A man on his back has a medical professional insert an airway device down his throat.

Photo/David Herraez Calzada

In every horror movie, particularly the one that I have been loosely referencing throughout this series, the good guys always find a way to defeat the monster. For good… There is some special silver bullet solution to their nightmares and the group that survived to the end of the movie gets to live on happily ever after.

Airway management in trauma is not much different. While there are no silver bullet solutions in airway management, particularly in the prehospital arena, combining all our tools and methods into one bundle may offer a viable solution.

In this final installment, we will unpack the utility of clinical bundles to address the dangers associated with airway management in the trauma patient.

Clinical Bundles

Aren’t these things that only hospitals do for certain types of patients? What can the prehospital world do with them?

A clinical bundle is a collection (usually three-to-five elements) of evidence-based interventions that can be used together to promote consistency in clinical practice and improve overall outcomes.1 Each of them should have evidentiary support and show improved outcomes so that when synergized with the other interventions in the bundle, in theory, can super charge the positive impact of the bundle.

Specific to airway management, several clinical bundles have been studied with varying levels of success. The make-up and execution of them varies from place to place. Implementation and execution are also widely variable. One thing that most of them have in common is a checklist, utilized as a double check to ensure that the evidence-based interventions are performed in the manner the leadership expects them to be.

This lends itself to a criticism of bundles and checklists: you cannot write a protocol for everyone, and you cannot uniformly apply a checklist to every single patient. This is true, and normally accounted for during the quality improvement phase of care in a post care review. That being said, let’s evaluate a few different airway management bundles.

NICU Airway Management Bundle – Children’s Hospital of Philadelphia (CHOP)

I personally cannot think of a more delicate and difficult airway management challenge than a neonate in extremis. Moreover, I cannot think of another airway management situation that may require as consistent execution as possible to ensure the best possible outcomes.

The team in the NICU at CHOP looked at 1182 neonatal intubations and demonstrated a 66% reduction in their intubation associated adverse events. This bundle looked to address areas of Risk Assessment (both overall and specifically BVM difficulty), Team Communication (who needs to know what, when), Team Preparation (who is doing what), and Premedication.

Notably, the bundle was created to increase the use of VL with these patients (a known contributor to first pass success), premedication w/ paralytics (to improve intubating conditions), and to decrease the overall amount of adverse events.2

They were able to demonstrate an improvement in the usage of the bundle elements, but no real improvement in three areas: dysrhythmias, cardiac arrest, and chest compressions for <1 minute which accounted for 60% of all their adverse events. The difficulty with extrapolating this to the EMS world is that if/then checklists require time to work through, and we may not have the time. Perhaps a more straightforward, “do these things every time…” approach may be more helpful.

ICU Airway Management Bundle – Jaber Paper

Jaber et al. studied endotracheal intubation in the ICU to ascertain if a clinical bundle/protocol would reduce intubation related complications. They evaluated 244 intubations in three different ICUs in two different university level hospitals.3

There were 10 elements to this bundle split into three different phases of the procedure:


  1. Presence of two operators
  2. Fluid loading (isotonic saline 500 ml or starch 250 ml) in absence of cardiogenic pulmonary edema
  3. Preparation of long-term sedation
  4. Preoxygenation for 3 min with NIPPV in case of acute respiratory failure (FiO2 100%, pressure support ventilation level between 5 and 15 cmH2O to obtain an expiratory tidal volume between 6 and 8 ml/kg and PEEP of 5 cmH2O)

During Intubation

  1. Rapid sequence induction: etomidate 0.2–0.3 mg/kg or ketamine 1.5–3 mg/kg combined with succinylcholine 1–1.5 mg/kg in absence of allergy, hyperkaliemia, severe acidosis, acute or chronic neuromuscular disease, burn patient for more than 48 h and medullar trauma
  2. Sellick maneuver


  1. Immediate confirmation of tube placement by capnography
  2. Norepinephrine if diastolic blood pressure remains \35 mmHg
  3. Initiate long-term sedation
  4. Initial ‘‘protective ventilation’’: tidal volume 6–8 ml/kg of ideal body weight, PEEP \5 cmH2O and respiratory rate between 10 and 20 cycles/min, FiO2 100% for a plateau pressure \30 cmH2O.3

