Airway and Ventilation

Management in the Trauma Patient

Airway / Ventilation of the Trauma Patient : Objectives

ƒ Recognize acute airway obstructionƒ Be familiar with airway management

techniques–Airway opening maneuvers–Orotracheal & nasotracheal intubation–Needle cricothyroidostomy / jet ventilation–Alternative difficult airway techniques–Surgical cricothyroidostomy

ƒ Be familiar with devices for oxygen administration and ventilation–Masks, bag-valve-mask, mechanical ventilators

Importance of Airway Management

ƒ Airway obstruction is the most rapid killer of the trauma patient

ƒ Airway management is always the first step in trauma management

Risk Factors for Airway Obstruction in the Trauma Patient

ƒ Decreased mental status–Head injury–Effects of alcohol or drugs

ƒ Facial fracturesƒ Blunt neck traumaƒ Burns / smoke inhalation

And in some : congenital airway structural abnormalities

Specific Causes of Airway Obstruction

ƒ Head position : slumped forward

ƒ Blood ƒ Vomitusƒ Foreign bodyƒ Extrinsic compression

–Neck hematomas–Neck abscesses

ƒ Airway wall edema

Signs of Airway Obstruction(Should Note These "From Across the Room")

ƒ Unconsciousƒ Unable to speakƒ Retractions

–Sternal, intercostal, subcostal

ƒ Poor or abstract air movementƒ Cyanotic or grey skin colorƒ "Noisy" or "gurgly" breathingƒ Stridor

Airway Management Precautions

ƒ If the patient may have a neck injury : always maintain neck immobilization during airway management

ƒ Avoid distraction of the neck

Best neck immobilization with towel, collar, and hands

Airway Opening Maneuvers

ƒ Head tilt / neck lift –Do not do if possible neck injury

ƒ Chin liftƒ Jaw thrustƒ Suction oropharynx &

nasopharynxƒ Remove oropharyngeal foreign

bodies with Magill forcepsƒ Always start oxygen concurrent

with airway maneuvers

Chin lift and head tilt maneuvers

Head tilt and neck lift

Initial Airway Adjuncts(act to hold open the upper airway)

ƒ Oropharyngeal airway–Do not use if patient conscious (will cause gagging & vomiting)

ƒ Nasopharyngeal airway–Do not use if mid-face fracture (may go through fracture site and penetrate brain)–Relatively contraindicated if severe coagulopathy (may stir up bleeding) and in children (may cause bleeding from enlarged adenoids)

Oropharyngeal airways (note how 2 can be hooked together to do mouth to tube ventilation)

Use the distance from the corner of the mouth to the ear to select the correct size oral airway

Actually a better insertion method is to insert the airway at a 90 degree angle and then rotate it into position over the tongue

Use of a tongue depressor to help insert an oral airway

Don’t allow this to happen !

Standard red rubber nasopharyngeal airways

Proper position of the inserted nasal airway

These protect the rescuer by allowing mouth to device ventilation rather than mouth to mouth

Other types of barrier ventilation masks

An oxygen reservoir is required in order to give the patient oxygen concentrations greater than 60 %

Another type of bag-valve with oxygen reservoir (the black corrugated tubing)

Correct hand position for one person ventilation

Two person bag-valve-mask ventilation (can achieve bigger ventilation volumes than by one person)

Patients in Whom a Definitive Airway Is Needed

ƒ Depressed mental statusƒ Protect from aspiration of blood or

vomitusƒ Head injury requiring hyperventilationƒ Patient requires sedation or anesthesia

to obtain computed tomography scanƒ Emergency surgeryƒ Major chest wall injuryƒ Respiratory failureƒ Anticipated prolonged ventilation

Advantages of Endotracheal Intubation

ƒ Protects the airway from aspirationƒ Facilitates ventilation & oxygenationƒ Enables direct suctioning of secretions

from tracheaƒ Provides route for administration of

resuscitative medicationsƒ Prevents gastric inflation from

ventilationsƒ Maintains airway against edema or

compression

Orotracheal Versus Nasotracheal Intubation

ƒ Orotracheal preferred–Patient apneic–Midfacial fractures–Known coagulopathy

ƒ Nasotracheal preferred–Patient breathing–Short / thick neck–Status epilepticus

ƒ Either method okay for patients with suspected neck injury as long as neck immobilization maintained (nasotracheal can cause higher incidence of delayed sinusitis)

Preparation for Endotracheal Intubation

ƒ Have suction ready and operating–Yankauer (large bore) catheter–Flexible catheter

