AIRWAY MANAGEMENT

DR. HERRY PURWANTO, SP.AN, FIPM

RSUD CIBINONG KAB BOGOR

WS. Basic Critical Support RSUD Cibinong

14/3/2020
 Airway and Ventilatory
Management in Trauma
M. NONTHACOUPT

Airway management includes a set of maneuvers and

medical procedures performed to prevent and
relieve airway obstruction. This ensures an open pathway
for gas exchange between a patient's lungs and the
atmosphere.

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 Initial assessment & management

 Preparation
 Triage
 Primary survey (A-B-C-D-E)
 Resuscitation
 Adjunct to primary survey
 Secondary survey
 Postresuscitation monitoring
 Definitive care

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 Why first priority?

 “The quickest killer”

 Secondary insult of CNS

 Supplemental oxygen must be administered in

trauma patient

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 Death from airway problem

 Failure to recognize
 the need for airway intervention
 the need for alternative airway

 incorrectly placed airway

 the need for ventilation

 Inability to establish an airway

 Displacement
 Aspiration

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 Recognize airway problem

 Sudden/ Complete
 Progressive/ Partial

“Reassessment”

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 Recognize airway problem

 Changed voice quality

 Stridor (noisy = partial, absence = complete)
 Sore throat
 Dyspnea
 Agitate
 Tachypnea
 Abnormal breathing pattern
 Decreased O2sat (late sign)

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 Objective signs of airway obstruction

 Agitation  hypoxia
 Obtund  hypercarbia
 Cyanosis  hypoxemia (late sign)
 Retraction
 Stridor/ Hoarseness
 Trachea shift
 Patient behavior

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 Quickest way?

Check verbal response

 Positive, appropriate

Patent airway
Intact ventilation
Adequate brain perfusion

 Negative, inappropriate
AOC Definitive airway
Airway/ ventilatory compromise
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 Definitive airway

“Tube placed in trachea with cuff inflated below the vocal

cords, connected to oxygen-enriched assisted
ventilation, Secured in place”

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 Definitive airway

Protectairway
Support ventilation

Maintain oxygenation

Prevent hypercarbia

Prevent Aspiration

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 Maxillofacial trauma

 Midface
 Fracture/dislocation

Loss structural support of airway

 Hemorrhage

 Dislodge teeth

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 Neck trauma

 Penetrating injury
 Hematoma displace/obst airway
 Blunt injury
 Hematoma

 Hemorrhage into soft tissue

 Disruption of larynx/trachea

 Hemorrhage in tracheobronchial tree

Progressive
Airway compromise
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 Laryngeal injury

 Clinical
 Hoarseness

 Subcutaneous emphysema
 Palpable fracture

 Incomplete obstruction
 Complete obstruction
 only 1 attempt of ETT, if fail  tracheostomy
(or surgical cricothyroidotomy if profuse bleed)

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 Recognize ventilation problem

 Mechanical
 Direct chest trauma
 Preexisting pulmonary dysfunction

 CNS depression
 Intracranial

 Spinal cord

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 Objective signs of inadequate ventilation

 Chest rising
 Labored breathing
 Breath sound (decreased/absent)
 Rapid RR
 Pulse oximetry, ETCO2

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 AIRWAY MANAGEMENT

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 Initial airway management

 Monitor pulse oximetry, ETCO2

 Remove helmet (if present)
 Airway maintenance + C-spine protection
 Suction
 Supplemental ventilation
 High flow oxygen

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 Predict difficult airway

 L : Look externally
 E : Evaluate 3-3-2 rule
 M : Mallampati
 O : Obstruction
 N : Neck mobility

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14/3/2020 WS. Basic Critical Support
 M: Mallampati

 I : soft palate, uvula,

fauces,
pillar

 II: soft palate, uvula, fauces

 III: soft palate, base of

uvula

 IV: hard palate

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 Airway decision flow

Preoxygenate (position, O2 mask c bag, oral airway)

no Definitive/
Able to oxygenate?
surgical airway
yes
LEMON difficult Call for assistance
easy
Intubation (±drug/cricoid pressure) Awake intubation

fail
Gum elastic bougie/LMA

Definitive/surgical airway
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 Airway maintenance

 By position
 Chin lift (should not hyperextend neck)

 Jaw thrust

 Manual in line immobilization first

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 Airway maintenance

 By device
 Oropharyngeal airway
 May Induce gag reflex & aspiration
 If pt can tolerate, ETT is highly likely required
 Tongue blade in children, No rotation

