Airway Management in the Trauma Patient: Review EMS Professions Temple College

Airway Management in the Trauma Patient: Review

EMS Professions

Temple College

Objectives of Airway Management & Ventilation

Primary Objective: Provide unobstructed passage for air

movement Ensure optimal ventilation Ensure optimal respiration

Objectives of Airway Management & Ventilation

Why is this so important in the trauma patient? Prevention of Secondary Injury

Shock & Anaerobic MetabolismSpinal Cord InjuryBrain Injury

Anatomy of the Upper Airway

Pediatric vs Adult Upper Airway Larger tongue in comparison to size of

mouth Floppy epiglottis Delicate teeth and gums Larynx is more superior Funnel shaped larynx due to undeveloped

cricoid cartilage Narrowest point at cricoid ring before 10 yoa

Anatomy of the Upper Airway

From: CPEM, TRIPP, 1998

VentilationDefined as movement of air into & out of lungs Inspiration

stimulus from respiratory center of brain (medulla) transmitted via phrenic nerve to diaphragm diaphragm flattens during contraction intercostal muscles contract ribs elevate and expand results in intrapulmonic pressure (pressure

gradient) results in air being drawn into lungs & alveoli inflated

Ventilation

Expiration Stretch receptors in lungs signal

respiratory center via vagus nerve to inhibit inspiration

Hering-Breuer Reflex Natural elasticity of lungs passively

expires air (in non-diseased lung)Control via Pons

Apneustic & Pneumotaxic centers

Ventilation

Chemoreceptors Carotid bodies & Aortic arch Stimulated by PaO2, PaCO2 or pH

PaCO2 considered normal neuroregulatory control of ventilations

Hypoxic Drive default regulatory control Senses changes in Pa02

Ventilation

Other stimulations or depressants to ventilatory drive body temp: w/ fever & w/hypothermia drugs/meds: increase or decrease pain: increases but occasionally decreases emotion: increases acidosis: increases sleep: decreases

Respiration

Ventilation vs. RespirationExchange of gases between a living

organism and its environmentExternal Respiration

exchange between lungs & blood cellsInternal Respiration

exchange between blood cells & tissues

Respiration

Oxygen saturation affected by: low Hgb (anemia, hemorrhage) inadequate oxygen availability at alveoli poor diffusion across pulm membrane

(pneumonia, pulm edema, COPD) Ventilation/Perfusion (V/Q) mismatch

blood moves past collapsed alveoli (shunting)

alveoli intact but blood flow impaired

Respiration

Carbon Dioxide content of blood Byproduct of work (cellular respiration) Transported as bicarbonate (HCO3

- ion) 20-30% bound to hemoglobin Pressure gradient causes CO2 diffusion

into alveoli from blood increased level - hypercarbia

Alveoli PO2 100 & PCO2 40

PO2 40 & PCO2 46 - Pulmonary circulation - PO2 100 & PCO2 40

Heart

PO2 40 & PCO2 46 - Systemic circulation - PO2 100 & PCO2 40

Tissue cell PO2 <40 & PCO2 >46

Inspired Air: PO2 160 & PCO2 0.3

OxygenatedDeoxygenated

Causes of Hypoxemia

Traumatic Reduced surface area for gas exchange

pneumothorax, hemothorax, atelectasis

Decreased mechanical effortpain, traumatic asphyxiation,

hypoventilationsucking chest wound, obstruction

Assessment & Recognition of Airway & Ventilatory Compromise

Visual Assessment Position

tripodorthopnea

Rise & Fall of chestParadoxical motion

Audible gasping, stridor, or wheezes

Obvious pulm edema

Visual Assessment Skin color Flaring of nares Pursed lips Retractions Accessory Muscle Use Altered Mental Status Inadequate Rate or

depth of ventilations

Assessment & Recognition of Airway & Ventilatory Compromise

Respiratory Patterns Cheyne-Stokes

brain stem

Kussmaulacidosis

Biot’sincreased ICP

Respiratory Patterns Central Neurogenic

Hyperventilationincreased ICP

Agonalbrain anoxia

Airway & Ventilation Methods: BLS

Progress from Non-invasive BLS to invasive ALS

Supplemental Oxygen increased FiO2 increases available

oxygen objective is to maximize hemoglobin

saturation


Airway Maneuvers Jaw thrust Sellick’s maneuver

Airway Devices Oropharyngeal

airway Nasopharyngeal

airway CombiTube ®


1/2/3 person BVMOne Person BVM

difficult to master mask seal often

inadequate may result in

inadequate tidal vol gastric distention

risk

Two person BVM most efficient

method Useful in C-spine inj improved mask seal

and tidal volume


Partial Airway Obstruction Techniques Positioning OPA/NPA Suctioning Removal via Direct laryngoscopy


