AIRWAY AND VENTILATORY MANAGEMENT

Airway and ventilation are the first priorities in managing the trauma patient.

Early preventable deaths from airway problems after trauma include:

1. Failure to recognise the partially obstructed airway and/or inadequate ventilation. 2. Delay in providing an airway when it is needed. 3. Delay in providing assisted ventilation when it is needed 4. Technical difficulties in securing a definitive airway

5. Aspiration of gastric contents.

Assessment, identification and management of airway and ventilatory compromise.

A. Establish responsiveness
B. Assessment of airway

C. Opening and maintenance of airway

D. Assessment of ventilation

E. Maintenance of ventilation
F. Definitive airway

 Supplemental oxygen should be provided before and immediately after airway measures are instituted. Protection of the cervical spine must be provided in patients who are unconscious, patients with injuries above the clavicle and multi system trauma. Care must be taken to maintain in line immobilisation of the cervical spine during airway management.

A. Establish responsiveness
- if the patient is able to speak and answer appropriately, it can be assumed: * the airway is unobstructed * cerebral perfusion adequate

B. Assessment of the Airway

1. LOOK
2. LISTEN 3. FEEL

LOOK
Agitation and obtundation - agitation suggests hypoxia - obtundation suggests hypercarbia Observe the chest movement and determine respiratory rate Look for retraction and use of accessory muscles Cyanosis indicates hypoxia. This is a late sign

LISTEN
Listen to breath sounds from patients mouth and nose. Noisy breathing such as stridor, snoring or gurgling indicates partial airway obstruction. Hoarseness (dysphonia) implies laryngeal obstruction

Abusive patient may be hypoxic and should not be presumed intoxicated.

FEEL
Feel for the expired breath Determine if the trachea is midline

CAUSES OF AIRWAY OBSTRUCTION

1. Soft tissue obstruction - Floppy tongue (main cause of airway obstruction) - maxillofacial or airway injuries - Oedema or haematoma occluding the airway 2. Foreign body obstruction - teeth - secretion - blood - foreign debris 3. Laryngospasm/bronchospasm

C. OPENING AND MAINTENANCE OF AIRWAY

main cause of airway obstruction is due to the floppy tongue especially in patients with altered sensorium. Obstructed airway can often be cleared by: - chin lift or jaw thrust and the use of airway adjuncts (obstruction by the floppy tongue). - removing and suctioning secretion and foreign body - manually reducing the fracture maxilla

Manoeuvres to open and maintain the airway

1. Manual manoeuvres - chin lift - jaw thrust 2. Airway adjuncts - oropharyngeal airway - nasopharyngeal airway 3. Definitive airway - endotracheal intubation - surgical airway - cricothyroidotomy - tracheostomy

ASSESSMENT OF VENTILATION
- The assessment of ventilation (breathing) and airway go hand-in-hand because their outcome may depend on one another. 1. Expose the chest 2. Determine the rate, depth, symmetry and regularity of respiration - rapid respiratory rate may indicate hypoxia and impending respiratory failure - Irregular respiration may indicate severe head injury

ASSESSMENT OF VENTILATION (cont.)

3. Inspection and palpation a) Chest movement - unequal or poor movement may suggest pneumo/haemothorax - paradoxical movement may indicate flail chest b) Chest deformities - rib and sternal fractures c) Open wounds d) Bruises - underlying fracture ribs, lung contusion and intrabdominal solid organ injury
MTLS

ASSESSMENT OF VENTILATION (cont.)

4. Auscultation - air entry - abnormal breath sounds - heart sounds - displaced apical beat

CAUSES OF VENTILATORY INADEQUACY

1. Trauma to the chest - Fracture ribs - haemo/pneumothorax - flail chest - lung contusion - diaphragmatic hernia - open chest injuries 2. Trauma to the laryngeal-tracheal-bronchial apparatus 3. Hypoventilation secondary to CNS effects - head injury - cervical spinal cord injury - drug overdose 4. Pulmonary oedema or aspiration

E. MAINTENANCE OF VENTILATION
1. Through a face mask - face to pocket mask - bag-valve-mask 2. Through a definitive airway - bag-valve-tube - jet insufflation - ventilator
Remember! The aim of ventilation is to achieve maximum cellular oxygenation. Always give oxygen 10-12L/min or 100% oxygen and maintain oxygen saturation (SpO2) of more than 95%.