 Nasopharyngeal airway
 Nostril oropharynx
 Lubricated
 Don’t attempt in suspected cribiform plate fx, Lefort
fx
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 Extraglottic, supraglottic devices

 Laryngeal mask airway

 Bridging, if ETT/mask c bag fail

 Laryngeal tube airway

 Doesn’t require significant manipulation of head & neck

 Multilumen esophageal airway

 Esophageal port, trachea port

 ETCO2

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 Indication for definitive airway
Need airway protection Need ventilation

Severe maxillofacial fx Inadequate respiratory effort

-tachypnea
-hypoxia
-hypercarbia
-cyanosis

Risk for obstruction Massive blood loss and need

-neck hematoma for volume resuscitation
-laryngeal/tracheal injury -anemia
-stridor

Risk for aspiration Severe closed head injury with

-bleeding need for brief
-vomiting hyperventilation if AOC
unconscious Apnea WS. Basic Critical Support
14/3/2020 RSUD Cibinong
 Endotracheal intubation

 Clearance of C-spine, but don’t delay

 Manual in-line
 Nasotracheal
 Contraindicated in
 Apnea
 Facial, frontal sinus, basal skull, cribiform plate fx
 Pressure necrosis, sinusitis

 Orotracheal
Indicated in apnea patient

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 Orotracheal intubation

 2-person manual inline

 Laryngeal manipulation “BURP”

 Backward, Upward, Rightward Pressure
 Thyroid cartilage

 Direct laryngoscopy

 Gum elastic bougie

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 Infant endotracheal intubation

 Same size as infant’s nostril or little finger

 Uncuffed Tube = (Age / 4) + 4
 Cuffed Tube = (Age / 4) + 3

 Suitable for age 1-12 yr

 above 12, typically most adult sizes (6.5-8.0)

 Insert not more than 2 cm past the cords

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 Is the tube in place?

 Listen
 equal breath sound
 no borborygmi
 ETCO2
 CXR

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 Rapid sequence intubation (RSI)

 Anesthetic
 Sedative
 Neuromuscular blocking
 Always have Plan B (surgical airway)

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 Rapid sequence intubation (RSI)
1. Be prepared for surgical airway
2. Suction, PPV ready
3. Preoxygenate
4. Cricoid pressure
5. Administer induction drug/sedative
Etomidate 0.3 mg/k
6. Succinylcholine 1-2 mg/kg v
7. Intubate
8. Confirm tube placement
9. Release cricoid pressure
10. ventilate
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• Video laryngoscopy affords more
grade 1 and 2 views than direct
laryngoscopy and improves glottic
exposure in most patients with
poor direct glottic visualization
• Video laryngoscopy affords more grade 1 and 2 views than direct laryngoscopy and
improves
glottic exposure in most patients with poor direct glottic visualization
• Indications for video laryngoscopy include morbid obesity, poor direct laryngoscopic view
from trauma or anatomic variation, inability to view the vocal cords, small mouth opening
(< 3 cm), limited neck extension, or suspected cervical spine injury
 Surgical airway

 Cricothyroidotomy/ tracheostomy
 Indication
 fail ETT
 Obstruction of upper airway (glottic edema, larynx fx,
severe oropharyngeal hemorrhage

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 Needle cricothyroidotomy

 Short term, bridging for definitive airway

 Jet insufflation
 Large caliber plastic canular
 12-14 adult

 16-18 children

 Through cricothyroid membrane into

trachea
 Connect to O2 15 LPM
 Hole cut in tubing between O2 source and
cannula, thumb over1 second,
off 4 seconds
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 complication

 Inadequate ventilation
 Blood aspiration
 Esophageal laceration
 Hematoma
 Posterior tracheal wall laceration
 Subcutaneous/mediastinal emphysema
 Thyroid perforation
 pneumothorax

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 Surgical cricothyroidotomy

 NOT recommended in children <12 y

 Skin incision extend through cricothyroid membrane

 Small ETT or tracheostomy (5-7mm OD) tube insertion
 Reapply cervical collar

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 complication

 Blood aspiration
 False tract
 Subglottic stenosis
 Laryngeal stenosis
 Hematoma
 Laceration of esophagus
 Laceration of trachea
 Mediastinal emphysema
 Vocal cord paralysis/ hoarseness

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