PHTLS5E4

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Airway Managementand Ventilation

Prehospital Trauma Life Support

Lesson

4

Copyright 2003, Elsevier Science (USA). All rights reserved.

PROVIDER COURSE

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Objectives

Identify patients in need of airway control Explain the need for increased oxygenation

and ventilation in the critical trauma patient

Discuss methods of manual and mechanicalmanagement of the airway

Discuss common errors in ventilation of the

trauma patient


4-2

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Airway Management

Keys Tools

Observation

Listening

Auscultation

Failing to appropriately assess the airway

Use of the wrong tool for the patients

condition


4-3

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Anatomy - Upper Airway

Tongue

Noisy ventilations =

obstructed airway

Gurgling and snoring

Stridor and wheezing


4-4

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Anatomy - Lower Airway

Conduction region Trachea

Bronchi

Exchange region Terminalbronchioles

Alveoli


4-5

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Capillary

endothelium

Alveolus

Alveolar

epithelium

Connective tissue

CO2

O2O2

Respiratory System

Ventilation Delivers O2 to the

alveoli

Removes CO2 from

the alveoli

Gas exchange

Across alveolar-

capillary membrane


4-6

Capillary

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You are dispatched to a motorcycle and

vehicle collision. Bystanders report that the

motorcycle was traveling at about 40 mph (65

km/h) when a car pulled in front of the

motorcycle. You find the patient laying on thepavement 30 ft (9 m) away from the crash.

His helmet is heavily damaged and has been

removed by a bystander.


4-7

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Findings

Gurgling ventilations

Blood is seen in the upper airway

Ventilations are rapid and labored

Patient is cyanotic

Is this airway compromised?


4-8

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Management Options

Essential skills

Manual clearing

Manual maneuvers Suctioning

Basic adjuncts


4-9

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Manual Maneuvers

Trauma jaw thrust

Trauma chin lift

Attempting more invasive methods before

essential skills have been applied


4-10

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Suctioning

Used to remove secretions from the

airway

Failing to suction when needed may cause a

partial or complete airway obstruction

Overaggressive use of suctioning maycause or worsen hypoxia


4-11

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Basic Adjuncts

Oropharyngeal airway (OPA)

Nasopharyngeal airway (NPA)

Dual lumen airways (Combitube

, PtL

)


4-12

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Oropharyngeal Airway (OPA)

Not indicated if gag

reflex present

Best used

temporarily

Does not protect

the trachea


4-13

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Nasopharyngeal Airway (NPA)

When would you use this device?What are its limitations?


4-14

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Dual Lumen Airways

How do they work?

What are the indications

for use?

What are the

contraindications for

use?


4-15

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Endotracheal Intubation

Orotracheal intubation

Nasotracheal intubation

Digital intubation

Improper tube placement

Hypoxia from improper technique


4-16

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Intubation with Inline Stabilization

What are the

indications for oral

endotracheal tube

placement?

When do we use the

inline technique?


4-17

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Nasotracheal Intubation

When would you perform nasotracheal

intubation?

Bleeding


4-18

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You arrive on the scene of a single vehicle MVC.

Your patient is a 25-year-old female who is trappedupright in the drivers seat. Her VR is 36 and she is

cyanotic. Gurgling sounds do not improve with

suctioning or manual maneuvers. The fire department

estimates that it will be 10 minutes before she isextricated.

How would you manage her airway at this

point?


4-19

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Your patient is a 35-year-old construction

worker who fell 25 ft (7.6 m) and landed onhis head. His GCS score is 3. He is apneic

and is being ventilated with a BVM. Three

attempts at orotracheal intubation are

unsuccessful.

What are the airway management options at

this point?


