A total of 713 residency directors were emailed requesting completion of the survey to assess intubation patterns in trauma wards. 170 survey responses were received from these trauma centers meeting the aforementioned inclusion criteria, for a respondent rate of 23.8%. Of these entries, 49 were duplicate entries from 39 institutions. Elimination of duplicate entries identified 121 original survey responses.
In the survey’s responses, the Emergency Department (ED) physicians were identified as the primary team managing the airway in the trauma bay at 77.4% (Fig. 1a). Physician anesthesiologists were the primary team in only a minority of cases (5.8%), compared to adopting a collaborative approach between all involved teams (13.9%). In very few cases, the primary team responsible for the trauma bay airway were trauma surgeons (1.5%) or a system of alternating between ED physicians and anesthesiologists (1.5%). Note that these respondents also indicated that their institutions implemented a formal scheduling that defined this responsibility as alternating between for ‘odd’ vs ‘even’ days, or an informal understanding between the departments to switch.
Institutions of 95.6% of those surveyed utilize a tiered trauma activation system, while only 4.4% do not (Fig. 1b). Participants were also asked if an anesthesia team member comes to the trauma bay in the setting of highest priority traumas. There was only a small difference between respondents who indicated that anesthesia providers respond to highest priority traumas versus those that do not, 48.1% versus 46% respectively. The remainder of responses indicated more nuanced situations – for 3.6%, an anesthesia team member comes to the trauma bay for high priority traumas only when requested for back-up or ‘as-needed’. In addition, one respondent (0.7%) indicated that anesthesia responds depending on who is on-call from the anesthesia team. Finally, 2 respondents (1.5%) noted that anesthesia responds in order to assess operating room needs and for operative planning.
69.3% of surveyed respondents’ institutions have a protocol for trauma bay intubations that delineates responsibilities for different providers, whereas 30.7% do not (Fig. 2a). 33.6% of respondents indicated that their institution does not have a protocol or guidelines to determine when anesthesia should become involved for an intubation/airway management (Fig. 2c). In addition, 32.8% of respondents indicate that the anesthesia team gets involved only by the request of the trauma surgeon or emergency department (ED) attending physician for encountered or anticipated difficult airways. Another significant portion (18.2%) of respondents described their criteria for anesthesia involvement as failure to intubate by the emergency medicine team, which includes the presence of multiple failed attempts. For 5.8% of respondents, anesthesia is involved for all highest-level trauma activations. Anesthesia is involved for trauma bay intubations on specific, scheduled days for 2.9% of cases, whereas for a similar portion (3.6%) the described airway management protocol does not involve the anesthesia service. For a minority of cases, anesthesia involvement is prompted in cases requiring operating room planning (1.5%). In one case each (0.7%), the protocol for anesthesia involvement is pediatric airways or for specific, defined characteristics of the patient and airway.
The anesthesia team is immediately available in 81.0% of respondents’ institutions even when not managing the airway in the trauma bay, leaving only 19.0% of cases where they are not readily available(Fig. 2b). For 38.7% of respondents, anesthesia at their institution takes over in the event that another team has a failed attempt at managing an airway (Fig. 3a). However, for 27.7%, anesthesia does not take over in this situation. A similar portion (26.3%) indicate that anesthesia does not automatically take over in such a situation but are available to be requested by the emergency medical team. For 6.6% of surveyed respondents, anesthesia steps-in after two or more failed attempts, whereas for only 1 respondent (0.7%), anesthesia automatically steps-in for difficult pediatric airways.
In this cohort of respondents, 61.3% of those surveyed indicated that their institution tracks airways complications encountered in the trauma bay (Fig. 3b). However, 34.3% indicated that their institution does not track such complications, and 4.4% of respondents did not know if trauma bay airway complications were tracked or not.
Those surveyed were additionally asked which service specifically would be responsible for the majority of airway complications, to which 72 respondents that found the question applicable (Fig. 3c). Of these respondents, 83.3% of respondents indicated that Emergency Medicine is responsible for the majority of airway complications in the trauma bay. 4.2% felt that anesthesia was responsible for the majority of such complications, and 5.6% indicated the surgical service. The remaining 6.9% indicated that none of these three services would be primarily held responsible for the majority of trauma bay airways complications.
When asked to select from residency programs - anesthesia, emergency medicine, surgery – that their institution has, most (67.2%) have all three (Fig. 4). 23.4% have emergency medicine and surgery residencies without an anesthesia residency. A minority have surgery only (2.9%) or anesthesia and surgery without emergency medicine (6.6%). No institution of those surveyed had only anesthesia, only emergency medicine, or emergency medicine and anesthesia residencies without a surgery residency.
Respondents were asked to select, from a list of nine criteria (Mallampati Score ; Presence of a C - Collar ; Trauma to head/face ; Fluid in Airway ; Thyromental Distance ; Neck Mobility ; Obesity ; Incisor Distance ; Unsuccessful Intubation by paramedics) those factors that are incorporated into their institution’s protocol for defining a difficult airway (Fig. 5). 114 of respondents’ institutions (83.2%) have a known, defined criteria for determining a difficult airway in the trauma bay that incorporates at least one of these nine criterium listed. The most often used criterium from these nine was ‘Trauma to head/face’ with 82.5% having this among their criteria, followed by ‘Fluid in the airway’ at 65.7%. ‘Obesity’ and ‘Unsuccessful intubation by paramedics’ each had 64.2% of respondents reporting these as included in their criteria. 58% of respondents’ institutions’ criteria incorporate the presence of a C-collar, followed by 51.1% for limited neck mobility and 39.4% for high Mallampati score. Of the nine criteria given, thyromental distance (32.1%) and incisor distance (26.3%) were least used. A minority of respondents (2.9%) used additional criteria not given (three respondents) or had a defined criteria that included none of the nine given (one respondent). For additional criteria not listed, one respondent each reported that their criteria include ‘King airway’, ‘difficult/unsuccessful intubation by surgery’, or ‘supraglottic airway’.
Figure 5 also indicates that, of survey respondents, 5.8% indicated that they did not know if their institution has a defined criteria for trauma bay difficult airways, while 10.2% indicated that their institution lacks a standard set of criteria, which may reflect in variation in practice according to each physician. The responses were additionally analyzed according to how many criteria from the nine given, that each respondent selected, including any additional criteria provided by respondents in the three cases mentioned above.
The largest portion of respondents selected all nine criteria (15.3%), while 10.2% of respondents selected all but one of the criteria given. 8.0% of respondents selected 7/9 criteria while a similar portion (8.8%) selected 5/9 criteria. 13.1% selected 6/9 criteria and, similarly, 11.7% selected 4 criteria. One respondent that indicated 4 criteria as part of their institution’s protocol selected, including 3 of 9 from the given criteria, adding ‘difficult intubation/unsuccessful by surgery’ as an additional defined criterion. In addition, 2 other respondents, both selecting 2/9 from the given criteria, described supplementary criteria of a ‘King airway’ or the presence of a previously placed ‘supraglottic airway’. Including these two respondents, 10.9% of total respondents selected 3 criteria. A minority indicated only 2 criteria (1.5%), none of the given criteria (0.7%), or selected only one criterion (3.6%).