AIRWAY MANAGEMENT

OBJECTIVES

• Demonstrate appropriate airway assessment techniques for the trauma patient.

• Identify signs and symptoms of airway compromise and respiratory distress.

• Demonstrate correct airway interventions for the trauma patient.

• Discuss complications of airway management.

AIRWAY & VENTILATION

• Goals– Maintain C-spine immobilization– Assess for airway obstruction– Establish definitive airway– Ensure adequate oxygenation– Provide adequate ventilation– Monitor ongoing airway status

AIRWAY ASSESSMENT

• Look– Presence of blood, emesis, foreign bodies, soot in

oral cavity– Stridor– Pallor or cyanosis– Agitation– Altered mental status– Severe maxillofacial trauma– Neck, larynx or tracheal injury

AIRWAY ASSESSMENT

• Listen– Snoring, gurgling– Hoarseness– Inability to talk

• Feel– Diminished air movement (LOC and ability

to speak provide info regarding airway patency)

VENTILATION ASSESSMENT

• Look– Asymmetrical chest wall movement– Paradoxical chest wall movement– Abnormal respiratory effort– Use of accessory muscles– Tachypnea or an abnormal respiratory rate

• Listen– Absence of breath sounds– Decreased breath sounds

VENTILATION ASSESSMENT

• Feel– Chest wall instability – Subcutaneous air in the soft tissues

(crepitus)

INTERVENTIONS

• Chin lift/Jaw thrust– Open the airway maintaining C-

spine immobilization– Suction the airway

• Oropharyngeal Airway (OPA)– Do not use if gag reflex is present– Size by placing flange at the

corner of the mouth and the tip at the angle of the jaw

Too short = depresses tongue into the pharynxToo long = pushes epiglottis against the entrance of the trachea

INTERVENTIONS

• Insert OPA upside down into the mount until it reaches the posterior pharynx then rotate 180 degrees

• Use a tongue blade to depress the tongue and insert the device right side up

• Assess for airway patency and auscultate breath sounds

INTERVENTIONS

• Nasopharyngeal Airway

– Size by placing the flange at the edge of the nares to the angle of the jaw

– Lubricate, gently insert into the nostril, the bevel is open at midline, resting in the posterior pharynx behind the tongue

– Do not force– Gently rotate to aid insertion– Assess for patient airway and

breath sounds

INTERVENTIONS

• Bag Valve Mask Ventilation– Place mask over mouth securing

seal (one or two man technique)– 100% high flow oxygen (assure

tubing is connected to oxygen source)

– Assure bag has a reservoir– Maintain airway– Continue to ventilate until definitive

airway is established

INTERVENTIONS

• Endotracheal Intubation - Indications– Presence of apnea– Inability to maintain a patent airway– Need to protect the lower airway from aspiration– Impending or potential compromise of the airway

(inhalation injury, facial fractures,)– Presence of a closed head injury GCS < 8– Inability to maintain adequate oxygenation by face

mask

INTERVENTIONS

• Endotracheal Intubation– Definitive airway = ET, Trach,

Cricothyroidotomy– Oral or nasal

• Oral is preferred for facial, sinus, basilar skull and cribriform plate fractures

• Oral is required for the apneic patient (Blind nasotracheal intubation requires a spontaneous breathing patient)

INTERVENTIONS

• Endotracheal Intubation– Avoid hyperextension of neck, maintain C-Spine

immobilization– Check equipment prior to procedure– Administer rapid sequence intubation medications as

indicated (mini neuro exam first)– Pre-oxygenate– Apply cricoid pressure to aid in visualization and to prevent

aspiration – maintain until balloon is inflated to avoid aspiration

– Monitor VS and pulse ox– Perform intubation– Do not over inflate cuff

INTERVENTIONS

• Endotracheal Intubation– Check for placement

• Listen over epigastrium for absence of sounds• Listen for breath sounds bilaterally, anterior, and laterally• Visualize equal chest excursion• Look for improvement in color and LOC

