Post on 04-Jan-2016
AIRWAY MANAGEMENT
OBJECTIVES
• Demonstrate appropriate airway assessment techniques for the trauma patient.
• Identify signs and symptoms of airway compromise and respiratory distress.
• Demonstrate correct airway interventions for the trauma patient.
• Discuss complications of airway management.
AIRWAY & VENTILATION
• Goals– Maintain C-spine immobilization– Assess for airway obstruction– Establish definitive airway– Ensure adequate oxygenation– Provide adequate ventilation– Monitor ongoing airway status
AIRWAY ASSESSMENT
• Look– Presence of blood, emesis, foreign bodies, soot in
oral cavity– Stridor– Pallor or cyanosis– Agitation– Altered mental status– Severe maxillofacial trauma– Neck, larynx or tracheal injury
AIRWAY ASSESSMENT
• Listen– Snoring, gurgling– Hoarseness– Inability to talk
• Feel– Diminished air movement (LOC and ability
to speak provide info regarding airway patency)
VENTILATION ASSESSMENT
• Look– Asymmetrical chest wall movement– Paradoxical chest wall movement– Abnormal respiratory effort– Use of accessory muscles– Tachypnea or an abnormal respiratory rate
• Listen– Absence of breath sounds– Decreased breath sounds
VENTILATION ASSESSMENT
• Feel– Chest wall instability – Subcutaneous air in the soft tissues
(crepitus)
INTERVENTIONS
• Chin lift/Jaw thrust– Open the airway maintaining C-
spine immobilization– Suction the airway
• Oropharyngeal Airway (OPA)– Do not use if gag reflex is present– Size by placing flange at the
corner of the mouth and the tip at the angle of the jaw
Too short = depresses tongue into the pharynxToo long = pushes epiglottis against the entrance of the trachea
INTERVENTIONS
• Insert OPA upside down into the mount until it reaches the posterior pharynx then rotate 180 degrees
• Use a tongue blade to depress the tongue and insert the device right side up
• Assess for airway patency and auscultate breath sounds
INTERVENTIONS
• Nasopharyngeal Airway
– Size by placing the flange at the edge of the nares to the angle of the jaw
– Lubricate, gently insert into the nostril, the bevel is open at midline, resting in the posterior pharynx behind the tongue
– Do not force– Gently rotate to aid insertion– Assess for patient airway and
breath sounds
INTERVENTIONS
• Bag Valve Mask Ventilation– Place mask over mouth securing
seal (one or two man technique)– 100% high flow oxygen (assure
tubing is connected to oxygen source)
– Assure bag has a reservoir– Maintain airway– Continue to ventilate until definitive
airway is established
INTERVENTIONS
• Endotracheal Intubation - Indications– Presence of apnea– Inability to maintain a patent airway– Need to protect the lower airway from aspiration– Impending or potential compromise of the airway
(inhalation injury, facial fractures,)– Presence of a closed head injury GCS < 8– Inability to maintain adequate oxygenation by face
mask
INTERVENTIONS
• Endotracheal Intubation– Definitive airway = ET, Trach,
Cricothyroidotomy– Oral or nasal
• Oral is preferred for facial, sinus, basilar skull and cribriform plate fractures
• Oral is required for the apneic patient (Blind nasotracheal intubation requires a spontaneous breathing patient)
INTERVENTIONS
• Endotracheal Intubation– Avoid hyperextension of neck, maintain C-Spine
immobilization– Check equipment prior to procedure– Administer rapid sequence intubation medications as
indicated (mini neuro exam first)– Pre-oxygenate– Apply cricoid pressure to aid in visualization and to prevent
aspiration – maintain until balloon is inflated to avoid aspiration
– Monitor VS and pulse ox– Perform intubation– Do not over inflate cuff
INTERVENTIONS
• Endotracheal Intubation– Check for placement
• Listen over epigastrium for absence of sounds• Listen for breath sounds bilaterally, anterior, and laterally• Visualize equal chest excursion• Look for improvement in color and LOC
• Confirm with end tidal CO2 detector