ƒ Choose endotracheal tube (ETT) size–Have 2 "adjacent" sizes also available

ƒ Have stylet and syringe ready (use of stylet to stiffen the ETT is routinely recommended for both adults & children)

ƒ Check equipment–Test bulb on laryngoscope, test inflate balloon on ETT

ƒ Have bag-valve-mask (BVM) ready and attached to oxygen flow

ƒ Have medications labeled and readyƒ Have stethescope ready

Suction canisters and tubing must be ready before intubation

Ideal patient positioning for intubation (assuming neck injury is not present)

Extra sheets and pillows may be needed for ideal airway positioning for a very obese patient

Choice of Laryngoscope Blades

ƒ Straight blade (such as Miller) used to directly lift the epiglottis–May be best if "floppy" epiglottis suspected (which is more common in children)

ƒ Curved blade (such as Macintosh) used to indirectly expose the glottic inlet by lifting up from the vallecula

ƒ Should have both available since unpredictably sometimes one works better than the other for some patients

Intubation equipment to have ready

Routine use of a stylet is recommended for intubation of both adults and children

You need to align the axes of the mouth, pharynx, and trachea for intubation to be successful ; these axes are not aligned when the neck is flexed

Good alignment of the mouth, pharynx, and tracheal axes for intubation

Also called the Sellick maneuver

Place the laryngoscope in the mouth and sweep the tongue to the left

Correct placement of straight blade

Correct placement of curved blade

Laryngoscopic view with the straight blade (left) and the curved blade (right)

Laryngoscopic views with different blades

Insert the endotracheal tube from the right (do not place it directly down the channel of the laryngoscope blade or it will obstruct your view)

Correct endotracheal tube positioning using a curved blade

Precautions About Endotracheal Intubation

ƒ Do not attempt if the patient is not adequately sedated

ƒ Before using ANY of the sedatives or paralytic agents, personnel MUST know well the pharmacology of these agents

ƒ If personnel are not skilled in intubation, continued ventilation by bag-valve-mask is preferable to a botched intubation attempt

General Guidelines for Endotracheal Intubation

ƒ If needed, it should be done as early as possible in the resuscitation

ƒ It should be attempted by the most experienced person present

ƒ No more than 30 seconds per attempt should be taken; the patient should be reventilated with BVM after each 30 seconds

Use of Medications for Assisted Intubation ("Rapid Sequence Intubation")*

ƒ If the patient is completely unconscious and unresponsive, medication use to assist in intubation (except perhaps IV lidocaine) is usually unnecessary

ƒ Complications are reduced by proper use of sedation and paralytic agents*This really should be called "Medication-Assisted-

Intubation" because if done properly, it is not actually "rapid"

Potential Complications of Endotracheal Intubation

ƒ Esophageal intubation : causes death if unrecognized

ƒ Mainstrem bronchus intubation : can result in collapse of other lung

ƒ Pneumothoraxƒ Oropharyngeal bleedingƒ Vocal cord injuryƒ Fractured teeth ; tooth fragments could be

aspiratedƒ Vomiting & aspirationƒ Movement of an unstable cervical spine injury

"Classic" Sequence of Medications to Use for Assisted Intubation ("Rapid Sequence Intubation")

ƒ Oxygen : preoxygenate the patient (VERY important)

ƒ Lidocaine : 1 to 1.5 mg/ Kg IV (to blunt the increase in ICP from intubation; efficacy of this is debated)

ƒ Pancuronium or vecuronium 0.01 mg/ Kg IV (usually one mg; to prevent fasciculations from succinylcholine)

ƒ Diazepam or Midazolam 0.1 to 0.7 mg/ Kg IV (usually 5 mg)

ƒ Succinylcholine 1 to 1.5 mg/ Kg IVƒ Cricoid pressure (Sellick maneuver) to prevent

aspirationƒ Intubate (Pass the ETT)Note : Usually wait 2 minutes in between each

medication to allow it time to take effect

Contraindications to Succinylcholine

ƒ Known hyperkalemia (as in renal failure patients)

ƒ Burns (if delayed time from injury)ƒ Muscular dystrophy / other muscle diseasesƒ Major crush injuries (if delayed time from

injury)ƒ Family history of Malignant Hyperthermia

or pseudocholinesterase deficiencyRemember that succinylcholine may not be needed (thereby avoiding the rare chance it will cause hyperkalemia or hyperthermia) if the patient is so sick that they already have very relaxed muscle tone

Considerations About Use of Paralytic Agents for Endotracheal Intubation

ƒ DO NOT USE if not able to ventilate the patient with a bag-valve mask in case the intubation fails

ƒ Succinylcholine has rapid onset (30 to 60 seconds) and relatively short duration (unless patient has pseudocholinesterase deficiency) of 10 to 15 minutes

