Airway and Ventilatory

Management in Trauma
Kelompok 2
Alfindra Sepalawandika (Bedah Umum)
Rashif Yali Anbia (Bedah Anak)
Wa'el Jaidi (Urologi)
Marielo Chaeli August (Bedah Plastik)
Amanda Putri permatasari (Tht)
M. Hafiz Alfarizie (Bedah Saraf)
Arvin Reinaldo (Orthopaedi)
Pebrian Diki (BM)
Swarantika Aulia Rarasati (BM)
Anggun Tri Sari (BM)
Initial assessment & management
• Preparation
• Triage
• Primary survey (A-B-C-D-E)
• Resuscitation
• Adjunct to primary survey
• Secondary survey
• Postresuscitation monitoring
• Definitive care
Why first priority?
• “The quickest killer”
• Secondary insult of CNS
• Supplemental oxygen must be administered in trauma patient
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
Recognize airway problem
• Sudden/ Complete
• Progressive/ Partial
Recognize airway problem
• Changed voice quality
• Stridor (noisy = partial, absence = complete)
• Sore throat
• Dyspnea
• Agitate
• Tachypnea
• Abnormal breathing pattern
• Decreased O2sat (late sign)
Objective signs of airway obstruction
• Agitation  hypoxia
• Obtund  hypercarbia
• Cyanosis  hypoxemia (late sign)
• Retraction
• Stridor/ Hoarseness
• Trachea shift
• Patient behavior
Quickest way?
Definitive airway
• “Tube placed in trachea with cuff inflated below the vocal cords,
connected to oxygen-enriched assisted ventilation, Secured in place”
Definitive airway
• Protect airway
• Support ventilation
• Maintain oxygenation
• Prevent hypercarbia
• Prevent Aspiration
Maxillofacial trauma
• Midface
• Fracture/dislocation
• Loss structural support of airway
• Hemorrhage
• Dislodge teeth
Neck trauma
• Penetrating injury
• Hematoma displace/obst airway
• Blunt injury
• Hematoma
• Hemorrhage into soft tissue
• Disruption of larynx/trachea
• Hemorrhage in tracheobronchial tree
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)
Recognize ventilation problem
• Mechanical
• Direct chest trauma
• Preexisting pulmonary dysfunction
• CNS depression
• Intracranial
• Spinal cord
Objective signs of inadequate ventilation
• Chest rising
• Labored breathing
• Breath sound (decreased/absent)
• Rapid RR
• Pulse oximetry, ETCO2
AIRWAY MANAGEMENT
Initial airway management
• Monitor pulse oximetry, ETCO2
• Remove helmet (if present)
• Airway maintenance + C-spine protection
• Suction
• Supplemental ventilation
• High flow oxygen
Predict difficult airway
Airway maintenance
• By position
• Chin lift (should not hyperextend
neck)
• Jaw thrust
• Manual in line immobilization
first
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
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
Indication for definitive airway
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
Orotracheal intubation
• 2-person manual inline
• Laryngeal manipulation “BURP”
• Backward, Upward, Rightward Pressure
• Thyroid cartilage
• Direct laryngoscopy
• Gum elastic bougie
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
Is the tube in place?
• Listen
• equal breath sound
• no borborygmi
• ETCO2
• CXR
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/kg
6. Succinylcholine 1-2 mg/kg
7. Intubate
8. Confirm tube placement
9. Release cricoid pressure
10. ventilate
Surgical airway
• Cricothyroidotomy/ tracheostomy
• Indication
• fail ETT
• Obstruction of upper airway (glottic edema, larynx fx, severe oropharyngeal
hemorrhage
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
complication
• Inadequate ventilation
• Blood aspiration
• Esophageal laceration
• Hematoma
• Posterior tracheal wall laceration
• Subcutaneous/mediastinal emphysema
• Thyroid perforation
• pneumothorax
Surgical cricothyroidotomy
• NOT recommended in children

• Skin incision extend through cricothyroid membrane

• Small ETT or tracheostomy (5-7mm OD) tube insertion
• Reapply cervical collar
complication
• Blood aspiration
• False tract
• Subglottic stenosis
• Laryngeal stenosis
• Hematoma
• Laceration of esophagus
• Laceration of trachea
• Mediastinal emphysema
• Vocal cord paralysis/ hoarsenes
Management of oxygenation
Adequate oxygenation
• Tight sealed mask c bag > 11 LPM
• Pulse oximetry
• O2sat ≥ 95%  PaO2 >70%
• Require intact peripheral perfusion
• Can’t distinguish oxyhemoglobin/ carboxyhemoglobin/ methemoglobin
Approximate PaO2 vs O2Sat
Management of ventilation
Adequate ventilation
• Bag-mask ventilation (1-2 person)
• Ventilate q 5 secs (RR 12)
• Volume/pressure regulated respirator
• Watch intrathoracic pressure
• Watch for tension PTX
• Secondary PTX from barotrauma
Gastric distention
• Secondary to bag-mask ventilation
• Vomit/ aspirate
• Stomach distention  vena cava pressure  hypotension, bradycardi
TERIMAKASIH