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Airway and Ventilation
Management in the
Trauma Patient
Airway / Ventilation of the Trauma
Patient : Objectives
ƒ Recognize acute airway obstruction
ƒ Be familiar with airway management techniques
–Airway opening maneuvers
–Orotracheal & nasotracheal intubation
–Needle cricothyroidostomy / jet ventilation
–Alternative difficult airway techniques
–Surgical cricothyroidostomy
ƒ Be familiar with devices for oxygen
administration and ventilation
–Masks, bag-valve-mask, mechanical ventilators
Importance of Airway
Management
ƒ Airway obstruction is the most rapid
killer of the trauma patient
ƒ Airway management is always the first
step in trauma management
Risk Factors for Airway Obstruction
in the Trauma Patient
ƒ Decreased mental status
–Head injury
–Effects of alcohol or drugs
ƒ Facial fractures
ƒ Blunt neck trauma
ƒ Burns / smoke inhalation
And in some : congenital airway
structural abnormalities
Specific Causes of Airway
Obstruction
ƒ Head position : slumped forward
ƒ Blood
ƒ Vomitus
ƒ Foreign body
ƒ Extrinsic compression
–Neck hematomas
–Neck abscesses
ƒ Airway wall edema
Signs of Airway Obstruction
(Should Note These "From Across the Room")
ƒ Unconscious
ƒ Unable to speak
ƒ Retractions
–Sternal, intercostal, subcostal
ƒ Poor or abstract air movement
ƒ Cyanotic or grey skin color
ƒ "Noisy" or "gurgly" breathing
ƒ Stridor
Airway Management Precautions
ƒ If the patient may have a neck injury :
always maintain neck immobilization
during airway management
ƒ Avoid distraction of the neck
Best neck immobilization with towel, collar, and hands
Airway Opening Maneuvers
ƒ Head tilt / neck lift
–Do not do if possible neck injury
ƒ Chin lift
ƒ Jaw thrust
ƒ Suction oropharynx & nasopharynx
ƒ Remove oropharyngeal foreign bodies
with Magill forceps
ƒ Always start oxygen concurrent with
airway maneuvers
Chin lift and
head tilt
maneuvers
Head tilt and neck lift
Initial Airway Adjuncts
(act to hold open the upper airway)
ƒ Oropharyngeal airway
–Do not use if patient conscious (will cause
gagging & vomiting)
ƒ Nasopharyngeal airway
–Do not use if mid-face fracture (may go through
fracture site and penetrate brain)
–Relatively contraindicated if severe
coagulopathy (may stir up bleeding) and in
children (may cause bleeding from enlarged
adenoids)
Oropharyngeal airways (note how 2 can be hooked together to
do mouth to tube ventilation)
Use the distance from the corner of the mouth to the ear to
select the correct size oral airway
Actually a better insertion method is to insert the airway at a 90
degree angle and then rotate it into position over the tongue
Use of a tongue depressor to help insert an oral airway
Don’t allow this to happen !
Standard red rubber nasopharyngeal airways
Proper position of the inserted nasal airway
These protect the rescuer by allowing mouth to device
ventilation rather than mouth to mouth
Other types of barrier ventilation masks
An oxygen reservoir is required in order to give the patient
oxygen concentrations greater than 60 %
Another type of bag-valve with oxygen reservoir (the black
corrugated tubing)
Correct hand position for one person ventilation
Two person bag-valve-mask ventilation (can achieve bigger
ventilation volumes than by one person)
Patients in Whom a Definitive
Airway Is Needed
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Depressed mental status
Protect from aspiration of blood or vomitus
Head injury requiring hyperventilation
Patient requires sedation or anesthesia to
obtain computed tomography scan
Emergency surgery
Major chest wall injury
Respiratory failure
Anticipated prolonged ventilation
Advantages of Endotracheal
Intubation
ƒ Protects the airway from aspiration
ƒ Facilitates ventilation & oxygenation
ƒ Enables direct suctioning of secretions from
trachea
ƒ Provides route for administration of
resuscitative medications
ƒ Prevents gastric inflation from ventilations
ƒ Maintains airway against edema or
compression
Orotracheal Versus Nasotracheal
Intubation
ƒ Orotracheal preferred
–Patient apneic
–Midfacial fractures
–Known coagulopathy
ƒ Nasotracheal preferred
–Patient breathing
–Short / thick neck
–Status epilepticus
ƒ Either method okay for patients with suspected neck
injury as long as neck immobilization maintained
(nasotracheal can cause higher incidence of delayed
sinusitis)
Preparation for Endotracheal
Intubation
ƒ Have suction ready and operating