• Confirm with end tidal CO2 detector

• Secure tube• Chest x-ray to confirm placement• Constant reevaluation

INTERVENTIONS

• Endotracheal Intubation– Complications

• Lacerations of lips, tongue, pharyngeal or tracheal mucosa

• Right mainstem intubation• Aspiration• Chipping of teeth• Esophageal intubation

INTERVENTIONS

• Endotracheal Intubation– CO2 Detection devices

• May be inaccurate in patients in cardiac arrest

• Colorimetric devices changes color based on measurable concentrations of CO2

– Low levels of CO2 turn the color strip purple (atmosphere)

– High levels of CO2 turn the color strip yellow

• In-line capnometry measures inspired and end tidal CO2 with each breath and displays wave form CO2 concentrations

INTERVENTIONS

• Laryngeal Mask Airway (LMA)– Seals around the larynx – contraindicated if high risk of

aspiration– Not usually used in the trauma patient

• Multi-lumen Esophageal Airway Devices (CombiTube)– Used if ET cannot be placed– Complication is incorrect identification of tube position and

ventilation through the wrong lumen– Pressure exerted by the pharyngeal balloon can also cause

swelling of the tongue if left in > 30 minutes– Too large for children

INTERVENTIONS

• Rapid Sequence Intubation (RSI)– Not without risk!– Individual performing intubation must be able to

obtain a surgical airway if needed– Induction agents (sedatives and paralytics ) are

dangerous in the hypovolemic patient– Small doses of etomidate or midazolam are

appropriate for the paralyzed patient– Reversal agents must be readily available

INTERVENTIONS

• Rapid Sequence Intubation (RSI)

Drug Adult

Dose

Child Dose

Side Effect

Duration Onset

Succinly-

choline

1-2mg/Kg 1-2 mg/kg once

Arrythmias Fasciculation

Aspiration

3-10 minutes

30-60 seconds

Morphine 2-5 IV 0.1 mg/kg IV

CNS/Resp depression

2 hours Immediate

Midazolam 1-3 mg IV 0.1 mg/kg IV

CNS/Resp depression

1-3 hours 3-5 min

Vecuronium 0.15 mg/kg IV

0.15 mg/kg/IV

Apnea 30-60 min Within 60 seconds

Etomidate 0.2-0.6 mg/kg IV

0.3 mg/kg IV

Apnea 30-60 min Within 30 seconds

INTERVENTIONS

• Needle Cricothyroidotomy (Transtracheal Catheter Ventilation)– Jet insufflation of the airway– Useful for children under 12– Temporary use 30-45 minutes (CO2 accumulation)– Large caliber plastic cannula over a needle is placed

through the cricoidthyroid membrane through the trachea, just below the obstruction

– The cannula is connected to wall oxygen at 15 L/min with either a Y-connector or a side hole cut in the tubing attached between the oxygen source and the cannula

– Intermittent insufflation is accomplished by placing the thumb over the hole, one second on and 4 seconds off

INTERVENTIONS

• Surgical Cricothyroidotomy– Indicated when oral or nasal intubation is

not possible– Must be completed quickly and accurately– Incision is made through the skin and

cricothyroid membrane and an ET or tracheostomy tube is placed in the upper airway

INTERVENTIONS

• Special Considerations– Tension Pneumothorax

• Impacts cardiac filling and decreases B/P• “One-way valve” effect allows increasing

amounts of air to be trapped in the pleural space

• Positive pressure ventilation, especially after intubation may convert a simple pneumothorax to a tension pneumothorax

INTERVENTIONS

• Special Considerations– Tension Pneumothorax

• Assessment– Hypotension– Respiratory distress– JVD– Absent breath sounds on affected side– Asymmetrical chest wall movement

• Intervention– Place a large bore angiocatheter in the second or third

intercostal space, mid-clavicular line just above the rib– Chest tube placement required

INTERVENTIONS

• Special Considerations– Burns

• Soot around the nose and mouth indicates inhalation burns that could result in edema and loss of airway

• Intubate the burn patient early

SUMMARY

• “A”irway is First

• Assessment: Oxygenation & Ventilation

• Sequence of Interventions

• Endotracheal Intubation

• Emergent Airways

• Special Considerations

QUESTIONS

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