Airway Management

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

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

3. 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

4. Anatomy of the Upper Airway Pediatric vs Adult Upper Airway Larger tongue in comparison to size of mouth Floppy epiglottis Delicate teeth and gums Larynx is more superior Funnel shaped larynx due to undeveloped cricoid cartilage Narrowest point at cricoid ring before 10 yoa

5. Anatomy of the Upper Airway

6. Ventilation Defined as movement of air into & out of lungs Inspiration stimulus from respiratory center of brain (medulla) transmitted via phrenic nerve to diaphragm diaphragm flattens during contraction intercostal muscles contract ribs elevate and expand results in ? intrapulmonic pressure (pressure gradient) results in air being drawn into lungs & alveoli inflated

7. Ventilation Expiration Stretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration Hering-Breuer Reflex Natural elasticity of lungs passively expires air (in non-diseased lung) Control via Pons Apneustic & Pneumotaxic centers

8. Ventilation Chemoreceptors Carotid bodies & Aortic arch Stimulated by ? PaO2, ? PaCO2 or ? pH PaCO2 considered normal neuroregulatory control of ventilations Hypoxic Drive default regulatory control Senses changes in Pa02

9. Ventilation Other stimulations or depressants to ventilatory drive body temp: ? w/ fever & ? w/hypothermia drugs/meds: increase or decrease pain: increases but occasionally decreases emotion: increases acidosis: increases sleep: decreases

10. Respiration Ventilation vs. Respiration Exchange of gases between a living organism and its environment External Respiration exchange between lungs & blood cells Internal Respiration exchange between blood cells & tissues

11. Respiration Oxygen saturation affected by: low Hgb (anemia, hemorrhage) inadequate oxygen availability at alveoli poor diffusion across pulm membrane (pneumonia, pulm edema, COPD) Ventilation/Perfusion (V/Q) mismatch blood moves past collapsed alveoli (shunting) alveoli intact but blood flow impaired

12. Respiration Carbon Dioxide content of blood Byproduct of work (cellular respiration) Transported as bicarbonate (HCO3- ion) ? 20-30% bound to hemoglobin Pressure gradient causes CO2 diffusion into alveoli from blood increased level - hypercarbia

13. Inspired Air: PO2 160 & PCO2 0.3

14. Causes of Hypoxemia Traumatic Reduced surface area for gas exchange pneumothorax, hemothorax, atelectasis Decreased mechanical effort pain, traumatic asphyxiation, hypoventilation sucking chest wound, obstruction

15. Assessment & Recognition of Airway & Ventilatory Compromise Visual Assessment Position tripod orthopnea Rise & Fall of chest Paradoxical motion Audible gasping, stridor, or wheezes Obvious pulm edema Visual Assessment Skin color Flaring of nares Pursed lips Retractions Accessory Muscle Use Altered Mental Status Inadequate Rate or depth of ventilations

16. Assessment & Recognition of Airway & Ventilatory Compromise Respiratory Patterns Cheyne-Stokes brain stem Kussmaul acidosis Biot’s increased ICP Respiratory Patterns Central Neurogenic Hyperventilation increased ICP Agonal brain anoxia Ch - deeper faster followed by shallower, slower biot - irregular rate and depth w/ apnea cnh- deep rapid respirations kus - deep slow or rapid, gasping breathing Ch - deeper faster followed by shallower, slower biot - irregular rate and depth w/ apnea cnh- deep rapid respirations kus - deep slow or rapid, gasping breathing

17. Airway & Ventilation Methods: BLS Progress from Non-invasive BLS to invasive ALS Supplemental Oxygen increased FiO2 increases available oxygen objective is to maximize hemoglobin saturation Fi - Fractional concentraion o fair - concentration of o2 in inspired airFi - Fractional concentraion o fair - concentration of o2 in inspired air

18. Airway & Ventilation Methods: BLS Airway Maneuvers Jaw thrust Sellick’s maneuver Airway Devices Oropharyngeal airway Nasopharyngeal airway CombiTube ®

19. Airway & Ventilation Methods: BLS 1/2/3 person BVM One Person BVM difficult to master mask seal often inadequate may result in inadequate tidal vol gastric distention risk Two person BVM most efficient method Useful in C-spine inj improved mask seal and tidal volume

