Transcript airway_management

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
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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 Cspine 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 pharynx
Too 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
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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
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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
Succinlycholine
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)
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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
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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
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“A”irway is First
Assessment: Oxygenation & Ventilation
Sequence of Interventions
Endotracheal Intubation
Emergent Airways
Special Considerations
QUESTIONS
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