Airway Management in the Trauma Patient: Review EMS Professions Temple College

Objectives of Airway Management & Ventilation zPrimary Objective: yProvide unobstructed passage for air movement yEnsure optimal ventilation yEnsure optimal respiration

Objectives of Airway Management & Ventilation zWhy is this so important in the trauma patient? yPrevention of Secondary Injury xShock & Anaerobic Metabolism xSpinal Cord Injury xBrain Injury

Anatomy of the Upper Airway zPediatric vs Adult Upper Airway yLarger tongue in comparison to size of mouth yFloppy epiglottis yDelicate teeth and gums yLarynx is more superior yFunnel shaped larynx due to undeveloped cricoid cartilage yNarrowest point at cricoid ring before 10 yoa

Anatomy of the Upper Airway From: CPEM, TRIPP, 1998

Ventilation zDefined as movement of air into & out of lungs zInspiration ystimulus from respiratory center of brain (medulla) ytransmitted via phrenic nerve to diaphragm ydiaphragm flattens during contraction yintercostal muscles contract yribs elevate and expand yresults in  intrapulmonic pressure (pressure gradient) yresults in air being drawn into lungs & alveoli inflated

Ventilation zExpiration yStretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration yHering-Breuer Reflex yNatural elasticity of lungs passively expires air (in non-diseased lung) zControl via Pons yApneustic & Pneumotaxic centers

Ventilation zChemoreceptors yCarotid bodies & Aortic arch yStimulated by  PaO 2,  PaCO 2 or  pH yPaCO 2 considered normal neuroregulatory control of ventilations zHypoxic Drive ydefault regulatory control ySenses changes in Pa0 2

Ventilation zOther stimulations or depressants to ventilatory drive ybody temp:  w/ fever &  w/hypothermia ydrugs/meds: increase or decrease ypain: increases but occasionally decreases yemotion: increases yacidosis: increases ysleep: decreases

Respiration zVentilation vs. Respiration zExchange of gases between a living organism and its environment zExternal Respiration yexchange between lungs & blood cells zInternal Respiration yexchange between blood cells & tissues

Respiration zOxygen saturation affected by: ylow Hgb (anemia, hemorrhage) yinadequate oxygen availability at alveoli ypoor diffusion across pulm membrane (pneumonia, pulm edema, COPD) yVentilation/Perfusion (V/Q) mismatch xblood moves past collapsed alveoli (shunting) xalveoli intact but blood flow impaired

Respiration zCarbon Dioxide content of blood yByproduct of work (cellular respiration) yTransported as bicarbonate (HCO 3 - ion) y  20-30% bound to hemoglobin yPressure gradient causes CO 2 diffusion into alveoli from blood yincreased level - hypercarbia

Alveoli P O2 100 & P CO2 40 P O2 40 & P CO Pulmonary circulation - P O2 100 & P CO2 40 Heart P O2 40 & P CO Systemic circulation - P O2 100 & P CO2 40 Tissue cell P O2 46 Inspired Air: P O2 160 & P CO2 0.3 Oxygenated Deoxygenated

Causes of Hypoxemia zTraumatic yReduced surface area for gas exchange xpneumothorax, hemothorax, atelectasis yDecreased mechanical effort xpain, traumatic asphyxiation, hypoventilation xsucking chest wound, obstruction

Assessment & Recognition of Airway & Ventilatory Compromise zVisual Assessment yPosition xtripod xorthopnea yRise & Fall of chest xParadoxical motion yAudible gasping, stridor, or wheezes y Obvious pulm edema z Visual Assessment ySkin color yFlaring of nares yPursed lips yRetractions yAccessory Muscle Use yAltered Mental Status yInadequate Rate or depth of ventilations

Assessment & Recognition of Airway & Ventilatory Compromise zRespiratory Patterns yCheyne-Stokes xbrain stem yKussmaul xacidosis yBiot’s xincreased ICP z Respiratory Patterns yCentral Neurogenic Hyperventilation xincreased ICP yAgonal xbrain anoxia

Airway & Ventilation Methods: BLS zProgress from Non-invasive BLS to invasive ALS zSupplemental Oxygen yincreased FiO 2 increases available oxygen yobjective is to maximize hemoglobin saturation

Airway & Ventilation Methods: BLS zAirway Maneuvers yJaw thrust ySellick’s maneuver z Airway Devices yOropharyngeal airway yNasopharyngeal airway yCombiTube ®

Airway & Ventilation Methods: BLS z1/2/3 person BVM zOne Person BVM ydifficult to master ymask seal often inadequate ymay result in inadequate tidal vol ygastric distention risk z Two person BVM ymost efficient method yUseful in C-spine inj yimproved mask seal and tidal volume

Airway & Ventilation Methods: BLS zPartial Airway Obstruction Techniques yPositioning yOPA/NPA ySuctioning yRemoval via Direct laryngoscopy

Airway & Ventilation Methods: BLS zGastric Distention yCommon when ventilating without intubation ypressure on diaphragm yresistance to BVM ventilation yavoid by increasing time of BVM ventilation

