Post on 05-Jan-2016
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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 MetabolismSpinal Cord InjuryBrain 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
VentilationDefined 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. RespirationExchange of gases between a living
organism and its environmentExternal Respiration
exchange between lungs & blood cellsInternal 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
Alveoli PO2 100 & PCO2 40
PO2 40 & PCO2 46 - Pulmonary circulation - PO2 100 & PCO2 40
Heart
PO2 40 & PCO2 46 - Systemic circulation - PO2 100 & PCO2 40
Tissue cell PO2 <40 & PCO2 >46
Inspired Air: PO2 160 & PCO2 0.3
OxygenatedDeoxygenated
Causes of Hypoxemia
Traumatic Reduced surface area for gas exchange
pneumothorax, hemothorax, atelectasis
Decreased mechanical effortpain, traumatic asphyxiation,
hypoventilationsucking chest wound, obstruction
Assessment & Recognition of Airway & Ventilatory Compromise
Visual Assessment Position
tripodorthopnea
Rise & Fall of chestParadoxical 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
Kussmaulacidosis
Biot’sincreased ICP
Respiratory Patterns Central Neurogenic
Hyperventilationincreased ICP
Agonalbrain 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 BVMOne 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 traumatolerated by awake patients but is
uncomfortableinterferes with BVM seal
orogastricusually used in unresponsive patientslarger tube may be usedsafe in facial trauma
Airway & Ventilation Methods: ALS
Endotracheal Intubation Indications
present or impending respiratory failureapneaunable to protect own airway
Advantagessecures airwayroute for a few medicationsoptimizes 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
ORabsolute 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 indicationRisks > benefitsAge < 8 years (some say 10)evidence of fx larynx or cricoid cartilageevidence of tracheal transection
Airway & Ventilation Methods: ALS
Needle Cricothyrotomy & Transtracheal Jet Ventilation Indications
Same as surgical cricothyrotomy along withContraindication for surgical cricothyrotomy
ContraindicationsNone when demonstrated needcaution with tracheal transection
Airway & Ventilation Methods: ALS
Jet Ventilation Usually requires high-
pressure 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
100 ml
No. 1100 ml
Combitube®
From AMLS, NAEMT
Airway & Ventilation Methods: BLS & ALS
Combitube®
Indications Contraindications
HeightGag reflexIngestion of corrosive or volatile substancesHx 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 paralysisIndications
• 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 amnesiaProvider unable to intubate or ventilate after
NMBAspiration during procedureDifficult to detect motor seizure activitySide effects and adverse effects of specific
meds
Airway & Ventilation Methods: ALS
Examples ofSecondary Tube
Placement Confirmation Devices
(From AMLS, NAEMT)
From AMLS, NAEMT
Airway & Ventilation Methods: ALS
Needle Thoracostomy (chest decompression) Indications
Positive sx/sx of tension pneumothoraxCardiac arrest with PEA or Asystole when
the possibility of trauma and/or tension pneumo exist
ContraindicationsAbsence of indications
Airway & Ventilation Methods: ALS
Tension Pneumothorax Sx/Sx
severe respiratory distress or absent lung sounds (unilateral
usually) resistance to manual ventilationCardiovascular collapse (shock)asymmetric chest expansionanxiety, 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
ProcedureIntubate if not already donePrep site and equipmentVertical incision to anterior axillary lineHorizontal incision only if necessaryCover and protect
Airway & Ventilation: Risks & Protective Measures
BSI Gloves Face & eye shields Respirator if concern for airborne disease Be prepared for
coughingspittingvomitingbiting