• Secure tube• Chest x-ray to confirm placement• Constant reevaluation
INTERVENTIONS
• Endotracheal Intubation– Complications
• Lacerations of lips, tongue, pharyngeal or tracheal mucosa
• Right mainstem intubation• Aspiration• Chipping of teeth• Esophageal intubation
INTERVENTIONS
• Endotracheal Intubation– CO2 Detection devices
• May be inaccurate in patients in cardiac arrest
• Colorimetric devices changes color based on measurable concentrations of CO2
– Low levels of CO2 turn the color strip purple (atmosphere)
– High levels of CO2 turn the color strip yellow
• In-line capnometry measures inspired and end tidal CO2 with each breath and displays wave form CO2 concentrations
INTERVENTIONS
• Laryngeal Mask Airway (LMA)– Seals around the larynx – contraindicated if high risk of
aspiration– Not usually used in the trauma patient
• Multi-lumen Esophageal Airway Devices (CombiTube)– Used if ET cannot be placed– Complication is incorrect identification of tube position and
ventilation through the wrong lumen– Pressure exerted by the pharyngeal balloon can also cause
swelling of the tongue if left in > 30 minutes– Too large for children
INTERVENTIONS
• Rapid Sequence Intubation (RSI)– Not without risk!– Individual performing intubation must be able to
obtain a surgical airway if needed– Induction agents (sedatives and paralytics ) are
dangerous in the hypovolemic patient– Small doses of etomidate or midazolam are
appropriate for the paralyzed patient– Reversal agents must be readily available
INTERVENTIONS
• Rapid Sequence Intubation (RSI)
Drug Adult
Dose
Child Dose
Side Effect
Duration Onset
Succinly-
choline
1-2mg/Kg 1-2 mg/kg once
Arrythmias Fasciculation
Aspiration
3-10 minutes
30-60 seconds
Morphine 2-5 IV 0.1 mg/kg IV
CNS/Resp depression
2 hours Immediate
Midazolam 1-3 mg IV 0.1 mg/kg IV
CNS/Resp depression
1-3 hours 3-5 min
Vecuronium 0.15 mg/kg IV
0.15 mg/kg/IV
Apnea 30-60 min Within 60 seconds
Etomidate 0.2-0.6 mg/kg IV
0.3 mg/kg IV
Apnea 30-60 min Within 30 seconds
INTERVENTIONS
• Needle Cricothyroidotomy (Transtracheal Catheter Ventilation)– Jet insufflation of the airway– Useful for children under 12– Temporary use 30-45 minutes (CO2 accumulation)– Large caliber plastic cannula over a needle is placed
through the cricoidthyroid membrane through the trachea, just below the obstruction
– The cannula is connected to wall oxygen at 15 L/min with either a Y-connector or a side hole cut in the tubing attached between the oxygen source and the cannula
– Intermittent insufflation is accomplished by placing the thumb over the hole, one second on and 4 seconds off
INTERVENTIONS
• Surgical Cricothyroidotomy– Indicated when oral or nasal intubation is
not possible– Must be completed quickly and accurately– Incision is made through the skin and
cricothyroid membrane and an ET or tracheostomy tube is placed in the upper airway
INTERVENTIONS
• Special Considerations– Tension Pneumothorax
• Impacts cardiac filling and decreases B/P• “One-way valve” effect allows increasing
amounts of air to be trapped in the pleural space
• Positive pressure ventilation, especially after intubation may convert a simple pneumothorax to a tension pneumothorax
INTERVENTIONS
• Special Considerations– Tension Pneumothorax
• Assessment– Hypotension– Respiratory distress– JVD– Absent breath sounds on affected side– Asymmetrical chest wall movement
• Intervention– Place a large bore angiocatheter in the second or third
intercostal space, mid-clavicular line just above the rib– Chest tube placement required
INTERVENTIONS
• Special Considerations– Burns
• Soot around the nose and mouth indicates inhalation burns that could result in edema and loss of airway
• Intubate the burn patient early
SUMMARY
• “A”irway is First
• Assessment: Oxygenation & Ventilation
• Sequence of Interventions
• Endotracheal Intubation
• Emergent Airways
• Special Considerations
QUESTIONS
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