Chapter Goejw Tighquie

8/13/2019 Chapter Goejw Tighquie

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Initial Assessment and Management

Committee on Trauma Presents

Airway

and

Ventilatory

Management


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Case Scenario

34-year-old motorcyclistlost control and crashed

into a fence Obvious facial trauma

No helmet

Smells of alcohol

Belligerent at scene;now not communicating

Pulse oximeter 85%

What is your f i rst pr ior i ty?


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Objectives

Identify the clinical settings in whichairway compromise is likely to occur.

Recognize the signs and symptoms ofairway obstruction.

Describe the techniques to establishand maintain a patent airway.

Discuss the importance of adequateoxygenation and ventilation in allphases of airway management.


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Airway Assessment

Patient is alert and oriented.

Patient is talking normally.

There is no evidence of injury to

the head or neck.

You have assessed andreassessed for deterioration.

How do I know the airway is adequate?


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Airway Assessment

Signs and symptoms of ai rway com prom ise

High index of suspicion

Change in voice / sore throat

Noisy breathing (snoring and stridor)

Dyspnea and agitation


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Airway Assessment

Signs and symptoms of ai rway com prom ise

(cont.)

Tachypnea

Abnormal breathing pattern

Low oxygen saturation (late sign)


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Airway Assessment

When to in tervene when the airway is patent

Inability to protect the airway

Impending airway compromise

Need for ventilation


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How do I manage the airway of a traum a patient?

Supplemental oxygen

Basic techniques Basic adjuncts

Definitive airway

Cuffed tube in the trachea

Difficult airway adjuncts

Unexpected difficult airway

Predicted difficult airway

Airway Management


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Protect the cervical spine duringairway management!

Airway Management

Caution


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Airway Management

Chin -l i f t ManeuverBasic Techniques


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Airway Management

Jaw-thrust ManeuverBasic Techniques


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Airway Management

Oropharyngeal airwayBasic Adjuncts

Patients who can tolerate an oral airwaywill usually need intubation.

Nasopharyngeal airway

Often well tolerated


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Airway Management

How do I predict a po tential ly dif f icul t airway? Maxillofacial trauma and deformity

Mouth opening

Anatomy

Beard

Short, thick neck

Receding jaw

Protruding upper teeth


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Airway Management

Is th is a dif f icul t airway?

How would you m anage

this pat ient?


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Airway Management

Oral intubation (medication assisted)

Cricoid pressure, suction, back-up

Maintain c-spine immobilization

Plan for failure:

Gum elastic bougie

LMA / LTA

Needle cricothyroidotomy

Surgical airway

Definitive Airway Easy


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Airway Management

Preoxygenate

Cricoid pressure

Sedate (midazolam)

Paralytic (succinylcholine)

Intubate

Confirm (Auscultate, CO2)

Release cricoid pressure and ventilate

Definitive Airway Easy


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Airway Management

Is th is a dif f icul t airway?

How would you m anage

this pat ient?


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Airway Management

Get help

Be prepared

Consider rapid sequence intubation vs.awake intubation

Maintain c-spine immobilization

Consider use of:

Gum elastic bougie

LMA / LTA

Surgical airway

Other advanced airway techniques, eg,fiberoptic intubation

Definitive Airway Difficult


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Airway Management

Surgical airway

CricothyroidotomyNeedle

Definitive Airway

Surgical


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How do I know the tube is in the r ight p lace?

Visualize it going through

the cords

Watch the chest

Auscultation

Pulse oximeter CO2 detector

Radiology

Airway Confirmation


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Summary

Suspect airway compromise in all injured

patients.

Adjuncts for establishing a patent airway

include:

Chin-lift and jaw-thrust maneuvers

Oropharyngeal and nasopharyngeal airways

Laryngeal mask airway

Multilumen esophageal airway

Gum elastic bougie device


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Summary

With all airway maneuvers, the cervical spine

must be protected by inline immobilization.

A surgical airway is indicated when an airway isneeded and intubation is unsuccessful.

The assessment of airway patency and

adequacy of ventilation must be performed

quickly and accurately. Pulse oximetry and end-tidal CO2measurement are

essential.


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Summary

A definitive airway requires a tube placed in the

trachea (inflated cuff, oxygen, assisted

ventilation, airway secure). Oxygenated inspired air is best provided via a

tight-fitting oxygen reservoir face mask with a

flow rate of greater than 11 L/min.

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