M . N O N T H A C O U P T

Airway and Ventilatory Management in Trauma

Initial assessment & management

PreparationTriagePrimary survey (A-B-C-D-E)ResuscitationAdjunct to primary surveySecondary surveyPostresuscitation monitoring Definitive care

Why first priority?

“The quickest killer”

Secondary insult of CNS

Supplemental oxygen must be administered in trauma patient

Death from airway problem

Failure to recognize the need for airway intervention the need for alternative airway incorrectly placed airway the need for ventilation

Inability to establish an airwayDisplacementAspiration

Recognize airway problem

Sudden/ CompleteProgressive/ Partial

“Reassessment”

Recognize airway problem

Changed voice qualityStridor (noisy = partial, absence = complete)Sore throatDyspneaAgitateTachypneaAbnormal breathing patternDecreased O2sat (late sign)

Objective signs of airway obstruction

Agitation hypoxiaObtund hypercarbiaCyanosis hypoxemia (late sign)RetractionStridor/ Hoarseness Trachea shiftPatient behavior

Quickest way?

Check verbal response Positive, appropriate

Patent airway Intact ventilation Adequate brain perfusion

Negative, inappropriate AOC Airway/ ventilatory compromise

Definitive airway

Definitive airway

“Tube placed in trachea with cuff inflated below the vocal cords, connected to oxygen-enriched assisted ventilation, Secured in place”

Definitive airway

Protect airwaySupport ventilationMaintain oxygenationPrevent hypercarbiaPrevent Aspiration

Maxillofacial trauma

MidfaceFracture/dislocation

Loss structural support of airwayHemorrhageDislodge teeth

Neck trauma

Penetrating injury Hematoma displace/obst airway

Blunt injury Hematoma Hemorrhage into soft tissue Disruption of larynx/trachea Hemorrhage in tracheobronchial tree

ProgressiveAirway compromise

Laryngeal injury

Clinical Hoarseness Subcutaneous emphysema Palpable fracture

Incomplete obstruction Complete obstruction

only 1 attempt of ETT, if fail tracheostomy (or surgical cricothyroidotomy if profuse bleed)

Recognize ventilation problem

Mechanical Direct chest trauma Preexisting pulmonary dysfunction

CNS depression Intracranial Spinal cord

Objective signs of inadequate ventilation

Chest risingLabored breathingBreath sound (decreased/absent)Rapid RRPulse oximetry, ETCO2

AIRWAY MANAGEMENT

Initial airway management

Monitor pulse oximetry, ETCO2Remove helmet (if present)Airway maintenance + C-spine protectionSuctionSupplemental ventilationHigh flow oxygen

Predict difficult airway

L : Look externallyE : Evaluate 3-3-2 ruleM : MallampatiO : ObstructionN : Neck mobility

M: Mallampati

I : soft palate, uvula, fauces, pillar

II: soft palate, uvula, fauces

III: soft palate, base of uvula

IV: hard palate

Airway decision flow

Preoxygenate (position, O2 mask c bag, oral airway)

Able to oxygenate?

LEMON

Intubation (±drug/cricoid pressure)

Gum elastic bougie/LMA

Definitive/surgical airway

yes

noDefinitive/surgical airway

difficult Call for assistance

Awake intubation

easy

fail

Airway maintenance

By position Chin lift (should not hyperextend neck) Jaw thrust

Manual in line immobilization first

Airway maintenance

By deviceOropharyngeal airway

May Induce gag reflex & aspiration If pt can tolerate, ETT is highly likely required Tongue blade in children, No rotation

Nasopharyngeal airway Nostril oropharynx Lubricated Don’t attempt in suspected cribiform plate fx,

Lefort fx

Extraglottic, supraglottic devices

Laryngeal mask airway Bridging, if ETT/mask c bag fail

Laryngeal tube airway Doesn’t require significant manipulation of head & neck

Multilumen esophageal airway Esophageal port, trachea port ETCO2

Indication for definitive airwayNeed airway protection Need ventilation

Severe maxillofacial fx Inadequate respiratory effort-tachypnea-hypoxia-hypercarbia-cyanosis

Risk for obstruction-neck hematoma-laryngeal/tracheal injury-stridor

Massive blood loss and need for volume resuscitation-anemia

Risk for aspiration-bleeding-vomiting

Severe closed head injury with need for brief hyperventilation if AOC

unconscious Apnea

Endotracheal intubation

Clearance of C-spine, but don’t delayManual in-lineNasotracheal

Contraindicated in Apnea Facial, frontal sinus, basal skull, cribiform plate fx

Pressure necrosis, sinusitisOrotracheal

Indicated in apnea patient

Orotracheal intubation

2-person manual inline

Laryngeal manipulation “BURP” Backward, Upward, Rightward Pressure Thyroid cartilage

Direct laryngoscopy

Gum elastic bougie

Infant endotracheal intubation

Same size as infant’s nostril or little finger Uncuffed Tube = (Age / 4) + 4 Cuffed Tube = (Age / 4) + 3 Suitable for age 1-12 yr above 12, typically most adult sizes (6.5-8.0)

Insert not more than 2 cm past the cords

Is the tube in place?

Listen equal breath sound no borborygmi

ETCO2CXR

Rapid sequence intubation (RSI)

AnestheticSedativeNeuromuscular blockingAlways have Plan B (surgical airway)

Rapid sequence intubation (RSI)

1. Be prepared for surgical airway2. Suction, PPV ready3. Preoxygenate4. Cricoid pressure5. Administer induction drug/sedative

Etomidate 0.3 mg/k

6. Succinylcholine 1-2 mg/kg v7. Intubate 8. Confirm tube placement9. Release cricoid pressure10. ventilate

Surgical airway

Cricothyroidotomy/ tracheostomyIndication

fail ETT Obstruction of upper airway (glottic edema, larynx fx, severe

oropharyngeal hemorrhage

Needle cricothyroidotomy

Short term, bridging for definitive airwayJet insufflation Large caliber plastic canular

12-14 adult 16-18 children

Through cricothyroid membrane into tracheaConnect to O2 15 LPMHole cut in tubing between

O2 source and cannula, thumb over1 second, off 4 seconds

complication

Inadequate ventilationBlood aspirationEsophageal lacerationHematomaPosterior tracheal wall lacerationSubcutaneous/mediastinal emphysemaThyroid perforationpneumothorax

Surgical cricothyroidotomy

NOT recommended in children <12 y

Skin incision extend through cricothyroid membraneSmall ETT or tracheostomy (5-7mm OD) tube insertionReapply cervical collar

complication

Blood aspirationFalse tractSubglottic stenosisLaryngeal stenosisHematomaLaceration of esophagusLaceration of tracheaMediastinal emphysemaVocal cord paralysis/ hoarseness

Management of oxygenation

Adequate oxygenation

Tight sealed mask c bag > 11 LPMPulse oximetry

O2sat ≥ 95% PaO2 >70% Require intact peripheral perfusion Can’t distinguish oxyhemoglobin/

carboxyhemoglobin/ methemoglobin

Approximate PaO2 vs O2Sat

PaO2 O2Sat90 mmHg 100 %60 mmHg 90 %30 mmHg 60 %27 mmHg 50 %

Management of ventilation

Adequate ventilation

Bag-mask ventilation (1-2 person) Ventilate q 5 secs (RR 12)

Volume/pressure regulated respirator Watch intrathoracic pressure Watch for tension PTX Secondary PTX from barotrauma

Gastric distention

Secondary to bag-mask ventilationVomit/ aspirateStomach distention vena cava pressure

hypotension, bradycardia