ƒ The nondepolarizing agents have slower onset and more prolonged half life–Use of "priming dose of 0.5 to 1 mg IV 3 minutes before main dose may shorten onset to 60 seconds

Other Medication Options for Medication-Assisted Intubation

ƒ Etomidate 0.3 mg / kg IV–Causes rapid brief sedation & apnea–If repeated can cause adrenal suppression–Usually causes no cardiovascular complications

ƒ Ketamine 2 mg / kg IV or 4 mg / kg IM–Older studies indicated it may cause increased intracranial & intraocular pressures, but this is debated–Can rarely cause laryngospasm & "emergence reactions" (agitation after awakening)–Usually minimal effects on cardiorespiratory status

More Medication Options for Medication-Assisted Intubation

ƒ Barbiturates (used as "induction" agent)–All commonly cause hypotension & apnea

ƒ Methohexital 1 to 3 mg / kg IVƒ Thiopental 3 to 5 mg / kg IVƒ Propofol 2 to 2.5 mg / kg IV (can be continuous infusion)

ƒ Narcotics–Also can cause hypotension & apnea & histamine release (but can reverse with naloxone 0.4 to 2 mg IV)

ƒ Morphine 0.01 to 0.1 mg / kg (often 2 mg initial dose)

ƒ Fentanyl 3 to 50 micrograms / kg (can rarely cause muscle & chest wall rigidity if high dose given rapidly)

Options for Nondepolarizing Neuromuscular Blockers (Paralytics)

Name Dosage (IV) Comments

Atracurium 0.4 to 0.5 mg/kg useful in renal failure

Cis-atracurium 0.1 to 0.2 mg/kg

Pancuronium 0.1 mg/kg can cause cardiac side effects

Rocuronium 0.6 to 1.2 mg/kg faster onset

Vecuronium 0.1 mg/kg useful for pro- longed paralysis

Additional Medication Considerations for Endotracheal Intubationƒ If a paralytic agent is used, a sedative or

induction agent MUST be also used (it is inhumane to chemically paralyze someone without making them unaware of the paralysis)–Benzodiazepines are useful for this because even in small doses they cause brief retrograde amnesia

ƒ They also may blunt the "emergence reactions" from ketamine, and can be reversed with Flumazenil 0.2 mg IV

ƒ In children < 8 years, atropine 0.01 mg/kg (minimum 0.1 mg) is recommended to prevent vagal reactions from succinylcholine (& the succinylcholine dose is 2 mg/kg)

More Considerations About Medication - Assisted Endotracheal Intubation

ƒ For inexperienced personnel, the safest agents to use are probably the benzodiazepines and narcotics (because they can be reversed), and etomidate or ketamine

ƒ Post - intubation paralytic agents are needed for patients who are combative from head trauma or intoxication–If possible and safe, a complete neurologic exam should be completed prior to use of extended paralytic agents

Sequence of Events for Intubation

ƒ Prepare equipmentƒ Preoxygenateƒ Administer medications; Sellick maneuver (cricoid

pressure)ƒ Pass the tube & inflate cuff balloonƒ Release Sellick maneuverƒ Ventilateƒ Listen with stethescope over both sides of chest

and upper abdomenƒ Use end-tidal CO2 detector if availableƒ Secure the tube with tape (record depth number at

lips ; usually 21 to 23 cm in adults)ƒ Obtain chest X-ray to check tube position

An X-ray you don’t want to see : Esophageal intubation

A qualitative colorimetric end tidal CO2 detector

(use helps recognize possible esophageal intubation)

Use of a GU syringe as an esophageal intubation detector

Use of a bulb syringe as an esophageal intubation detector

How to tape secure an oral endotracheal tube

Securing an oral endotracheal tube (using also an oral airway keeps the patient from biting on the endotracheal tube)

How to tape secure a nasotracheal tube

Indications for Surgical Airway (Cricothyroidotomy)

ƒ Inability to orotracheally or nasotracheally intubate and airway control required–Failure or impossibility of "backup" intubation methods

ƒ Upper airway obstruction (above level of vocal cords)

"Backup" Alternative Endotracheal Intubation Techniques

ƒ Should have a "Difficult Airway " cart with this extra airway equipment available in the E.D.–Combitube

ƒ Can be inserted blindlyƒ Often helpful in controlling oropharyngeal bleeding

–Trach-Liteƒ Also a "blind" technique

–Retrograde intubation over a guide wireƒ Uses a central intravenous line kit

–Commercial percutaneous tracheostomy insertion sets

The Combitube is a good “backup” alternative airway technique

Combitube in the esophageal position (about 85 % of the time when inserted it will be in the esophagus)

