Airway Management In Trauma Patients

byMohammed Taher Rageh

mohammedtaher112@gmail.com

Airway management in case of trauma can be CHALLENGIN

G

Difficult Airway

Need Rapid Action

Disrupted Anatomy

Failure or delay = high morbidity and mortality

Introduction

Spotting light on recent recommendations and guidelines will help every anesthesit to avoid risks and to success in airway assessment and management which could help in saving many lives

Introduction

Anatomical considerationsCribriform plate may be fractured so in the presence of basal skull fractures nasogastric tube insertion or nasotracheal intubation is contraindicated

Anatomical considerationsDuring nasotracheal intubation:

•The tube should be lubricated• Vasoconstricting solutions should be applied•The bevel of the tube should be parallel to the nasal septum •The tube directed vertically downward, at a right angle to the horizontal, until it reaches the oropharynx.

In The oral cavity:•The uvula is a useful landmark for assessing the ease or difficulty of tracheal intubation

•The tongue can be displaced posteriorly obstructing the airway in unconscious patients

Anatomical considerationsIn The larynx:

•The external application of pressure to the cricoid cartilage is a technique used to make aspiration less likely by compression of the esophagus against cervical vertebrae

•The Cricothyroid ligament lies between the thyroid cartilage and the cricoid. It is the recommended site for emergency laryngotomy in cases of laryngeal obstruction

Anatomical considerationsEffect of Recurrent laryngeal nerve injury:

•Complete cut of the RLN causing paralysis of both abductors and adductors, the affected cord lies in a position midway between abduction and adduction.

• Partial RLN injury results in a selective abductor paralysis, sparing the adductors. The affected vocal cord is adducted to the midline.

Mechanisms of TraumaInjury is a leading cause of death worldwide

•Motor vehicle traffic-related injury.•Motorcycle collision•Pedestrian vehicle collision•Falls•Fire and burn•Penetrating trauma

Types:

Airway Assessment in TraumaSelection of airway devices, techniques, and procedures all pivot on airway evaluation

• Previous intubation successes or failures• Patient’s medical records • Medic alert bracelet

Historical indicators of Airway Difficulty:

Airway Assessment in Trauma

• Neck: Bull neck, obesity and decreased head extension or neck flexion.

•Tongue: Large tongue.

•Mandible: Receding mandible and decreased jaw movement.

•Teeth: Buck teeth.

Anatomical indicators of Airway Difficulty:

Airway Assessment in Trauma

•Maxillofacial: Fractures or plethora.

•Oropharyngeal : Edema, hematoma, inflammation and foreign body.

•Glottis: Edema, vocal cord paralysis and tumor.

•Neck: Mass or hematoma, subcutaneous emphysema, rheumatoid arthritis, spondylitis and C-spine injury.

Pathological indicators of Airway Difficulty:

Airway Assessment in TraumaAirway examination:

Eleven-Step Airway Examination

Airway Assessment in TraumaMallampati test:

Class I: soft palate, tonsillar fauces, tonsillar pillars, and uvula visualizedClass II: soft palate, tonsillar fauces, and uvula visualized (except the tip )Class III: soft palate and base of uvula visualizedClass IV: uvula not visualizedClass 0 : epiglottis is visualized.

Airway Assessment in TraumaCormack and Lehane classification:

• Class I: Most of the glottis is visible• Class II: Only the posterior part of the glottis is visible.• Class III: The glottis is not visible but the epiglottis can be seen.• Class IV: The epiglottis is not visible..

Airway Assessment in TraumaOther measurments:

Upper Lip Bite Test

Airway Assessment in TraumaImaging in airway assesment:

X-ray findings indicating DI:

• Short neck.• Receding lower jaw.• Obtuse mandibular angles.• Protruding upper incisors.• Relative overgrowth of the premaxilla.• Short descending ramus of the mandible.• High arched palate with narrow oral cavity.

Computerized facial analysis.

Airway Assessment in TraumaUltrasonography:

•Important structures could be seen using USG from the mouth to the mid-trachea.

• Highly relevant images in airway management: Identification of the cricothyroid membrane and tracheal rings inter-space and depth in percutaneous tracheostomy.