Here are the results:

Control (n=121) Bundle (n=123)
Severe Complications 34% 21%
Hypoxemia 25% 10%
Hemodynamic Collapse 27% 15%
Arrest / Death 3% 1%

When implemented, each category demonstrated a dramatic reduction in occurrence. Not only did this bundle address the need for certain things like pre-oxygenation and controlling hemodynamics, they went a step further and prescribed how these treatments were to be employed, based on the available evidence. Interestingly, of the 10 elements in the bundle 6 of them are individually supported by evidence that they independently improve outcomes.3-9

But how can prehospital providers, who are resource limited and under a time constraint, implement a clinical bundle to such an effect?

The Williamson County EMS – Texas Bundle – Dr. Jeff Jarvis et al.

Dr. Jarvis and his team in Texas evaluated 191 prehospital RSI procedures: 104 prior to bundle implementation and 87 post-bundle implementation.10 Not only did the team implement a clinical bundle, they significantly modified the RSI procedure to a Delayed Sequence Intubation9 procedure that forced the paramedics to slow down and allow for adequate preoxygenation prior to the apnea period.10

With aims to reduce peri-intubation hypoxia, peri-intubation hypotension, and reducing the number of attempts, Dr. Jarvis and his team implemented the following bundle:

  • Position the patient ear-to-sternal notch.9-10
  • Apneic Oxygenation w/ a nasal cannula in place at flush rate9-10
  • Ketamine administration 2mg/kg à 3:00 before paralytic
  • Presence of 2 trained operators

There were two particularly important safety controls in this bundle: 1) intubation could not be attempted if Spo2 dropped or remained <94%; 2) the paramedics were limited to two attempts at laryngoscopy, maximum.10

Control (n=104) Bundle (n=87)
First Pass Success 84.6% 88.5%
Peri-intubation hypoxia 44.2% 3.5%
Peri-intubation hypotension 16.3% 9.2%
Arrest / Death 1.9% 1.2%

Applied to Trauma

As we discussed in Part 2 of this Nightmares series, hypotension in airway management is an incredibly dangerous high risk airway management (HRAM) situation for the patient. In the actively hemorrhaging patient, it is unavoidable, and in some systems even recommended as part of the overall management strategy (permissive hypotension).

However, the risk of anoxic brain injury secondary to persistent profound hypotension overshadows the theoretical risk of “popping clots.” It is hypothesized that the advantage of permissive hypotension is the reduction of the instance of massive crystalloid boluses and the avoidance of their untoward secondary effects than it is protecting native clots that may or may not be formed.

It is a resuscitate then intubate situation that we often find ourselves in. In fact, these situations may require a significant modification of approach to ensure the best chance for survival. We need to build a bundle of contingencies.

Building on what Dr. Jarvis and his team established with their study, clinicians could add volume resuscitation with blood products or crystalloid (for those without access to blood products) to the bundle. Small aliquots of bolus dose vasopressors such as vasopressin, epinephrine, or neosynephrine could be utilized to prevent hemodynamic collapse.

Davis et al. performed a study that evaluated the use of bolus dose vasopressors for peri-intubation hypotension in the prehospital (air medical) environment in both trauma and non-trauma patients.11

They evaluated vasopressin and phenylephrine in the peri-RSI period and while there was no significant difference between the results the two medications, the impact on hypotension was notable. Both medications reversed hypotension in 95-96% of the patients, including trauma patients.11

Beyond volume resuscitation and use of bolus dose vasopressors, a prudent clinician should stop and ask, should this patient be intubated or have their airway managed via other means. Supraglottic airways are a viable alternative to intubation when the patient’s hemodynamics may not support it. There may still be a need for moderate sedation so that the patient can tolerate the SGA, but it is a quick and relatively uncomplicated solution that allows the clinician to move on with the rest of the resuscitation.

Another effective method of airway management is the surgical cricothyroidotomy. While not generally a first-line airway placed, the situation may present itself where it is the most viable and safest option. It may still require some moderate sedation in order to place it, but it can be done quickly and allow clinicians to move on and continue resuscitation.

