ATLS Chapt 2: Airway & Ventilatory Management

• Managing an injured patient starts with ensuring an intact airway and recognizing a compromised one.

Priorities in Airway and Ventilatory Management

• Securing a compromised airway takes precedence over managing all other conditions.
• Supplemental oxygen is necessary for all severely injured trauma patients.
• Critical to prevent hypoxemia requires a protected airway to administer blood to vital structures.
• Early preventable trauma deaths often stem from failure to assess the airway, recognize the need for intervention, establish an airway, or ventilate.
• Alternative airway plans are needed in the setting of repeated failed intubation attempts
• Lack of recognizing incorrectly placed airways or to use appropriate techniques to ensure correct rube placement are also possible factors.

Airway Compromise

• Initial airway assessment and frequent reassessment are critical.
• Sudden and complete airway compromise can happen.
• Also insidious, partial, progressive, and recurrent instances can come up.
• Tachypnea, which may be related to pain or anxiety, can also be an early sublte sign.
• Maintaining oxygenation that protects the patient from hypercarbia is important, especially if the patient has sustained a head injury
• Talk to the patient to stimulate a verbal response, and assess the airway (a talking patient means the airway is patent, ventilation is intact, and brain perfusion is sufficient)

Definitive Airway

• Those with an altered level of consciousness are at particular risk for airway compromise
• Defined as a tube placed in the trachea with an inflated cuff below the vocal cords and connected to assisted ventilation.

Facial/Neck/Larynx Trauma

• First identify objective signs of airway obstruction and any trauma or burns to the face, neck, and larynx.
• Trauma to the face demands aggressive airway management
• Maxillofacial injuries frequently occur when unrestrained passengers are thrown into the windshield during a crash.
• Midface trauma can produce fractures and dislocations that compromise the nasopharynx and oropharynx.
• Facial fractures can result in hemorrhage, swelling, secretions, plus dislodged teeth, causing difficulties in maintaining a patent airway.
• Bilateral body fractures (mandible) can cause airway obstruction if a patient is supine through the lack of structural support
• Patients who refuse to lie down may be experiencing difficulty maintaining their airway or handling secretions.
• General anesthesia or muscle relaxation can lead to total airway loss from diminished muscle tone.
• Endotracheal intubation may be used to maintain airway patency.
• Penetrating neck injuries can cause vascular injury and hematoma, leading to airway displacement/obstruction and the potential need of a surgical airway.
• Laryngeal fractures, though rare, can cause acute obstruction, indicated by hoarseness, subcutaneous emphysema, and a palpable fracture.
• Complete airway obstruction or severe distress warrants intubation or emergency tracheostomy if intubation fails.

Vomiting

• Important to anticipate vomiting in patients
• Immediately suction and rotate the patient to the lateral position while restricting cervical spinal motion if the oropharynx has gastric contents

Signs of Airway Obstruction

• Agitation (suggesting hypoxia)/obtundation (suggesting hypercarbia)
• Cyanosis (a late finding of hypoxia as identified by the nail beds, may be difficult to detect in pigmented skin.)
• Retractions and accessory muscle use.
• Noisy breathing (snoring, gurgling, crowing/stridor)
• Hoarseness/dysphonia (functional laryngeal obstruction).
• Abusive patients may be hypoxic; do not automatically assume intoxication.

Ventilation Compromise

• Impeding factors are airway obstruction, altered ventilatory mechanics, and/or central nervous system (CNS) depression.
• Direct chest trauma, especially rib fractures, can cause rapid, shallow ventilation/hypoxemia.
• Intracranial injury and cervical spinal cord injury can also cause ventilation compromise (the more proximal the injury, the more likely there will be respiratory impairment).
• "Abdominal breathing," which results in rapid, shallow breaths, atelectasis, ventilation/perfusion mismatching, and respiratory failure.

Objective Signs of Inadequate Ventilation

• Asymmetrical rise/fall of the chest (splinting, pneumothorax, flail chest).
• Labored breathing may indicate imminent threat
• Decreased/absent breath sounds indicating thoracic injury.
• Rapid respiratory rate/tachypnea can indicate respiratory distress.
• Inadequate ventilation requires monitoring the patient's respiratory rate and work of breathing, obtaining blood gas analysis, and performing capnography.

