantly different well as anesthesiologists. Airway management in trauma
between cohorts (by Fishers exact test). patients can be complicated by anatomic injury, shock,
Trauma Airway Management
respiratory failure, or neurologic impairment (810). The
time of intubation in a trauma bay is typified by a high-
stress and fast-paced environment, and there is little
time to adequately assess the airway for difficulty
(11,12). These patients are also often immobilized and
require in-line cervical stabilization during intubation,
making it more difficult to optimally align the airway,
or they might be combative without intravenous access.
Blood or vomit is frequently present in the airway, and
the anatomy can be distorted from facial trauma or
neck injuries, causing compression of the airway. All of
these factors can lead to increased rates of complications
during the intubation of severely injured patients
(2,3,9,13). In the present study, the EP, on average,
managed more difficult airways based on the overall
higher Injury Severity Score of the patient population.
Given the overall higher Injury Severity Scores, one
would expect the complication rate to be increased, but
this was not supported by the data. This difference
might suggest that EPs might be better at managing
difficult airways than anesthesiologists.
For these reasons, the trauma airway has historically
been managed by anesthesiologists with excellent results
(13). In a survey of anesthesia residency directors,
Nayyar and Lisbon found that anesthesiologists were re-
sponsible for airway management in 76% of institutions
when it involved the trauma airway, and 68% of institu-
tions reported being uncomfortable with nonanesthesiol-
ogists managing the trauma airway (14). However, during
the past decade, more and more institutions have changed
policy to place control of the airway in the hands of EPs.
Despite the frequency with which this policy change has
been made, there is a paucity of data comparing the out-
comes of airway management by EPs and anesthesiolo-
gists specifically with trauma patients (1,3,7).
To our knowledge, only one other study has been con-
ducted directly comparing the complication rates of EP
attendings and anesthesiologists (1). Omert et al. reviewed
200 trauma intubations, with 101 being managed by anes-
thesiologists and 99 managed by EP, and concluded that
complication rates were similar between the two groups
(37.6% and 33.3%) (1). Notably, the data from the second
half of Omert et al.s study were prospectively collected
by EPs and compared with retrospective data, raising
the possibility of reporter bias.
The present study supports these earlier data suggesting
that anesthesiologists and EPs demonstrate equal compli-
cation rates in airway management in trauma, utilizing the
same basic complication criteria but a much larger sample,
and taking into consideration delayed complications. Our
overall success at emergent airway management was
96.9%, with a need for surgical airway 2.6% of the time.
This rate is comparable with literature reports of surgical
airway rates ranging from 0.3% to 5.6% (13,15,16).
1193
Further, by collecting all data retrospectively, we have
attempted to eliminate the problem of reporter bias, pro-
viding a stronger basis for the validity of the results. Our
complication rate was much lower than that of the study
by Omert et al. (18.1% vs. 35.5%) using similar criteria,
although it is still higher than other published results
(13). This difference in overall complication rates is
significant and could be due to our larger sample size.
In comparison, Sakles et al. found a complication rate
of only 9.3% among 610 EP intubations in an urban
teaching hospital, but their study was not specific to
trauma patients and their criteria did not include need
for surgical airway, number of failed attempts,
esophageal intubations, or delayed complication, such
as infection (2). Our study, on the other hand, included
all complications, including cases where a single patient
had more than one complication as a result of the intuba-
tion. This scenario is more common with traumatic injury
patients, where one complication can lead to others. In
our study, the EP group had six patients with more than
one complication and the anesthesia group had three pa-
tients with more than one complication. If we counted
only a single complication per patient, our overall com-
plication rates dropped to 16.2% for the anesthesia group
and 14.8% for the EP group.
Another factor that might have impacted complication
rates in the present study is the choice of medication dur-
ing intubation. In both the anesthesia and EP groups, the
majority of patients (75.8% and 78.8%, respectively)
were intubated using etomidate and succinylcholine. By
looking at the timing of the medication dosage and the
recorded vital signs, it was apparent that all episodes of
hypotension and hypoxia occurred after rapid sequence
intubation with etomidate and succinylcholine. We were
unable to determine from the chart review whether the
medication choice and administration were predictive of
the hypotension and hypoxia complications. Only 2.9%
of the intubations performed by anesthesiologists used
other medications, such as propofol or fentanyl. In this
2.9% of patients, there were no records of any complica-
tions. Although in the present study, there was no differ-
ence in complication rate depending on type of induction
agent (p = 0.642, Fishers exact test), the small sample
size of patients who received other medications pre-
cluded accurate testing of potential differences in induc-
tion agent and complication rate. Future studies would
do well to examine the role of medication choice in the
complication rates of airway management in trauma.
Limitations
While the present study makes several important contribu-
tions to the literature on airway management, it should be
acknowledged that there are limits to its generalizability.
1194
First, as a retrospective analysis, the study is limited by the
possibility of potentially confounding factors around the
intubation time period that may not be clearly delineated
in the chart. Due to the retrospective nature of this study, it
is quite possible that some clinical outcomes may not have
been fully documented in the chart and would not have
come out during the chart review. In addition, we defined
aspiration as the presence of gastric contents or blood in
the airway. As we were unable to distinguish if the blood
or gastric contents were deep in the airway or just in the
oropharynx, we elected to include all of the data so no pos-
sible aspirations were missed, while acknowledging the
possibility that this inclusion may limit the applicability
of the results.