An additional bundle for trauma patients may look like this (in addition to the Jarvis bundle):

  • Shock index >0.8 ? à volume resuscitation w/ blood or crystalloid.
  • Low dose ketamine (1/2 dose to reduce the chance of dramatic side effects)
  • Persistent Hypoxia <94% despite BLS maneuvers and BVM compliance? à SGA placement / Front of Neck Access (FONA)
  • Continue the resuscitation.


The most important thing to remember with airway management in trauma patients is that managing the airway is only a part of a greater resuscitation strategy. It is also not without increased risk to the patient. The addition of PPV in the hypotensive/hypovolemic trauma patient, while maybe unavoidable, will complicate the resuscitation to some degree.

It must be cemented in the clinician’s mind that the patient needs to have their airway managed, and this does not always mean intubation or RSI. SGA and FONA remain viable alternatives to airway management in the trauma patient and should even be considered first line approaches in some cases.

It is rare that in the trauma patient that the airway is the only thing we have to worry about. Resuscitation with blood products and ensuring a perfusing MAP is essential to the survival and good outcomes of these patients. Aggressive but prudent hemodynamic control and hemostatic resuscitation are essential to the overall survival of the patient.

Bring out all of the tools in an organized manner and implement them in a systemized approach. Clinical bundles are just one way to achieve just that. 


  1. McCarron, Kim MS, CRNP. Understanding care bundles. Nursing Made Incredibly Easy! 9(2):p 30-33, March 2011. | DOI: 10.1097/01.NME.0000394024.85792.42
  2. Heidi M. Herrick, Nicole Pouppirt, Jacqueline Zedalis, Bridget Cei, Stephanie Murphy, Leane Soorikian, Kelle Matthews, Rula Nassar, Natalie Napolitano, Akira Nishisaki, Elizabeth E. Foglia, Anne Ades, Ursula Nawab; Reducing Severe Tracheal Intubation Events Through an Individualized Airway Bundle. Pediatrics October 2021; 148 (4): e2020035899. 10.1542/peds.2020-035899
  3. Samir Jaber, Boris Jung, Philippe Corne, Mustapha Sebbane, Laurent Muller, et al.. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Medicine, 2010, 36, pp.248 – 255. ff10.1007/s00134-009-1717-8ff. ffhal-02550540f
  4. Hasegawa, K. (2012). Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Annals of Emergency Medicine, 749-754.
  5. Heffner. (2012). Predictors of the complication of post intubation hypotension during emergency airway management. Journal of Critical Care, 587-593.
  6. Heffner, A. (2012). The frequency and significance of postintubation hypotension during emergency airway management. Journal of Critical Care, 417-419.
  7. Jarrod, M. (2015). The Physiologically Difficult Airway. West J Emerg. Med., 1109-1117.
  8. Sackles, J. (2013). The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg. Med, 71-78.
  9. Weingart, S. (2012). Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine, 165-175.
  10. Jeffrey L. Jarvis, Ashish R. Panchal, John W. Lyng, Nichole Bosson, Joelle J. Donofrio-Odmann, Darren A. Braude, Lorin R. Browne, Michael Arinder, Scott Bolleter, Toni Gross, Michael Levy, George Lindbeck, Lauren M. Maloney, Connie J. Mattera, Cheng-Teng Wang, Remle P. Crowe, Christopher B. Gage, Eddy S. Lang & J. Matthew Sholl (2023) Evidence-Based Guideline for Prehospital Airway Management, Prehospital Emergency Care, DOI: 10.1080/10903127.2023.2281363
  11. Davis DP, Olvera D, Selde W, Wilmas J, Stuhlmiller D. Bolus Vasopressor Use for Air Medical Rapid Sequence Intubation: The Vasopressor Intravenous Push to Enhance Resuscitation Trial. Air Med J. 2023 Jan-Feb;42(1):36-41. doi: 10.1016/j.amj.2022.09.004. Epub 2022 Oct 20. PMID: 36710033.

Cody Winniford is a flight paramedic and base manager in Baltimore, MD. He has a passion for sharing his professional experience in EMS and management. Cody’s clinical and leadership development background spans both military and civilian settings and has served in several capacities as a leader and prehospital clinician. He specializes in air medical and critical care transport, as well as organizational development and leadership development. He is an active speaker on various leadership and clinical topics and is an established and successful educator for prehospital clinicians of all levels. He has a passion for human performance improvement and the mental health and performance aspects of prehospital care.

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