Airway Management Steps

• Airway patency and ventilation adequacy is based on pulse and CO₂ measurements
• Include airway techniques, definitive airway measures, and methods of supplemental ventilation

Maintain Cervical Spinal Motion Restriction

• Is important, this is required in all trauma patients at risk for spinal injury until exclusion by radiographic adjuncts/clinical evaluation

Oxygen

• High-flow oxygen is required both before and immediately after instituting airway management measures
• A rigid suction device is essential and readily available.

Helmet Removal

• Helmets require two people
• One restricts cervical spinal motion below
• The other expands sides of the helmet and then removes it from above, clinicians reestablish restriction and secure head/neck during airway management
• A cast cutter can remove a helmet while stabilizing the head

Potential Difficulties with Airway Maneuvers

• C-spine injury
• Severe arthritis of the c-spine
• Significant maxillofacial or mandibular trauma
• Limited mouth opening
• Obesity
• Anatomical variations (receding chin, overbite, short, muscular neck)
• Pediatric patients
• Mnemonic device LEMON can indicate difficulties, LEMON has proved useful for preanesthetic evaluation, and several of its components are particularly relevant in trauma, c-spine injury and limited mouth opening

Airway Decision Scheme

• Useful for determining appropriate airway route

Airway Maintenance Techniques

• Chin-lift & Jaw-thrust maneuver corrects the tongue falling backward, which is used with a nasopharyngeal or oropharyngeal airway
• Restrictions are mandatory when using maneuvers during procedures
• Chin-lift is performed by finger placements, while the Jaw-thrust displaces the mandible

Airways

Nasopharyngeal

• Inserted in one nostril and is passed to the posterior oropharynx after well lubrication; do attempt this procedure in patients with suspected or potential cribriform plate fracture.

Oropharyngeal

• Inserted into the mouth behind the tongue upside down; do not use with children.

Extraglottic and Supraglottic Devices

Laryngeal Mask Airway (LMA) and Intubating LMA (ILMA)

• Effective for difficult airways
• When a patient has this upon ED arrival, plan for a definitive airway.
• Do not require cuff inflation and can be used in place of an LMA

Laryngeal Tube Airway (LTA)

• Has similar capabilities to the LMA with successful ventilation

Multilumen Esophageal Airway

• Used by prehospital personnel when a definitive airway isnt feasible, with one end connecting to the esophagus and the other with the airway.
• They are trained to observe the esophageal port and which provides air to the trachea, with a carbon dioxide detector providing evidence of the ventilation

Definitive Airways

• Requires a tube placed in the trachea with the cuff inflated below the vocal cords, connected to oxygen, and stabilized
• The types are: orotracheal tube, nasotracheal tube, and surgical airway (cricothyroidotomy and tracheostomy)
• The criteria is based on clinical findings

Drug Assisted Indications for a Definitive Airway

• Inability to maintain patent airway, oxygen, or ventilation
• Obtundation or combativeness
• Head injury with assisted ventilation with scores in the Glasgow Coma Scale 8 or less.

Endotracheal Intubation

• Needed with GCS scores of 8 or less is required, otherwise, obtain radiological c-spine evaluation, but a normal film doesn't exclude possibility.
• Orotracheal is perferred protection route, while nasotracheal is a alternative (Both techniques are safe.)
• If the patient has is in apnea, orotracheal must happen
• Cervical Spinal Restriction should be followed
• Alternative intergrating video are beneficial as well per a traumatic circumstance and experienced providers

Eschmann Tracheal Tube Introducer (ETTI)

• Used when a vocal cord cannot be visualization on direct laryngoscopy

Surgical Airway

• Inability to intubate the trachea is a clear indication for an alternate airway plan
  • Laryngeal mark airway etc etc
• Perform needle cricothyroidotomy followed by a surgical airway

Management of Oxygenation

• Provide a tight-fitting oxygen reservoir face mask and flow rate of 10L per minute, can improve oxgen concentration

Pulse Oximetry

• Should be constiant
• It doesn't specify partial pressure
• requires intact peripheral perusion
• A good tool for therapeutic interventions