بنام خداوند جان وخرد

1. بنام خداوند جان وخرد

2. Airway Management in the Trauma Patient

3. Objectives of Airway Management & Ventilation • Primary Objective: • Provide unobstructed passage for air movement • Ensure optimal ventilation • Ensure optimal respiration

4. Objectives of Airway Management & Ventilation • Why is this so important in the trauma patient? • Prevention of Secondary Injury • Shock & Anaerobic Metabolism • Spinal Cord Injury • Brain Injury

5. Airway/Breathing • Verification of adequate airway and acceptable respiratory mechanics is of primary importance • Hypoxia is the most immediate threat to life • Inability to oxygenate a patient will lead to permanent brain injury and death within 5 to 10 Minutes

6. Airway obstruction • Direct injury • Face, Mandible, or Neck • Hemorrhage • Pharynx, Sinuses, and Upper airway • Diminished Consciousness • Traumatic Brain injury, Intoxication, Analgesic medications • Aspiration • Gastric contents, Foreign body • Misapplication of Airway/Endotracheal Tube • Esophageal Intubation

7. Inadequate Ventilation • Diminished Respiratory Drive • Traumatic Brain injury, Shock, Intoxication, Hypothermia, Over Sedation • Direct Injury • Cervical Spine, Chest Wall, Pneumo/Hemothorax, Trachea, Bronchi, Pulmonary Contusion • Aspiration • Gastric contents, Foreign body • Bronchospasm • Smoke, Toxic Gas Inhalation

8. Nasal Cannula Flow Rates 1 liters/min. =24% 2 liters/min. = 28% 3 liters/min. = 32% 4 liters/min. = 36% 5 liters/min. = 40% 6 liters/min. = 44%

9. Simple Face Mask • No reservoir • Can deliver up to 60% concentration • Rate 6 to 10 liters/min. • Not recommended for prehospital use

10. Opening the airway Richard Lake

12. Prophylaxis against Aspiration • Trauma patients are always considered to have full stomach • Ingestion of food or liquids before injury • Swallowed blood from oral or nasal injury • Delayed gastric emptying • Administration of liquid contrast medium • Reasonable to administer nonparticulate antacid prior to induction • Cricoid pressure/Sellick Maneuver should be applied continuously during airway management • Rapid Sequence Induction • Avoidance of ventilation between administration of medication and intubation

13. Cervical Spine Injury • Trauma Patients • No Radiological Studies • Alert, Awake, and Oriented • No Neurological Deficits • No Distracting Pain • MRI Cervical Spine • Neck Pain • Cervical Tenderness to Palpation

14. Cervical Spine Injury • All Other Trauma Patients • Lateral radiograph of cervical spine • Anteropostererior spinous process C2-T1 • Open mouth odontoid view • Axial CT with reconstruction • Regions of questionable injury • Inadequate visualization

15. Protection of the Cervical Spine • All blunt trauma victims should be assumed to have an unstable cervical spine until proven otherwise • Direct laryngoscopy causes cervical motion and the potential to exacerbate spinal cord injury • An “uncleared” cervical spine mandates In-line Stabilization (Not Traction) • The front of the cervical collar may be removed for greater mouth opening and jaw displacement

16. Protection of the Cervical Spine • Emergency Awake Fiberoptic Intubation • Requires less manipulation of the neck • Generally very difficult • Airway Secretions • Hemorrhage • Rapid Desaturation • Lack of Patient cooperation

17. MANUAL TECHNIQUES Modify for suspected spinal injury: 1. Tongue/jaw lift 2. Modified jaw thrust

19. Jaw thrust technique may be needed if C-spine injury

22. Indications for Endotracheal Intubation • Cardiac or Respiratory Arrest • Respiratory Insufficiency • Airway Protection • Deep Sedation or Analgesia • General Anesthesia • Transient Hyperventilation • Space Occupying Intracranial Lesion/Increased ICP • Delivery of 100% O2 • Carbon Monoxide Poisoning • Facilitation of Diagnostic Workup • Uncooperative or Intoxicated Patient

23. Induction of Anesthesia • Propofol/Thiopental • Vasodilator, Negative Inotropic effect • May Potentate hypotension/Cardiac Arrest • Etomidate • Increased cardiovascular stability • Ketamine • Direct myocardial depressant • Catecholamine release • Hypertension/Tachycardia • Midazolam • Reduced Awareness • Hypotension • Scopolamine (Tertiary Amine) • Inhibits memory formation • Muscle relaxants alone • Recall of Intubation/Recall of Emergency procedures

24. Induction of Anesthesia • Succinylcholine • Fastest onset <1 min • Shortest Duration5-10 min • Potassium increase 0.5-1.0mEq/L • Potassium increase >5mEq/L • After 24 hours • Safe in acute airway management • Burn Victims • Muscle Pathology • Direct Trauma • Denervation • Immobilization • Increase intraocular pressure • Caution in patients with ocular trauma • Increase ICP • Controversial in head trauma

25. Induction Agents • Non-depolarizing • Vecuronium • Minimal cardiovascular effect • Long duration of action (may exceed 90 mins) • Shorter onset than Pancuronium • 0.1 mg/kg

26. Rapid-Sequence Induction

27. Department of Anesthesiology Uniformed Services University of the Health Sciences

28. ETT

29. Ped and Adult Normal Trachea

30. And This (after failed ETT attempt)

31. And This:

32. They Tend to look like This:

34. Combitube®

35. Combitube® • Advantages: Protect airway from aspiration Easy to use AHA: alternative to ETT for CPR • Disadvantages: Trauma to soft tissues

36. Combitube® • Head neutral or slightly flexed • Hold tongue and jaw between thumb & forefinger and lift • Gently insert Combitube® in a curved back and downward movement until black markers aligned with teeth • Inflate (proximal) pharyngeal balloon • Inflate (distal) tracheal balloon • Confirm which one of #1 or #2 tube is in lungs by using bag ventilator

38. Combitube® Insertion

39. COMBITUBE/ESSENTIALS • Use only in patients who are unresponsive and without protective gag reflex • Do not use in any patient with injury to the esophagus and children below 15 • Pay attention to placement • Insert gently and without force • Remove once patient regains consciousness

40. LMA

41. LMA • Advanced airway • Useful alternative for “difficult intubation” • Easy to use • Sits on larynx - Protects lungs?

44. Airway & Ventilation Methods • Surgical Cricothyrotomy • Indications • absolute 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 • OR • absolute 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

45. Airway & Ventilation Methods: ALS • Surgical Cricothyrotomy • Contraindications (relative) • Age < 8 years (some say 10) • evidence of fx larynx or cricoid cartilage • evidence of tracheal transection

46. Airway & Ventilation Methods • Jet Ventilation • Usually requires high-pressure equipment • Ventilate 1 sec then allow 3-5 sec pause • Hypercarbia likely • Temporary: 20-30 mins • High risk for barotrauma

47. Facial and Pharyngeal Trauma • Swelling and hematoma acute airway obstructin • Chemical or thermal injury laryngeal edema

48. Indication For Early Intubation • Intraoral hemorrhage • Pharyngeal erythema • Change in voice

49. 1. Maxillary and Mandibular Fx Mask ventilation difficult 2. Mandibular Fx endotracheal intubation easier

50. 3. Bilateral Mandibular Fx, and pharyngeal hemorrhage • Upper airway obstruction • Intubation easier • 4. Injury to the Jaw and Zygomatic Arch • Trismus • Assessment of airway anatomy difficult