Airway & Ventilation Methods: ALS zGastric Tubes ynasogastric xcaution with facial trauma xtolerated by awake patients but is uncomfortable xinterferes with BVM seal yorogastric xusually used in unresponsive patients xlarger tube may be used xsafe in facial trauma

Airway & Ventilation Methods: ALS zEndotracheal Intubation yIndications xpresent or impending respiratory failure xapnea xunable to protect own airway yAdvantages xsecures airway xroute for a few medications xoptimizes ventilation and oxygenation

Airway & Ventilation Methods: ALS zComplications of endotracheal intubation yBleeding or dental injury yLaryngeal edema yLaryngospasm yVocal cord injury yBarotrauma yHypoxia yAspiration yDislodged tube or esophageal intubation yRight or Left mainstem intubation

Airway & Ventilation Methods: ALS zPatient Positioning for Intubation yGoal xAlign the 3 planes of view, so that xThe vocal cords are most visible yT - trachea yP - Pharynx yO - Oropharynx From AHA PALS

Airway & Ventilation Methods: ALS zSurgical Cricothyrotomy yIndications xabsolute need for a definitive airway AND unable to perform ETT due for structural or anatomic reasons, AND risk of not intubating is > than surgical airway risk xOR xabsolute need for a definitive airway AND unable to clear an upper airway obstruction, AND multiple unsuccessful attempts at ETT, AND other methods of ventilation do not allow for effective ventilation and respiration

Airway & Ventilation Methods: ALS zSurgical Cricothyrotomy yContraindications (relative) xNo real demonstrated indication xRisks > benefits xAge < 8 years (some say 10) xevidence of fx larynx or cricoid cartilage xevidence of tracheal transection

Airway & Ventilation Methods: ALS zNeedle Cricothyrotomy & Transtracheal Jet Ventilation yIndications xSame as surgical cricothyrotomy along with xContraindication for surgical cricothyrotomy yContraindications xNone when demonstrated need xcaution with tracheal transection

Airway & Ventilation Methods: ALS z Jet Ventilation yUsually requires high- pressure equipment yVentilate 1 sec then allow 3-5 sec pause yHypercarbia likely yTemporary: mins yHigh risk for barotrauma

Airway & Ventilation Methods: BLS & ALS Combitube® From AMLS, NAEMT

Airway & Ventilation Methods: BLS & ALS zCombitube ® yIndications yContraindications xHeight xGag reflex xIngestion of corrosive or volatile substances xHx of esophageal disease

Airway & Ventilation Methods: ALS zPharmacologic Assisted Intubation (“RSI”) ySedation xUsed for induction anxious or agitated patient xContraindications hypersensitivity hypotension (e.g. hypovolemia 2° to trauma)

Airway & Ventilation Methods: ALS zPharmacologic Assisted Intubation (“RSI”) yNeuromuscular Blockade xInduces temporary skeletal muscle paralysis xIndications When Intubation is required in a patient who –is awake, –has a gag reflex, or –is agitated or combative

Airway & Ventilation Methods: ALS zPharmacologic Assisted Intubation (“RSI”) yNeuromuscular Blockade xContraindications Most are Specific to the medication inability to ventilate patient once paralysis is induced xAdvantages enables provider to intubate patients who otherwise would be difficult or impossible to intubate minimizes patient resistance to intubation reduces risk of laryngospasm

Airway & Ventilation Methods: ALS zPharmacologic Assisted Intubation (“RSI”) yDisadvantages & Potential Complications xDoes not provide sedation or amnesia xProvider unable to intubate or ventilate after NMB xAspiration during procedure xDifficult to detect motor seizure activity xSide effects and adverse effects of specific meds

Airway & Ventilation Methods: ALS Examples of Secondary Tube Placement Confirmation Devices (From AMLS, NAEMT) From AMLS, NAEMT

Airway & Ventilation Methods: ALS zNeedle Thoracostomy (chest decompression) yIndications xPositive sx/sx of tension pneumothorax xCardiac arrest with PEA or Asystole when the possibility of trauma and/or tension pneumo exist yContraindications xAbsence of indications

Airway & Ventilation Methods: ALS zTension Pneumothorax ySx/Sx xsevere respiratory distress x  or absent lung sounds (unilateral usually) x  resistance to manual ventilation xCardiovascular collapse (shock) xasymmetric chest expansion xanxiety, restlessness or cyanosis (late) xJVD or tracheal deviation (late)

Airway & Ventilation Methods: ALS zChest Escharotomy yIndications xIn the presence of severe edema to the soft tissue of the thorax as with circumferential burns: inability to maintain adequate tidal volume even with PPV inability to obtain adequate chest expansion with PPV xRarely needed

Airway & Ventilation Methods: ALS zChest Escharotomy yConsiderations xmust rule out the possibility of upper airway obstruction yProcedure xIntubate if not already done xPrep site and equipment xVertical incision to anterior axillary line xHorizontal incision only if necessary xCover and protect

Airway & Ventilation: Risks & Protective Measures zBSI yGloves yFace & eye shields yRespirator if concern for airborne disease yBe prepared for xcoughing xspitting xvomiting xbiting