2 - AIRWAY AND VENTILATORY MANAGEMENT

1. What are common causes of early preventable deaths from airway problems after trauma? failure to recognize the need for an airway intervention inability to establish an airway failure to recognize an incorrectly placed airway displacement of a previously established airway failure to recognize the need for ventilation aspiration of gastric contents 2. Outline airway problem recognition. assess level of consciousness anticipate vomiting Particularly close attention paid to: maxillofacial trauma neck trauma laryngeal trauma 3. Airway significance of maxillofacial trauma. midface trauma - fractures and dislocations that compromise the nasopharynx and oropharynx facial fractures - hemorrhage, secretions, dislodged teeth mandibular fractures (especially bilateral) - loss of normal airway support 4. Airway significance of neck trauma. penetrating injury - vascular injury causes hemorrhage that can displace and obstruct the airway disruption of larynx or trachea - obstruction and/or severe bleeding into airways 5. Airway significance of laryngeal trauma. Presents with acute airway obstruction. Triad of clinical signs: hoarseness subcutaneous emphysema palpable fracture 6. How should laryngeal trauma + airway obstruction be managed? intubation required - flexible endoscopic intubation may be helpful if intubation unsuccessful, emergency tracheotomy surgical crichothyroidotomy is easier, though not preferred 7. How should laryngeal fracture be diagnosed? If suspected, CT will confirm. If the patient is talking, no investigation is urgent. 8. What are objective signs of airway obstruction?
Look:

Listen: noisy breathing = partial obstruction snoring, gurgling, stridor - partial occlusion of the pharynx or larynx hoarseness - functional laryngeal obstruction

Agitated or obtunded: - Agitation suggests hypoxia - Obtundation suggests hypercarbia Cyanosis - hypoxia (late sign) Accessory muscle use

Feel:

tracheal deviation 9. Ventilation problem recognition Risk factors: direct trauma to the chest elderly patients patients with preexisting pulmonary dysfunction intracranial injury cervical spinal cord injury or cervical spinal cord transection 10. Objective signs of inadequate ventilation. Look: symmetrical chest wall movement labored breathing Listen: bilateral breath sounds Pulse oximetry 11. How should helmets be removed? Two person technique: 1st person - inline stabilization 2nd person - expands helmet laterally and removes it, ensuring it clears the nose and occiput 1st person then supports the weight of the head, while 2nd person takes over inline stabilization 12. Describe the chin-lift maneuver. fingers of one hand placed under mandible mandible gently lifted upward to bring the chin anterior thumb of same hand lightly depresses the lower lip to open the mouth this maneuver should not extend the neck! 13. Describe the jaw-thrust maneuver. grasp the angles of the lower jaw, one hand on each side displace the mandible forward take care to prevent neck extension 14. Describe insertion of orophagyneal airways. airway inserted into the mouth behind the tongue normally inserted upside down, then turning around to the tip faces down into the laryngopharynx may induce gagging, vomiting and aspiration in conscious patients 15. Describe insertion of nasopharyngeal airways. inserted in one nostril and passed gently into the posterior oropharynx should be well lubricated if obstruction is noted, stop and try the other nostril 16. Role of laryngeal mask airways. established role in difficult airways however, not a definitive airway, so plans for further definitive airway placement should be made 17. Multilumen esophageal airways. used by some prehospital personnel to achieve an airway when a definitive airway is not feasible

one lumen communicates with the esophagus and the other with the airway personnel are trained to observe which lumen is which (capnography helps) requires removal and definitive airway placement ASAP 18. Laryngeal tube airways. extraglottic airway device similar to LMA not a definitive airway device, and will need replacement 19. Gum elastic bougie. also called Eschmann Tracheal Tube Introducer (ETTI) 60cm long, 15 Fr stylette, with angled tip at distal end used when vocal cords cannot be directly visualized GEB passed blindly behind the epiglottis with angled tip anteriorly tracheal position confirmed by: - clicking on tracheal rings - tube rotating left or right when entering bronchi - tube held up in bronchial tree (around 50cm mark) when ready, ETT railroaded over, and GEB removed, then tube position confirmed by conventional means 20. Define "definitive airway". Tube placed in trachea with cuff inflated. Tube connected to some form of oxygen-enric 21. Types of definitive airway. 1. orotracheal tube 2. nasotracheal t 22. What are some indications for a definitive airway. Airway protection: unconscious severe maxillofacial fractures risk of aspiration - bleeding, vomiting risk of obstruction - neck hematoma, laryngeal/tracheal injury, stridor Need for ventilation or oxygenation: apnea - neuromuscular paralysis or unconsciousness inadequate respiratory efforts severe closed head injury warranting forced hyperventilation for raised ICP 23. Outline an airway decision scheme. prepare equipment preoxygenate if unable to oxygenate, definitive or surgical airway if able to oxygenate, predict ease of intubation if easy, proceed with RSI if difficult, call help, consider awake intubation if unsuccessful, use adjunct devices (GEB, LMA, LTA) if all fails, surgical airway 24. What equipment should be ready for airway management? Facilities: suction O2 pulse oximetry

 capnography assistant Airways: GEB LMA surgical or needle cricothyroidotomy kit ETT Misc equipment: drugs bag-mask laryngoscope

25. Confirming tube position. equal bilateral breath sounds + no gastric sounds capnography CXR confirmation 26. LEMON assessment for difficult intubation. L = look externally E = evaluate with 3-3-2 rule M = Mallampati O = obstruction N = neck mobility 27. What are external indicators of difficult intubation? small mouth/jaw large overbite facial trauma 28. What is the 3-3-2 rule? Assess the following relationships: distance between patient's incisors should be at least 3 finger breadths distance between hyoid bone + chin should be at least 3 finger breadths distance between thyroid notch and floor of mouth should be at least 2 finger breadths 29. What is the Mallampati score? patient asked to open mouth fully and protrude tongue as far as possible best done in a sitting position examiner looks into mouth to assess degree of hypopharynx visible: - soft palate, uvula, fauces, pillars - soft palate, uvula, fauces - soft palate, base of uvula - hard palate only 30. Describe the technique of rapid sequence induction (RSI). preparation - surgical kit available, suction available, ventilator ready, assistant ready, etc preoxygenate with 100% oxygen apply cricoid pressure give induction agent suxamethonium 1-2 mg/kg IV after fasciculations, intubate as normal inflate cuff + confirm tube placement release cricoid pressure

 commence ventilation 31. What are some contraindications to suxamethonium? severe crush injuries major burns and electrical injuries chronic renal failure chronic neuromuscular disease 32. Describe the technique of jet insufflation. Large-calibre plastic cannula (12- to 14-gauge for adults, 16- to 18-gauge for children) through cricothyroid membrane. Cannula connected to oxygen at 15L/min with a Y-connected or side hole cut in tubing. Intermittent insufflation (1 sec on, 4 secs off) allows some time for expiration.

Only suitable for 30-45 minutes, and potentially dangerous due to large pressures that can build up.