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Lecture given in Trauma Update 2014 CME in SUT Trivandrum on 19.09.2014
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Airway solutions in an acute trauma scenario
Dr.Venugopalan.P.PDA;DNB;MNAMS;MEM[GWU]Director ; Emergency Medicine
Aster DM Health Care LtdDeputy Director ;MIMS Academy
Founder and executive director -ANGELS
Focus
• Why?• When?• How?• What is different?• What is new ?
Case ScenarioWhat is your first priority?
28year old man was brought to ED following a motor bike accident , Pulse 112,BP 110/60,Rapid breathing , Snoring+ SpO2 87 in room air and CGS 8/15. Smell of alcohol +
Priority –One
• Airway is the first system to be taken care in any trauma victim
• Compromised airway will endanger the patient life more rapidly than any other system compromise
Airway is always priority -ONE
Airway Assessment
● Patient is alert and oriented.
● Patient is talking normally.
● There is no evidence of injury to the head or neck.
● You have assessed and reassessed for deterioration.
How do I know the airway is adequate?
Airway Assessment
Signs and symptoms of airway compromise
● High index of suspicion● Change in voice / sore throat● Noisy breathing (snoring and stridor)● Dyspnea and agitation
Airway Assessment
Signs and symptoms of airway compromise (cont.)
● Tachypnea● Abnormal breathing pattern● Low oxygen saturation (late sign)
Airway Assessment
When to intervene when the airway is patent
● Inability to protect the airway● Impending airway compromise● Need for ventilation
Trauma :Definitive airway
• Apnoea • Glasgow Coma Scale < 8 or sustained seizure activity. • Unstable mid-face trauma. • Airway injuries. • Large flail segment or respiratory failure. • High aspiration risk. • Inability to otherwise maintain an airway or
oxygenation.
Airway Assessment
Impending Airway Obstruction
How do I manage the airway of a trauma patient?● Supplemental oxygen
● Basic techniques
● Basic adjuncts
● Definitive airway● Cuffed tube in the trachea
● Difficult airway adjuncts● Unexpected difficult airway
● Predicted difficult airway
Airway Management
Protect the cervical spine during airway management!
Airway Management
Caution
Obstructed airway ?
• Tongue and Epiglottis• Any Foreign materials ?
Clear it
Noisy breathing ?
Tongue obstructing Airway
Airway Management
Chin-lift Maneuver
Basic Techniques
Jaw thrust
Trauma ?
Airway
Not – Maintainable ?
Adjuncts
Airway Management
Oropharyngeal airway
Basic Adjuncts
● Patients who can tolerate an oral airway will usually need intubation.
Nasopharyngeal airway
● Often well tolerated
• Airway Reflexes ? …..No !
Choice –OPA !
O P A
Sizing - oropharyngeal airway
• OPA is not tolerating ?• Airway reflexes retained ?• Inability to open mouth ?
N P A
NPA
• Facial and Maxillary injury• Fracture Base of skull
Caution
Raccoons' eye Battles sign
Airway Management
How do I predict a potentially difficult airway?
● Maxillofacial trauma and deformity● Mouth opening● Anatomy
● Beard● Short, thick neck● Receding jaw● Protruding upper teeth
Airway Management
Is this a difficult airway?How would you manage this patient?
Airway Management
● Oral intubation (medication assisted)● Cricoid pressure, suction, back-up● Maintain c-spine immobilization
● Plan for failure:● Gum elastic bougie● LMA / LTA● Needle cricothyroidotomy● Surgical airway
Definitive Airway – Easy
RSI: “7 P’s”
1. P = Preoxygenation2. P = Preparation3. P = Pretreatment4. P = Paralysis with induction5. P = Protection6. P = Placement of the tube7. P = Post-Intubation management
RSI: TimelineT – 10 minutes PrepareT – 5 minutes PreoxygenateT – 3 minutes PretreatT = 0 Paralysis with
inductionT + 30 seconds ProtectionT + 45 seconds PlacementT + 90 seconds Post-Intubation
management
Airway Management
● Preoxygenate● Cricoid pressure ● Sedate (midazolam)● Paralytic (succinylcholine) ● Intubate● Confirm (Auscultate, CO2) ● Release cricoid pressure and ventilate
Definitive Airway – Easy
Airway Management
Is this a difficult airway?How would you manage this patient?
Airway Evaluation
Problem Airway
epiglottis Vocal cords
Difficult Airway Assessment• 4 D’s– Distortion, Disproportion, Dysmobility, Dentition
• BONES– Beard, Obese, No teeth, Elderly, Snores (sleep apnea)
• SHORT– Surgery (head/neck/jaw), Hematoma, Obese,
Radiation, Tumor• LEMON• MALLAMPATI• Always have a “Rescue Airway” technique ready
MALLAMPATI SCORE
Class I Class II Class III Class IV
Anticipate the worst !!!
60-SECOND EXAM “LEMON”
• Look for external difficulty• Evaluate using 3=3=2 rule• Mallampati (Class I & II)• Obstruction• Neck Mobility
3 fingers fit in mouth 3 fingers fit from mentum to hyoid cartilage 2 fingers fit from mandible to top of thyroid cartilage
McI
ntyr
e; T
he d
ifficu
lt tr
ache
al in
tuba
tion
Airway Management
● Get help● Be prepared● Consider rapid sequence intubation vs. awake
intubation● Maintain c-spine immobilization
● Consider use of:● Gum elastic bougie● LMA / LTA● Surgical airway● Other advanced airway techniques, eg, fiberoptic
intubation
Definitive Airway – Difficult
Gum elastic bougie
LMA
Igel
Intubating LMA
Kings LT airway
Video Laryngoscope
Video Assisted Laryngoscope
Other methods Useful in semi elective scenarios
• Fiberoptic intubation
Airway Management
● Surgical airway● Cricothyroidotomy
Needle
Definitive Airway
Surgical
Always
Do confirm tube positions !!
How do I know the tube is in the right place?
● Visualize it going through the cords
● Watch the chest
● Auscultation
● Pulse oximeter
● CO2 detector
● Radiology
Airway Confirmation
Rule out wrong tube position
End tidal CO2 detection
Esophageal Detector Devices (EDD)
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level !
SpO2 100% = PaO2 100mm of HgSpO2 90%= PaO2 60mm of HgSpO2 60%= PaO2 30mm of HgSpO2 50%= PaO2 27mm of Hg
Airway Decision Scheme
Airway can be tricky always
…
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