Combitube in the tracheal position (note ventilation bag is now attached to the other lumen)

Another type of “blind” insertion airway : the pharyngotracheal lumen airway (PTL)

Another “backup” technique: placing an endotracheal tube down the lumen of the intubating LMA (laryngeal mask airway)

Technique for Retrograde Intubation Over a Guide Wire

ƒ Puncture cricothyroid membrane with needle aimed proximally, then pass central intravenous line guide wire thru the needle into the pharynx

ƒ Look into the pharynx and pull the guide wire with a Magill forceps so it exits from the mouth

ƒ Cut off the proximal thicker portion of a nasogastric tube and insert the lubricated tube over the wire to the predetermined depth equivalent to the distance from the mouth to the cricoid puncture site

ƒ Insert an endotracheal tube over the nasogastric tube

ƒ Pull the wire and nasogastric tube out of the mouthƒ Advance the endotracheal tube a little farther

Needle Cricothyroidostomy : Technique

ƒ Prep neck with iodine or alcohol if time allowsƒ Insert 14 gauge needle thru cricothyroid

membrane (or use IV catheter over needle & withdraw needle)

ƒ Attach stopcock and oxygen tubingƒ Run oxygen in for one second ; open stopcock

for 3 to 4 seconds & keep repeating this cycleƒ Can instead attach 3 cc syringe barrel & then

attach ETT connector & ventilate with BVM directly

ƒ Prepare for surgical cricothyroidostomy if possible (to establish larger diameter airway)

High pressure tubing required for jet ventilation for a needle cricothyroidostomy

Technique of verifying entry into the trachea with a catheter over needle

Setup for direct ventilation of a needle cricothyroidostomy

Direct bag valve ventilation to a needle cricothyroidostomy

Surgical Cricothyroidostomy : Technique

ƒ Prep front of neck if time allowsƒ Incise skin & cricothyroid membrane

horizontallyƒ Insert tracheostomy tube or 6.0 or 6.5

mm. diameter endotracheal tube & inflate cuff balloon

ƒ Ventilate thru tubeƒ Auscultate over chest and abdomenƒ Secure tube with tape or straps around

neckƒ Chest X-ray to check tube position

Surgical cricothyroidostomy

Minimum instruments needed for surgical cricothyroidostomy

Emergency tracheostomy

One of several available types of percutaneous cricothyroidostomy tubes

Choosing Endotracheal Tube Size (Inner Diameter in mm.)

ƒ Small adults : 7.0, 7.5ƒ Large adults : 8.0, 8.5, 9.0ƒ Children :

–Can use formula 16 + age in years divided by 4–Or use tube with diameter same as child's little finger

ƒ For nasotracheal intubation, choose tube 0.5 to 1 mm. diameter smaller than for oral

Reassessment of the Intubated Patientƒ Reauscultate to check tube position

after each time the patient is movedƒ Note printed number on the tube at the

level of the lips & record in chartƒ Continuous pulse oximetry if availableƒ Consider hand restraints if patient

combative or likely to awaken and attempt to pull tube

ƒ Suction the ETT frequentlyƒ Recheck pressure in cuff balloon every

6 to 8 hours (should be < 25 mm Hg)

Technique of Tracheobronchial Suctioning

ƒ Set suction pressure between 80 to 120 mm Hg

ƒ Preoxygenate with 100 % oxygen for 3 to 5 minutes

ƒ Use sterile technique (gloves)ƒ Insert suction catheter thru tubeƒ Apply suction & pull out catheter with a

rotary motionƒ Limit suction to no more than 10 seconds

per attempt

Oxygen Concentrations Deliverable from Airway Adjuncts

Device O2 Concentration

Nasal cannula (2 to 6 l/min)

24 to 44 %

Face mask (6 to 10 l/min)

40 to 60 %

Face mask with O2 Reservoir

60 to 98 %

Venturi mask 28 to 40 % by selected increments

Airway Management Summary

ƒ Airway management is always first priority

ƒ Always maintain cervical spine precautions

ƒ Decide early if definitive airway needed

ƒ Complete preparations before attempting to intubate

ƒ Reassess the intubated patient frequently

Specific Airway Skills : Practice Session

ƒ Airway opening maneuversƒ Placement of airway adjuncts (oral & nasal

airways)ƒ Adult orotracheal intubationƒ Adult nasotracheal intubationƒ Pediatric orotracheal intubationƒ "Backup" alternative intubation techniquesƒ Needle cricothyroidostomyƒ Use of bag-valve-mask (perhaps the most

important skill)