Transcript Airway Management

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 Metabolism
Spinal Cord Injury
Brain 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
Ventilation
Defined 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. Respiration
Exchange of gases between a living
organism and its environment
External Respiration
exchange between lungs & blood cells
Internal 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
Inspired Air: PO2 160 & PCO2 0.3
Alveoli PO2 100 & PCO2 40
PO2 40 & PCO2 46 - Pulmonary circulation - PO2 100 & PCO2 40
Deoxygenated
Heart
Oxygenated
PO2 40 & PCO2 46 - Systemic circulation - PO2 100 & PCO2 40
Tissue cell PO2 <40 & PCO2 >46
Causes of Hypoxemia
Traumatic
Reduced surface area for gas exchange
pneumothorax, hemothorax, atelectasis
Decreased mechanical effort
pain, traumatic asphyxiation, hypoventilation
sucking chest wound, obstruction
Assessment & Recognition of
Airway & Ventilatory Compromise
Visual Assessment
Position
tripod
orthopnea
Rise & Fall of chest
Paradoxical 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
Kussmaul
acidosis
Biot’s
increased ICP
Respiratory Patterns
Central Neurogenic
Hyperventilation
increased ICP
Agonal
brain 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 & Ventilation Methods:
BLS
Airway Maneuvers
Jaw thrust
Sellick’s maneuver
Airway Devices
Oropharyngeal airway
Nasopharyngeal
airway
CombiTube ®
Airway & Ventilation Methods:
BLS
1/2/3 person BVM
One 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
Airway & Ventilation Methods:
BLS
Partial Airway Obstruction Techniques
Positioning
OPA/NPA
Suctioning
Removal via Direct laryngoscopy
Airway & Ventilation Methods:
BLS
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 trauma
tolerated by awake patients but is uncomfortable
interferes with BVM seal
orogastric
usually used in unresponsive patients
larger tube may be used
safe in facial trauma
Airway & Ventilation Methods:
ALS
Endotracheal Intubation
Indications
present or impending respiratory failure
apnea
unable to protect own airway
Advantages
secures airway
route for a few medications
optimizes ventilation and oxygenation
Airway & Ventilation Methods:
ALS
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
Airway & Ventilation Methods:
ALS
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
Airway & Ventilation Methods:
ALS
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
OR
absolute 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
Airway & Ventilation Methods:
ALS
Surgical Cricothyrotomy
Contraindications (relative)
No real demonstrated indication
Risks > benefits
Age < 8 years (some say 10)
evidence of fx larynx or cricoid cartilage
evidence of tracheal transection
Airway & Ventilation Methods:
ALS
Needle Cricothyrotomy & Transtracheal Jet
Ventilation
Indications
Same as surgical cricothyrotomy along with
Contraindication for surgical cricothyrotomy
Contraindications
None when demonstrated need
caution with tracheal transection
Airway & Ventilation Methods:
ALS
Jet Ventilation
Usually requires highpressure 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
No. 1
100 ml
.
No
.
No
2
2
No. 1
100 ml
No. 1
Combitube®
No
.2
15
ml
No
.
2
15
ml
From AMLS, NAEMT
Airway & Ventilation Methods:
BLS & ALS
Combitube®
Indications
Contraindications
Height
Gag reflex
Ingestion of corrosive or volatile substances
Hx of esophageal disease
Airway & Ventilation Methods:
ALS
Pharmacologic Assisted Intubation (“RSI”)
Sedation
Used for
• induction
• anxious or agitated patient
Contraindications
• hypersensitivity
• hypotension (e.g. hypovolemia 2° to trauma)
Airway & Ventilation Methods:
ALS
Pharmacologic Assisted Intubation (“RSI”)
Neuromuscular Blockade
Induces temporary skeletal muscle paralysis
Indications
• When Intubation is required in a patient who
– is awake,
– has a gag reflex, or
– is agitated or combative
Airway & Ventilation Methods:
ALS
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
Airway & Ventilation Methods:
ALS
Pharmacologic Assisted Intubation (“RSI”)
Disadvantages & Potential Complications
Does not provide sedation or amnesia
Provider unable to intubate or ventilate after NMB
Aspiration during procedure
Difficult to detect motor seizure activity
Side effects and adverse effects of specific meds
Airway & Ventilation Methods:
ALS
Examples of
Secondary Tube
Placement Confirmation
Devices
(From AMLS, NAEMT)
From AMLS, NAEMT
Airway & Ventilation Methods:
ALS
Needle Thoracostomy (chest
decompression)
Indications
Positive sx/sx of tension pneumothorax
Cardiac arrest with PEA or Asystole when the
possibility of trauma and/or tension pneumo exist
Contraindications
Absence of indications
Airway & Ventilation Methods:
ALS
Tension Pneumothorax
Sx/Sx
severe respiratory distress
 or absent lung sounds (unilateral
usually)
 resistance to manual ventilation
Cardiovascular collapse (shock)
asymmetric chest expansion
anxiety, restlessness or cyanosis (late)
JVD or tracheal deviation (late)
Airway & Ventilation Methods:
ALS
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
Airway & Ventilation Methods:
ALS
Chest Escharotomy
Considerations
must rule out the possibility of upper airway
obstruction
Procedure
Intubate if not already done
Prep site and equipment
Vertical incision to anterior axillary line
Horizontal incision only if necessary
Cover and protect
Airway & Ventilation: Risks &
Protective Measures
BSI
Gloves
Face & eye shields
Respirator if concern for airborne disease
Be prepared for
coughing
spitting
vomiting
biting