–Yankauer (large bore) catheter
–Flexible catheter
ƒ Choose endotracheal tube (ETT) size
–Have 2 "adjacent" sizes also available
ƒ Have stylet and syringe ready (use of stylet to stiffen the ETT is
routinely recommended for both adults & children)
ƒ Check equipment
–Test bulb on laryngoscope, test inflate balloon on ETT
ƒ Have bag-valve-mask (BVM) ready and attached to oxygen flow
ƒ Have medications labeled and ready
ƒ Have stethescope ready
Suction canisters and
tubing must be ready
before intubation
Ideal patient positioning for intubation (assuming neck injury is
not present)
Extra sheets and
pillows may be needed
for ideal airway
positioning for a very
obese patient
Choice of Laryngoscope Blades
ƒ Straight blade (such as Miller) used to directly
lift the epiglottis
–May be best if "floppy" epiglottis suspected (which is
more common in children)
ƒ Curved blade (such as Macintosh) used to
indirectly expose the glottic inlet by lifting up
from the vallecula
ƒ Should have both available since unpredictably
sometimes one works better than the other for
some patients
Intubation equipment to have ready
Routine use of a stylet is recommended for intubation of both
adults and children
You need to align the axes of the mouth, pharynx, and trachea
for intubation to be successful ; these axes are not aligned
when the neck is flexed
Good alignment of the mouth, pharynx, and tracheal axes for
intubation
Also called the Sellick maneuver
Place the laryngoscope in the mouth and sweep the tongue
to the left
Correct placement of straight
blade
Correct placement of
curved blade
Laryngoscopic view with the straight blade (left) and the
curved blade (right)
Laryngoscopic views with different blades
Insert the endotracheal tube from the right (do not place it
directly down the channel of the laryngoscope blade or it will
obstruct your view)
Correct endotracheal
tube positioning using a
curved blade
Precautions About Endotracheal
Intubation
ƒ Do not attempt if the patient is not
adequately sedated
ƒ Before using ANY of the sedatives or
paralytic agents, personnel MUST know
well the pharmacology of these agents
ƒ If personnel are not skilled in intubation,
continued ventilation by bag-valve-mask is
preferable to a botched intubation attempt
General Guidelines for
Endotracheal Intubation
ƒ If needed, it should be done as early
as possible in the resuscitation
ƒ It should be attempted by the most
experienced person present
ƒ No more than 30 seconds per attempt
should be taken; the patient should be
reventilated with BVM after each 30
seconds
Use of Medications for Assisted Intubation
("Rapid Sequence Intubation")*
ƒ If the patient is completely
unconscious and unresponsive,
medication use to assist in intubation
(except perhaps IV lidocaine) is
usually unnecessary
ƒ Complications are reduced by proper
use of sedation and paralytic agents
*This really should be called "Medication-Assisted-Intubation"
because if done properly, it is not actually "rapid"
Potential Complications of
Endotracheal Intubation
ƒ Esophageal intubation : causes death if unrecognized
ƒ Mainstrem bronchus intubation : can result in collapse
of other lung
ƒ Pneumothorax
ƒ Oropharyngeal bleeding
ƒ Vocal cord injury
ƒ Fractured teeth ; tooth fragments could be aspirated
ƒ Vomiting & aspiration
ƒ Movement of an unstable cervical spine injury
"Classic" Sequence of Medications to Use for
Assisted Intubation ("Rapid Sequence Intubation")
ƒ Oxygen : preoxygenate the patient (VERY important)
ƒ Lidocaine : 1 to 1.5 mg/ Kg IV (to blunt the increase in ICP
from intubation; efficacy of this is debated)
ƒ Pancuronium or vecuronium 0.01 mg/ Kg IV (usually one
mg; to prevent fasciculations from succinylcholine)
ƒ Diazepam or Midazolam 0.1 to 0.7 mg/ Kg IV (usually 5 mg)
ƒ Succinylcholine 1 to 1.5 mg/ Kg IV
ƒ Cricoid pressure (Sellick maneuver) to prevent aspiration
ƒ Intubate (Pass the ETT)
Note : Usually wait 2 minutes in between each medication to
allow it time to take effect
Contraindications to
Succinylcholine
ƒ Known hyperkalemia (as in renal failure patients)
ƒ Burns (if delayed time from injury)
ƒ Muscular dystrophy / other muscle diseases
ƒ Major crush injuries (if delayed time from injury)
ƒ Family history of Malignant Hyperthermia or
pseudocholinesterase deficiency
Remember that succinylcholine may not be needed (thereby
avoiding the rare chance it will cause hyperkalemia or