4-21

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Alternative Airway Procedures

Laryngeal mask airway (LMA)

Digital intubation

Retrograde intubation

Percutaneous transtracheal ventilation (PTV)

Surgical cricothyrotomy


4-22

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Laryngeal Mask Airway

Advantages:

Blind insertion

Available in a range of

sizes

Disadvantages:

Aspiration can occur

Limited prehospital

research


4-23

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Digital Intubation

Advantages: Blind insertion

Requires no specialty equipment

Disadvantages: Requires unconscious patient

Takes significant practice


4-24

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Retrograde Intubation

Potentially useful in certain situations

Requires tracheal puncture

Needs specialized equipment

Requires practice at manipulating guidewire Poor choice when anatomic distortion exists


4-25

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Percutaneous Transtracheal

Ventilation Advantages: Ease of access

Ease of insertion

Minimal equipmentrequired

No surgical proceduresnecessary

Minimal educationrequired

Hypercarbia not a problemfor short-term use in first45 minutes


4-26

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Surgical Cricothyrotomy

Airway ofLAST RESORT

Requires extensive training, knowledge of

neck anatomy, and ongoing QI/QA

Complications: Hemorrhage

Damage to vocal cords


4-27

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At a college baseball game a 22-year-old

third baseman is struck in the head by a

line drive. Upon your arrival his GCS score

is 7 (E-1, V-1, M-5). His teeth are clenched

and he is vomiting.

How would you manage his airway?


4-28

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Pharmacologically Assisted

Intubation (PAI) PAI includes the use of sedation, narcotics, and

paralytic agents

RSI involves the use of a paralytic agent Benefits must outweigh the risk

Back-up airway techniques must be anticipated and

available

Current research does not conclusively demonstrateimproved outcome


4-29

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PAI

Indications: Patient requiring secure airway withuncooperative behavior

Relative contraindications:

Alternative airway available Severe facial trauma

Neck deformity or swelling

Known allergy to indicated medications,

medical problems that preclude use ofmedications


4-30

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Drugs Used in PAI

Pretreatment

Oxygen

Lidocaine or atropine

Sedatives Midazolam, fentanyl, etomidate

Paralytics

Succinylcholine, vecuronium, pancuronium

Copyright 2003, Elsevier Science (USA). All rights reserved.4-31

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Oxygen

All trauma patients should receivesupplemental oxygen

The goal is to maintain an SpO2 95%

If in doubt, use a device that will deliver a

concentration of at least 85% (FiO2of 0.85)

Failing to recognize and treat hypoxia


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Minute Volume

Normal minute volume (MV)500 mL(VT) x 12 bpm (VR) = 6000 mL air/min (MV)

Normal MV 6000 -7500 mL

What happens when VT decreases to 250 mL?


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Minute Volume

First patient breathingVT = 500 mL

VR = 12 bpm

MV = 6000 mL Second patient breathing

VT = 250 mL

VR = 30 bpmMV = 7500 mL


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What About Deadspace?

Deadspace = VD First patient breathing

VT VD = 500 mL 150 mL = 350 mL

VR = 12

Air reaching alveoli = 4200 mL

Second patient breathing

VT VD= 250 mL 150 mL = 100 mL

VR = 30Air reaching alveoli = 3000 mL

DEADSPACE MATTERS!


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Minute Volume

Alveolar ventilation is usually inadequate in

patients who breathe slower than 12 bpm or

faster than 30 bpm. These trauma patients

will require assisted ventilations.


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Assisted Ventilation

Goal is to improve MV (alveolar ventilation)and oxygenation

Devices:

BVM is the most commonly used device Oxygen-powered demand valve

Transport ventilators


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Bag-Valve-Masks (BVM)

Minimum of 800 mL per breath

95% to 100% oxygen (FiO2 0.95 1.0)

May require two or three providers

Maintain stabilization of cervical spine


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Summary

Essential Skills Manual techniques

Suctioning

Basic adjuncts

Endotracheal Intubation remains the goldstandard

Options Dual Lumen Airways

LMA

Retrograde Intubation

PTV and surgical cricothyrotomy


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Summary

Aggressive management of the airway,

ventilations, and oxygenation improves

patient outcomes.


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1

Prehospital Trauma Life Support

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