In the deteriorating trauma patient who is exsanguinating but spontaneously ventilating and able to protect their airway, it is reasonable to perform basic airway management and delay intubation until resuscitation efforts, such as blood product administration, have been initiated. The rationale behind this approach is to preserve the remaining physiologic reserve and compensatory mechanisms while avoiding further decompensation from induction of anesthesia, paralysis, and positive pressure ventilation until definitive surgical care can be provided in the operating room. Once in the operating room, the best way to protect the patient's airway is to perform a rapid-sequence induction while maintaining inline cervical spine immobilization if the patient is in a cervical collar. For the patient with a suspected difficult airway, one could perform awake, topicalized tracheal intubation; however, awake intubation can be difficult because patients can be confused, uncooperative, and even combative.

If tolerated, the patient should be preoxygenated for 3 to 5 minutes. Next, ketamine 0.5 to 2 mg/kg, depending on the patient's physiology, can be given followed by succinylcholine 1.5 mg/kg. Ketamine was chosen in this case because of its hemodynamically favorable profile. Etomidate (0.15-0.2 mg/kg) would be another appropriate choice for an induction agent.

If the patient is comatose, in severe shock, or in full arrest on admission to the resuscitation room, no drugs other than oxygen and possibly a neuromuscular blocking agent are required until the blood pressure and HR sufficiently rebound so that anesthetics can be titrated.

References

• Brown CVR, Inaba K, Shatz DV, et al. Western trauma association critical decisions in trauma: airway management in adult trauma patients. Trauma Surg Acute Care Open. 2020;5:e000539.