hyperthermia) if the patient is so sick that they already have very
relaxed muscle tone
Considerations About Use of Paralytic
Agents for Endotracheal Intubation
ƒ DO NOT USE if not able to ventilate the patient
with a bag-valve mask in case the intubation fails
ƒ Succinylcholine has rapid onset (30 to 60 seconds)
and relatively short duration (unless patient has
pseudocholinesterase deficiency) of 10 to 15
minutes
ƒ The nondepolarizing agents have slower onset
and more prolonged half life
–Use of "priming dose of 0.5 to 1 mg IV 3 minutes before
main dose may shorten onset to 60 seconds
Other Medication Options for
Medication-Assisted Intubation
ƒ Etomidate 0.3 mg / kg IV
–Causes rapid brief sedation & apnea
–If repeated can cause adrenal suppression
–Usually causes no cardiovascular complications
ƒ Ketamine 2 mg / kg IV or 4 mg / kg IM
–Older studies indicated it may cause increased intracranial
& intraocular pressures, but this is debated
–Can rarely cause laryngospasm & "emergence reactions"
(agitation after awakening)
–Usually minimal effects on cardiorespiratory status
More Medication Options for
Medication-Assisted Intubation
ƒ Barbiturates (used as "induction" agent)
–All commonly cause hypotension & apnea
Methohexital 1 to 3 mg / kg IV
ƒ Thiopental 3 to 5 mg / kg IV
ƒ Propofol 2 to 2.5 mg / kg IV (can be continuous infusion)
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ƒ Narcotics
–Also can cause hypotension & apnea & histamine
release (but can reverse with naloxone 0.4 to 2 mg IV)
Morphine 0.01 to 0.1 mg / kg (often 2 mg initial dose)
ƒ Fentanyl 3 to 50 micrograms / kg
(can rarely cause muscle &
chest wall rigidity if high dose given rapidly)
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Options for Nondepolarizing
Neuromuscular Blockers (Paralytics)
Name
Dosage (IV)
Comments
Atracurium
0.4 to 0.5 mg/kg
useful in renal
failure
Cis-atracurium
0.1 to 0.2 mg/kg
Pancuronium
0.1 mg/kg
Rocuronium
0.6 to 1.2 mg/kg
Vecuronium
0.1 mg/kg
can cause cardiac
side effects
faster onset
useful for prolonged paralysis
Additional Medication Considerations for
Endotracheal Intubation
ƒ If a paralytic agent is used, a sedative or induction
agent MUST be also used (it is inhumane to
chemically paralyze someone without making
them unaware of the paralysis)
–Benzodiazepines are useful for this because even in small
doses they cause brief retrograde amnesia
ƒ They also may blunt the "emergence reactions" from
ketamine, and can be reversed with Flumazenil 0.2 mg IV
ƒ In children < 8 years, atropine 0.01 mg/kg (minimum 0.1 mg) is
recommended to prevent vagal reactions from succinylcholine
(& the succinylcholine dose is 2 mg/kg)
More Considerations About Medication Assisted Endotracheal Intubation
ƒ For inexperienced personnel, the safest agents to
use are probably the benzodiazepines and
narcotics (because they can be reversed), and
etomidate or ketamine
ƒ Post - intubation paralytic agents are needed for
patients who are combative from head trauma or
intoxication
–If possible and safe, a complete neurologic exam should
be completed prior to use of extended paralytic agents
Sequence of Events for Intubation
ƒ Prepare equipment
ƒ Preoxygenate
ƒ Administer medications; Sellick maneuver (cricoid pressure)
ƒ Pass the tube & inflate cuff balloon
ƒ Release Sellick maneuver
ƒ Ventilate
ƒ Listen with stethescope over both sides of chest and upper
abdomen
ƒ Use end-tidal CO2 detector if available
ƒ Secure the tube with tape (record depth number at lips ;
usually 21 to 23 cm in adults)
ƒ Obtain chest X-ray to check tube position
An X-ray you don’t want to see : Esophageal intubation
A qualitative colorimetric end tidal CO2 detector
(use helps recognize possible esophageal intubation)
Use of a GU syringe as an esophageal intubation detector
Use of a bulb syringe as an esophageal intubation detector
How to tape secure an oral endotracheal tube
Securing an oral
endotracheal tube (using
also an oral airway keeps
the patient from biting on
the endotracheal tube)
How to tape secure a nasotracheal tube
Indications for Surgical Airway
(Cricothyroidotomy)
ƒ Inability to orotracheally or nasotracheally
intubate and airway control required
–Failure or impossibility of "backup" intubation
methods
ƒ Upper airway obstruction (above level of
vocal cords)
"Backup" Alternative Endotracheal
Intubation Techniques
ƒ Should have a "Difficult Airway " cart with this
extra airway equipment available in the E.D.