Gastric Distention Common when ventilating without

intubation pressure on diaphragm resistance to BVM ventilation avoid by increasing time of BVM

ventilation

Airway & Ventilation Methods: ALS

Gastric Tubes nasogastric

caution with facial traumatolerated by awake patients but is

uncomfortableinterferes with BVM seal

orogastricusually used in unresponsive patientslarger tube may be usedsafe in facial trauma


Endotracheal Intubation Indications

present or impending respiratory failureapneaunable to protect own airway

Advantagessecures airwayroute for a few medicationsoptimizes ventilation and oxygenation


Complications of endotracheal intubation Bleeding or dental injury Laryngeal edema Laryngospasm Vocal cord injury Barotrauma Hypoxia Aspiration Dislodged tube or esophageal intubation Right or Left mainstem intubation


Patient Positioning for Intubation Goal

Align the 3 planes of view, so that

The vocal cords are most visible

T - trachea P - Pharynx O - Oropharynx

From AHA PALS


Surgical Cricothyrotomy Indications

absolute need for a definitive airway AND• unable to perform ETT due for structural or

anatomic reasons, AND• risk of not intubating is > than surgical airway risk

ORabsolute need for a definitive airway AND

• unable to clear an upper airway obstruction, AND• multiple unsuccessful attempts at ETT, AND• other methods of ventilation do not allow for

effective ventilation and respiration


Surgical Cricothyrotomy Contraindications (relative)

No real demonstrated indicationRisks > benefitsAge < 8 years (some say 10)evidence of fx larynx or cricoid cartilageevidence of tracheal transection


Needle Cricothyrotomy & Transtracheal Jet Ventilation Indications

Same as surgical cricothyrotomy along withContraindication for surgical cricothyrotomy

ContraindicationsNone when demonstrated needcaution with tracheal transection


Jet Ventilation Usually requires high-

pressure equipment Ventilate 1 sec then

allow 3-5 sec pause Hypercarbia likely Temporary: 20-30

mins High risk for

barotrauma

Airway & Ventilation Methods: BLS & ALS

No. 1

100 ml

No. 1100 ml

Combitube®

From AMLS, NAEMT

Airway & Ventilation Methods: BLS & ALS

Combitube®

Indications Contraindications

HeightGag reflexIngestion of corrosive or volatile substancesHx of esophageal disease


Pharmacologic Assisted Intubation (“RSI”) Sedation

Used for• induction• anxious or agitated patient

Contraindications• hypersensitivity• hypotension (e.g. hypovolemia 2° to trauma)


Pharmacologic Assisted Intubation (“RSI”) Neuromuscular Blockade

Induces temporary skeletal muscle paralysisIndications

• When Intubation is required in a patient who– is awake,– has a gag reflex, or– is agitated or combative


Pharmacologic Assisted Intubation (“RSI”) Neuromuscular Blockade

Contraindications• Most are Specific to the medication• inability to ventilate patient once paralysis is induced

Advantages• enables provider to intubate patients who otherwise

would be difficult or impossible to intubate• minimizes patient resistance to intubation• reduces risk of laryngospasm


Pharmacologic Assisted Intubation (“RSI”) Disadvantages & Potential Complications

Does not provide sedation or amnesiaProvider unable to intubate or ventilate after

NMBAspiration during procedureDifficult to detect motor seizure activitySide effects and adverse effects of specific

meds


Examples ofSecondary Tube

Placement Confirmation Devices

(From AMLS, NAEMT)

From AMLS, NAEMT


Needle Thoracostomy (chest decompression) Indications

Positive sx/sx of tension pneumothoraxCardiac arrest with PEA or Asystole when

the possibility of trauma and/or tension pneumo exist

ContraindicationsAbsence of indications


Tension Pneumothorax Sx/Sx

severe respiratory distress or absent lung sounds (unilateral

usually) resistance to manual ventilationCardiovascular collapse (shock)asymmetric chest expansionanxiety, restlessness or cyanosis (late)JVD or tracheal deviation (late)


Chest Escharotomy Indications

In the presence of severe edema to the soft tissue of the thorax as with circumferential burns:

• inability to maintain adequate tidal volume even with PPV

• inability to obtain adequate chest expansion with PPV

Rarely needed


Chest Escharotomy Considerations

must rule out the possibility of upper airway obstruction

ProcedureIntubate if not already donePrep site and equipmentVertical incision to anterior axillary lineHorizontal incision only if necessaryCover and protect

Airway & Ventilation: Risks & Protective Measures

BSI Gloves Face & eye shields Respirator if concern for airborne disease Be prepared for

coughingspittingvomitingbiting

Documents

Airway Management in the Trauma Patient: Review EMS Professions Temple College