A second concern is our reliance on the records from
the attending completing the intubation for the reporting
of multiple attempts and most immediate complications,
leaving a potential for under-reporting of complications.
We attempted to mitigate this limitation by including the
nursing record of the event in our chart review, but, as
with all chart-review studies, all data were dependent
on appropriate charting. It was also not well documented
who actually performed the intubation. The notes were
written by the attending supervising the intubation and
often did not describe if they themselves or one of their
residents or a trauma flight nurse did the intubation.
Finally, our data collectors were not blinded as to who
performed the intubation, leaving a potential for bias
when assessing for complications. We attempted to man-
age this limitation by requiring all complications identi-
fied in the chart review to be reviewed by a third party
that was not from Emergency Medicine or anesthesia.
Despite these limitations, the present study offers a valu-
able contribution to the literature, which may be ex-
panded upon by future studies designed as prospective
observational models with standard data collections
sheets for all trauma intubations.
CONCLUSIONS
In conclusion, our study supports earlier data that EPs
can manage the airway in trauma patients as well as
S. Varga et al.
anesthesiologists and with similar success and compli-
cation rates.
REFERENCES
1. Omert L, Woodrow Y, Mizikowski, et al. Role of the emergency
medicine physician in airway management of the trauma patient.
J Trauma 2001;51:10658.
2. Sakles JC, Laurin EG, Rantapaa AA, et al. Airway management in
the emergency department: a one-year study of 610 tracheal intuba-
tions. Ann Emerg Med 1998;31:32533.
3. Bushra JS, McNeil B, Wald D, et al. A comparison of trauma intu-
bations managed by anesthesiologists and emergency physicians.
Acad Emerg Med 2004;11:6670.
4. Sakles JC, Deacon JM, Bair AE, et al. Delayed complications of
emergency airway management: a study of 533 emergency depart-
ment intubations. West J Emerg Med 2008;9:1904.
5. Kovacs G, Law A, Ross J, et al. Acute airway management in the
emergency department by non-anesthesiologists. Can J Anesth
2004;51:17480.
6. Tayal VS, Riggs RW, Marx JA, et al. Rapid-sequence intubation at
an emergency medicine residency: success rate and adverse events
during a two-year period. Acad Emerg Med 1999;6:317.
7. Levitan RM, Rosenblatt B, Meiner EM, et al. Alternating day emer-
gency medicine and anesthesia resident responsibility for manage-
ment of the trauma airway: a study of laryngoscopy performance
and intubation success. Ann Emerg Med 2004;43:4853.
8. Walls RM. Management of the difficult airway in the trauma
patient. Emerg Med Clin North Am 1998;16:4561.
9. Langeron O, Birenbaum A, Amour J. Airway management in
trauma. Minerva Anestesiol 2009;75:30711.
10. Dunham CM, Barraco RD, Clark DE, et al. Guidelines for emer-
gency tracheal intubation immediately after traumatic injury.
J Trauma 2003;55:16279.
11. American Society of Anesthesiologists Task Force on Management
of the Difficult Airway. Practice guidelines for management of the
difficult airway: an updated report by the American Society of An-
esthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology 2003;98:126977.
12. Levitan RM, Everett WM, Ochroch EA. Limitations of difficult air-
way prediction in patients intubated in the emergency department.
Ann Emerg Med 2004;44:30713.
13. Stephens CT, Kahntroff S, Dutton R. The success of emergency
endotracheal intubation in trauma patients: a 10-year experience
at a major adult trauma referral center. Anesth Analg 2009;109:
86672.
14. Nayyar P, Lisbon A. Non-operating room emergency airway man-
agement and endotracheal intubation practices: a survey of anesthe-
siology program directors. Anesth Analg 1997;85:628.
15. Wright MJ, Greenberg DE, Hunt JP, et al. Surgical cricothyroidotomy
in trauma patients. South Med J 2003;96:4657.
16. Salvina CK, Dries D, Gamelli R, et al. Emergency cricothyroidotomy
in trauma victims. J Trauma 1993;34:5035.
Trauma Airway Management 1195

ARTICLE SUMMARY
1. Why is this topic important?
This study is important because it demonstrates that
Emergency Physicians are able to manage traumatic air-
ways with similar success and complication rates as anes-
thesiologists.
2. What does this study attempt to show?
This study attempts to show that Emergency Physicians
are able to manage difficult traumatic airways as well as
anesthesiologists.
3. What are the key findings?
The overall complication rate was 18.3% for the anes-
thesiologist group and 18% for the Emergency Physician
group (p = 0.476). There were no significant differences in
specific complication rates between anesthesiologists and
Emergency Physicians.
4. How is patient care impacted?
Emergency Physicians are typically the first provider to
evaluate a trauma patient. Control of the airway is the first
step in trauma management and Emergency Physicians
can intubate quickly and effectively without the need to
call anesthesia and possibly delay airway control.