20. Airway & Ventilation Methods: BLS Partial Airway Obstruction Techniques Positioning OPA/NPA Suctioning Removal via Direct laryngoscopy

21. Airway & Ventilation Methods: BLS Gastric Distention Common when ventilating without intubation pressure on diaphragm resistance to BVM ventilation avoid by increasing time of BVM ventilation

22. Airway & Ventilation Methods: ALS Gastric Tubes nasogastric caution with facial trauma tolerated by awake patients but is uncomfortable interferes with BVM seal orogastric usually used in unresponsive patients larger tube may be used safe in facial trauma

23. Airway & Ventilation Methods: ALS Endotracheal Intubation Indications present or impending respiratory failure apnea unable to protect own airway Advantages secures airway route for a few medications optimizes ventilation and oxygenation

24. Airway & Ventilation Methods: ALS Complications of endotracheal intubation Bleeding or dental injury Laryngeal edema Laryngospasm Vocal cord injury Barotrauma Hypoxia Aspiration Dislodged tube or esophageal intubation Right or Left mainstem intubation

25. Airway & Ventilation Methods: ALS Patient Positioning for Intubation Goal Align the 3 planes of view, so that The vocal cords are most visible T - trachea P - Pharynx O - Oropharynx

26. Airway & Ventilation Methods: ALS 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

27. Airway & Ventilation Methods: ALS Surgical Cricothyrotomy Contraindications (relative) No real demonstrated indication Risks > benefits Age < 8 years (some say 10) evidence of fx larynx or cricoid cartilage evidence of tracheal transection

28. Airway & Ventilation Methods: ALS Needle Cricothyrotomy & Transtracheal Jet Ventilation Indications Same as surgical cricothyrotomy along with Contraindication for surgical cricothyrotomy Contraindications None when demonstrated need caution with tracheal transection

29. Airway & Ventilation Methods: ALS 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

30. Airway & Ventilation Methods: BLS & ALS

31. Airway & Ventilation Methods: BLS & ALS Combitube® Indications Contraindications Height Gag reflex Ingestion of corrosive or volatile substances Hx of esophageal disease

32. Airway & Ventilation Methods: ALS Pharmacologic Assisted Intubation (“RSI”) Sedation Used for induction anxious or agitated patient Contraindications hypersensitivity hypotension (e.g. hypovolemia 2° to trauma)

33. Airway & Ventilation Methods: ALS Pharmacologic Assisted Intubation (“RSI”) Neuromuscular Blockade Induces temporary skeletal muscle paralysis Indications When Intubation is required in a patient who is awake, has a gag reflex, or is agitated or combative

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

35. Airway & Ventilation Methods: ALS Pharmacologic Assisted Intubation (“RSI”) Disadvantages & Potential Complications Does not provide sedation or amnesia Provider unable to intubate or ventilate after NMB Aspiration during procedure Difficult to detect motor seizure activity Side effects and adverse effects of specific meds

36. Airway & Ventilation Methods: ALS

37. Airway & Ventilation Methods: ALS Needle Thoracostomy (chest decompression) Indications Positive sx/sx of tension pneumothorax Cardiac arrest with PEA or Asystole when the possibility of trauma and/or tension pneumo exist Contraindications Absence of indications

38. Airway & Ventilation Methods: ALS Tension Pneumothorax Sx/Sx severe respiratory distress ? or absent lung sounds (unilateral usually) ? resistance to manual ventilation Cardiovascular collapse (shock) asymmetric chest expansion anxiety, restlessness or cyanosis (late) JVD or tracheal deviation (late)

39. Airway & Ventilation Methods: ALS Chest Escharotomy Indications In 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 Rarely needed

40. Airway & Ventilation Methods: ALS Chest Escharotomy Considerations must rule out the possibility of upper airway obstruction Procedure Intubate if not already done Prep site and equipment Vertical incision to anterior axillary line Horizontal incision only if necessary Cover and protect

41. Airway & Ventilation: Risks & Protective Measures BSI Gloves Face & eye shields Respirator if concern for airborne disease Be prepared for coughing spitting vomiting biting