Airway Management in TraumaEssential preparations:

• Oxygen source

• Ventilation: - Bag-valve-mask device (connect to O2 source). - Soft nasal airway - Rigid oral airway - Transtracheal jet ventilation equipment - Laryngeal mask airway - Esophageal-tracheal Combitube

Airway Management in TraumaEssential preparations:

• Intubation :

- Laryngoscope with new tested batteries - #3 and #4 Macintosh blades with functioning light bulbs - #2 and #3 Miller blades with functioning light bulbs - Endotracheal tubes – various sizes styletted with balloon tested - Tracheal tube guides (gum elastic bougie, stylets) - Flexible fiberoptic intubation equipment - Retrograde intubation equipment - Adhesive tape or umbilical tape for securing ETT

Airway Management in TraumaEssential preparations:

• Suction device.

• Monitor : Capnography, pulse oximeter, ECG, BP.

• Drugs: IV induction, Muscle relaxants, Vasopressors and resuscitation drugs.

Airway Management in TraumaConventional trauma airway management:

Position:

• The sniffing position is the optimum orientation for laryngoscopy-assisted orotracheal intubation.

• It involves forward flexion of the neck on the chest and atlanto-occipital extension of the head at the neck.

• This position attempts to create a line-of-sight between the operator’s eye and the patient’s larynx

• Contraindicated whenever C-spine injury is suspected

Airway Management in TraumaSniffing position:

Airway Management in TraumaRapid sequence induction principles: • preoxygenation with 100 percent O2 for five minutes

• application of cricoid pressure

• IV administration of an induction drug such as Midazolam or Propofol

• Rapid-acting neuromuscular blockade drug such as succinylcholine

• As soon as airway reflexes are lost, the laryngoscope is used to visualize the glottis and facilitate placement of a styletted ETT

• Modification to the RSI technique involves gentle bag-mask ventilation with 100 percent O2 while maintaining cricoid pressure

Airway Management in TraumaDifficult trauma airway techniques :

Awake technique:

• Recommended for trauma patients with known or anticipated difficult airways, provided they are cooperative, stable, spontaneously ventilating and time allows.

• An awake fiberoptic flexible bronchoscope (FOB) guided technique is generally safe and appropriate for stable trauma scenarios. Even when a surgical airway is planned

Airway Management in TraumaDifficult trauma airway techniques :

Techniques/Devices for Unstable, Uncooperative, or Apneic patient :

The guidelines covering the anesthetized limb of the American Society of Anesthesiologists (ASA) difficult airway algorithm are followed .

ASA difficult algorithm (modified for trauma)

Airway Management in TraumaSurgical airway options:

Transtracheal jet ventilation:

• Considered when the reason for failure to ventilate is supra laryngeal or peri-laryngeal and the LMA and Combitube have failed.

• It involves: - Advancing a 14-gauge angio-catheter through the cricothyroid membrane in the midline aimed about 45 degrees, and caudally from the perpendicular direction

- The catheter is connected to adaptor of a high-pressure inflation system

Airway Management in TraumaSurgical airway options:

Transtracheal jet ventilation:

Airway Management in TraumaSurgical airway options:

Percutaneous Cricothyroidotomy :

• TTJV technique is used to place a thin wall (14 G or larger) needle into the trachea.

• Wire is passed through the needle into the trachea by using the Seldinger technique.

•The cricothyroidotomy site is dilated. Then, using the Seldinger technique, the cricothyrotomy tube is advanced, confirmed to be intratracheal and secured in place

Airway Management in TraumaSurgical airway options:

Open Cricothyroidotomy :

Step 1: Identification of the cricothyroid membraneStep 2: Horizontal stab incision through skin and membraneStep 3: Caudal traction on the cricoid membrane with a tracheal hookStep 4: Intubation of the trachea by the tube

Airway Management in TraumaSurgical airway options:

Tracheostomy :

• The first few tracheal rings are exposed

• a horizontal incision is made between the first and second tracheal rings

• the tube is introduced into the trachea

Considerations for specific injuriesMaxillofacial trauma:

• Airway obstruction could occur due to:

- Pharyngeal blood clots- loose teeth - posterior displacement of the tongue and periglottic tissues

• limited mouth opening.