–Combitube
ƒ Can be inserted blindly
ƒ Often helpful in controlling oropharyngeal bleeding
–Trach-Lite
ƒ Also a "blind" technique
–Retrograde intubation over a guide wire
ƒ Uses a central intravenous line kit
–Commercial percutaneous tracheostomy insertion sets
The Combitube is a
good “backup”
alternative airway
technique
Combitube in the
esophageal
position (about 85
% of the time
when inserted it
will be in the
esophagus)
Combitube in
the tracheal
position (note
ventilation bag
is now attached
to the other
lumen)
Another type of
“blind” insertion
airway : the
pharyngotracheal
lumen airway (PTL)
Another “backup”
technique: placing an
endotracheal tube down
the lumen of the
intubating LMA
(laryngeal mask airway)
Technique for Retrograde
Intubation Over a Guide Wire
ƒ Puncture cricothyroid membrane with needle aimed proximally,
then pass central intravenous line guide wire thru the needle
into the pharynx
ƒ Look into the pharynx and pull the guide wire with a Magill
forceps so it exits from the mouth
ƒ Cut off the proximal thicker portion of a nasogastric tube and
insert the lubricated tube over the wire to the predetermined
depth equivalent to the distance from the mouth to the cricoid
puncture site
ƒ Insert an endotracheal tube over the nasogastric tube
ƒ Pull the wire and nasogastric tube out of the mouth
ƒ Advance the endotracheal tube a little farther
Needle Cricothyroidostomy :
Technique
ƒ Prep neck with iodine or alcohol if time allows
ƒ Insert 14 gauge needle thru cricothyroid membrane (or
use IV catheter over needle & withdraw needle)
ƒ Attach stopcock and oxygen tubing
ƒ Run oxygen in for one second ; open stopcock for 3 to
4 seconds & keep repeating this cycle
ƒ Can instead attach 3 cc syringe barrel & then attach
ETT connector & ventilate with BVM directly
ƒ Prepare for surgical cricothyroidostomy if possible (to
establish larger diameter airway)
High pressure tubing
required for jet
ventilation for a needle
cricothyroidostomy
Technique of verifying
entry into the trachea
with a catheter over
needle
Setup for direct
ventilation of a
needle
cricothyroidostomy
Direct bag valve
ventilation to a
needle
cricothyroidostomy
Surgical Cricothyroidostomy :
Technique
ƒ Prep front of neck if time allows
ƒ Incise skin & cricothyroid membrane horizontally
ƒ Insert tracheostomy tube or 6.0 or 6.5 mm.
diameter endotracheal tube & inflate cuff balloon
ƒ Ventilate thru tube
ƒ Auscultate over chest and abdomen
ƒ Secure tube with tape or straps around neck
ƒ Chest X-ray to check tube position
Surgical
cricothyroidostomy
Minimum instruments needed for surgical cricothyroidostomy
Emergency
tracheostomy
One of several available types of percutaneous
cricothyroidostomy tubes
Choosing Endotracheal Tube Size
(Inner Diameter in mm.)
ƒ Small adults : 7.0, 7.5
ƒ Large adults : 8.0, 8.5, 9.0
ƒ Children :
–Can use formula 16 + age in years divided by 4
–Or use tube with diameter same as child's little
finger
ƒ For nasotracheal intubation, choose tube 0.5
to 1 mm. diameter smaller than for oral
Reassessment of the Intubated
Patient
ƒ Reauscultate to check tube position after each
time the patient is moved
ƒ Note printed number on the tube at the level of
the lips & record in chart
ƒ Continuous pulse oximetry if available
ƒ Consider hand restraints if patient combative
or likely to awaken and attempt to pull tube
ƒ Suction the ETT frequently
ƒ Recheck pressure in cuff balloon every 6 to 8
hours (should be < 25 mm Hg)
Technique of Tracheobronchial
Suctioning
ƒ Set suction pressure between 80 to 120 mm Hg
ƒ Preoxygenate with 100 % oxygen for 3 to 5 minutes
ƒ Use sterile technique (gloves)
ƒ Insert suction catheter thru tube
ƒ Apply suction & pull out catheter with a rotary
motion
ƒ Limit suction to no more than 10 seconds per
attempt
Oxygen Concentrations Deliverable
from Airway Adjuncts
Device
O2 Concentration
Nasal cannula
(2 to 6 l/min)
Face mask
(6 to 10 l/min)
Face mask with O2
Reservoir
Venturi mask
24 to 44 %
40 to 60 %
60 to 98 %
28 to 40 % by
selected increments
Airway Management Summary
ƒ Airway management is always first
priority
ƒ Always maintain cervical spine
precautions
ƒ Decide early if definitive airway needed
ƒ Complete preparations before attempting
to intubate
ƒ Reassess the intubated patient frequently
Specific Airway Skills :
Practice Session
ƒ Airway opening maneuvers
ƒ Placement of airway adjuncts (oral & nasal airways)
ƒ Adult orotracheal intubation
ƒ Adult nasotracheal intubation
ƒ Pediatric orotracheal intubation
ƒ "Backup" alternative intubation techniques
ƒ Needle cricothyroidostomy
ƒ Use of bag-valve-mask (perhaps the most important skill)