Post on 12-Aug-2015
transcript
M . N O N T H A C O U P T
Airway and Ventilatory Management in Trauma
Initial assessment & management
PreparationTriagePrimary survey (A-B-C-D-E)ResuscitationAdjunct to primary surveySecondary surveyPostresuscitation monitoring Definitive care
Why first priority?
“The quickest killer”
Secondary insult of CNS
Supplemental oxygen must be administered in trauma patient
Death from airway problem
Failure to recognize the need for airway intervention the need for alternative airway incorrectly placed airway the need for ventilation
Inability to establish an airwayDisplacementAspiration
Recognize airway problem
Sudden/ CompleteProgressive/ Partial
“Reassessment”
Recognize airway problem
Changed voice qualityStridor (noisy = partial, absence = complete)Sore throatDyspneaAgitateTachypneaAbnormal breathing patternDecreased O2sat (late sign)
Objective signs of airway obstruction
Agitation hypoxiaObtund hypercarbiaCyanosis hypoxemia (late sign)RetractionStridor/ Hoarseness Trachea shiftPatient behavior
Quickest way?
Check verbal response Positive, appropriate
Patent airway Intact ventilation Adequate brain perfusion
Negative, inappropriate AOC Airway/ ventilatory compromise
Definitive airway
Definitive airway
“Tube placed in trachea with cuff inflated below the vocal cords, connected to oxygen-enriched assisted ventilation, Secured in place”
Definitive airway
Protect airwaySupport ventilationMaintain oxygenationPrevent hypercarbiaPrevent Aspiration
Maxillofacial trauma
MidfaceFracture/dislocation
Loss structural support of airwayHemorrhageDislodge teeth
Neck trauma
Penetrating injury Hematoma displace/obst airway
Blunt injury Hematoma Hemorrhage into soft tissue Disruption of larynx/trachea Hemorrhage in tracheobronchial tree
ProgressiveAirway compromise
Laryngeal injury
Clinical Hoarseness Subcutaneous emphysema Palpable fracture
Incomplete obstruction Complete obstruction
only 1 attempt of ETT, if fail tracheostomy (or surgical cricothyroidotomy if profuse bleed)
Recognize ventilation problem
Mechanical Direct chest trauma Preexisting pulmonary dysfunction
CNS depression Intracranial Spinal cord
Objective signs of inadequate ventilation
Chest risingLabored breathingBreath sound (decreased/absent)Rapid RRPulse oximetry, ETCO2
AIRWAY MANAGEMENT
Initial airway management
Monitor pulse oximetry, ETCO2Remove helmet (if present)Airway maintenance + C-spine protectionSuctionSupplemental ventilationHigh flow oxygen
Predict difficult airway
L : Look externallyE : Evaluate 3-3-2 ruleM : MallampatiO : ObstructionN : Neck mobility
M: Mallampati
I : soft palate, uvula, fauces, pillar
II: soft palate, uvula, fauces
III: soft palate, base of uvula
IV: hard palate
Airway decision flow
Preoxygenate (position, O2 mask c bag, oral airway)
Able to oxygenate?
LEMON
Intubation (±drug/cricoid pressure)
Gum elastic bougie/LMA
Definitive/surgical airway
yes
noDefinitive/surgical airway
difficult Call for assistance
Awake intubation
easy
fail
Airway maintenance
By position Chin lift (should not hyperextend neck) Jaw thrust
Manual in line immobilization first
Airway maintenance
By deviceOropharyngeal airway
May Induce gag reflex & aspiration If pt can tolerate, ETT is highly likely required Tongue blade in children, No rotation
Nasopharyngeal airway Nostril oropharynx Lubricated Don’t attempt in suspected cribiform plate fx,
Lefort fx
Extraglottic, supraglottic devices
Laryngeal mask airway Bridging, if ETT/mask c bag fail
Laryngeal tube airway Doesn’t require significant manipulation of head & neck
Multilumen esophageal airway Esophageal port, trachea port ETCO2
Indication for definitive airwayNeed airway protection Need ventilation
Severe maxillofacial fx Inadequate respiratory effort-tachypnea-hypoxia-hypercarbia-cyanosis
Risk for obstruction-neck hematoma-laryngeal/tracheal injury-stridor
Massive blood loss and need for volume resuscitation-anemia
Risk for aspiration-bleeding-vomiting
Severe closed head injury with need for brief hyperventilation if AOC
unconscious Apnea
Endotracheal intubation
Clearance of C-spine, but don’t delayManual in-lineNasotracheal
Contraindicated in Apnea Facial, frontal sinus, basal skull, cribiform plate fx
Pressure necrosis, sinusitisOrotracheal
Indicated in apnea patient
Orotracheal intubation
2-person manual inline
Laryngeal manipulation “BURP” Backward, Upward, Rightward Pressure Thyroid cartilage
Direct laryngoscopy
Gum elastic bougie
Infant endotracheal intubation
Same size as infant’s nostril or little finger Uncuffed Tube = (Age / 4) + 4 Cuffed Tube = (Age / 4) + 3 Suitable for age 1-12 yr above 12, typically most adult sizes (6.5-8.0)
Insert not more than 2 cm past the cords
Is the tube in place?
Listen equal breath sound no borborygmi
ETCO2CXR
Rapid sequence intubation (RSI)
AnestheticSedativeNeuromuscular blockingAlways have Plan B (surgical airway)
Rapid sequence intubation (RSI)
1. Be prepared for surgical airway2. Suction, PPV ready3. Preoxygenate4. Cricoid pressure5. Administer induction drug/sedative
Etomidate 0.3 mg/k
6. Succinylcholine 1-2 mg/kg v7. Intubate 8. Confirm tube placement9. Release cricoid pressure10. ventilate
Surgical airway
Cricothyroidotomy/ tracheostomyIndication
fail ETT Obstruction of upper airway (glottic edema, larynx fx, severe
oropharyngeal hemorrhage
Needle cricothyroidotomy
Short term, bridging for definitive airwayJet insufflation Large caliber plastic canular
12-14 adult 16-18 children
Through cricothyroid membrane into tracheaConnect to O2 15 LPMHole cut in tubing between
O2 source and cannula, thumb over1 second, off 4 seconds
complication
Inadequate ventilationBlood aspirationEsophageal lacerationHematomaPosterior tracheal wall lacerationSubcutaneous/mediastinal emphysemaThyroid perforationpneumothorax
Surgical cricothyroidotomy
NOT recommended in children <12 y
Skin incision extend through cricothyroid membraneSmall ETT or tracheostomy (5-7mm OD) tube insertionReapply cervical collar
complication
Blood aspirationFalse tractSubglottic stenosisLaryngeal stenosisHematomaLaceration of esophagusLaceration of tracheaMediastinal emphysemaVocal cord paralysis/ hoarseness
Management of oxygenation
Adequate oxygenation
Tight sealed mask c bag > 11 LPMPulse oximetry
O2sat ≥ 95% PaO2 >70% Require intact peripheral perfusion Can’t distinguish oxyhemoglobin/
carboxyhemoglobin/ methemoglobin
Approximate PaO2 vs O2Sat
PaO2 O2Sat90 mmHg 100 %60 mmHg 90 %30 mmHg 60 %27 mmHg 50 %
Management of ventilation
Adequate ventilation
Bag-mask ventilation (1-2 person) Ventilate q 5 secs (RR 12)
Volume/pressure regulated respirator Watch intrathoracic pressure Watch for tension PTX Secondary PTX from barotrauma
Gastric distention
Secondary to bag-mask ventilationVomit/ aspirateStomach distention vena cava pressure
hypotension, bradycardia