Airway Management in Trauma Trauma Conference UW Hospital and Clinics Karen D. Serrano, MD EM-2 Resident September 3, 2

1. Airway Management in TraumaTrauma ConferenceUW Hospital and ClinicsKaren D. Serrano, MDEM-2 ResidentSeptember 3, 2009

2. Airway management in trauma Unique Challenges

3. Airway assessment • Can the patient talk? • Quality of respirations? • Mental status? • Facial trauma with massive bleeding? • Neck hematoma compressing airway? • Oxygenating well? • Ventilating well? • Impending cardiovascular collapse?

4. Airway assessment • Indications for definitive airway • Head injury with GCS < 9 • Midface instability or upper airway injury • Hemodynamic instability • Inadequate oxygenation/ventilation • High aspiration risk

5. Who needs an airway? • 56 yo M with blunt trauma from MVA: SBP 60s, HR 140, RR of 30, O2 sats 88% on 100% NRB.

6. Who needs an airway? 24 yo F in MVA. Facial trauma with bleeding out of nose and mouth

7. Who needs an airway? 44 yo M construction worker who fell off a roof. Opens eyes to only to painful stimuli, moans incoherently, withdraws from a painful stimulus. GCS?

8. GCS

9. Airway basics • 1. Evaluate for difficult Airway • 2. Relieve obstruction • 3. Oral airway or nasal airway • 4. Neck immobilization • Assume unstable c-spine injury

10. Difficult airway • Evaluate for Difficult Airway • Look externally • Evaluate the “3-3-2” Rule • Mallampati class • Obstruction • Neck mobility

12. Difficult airway • Evaluate for Difficult Airway • Look externally • Evaluate the “3-3-2” Rule • Mallampati class • Obstruction • Neck mobility

13. Relieve obstruction • Head tilt/chin lift • Jaw thrust • Oral airway or nasopharyngeal airway

14. C-spine injury • Cervical spine injury in trauma • MVC 42% • Falls 27% • Violence 15% • Sports-related 7.4 % • Always assume an unstable cervical spine injury

15. Page: Level 2 trauma. 20 yo male MVC ejected from vehicle, can’t move arms or legs. A cervical spine injury suspected. • On arrival, the patient’s mental status begins to deteriorate. Definitive airway control is needed. • Is direct laryngoscopy and orotracheal intubation safe in the patient with suspected cervical spine injury?

16. C-spine injury • DL and orotracheal intubation with manual in-line stabilization • Standard of care in trauma since 1980s • Data from lower quality studies in uninjured volunteers, cadaver models, and case series • Rare reports of neurologic deterioration

17. Conflicting data • 1993 Donaldson et al: Created an unstable posterior injury on 5 cadavers and used fluoroscopy to compare movement at C5-C6 with various airway manuevers. • Results: DL intubation with inline stabilization reduced subluxation and angulation at injury site compared to “crash” DL and intubation without inline stabilization • Conclusion: manual inline stabilization limits neck motion • 2000 Brimacombe et al: Used fluoroscopy to analyze spine movement in 10 fresh cadavers with artificial unstable C2-C4 injury using various airway manuevers. • Results: Subluxation occurred with all airway manuevers except flexible fiberoptic intubation. • Conclusion: “….manual inline stabilization is generally ineffective in preventing motion.”

18. Case series • Limited data in actual patients: only 9 case series • Manoach & Paladino 2007 Review of 5 case series in which 120 patients with unstable injuries underwent DL orotracheal intubation • Results: no intubation-related complications • Conclusion: probably safe

19. Laryngoscopic view • 1993 Nolan and Wilson et al evaluated effect of manual in-line stabilization on laryngoscopic view • 157 elective surgery patients who acted as their own controls. • Compared laryngoscopic view with optimal positioning to laryngoscopic view when inline manual stabilization utilized

20. Laryngoscopic view

21. Results • Conclusion: DL with manual inline stabilization worsens laryngoscopic view.

22. Conclusions? • DL and orotracheal intubation with manual in-line stabilization • Likely does not worsen c-spine injury • Probably worsens laryngoscopic view • “Any beneficial effects of using manual in-line stabilization with direct laryngoscopy and orotracheal intubation must be balanced against the potential for the practice to contribute to clinically apparent and subtle hypoxic impairment in brain function.” • Manoach & Paladino. “Manual in-line stabilization for acute airway management of suspected cervical spine injury: Historical review and current questions. Annals of Emergency Medicine. 2007;50:236-245. • A failed airway is a bad outcome!

23. Risk-benefit analysis Direct laryngoscopy with orotracheal intubation and manual in-line stabilization Risk of exacerbating cervical spine injury Risk of anoxic brain injury from failed intubation

24. Alternative airways What are the options for securing an airway in trauma patients?

25. Glidescope • Videolaryngoscopy • Pros: • Minimizes neck movement • Good at visualizing glottis when neck unable to be moved or mouth unable to be opened wide • Cons: • Difficult to pass tube • Availability

26. Fiberoptic intubation • Fiberoptic • Pros: • Good visualization • Minimal neck motion • Cons: • Availability • Operator dependent • Relatively slow

27. Rescue airways: LMA • Supraglottic airway • Pros: • Easy to put in • Cons: • Not a definitive airway • Aspiration risk • ? Neck movement

28. Intubating LMA

29. King LT • King laryngeal tube • Supraglottic airway • Easy to use • May be more difficult to change to ET tube

30. Nasotracheal intubation More common in pre-RSI days • Pros: • Can be done in awake patient • Cons: • Contraindicated with facial trauma and basilar skull fracture • Operator dependent • Complications: • bleeding • incorrect tube placement

31. Cricothyrotomy • Surgical airway • Incision through cricothyroid membrane • Indicated when oral or nasotracheal intuation fails and when BVM ineffective • “can’t oxygenate, can’t ventilate.”

32. Case report • 46 yo M with ankylosing spondylitis was assaulted after leaving a bar. Reportedly someone pushed him forward as he was walking, causing hyperextension of his neck. He collapsed and became unable to move his extremities but did not lose consciousness. He was immobilized with a c-collar and backboard and transported to a nearby hospital. CT head was negative, but lateral c-spine films showed bilateral jumped facets at C4-C5.

33. Case report • The patient was alert and oriented but unable to move his extremities and had no sensation below the clavicles. He exhibited paradoxic abdominal movements with respirations. • When the patient’s mental status deteriorated, he required emergent intubation. • How would you intubate him?

34. Case report • Challenges to securing airway: • Limited mouth opening • Rigid cervical spine • Known cervical spine injury • Small hospital with limited resources

35. Case report • How would you intubate him? • A. Direct laryngoscopy with manual in-line stabilization • B. Videolaryngoscopy (i.e. Glidescope) • C. Supraglottic airway (LMA or King LT) • D. Nasotracheal intubation • E. Grab a scalpel and do a cricothyrotomy

37. Videolaryngoscope-assisted nasotracheal intubation • Posterior nasopharynx anesthetized with benzocaine • Glidescope inserted into oropharynx • 6-0 ET tube passed through left nare until visualized with Glidescope • Intubation timed with respirations and ET tube passed easily through vocal cords and without neck motion • Transported emergently for posterior spinal fusion

38. Summary • 1. Airway management in trauma has significant challenges • 2. Don’t forget airway basics • 3. DL with manual in-line stabilization • probably safe • may reduce success of intubation • 4. Be familiar with rescue airways