INDICATIONS FOR VENTILATION IN THE TRAUMA PATIENT

1. Apnoea 2. Respiratory failure - PaO2 < 60 mmHg - PaCO2 > 60 mmHg 3. Severe head injury requiring cerebral resuscitation

4. Cardiopulmonary arrest

F. DEFINITIVE AIRWAY
A definitive airway requires a tube in the trachea
with the cuff inflated and oxygen delivered to the patient The gold standard for a definitive airway is the presence of a cuffed endotracheal tube in the trachea. Definitive airway can be achieved by: 1. Endotracheal intubation 2. Surgical airway a) cricothyroidotomy - percutaneous needle cricothyroidotomy - surgical cricothyroidotomy 3. Tracheostomy

INDICATIONS FOR DEFINITIVE AIRWAY (ENDOTRACHEAL INTUBATION)

1. In ability to maintain an adequately patent airway by jaw thrust or oro/nasopharyngeal airway 2. Prevention of aspiration by blood or gastric content 3. Impending or potential airway compromise eg in maxillofacial injury 4. Head injury requiring cerebral resuscitation 5. Failure to maintain adequate oxygenation by face mask oxygen supplementation 6. Apnoea

ENDOTRACHEAL INTUBATION
- always preoxygenate the patient with 100% oxygen prior to intubation. - Attempts at intubation should not exceed 30 seconds and 2 attempts. Get expert help if you are unable to intubate. REMEMBER! IF ONE ENCOUNTERS DIFFICULT OR FAILED INTUBATION DO NOT CONTINUE THE INTUBATION ATTEMPT BUT PROVIDE VENTILATION AND OXYGENATION VIA THE BAG-VALVE MASK

- Manual in-line stabilisation of the cervical spine must be maintained at all times in patients with suspected cervical spine injury.
- ETT size 8 - 9 mm in male and 7 - 8 mm in female.

COMPLICATIONS OF ENDOTRACHEAL INTUBATION

1. Physiological response ie hypertension, tachycardia, dysrhythmia, increase ICP and IOP, layngospasm and bronchospasm 2. Oesophageal intubation 3. Endobronchial intubation (usually right mainstem) 4. Failed intubation 5. Induction of vomiting leading to aspiration 6. Trauma - teeth, lips, tongue, mucosa - dislocation of mandible, arytenoid cartilage 7. Conversion of a cervical spine injury without neurological deficit to one with neurological deficit

SURGICAL AIRWAY
- An emergency surgical airway is only indicated when there is an inability to intubate the trachea in the presence of an unrelieved airway obstruction. - Indications for surgical airway 1. Failure of ETT insertion due to laryngeal oedema 2. Severe maxillofacial injury that distorts the anatomy 3. Severe oropharyngeal haemorrhage that prevents vocal cord visualisation

SURGICAL AIRWAY
1. Cricothyroidotomy - percutaneous needle cricothyroidotomy - surgical cricothyroidotomy 2. Tracheostomy - too time consuming in the emergency setting. Not usually done.

MTLS

AIRWAY MANAGEMENT ALGORITHM

Establish unresponsiveness Airway + Collar/in-line immobilisation of cervical spine

BREATHING
ADEQUATE INADEQUATE
Partial obstruction O2 via face mask

NOT BREATHING
OBSTRUCTION
Complete obst Insert airway Bag-valve mask vent.

RESP.ARREST

Tongue--> Chin lift/Jaw thrust oro/nasopharyngeal airway FB/secretions/blood--> suction/removal Maxillofacial injury --> reduction Endotracheal intubation Surgical airway