Considerations for specific injuriesMaxillofacial trauma Algorithm

Considerations for specific injuriesPenetrating neck trauma:

Considerations for specific injuriesPenetrating neck trauma:

• Zone 1: Requires emergency airway management because airway is usually compromised by hemorrhage and the patient may develop profound shock.

• Zone 2: Requires intubation for evaluation or surgical repair, in this area major vascular structures and their sympathetic ganglia and the hypopharynx, larynx and trachea are all at risk.

•Zone 3:Direct airway compromise is uncommon.

Considerations for specific injuriesBlunt neck trauma:

Initial evaluation of the patient should include:

• Identification of bruising related to the external injury.

• Inspection of the oropharynx to ensure no injury to the tongue or dentition.

• Careful palpitation from the mandible to the clavicle for the presence of swellings, tenderness or direct airway injury.

Considerations for specific injuriesAirway disruption:Any interruption of airway integrity due to either blunt or penetrating trauma

Considerations for specific injuriesCervical spine injury:

• In-line immobilization should be maintained.

• If rigid laryngoscopy is used: gum elastic bougie usage could be helpful.

• Usage of other intubation techniques as FOB, McCoy blade or Glidescope would be better due to immobilization.

• If there is associated airway risks, awake technique should be considered.

Helpful airway devicesSupraglottic airway devices:

LMA Classic

• Designed to overcome the disadvantages of the ETT• Forms a seal around the larynx• Allow the practitioner to use both hands ( better than facemask)

Helpful airway devices

LMA Flexible

• It’s wire-Reinforced LMA.• Used successfully in patients undergoing head and neck procedures when sharing airway between anesthesiologists and surgeons in required.

Helpful airway devices

LMA Fastrach

Intubating LMA facilitate endotracheal intubation without the need to move the cervical spine during intubation

Helpful airway devices

LMA Proseal

Permits access to the stomach using gastric tubes and reduces the leakage of inspired gases into stomach

Helpful airway devices

LMA supreme

Combines the features of the intubating LMA and Proseal LMA

Helpful airway devices

LMA CTrach

An intubating LMA which contains fiberoptics to enable viewing on a liquid crystal display

Helpful airway devices

The I-gel

Creates a better anatomical seal with pharyngeal, laryngeal, and peri-laryngeal structures

Helpful airway devices

Baska mask

• Provides 2 large tubes for rapid gastric fluid clearance• More effective laryngeal seal even with increased pressure

Helpful airway devices

SLIPA

• Provides a better protection from regurgitation ( than LMA )• Effective in DA management esp. with narrow pharyngeal space

Helpful airway devices

Laryngeal tube suction II

Similar to PLMA and much easier to insert than LTS I

Helpful airway devicesRigid Laryngoscopes:

Rigid laryngoscopic blades

Macintosh type : the most commom.Miller type: different technique from MacintoshLevering type: useful in recessed mandible and decreased MOViewmax: provide better view of the larynx

Helpful airway devicesVideo-assisted Laryngoscopes:

AIRTRAQ laryngoscope

Requires minimal head manipulation and provides a better view without the need of alignment of the visual axes

Helpful airway devicesVideo-assisted Laryngoscopes:

C-MAC laryngoscope

• Comes with regular reusable Macintosh blades. It offers a large colour display• reduces the risk of oral or dental injury ( beveled shoulder)• useful in limited MO ( D-Blade )

Helpful airway devicesVideo-assisted Laryngoscopes:

Pentax Airwayscope

Video laryngoscope with an LCD colour screen attached to the handle

Helpful airway devicesVideo-assisted Laryngoscopes:

Glidescope® Video Laryngoscope

High resolution digital camera located in the middle of the blade tip

Helpful airway devicesVideo-assisted Laryngoscopes:

Flexible fiberoptic laryngoscopes:

• Used when the patient’s neck cannot be manipulated, as when cervical spine is not stable.

•It can also be used when it is not possible to visualize the vocal cords because s straight line view cannot be established from the mouth to the larynx

Helpful airway devicesVideo-assisted Laryngoscopes:

Rigid fiberoptic laryngoscopes:

• Facilitate tracheal intubation in DA management situations such as limited mouth opening or neck movement.

• Intubation can be performed via the nasal or oral route and can be accomplished in awake or anesthetized patients

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