1. AIRWAY MANAGEMENT

2. 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.

3. AIRWAY & VENTILATION Goals –Maintain C-spine immobilization –Assess for airway obstruction –Establish definitive airway –Ensure adequate oxygenation –Provide adequate ventilation –Monitor ongoing airway status

4. 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

5. AIRWAY ASSESSMENT Listen –Snoring, gurgling –Hoarseness –Inability to talk Feel –Diminished air movement (LOC and ability to speak provide info regarding airway patency)

6. 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

7. VENTILATION ASSESSMENT Feel –Chest wall instability –Subcutaneous air in the soft tissues (crepitus)

8. 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 pharynx Too long = pushes epiglottis against the entrance of the trachea

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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 CO 2 detector Secure tube Chest x-ray to confirm placement Constant reevaluation

16. INTERVENTIONS Endotracheal Intubation –Complications Lacerations of lips, tongue, pharyngeal or tracheal mucosa Right mainstem intubation Aspiration Chipping of teeth Esophageal intubation

17. INTERVENTIONS Endotracheal Intubation –CO 2 Detection devices May be inaccurate in patients in cardiac arrest Colorimetric devices changes color based on measurable concentrations of CO 2 –Low levels of CO 2 turn the color strip purple (atmosphere) –High levels of CO 2 turn the color strip yellow In-line capnometry measures inspired and end tidal CO 2 with each breath and displays wave form CO 2 concentrations

18. 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

19. 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

20. INTERVENTIONS Rapid Sequence Intubation (RSI) DrugAdult Dose Child Dose Side Effect DurationOnset Succinly- choline 1-2mg/Kg1-2 mg/kg once Arrythmias Fasciculation Aspiration 3-10 minutes 30-60 seconds Morphine2-5 IV0.1 mg/kg IV CNS/Resp depression 2 hoursImmediate Midazolam1-3 mg IV0.1 mg/kg IV CNS/Resp depression 1-3 hours3-5 min Vecuronium0.15 mg/kg IV 0.15 mg/kg/IV Apnea30-60 minWithin 60 seconds Etomidate0.2-0.6 mg/kg IV 0.3 mg/kg IV Apnea30-60 minWithin 30 seconds

21. INTERVENTIONS Needle Cricothyroidotomy (Transtracheal Catheter Ventilation) –Jet insufflation of the airway –Useful for children under 12 –Temporary use 30-45 minutes (CO 2 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

22. 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

23. 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

24. 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

25. 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

26. SUMMARY “A”irway is First Assessment: Oxygenation & Ventilation Sequence of Interventions Endotracheal Intubation Emergent Airways Special Considerations

27. QUESTIONS ?