Airway solutions in an acute trauma scenario

Dr.Venugopalan.P.PDA;DNB;MNAMS;MEM[GWU]Director ; Emergency Medicine

Aster DM Health Care LtdDeputy Director ;MIMS Academy

Founder and executive director -ANGELS

Focus

• Why?• When?• How?• What is different?• What is new ?

Case ScenarioWhat is your first priority?

28year old man was brought to ED following a motor bike accident , Pulse 112,BP 110/60,Rapid breathing , Snoring+ SpO2 87 in room air and CGS 8/15. Smell of alcohol +

Priority –One

• Airway is the first system to be taken care in any trauma victim

• Compromised airway will endanger the patient life more rapidly than any other system compromise

Airway is always priority -ONE

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 and reassessed for deterioration.

How do I know the airway is adequate?

Airway Assessment

Signs and symptoms of airway compromise

● High index of suspicion● Change in voice / sore throat● Noisy breathing (snoring and stridor)● Dyspnea and agitation

Airway Assessment

Signs and symptoms of airway compromise (cont.)

● Tachypnea● Abnormal breathing pattern● Low oxygen saturation (late sign)

Airway Assessment

When to intervene when the airway is patent

● Inability to protect the airway● Impending airway compromise● Need for ventilation

Trauma :Definitive airway

• Apnoea • Glasgow Coma Scale < 8 or sustained seizure activity. • Unstable mid-face trauma. • Airway injuries. • Large flail segment or respiratory failure. • High aspiration risk. • Inability to otherwise maintain an airway or

oxygenation.

Airway Assessment

Impending Airway Obstruction

How do I manage the airway of a trauma 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

Protect the cervical spine during airway management!

Airway Management

Caution

Obstructed airway ?

• Tongue and Epiglottis• Any Foreign materials ?

Clear it

Noisy breathing ?

Tongue obstructing Airway

Airway Management

Chin-lift Maneuver

Basic Techniques

Jaw thrust

Trauma ?

Airway

Not – Maintainable ?

Adjuncts

Airway Management

Oropharyngeal airway

Basic Adjuncts

● Patients who can tolerate an oral airway will usually need intubation.

Nasopharyngeal airway

● Often well tolerated

• Airway Reflexes ? …..No !

Choice –OPA !

                                                                                                     

O P A

Sizing - oropharyngeal airway

• OPA is not tolerating ?• Airway reflexes retained ?• Inability to open mouth ?

N P A

NPA

• Facial and Maxillary injury• Fracture Base of skull

Caution

Raccoons' eye Battles sign

Airway Management

How do I predict a potentially difficult airway?

● Maxillofacial trauma and deformity● Mouth opening● Anatomy

● Beard● Short, thick neck● Receding jaw● Protruding upper teeth

Airway Management

Is this a difficult airway?How would you manage this patient?

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

RSI: “7 P’s”

1. P = Preoxygenation2. P = Preparation3. P = Pretreatment4. P = Paralysis with induction5. P = Protection6. P = Placement of the tube7. P = Post-Intubation management

RSI: TimelineT – 10 minutes PrepareT – 5 minutes PreoxygenateT – 3 minutes PretreatT = 0 Paralysis with

inductionT + 30 seconds ProtectionT + 45 seconds PlacementT + 90 seconds Post-Intubation

management

Airway Management

● Preoxygenate● Cricoid pressure ● Sedate (midazolam)● Paralytic (succinylcholine) ● Intubate● Confirm (Auscultate, CO2) ● Release cricoid pressure and ventilate

Definitive Airway – Easy

Airway Management

Is this a difficult airway?How would you manage this patient?

Airway Evaluation

Problem Airway

epiglottis Vocal cords

Difficult Airway Assessment• 4 D’s– Distortion, Disproportion, Dysmobility, Dentition

• BONES– Beard, Obese, No teeth, Elderly, Snores (sleep apnea)

• SHORT– Surgery (head/neck/jaw), Hematoma, Obese,

Radiation, Tumor• LEMON• MALLAMPATI• Always have a “Rescue Airway” technique ready

MALLAMPATI SCORE

Class I Class II Class III Class IV

Anticipate the worst !!!

60-SECOND EXAM “LEMON”

• Look for external difficulty• Evaluate using 3=3=2 rule• Mallampati (Class I & II)• Obstruction• Neck Mobility

3 fingers fit in mouth 3 fingers fit from mentum to hyoid cartilage 2 fingers fit from mandible to top of thyroid cartilage

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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

Gum elastic bougie

LMA

Igel

Intubating LMA

Kings LT airway

Video Laryngoscope

Video Assisted Laryngoscope

Other methods Useful in semi elective scenarios

• Fiberoptic intubation

Airway Management

● Surgical airway● Cricothyroidotomy

Needle

Definitive Airway

Surgical

Always

Do confirm tube positions !!

How do I know the tube is in the right place?

● Visualize it going through the cords

● Watch the chest

● Auscultation

● Pulse oximeter

● CO2 detector

● Radiology

Airway Confirmation

Rule out wrong tube position

End tidal CO2 detection

Esophageal Detector Devices (EDD)

Recognize Adequacy of Ventilations

Pulse oximeter

Approximate Blood oxygen level !

SpO2 100% = PaO2 100mm of HgSpO2 90%= PaO2 60mm of HgSpO2 60%= PaO2 30mm of HgSpO2 50%= PaO2 27mm of Hg

Airway Decision Scheme

Airway can be tricky always

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