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M A N A G E M E N T O F T H E A I R W AY

AMERICAN COLLEGE OF SURGEONS


COMMITTEE ON TRAUMA
SEPTEMBER 2002

M A N A G E M E N T
2002 American College of Surgeons

RECOGNITION
PURPOSE

IMMEDIATE INTERVENTION

Apnea
Airway obstruction
Partial
Complete

Provide and maintain a secure airway


Ensure adequate oxygenation and ventilation
Prevent aspiration
Protect the cervical spine

O F

T H E

A I R W A Y

This publication is designed to offer information suitable for use by an appropriately trained
physician. The information provided is not intended to be comprehensive or to offer a defined
standard of care. The user agrees to release and indemnify the American College of Surgeons
from claims arising from use of the publication.

Frederic J. Cole, MD, FACS

ALTERNATIVE MANAGEMENT TECHNIQUES


S U R G I C A L A I R W AY
ANATOMY

NEEDLE CRICOTHYROIDOTOMY

SURGICAL
CRICOTHYROIDOTOMY
ANATOMY

thyroid notch

INDICATION

URGENT INTERVENTION

Patients at risk:
Head injury
Direct airway injury
Shock
Facial fractures
Thoracic injury
Drugs/alcohol

Respiratory distress
RR >30, <6
Use of accessory muscles
Nasal flaring/retractions
Flail chest/paradoxical motion
Combative patient
Need for urgent operation

thyroid cartilage
cricothyroid membrane
cricoid cartilage

indent

trachea

Jet insufflation
O2 15 L/min
Maintains oxygenation

#6 tube (tracheostomy or
endotracheal)
Age >12
Caution: Laryngeal fracture

TECHNIQUE

MANAGEMENT TECHNIQUES
SIMPLE
JAW THRUST

CHIN LIFT

OROPHARYNGEAL AIRWAY

NASOPHARYNGEAL AIRWAY

Stabilize the larynx,


make vertical/
horizontal skin incision

DEFINITIVE
ORAL

TRACHEAL INTUBATION
Preoxygenation
Cricoid pressure/prevent aspiration
Topical anesthesia
Sedation/neuromuscular blockade
Tube size: Male - 8.0
Female - 7.0
Oral: Requires adequate visualization
Nasal: Requires spontaneous respiration and patient cooperation; contraindicated in midface/basilar skull fractures

NASAL

DOSE
0.3 mg/kg IV
0.020.1 mg/kg IV
0.61.5 mg/kg IV

Enlarge the opening

Insert the tube


into the opening

LARYNGEAL MASK AIRWAY

REVERSAL

DOSE

Flumazenil

0.2 mg IV

Difficult airway
Unconscious or sedated patients
Spontaneous or controlled ventilation
Experienced anesthesia personnel

PEDIATRIC CONSIDERATIONS

PHARMACOLOGIC ADJUNCTS TO TRACHEAL INTUBATION/RAPID SEQUENCE


AGENTS
Etomidate
Midazolam
Succinylcholine

Incise cricothyroid
membrane

Give atropine for bradycardia


Craniofacial disproportion: large head, small chin
Occipital cervical flexion
Infants: obligate nasal breathers
Larynx: anterior caudad angle
Trachea: short

Direct placement of oral airway


Orotracheal intubation preferred (under age 9)
Size endotracheal tube to childs small finger/external
nares
No cricothyroidotomy (under age 12)
Uncuffed endotracheal tubes (under age 9)

Illustrations from Advanced Trauma Life Support for Doctors, 6th ed. Chicago, American College of Surgeons, 1997.

O F

T H E

A I R W A Y
Frederic J. Cole, MD, FACS

ALTERNATIVE MANAGEMENT TECHNIQUES


S U R G I C A L A I R W AY
ANATOMY

NEEDLE CRICOTHYROIDOTOMY

SURGICAL
CRICOTHYROIDOTOMY
ANATOMY

thyroid notch
thyroid cartilage
cricothyroid membrane
cricoid cartilage

indent

trachea

Jet insufflation
O2 15 L/min
Maintains oxygenation

#6 tube (tracheostomy or
endotracheal)
Age >12
Caution: Laryngeal fracture

TECHNIQUE

Stabilize the larynx,


make vertical/
horizontal skin incision

Incise cricothyroid
membrane

Enlarge the opening

Insert the tube


into the opening

LARYNGEAL MASK AIRWAY

Difficult airway
Unconscious or sedated patients
Spontaneous or controlled ventilation
Experienced anesthesia personnel

PEDIATRIC CONSIDERATIONS

Give atropine for bradycardia


Craniofacial disproportion: large head, small chin
Occipital cervical flexion
Infants: obligate nasal breathers
Larynx: anterior caudad angle
Trachea: short

Direct placement of oral airway


Orotracheal intubation preferred (under age 9)
Size endotracheal tube to childs small finger/external
nares
No cricothyroidotomy (under age 12)
Uncuffed endotracheal tubes (under age 9)

Illustrations from Advanced Trauma Life Support for Doctors, 6th ed. Chicago, American College of Surgeons, 1997.