Prof.Dr. Koeshartono,SpAnK.IC.PGD.Pall.Med.

ECU
Lab.Anestesiologi & Reanimasi
(Kedokteran Gawat Darurat)
Darurat)
FK. Unair / RSU Dr. Soetomo
Surabaya
Injured Patient / Trauma - Burn
By Passing Transtracheal Airway
Difficult Airway / Mucosal Oedema
Airway Management Can be More Difficult
The Senior Help Should be Present to Assist if Difficulties Arise
 Potential Cervical Spine Instability

Hold the Head to Prevent

Neck Movement

A Head Collar Around The Neck

• Restricting Flexion and Extension

Sand Bag
• Preventing Laterel Flexion and Rotation
Unlike the elective surgical patient
usually presents a complex scenario
for airway management :
1. The patient must undergo multiple therapeutic and
diagnostic interventions while airway assessment
and management take place
2. Traumatic injuries themselves often interfere with
routine airway management techniques
3. Injuries and hemorrhage place increased oxygen
demands on the body, while other injuries may
interfere with gas exchange
4. Unlike the airway in elective surgical patients, the
airway in trauma patients often must be controlled
expeditiously by one means or another
5. The patient must always be considered to have a full
stomach
• Although anesthesiologists tend to focus
on this last condition (aspiration
prophylaxis), it is only one of the many
problem associated with post traumatic
airway management

• Comatose patient require tracheal

intubation to protect their airways from
aspiration and to allow mechanical
ventilation that will reduce arterial
carbon dioxide pressure (PaCO2) and
intracranial pressure (ICP). In other
cases early mechanical ventilation may
reduce later morbidity and mortality.
• If manual attempts to open the airway and
provide mask ventilation are unsuccessful,
immediate oral endotracheal intubation
should be attempted. In such cases all but the
most routine precautions to avoid injury during
the intubation process.

• Even experienced anesthetists are faced with

patients who cannot be managed by direct
oral intubation, such as those with blunt or
penetrating injuries of the trachea or severe
maxillofacial trauma that distorts normal
anatomic relationships. Provisions for an
emergency cricothyrotomy or tracheostomy
should always be alvailable.
 R female / 30 years old/ 50 kg
Dx : Head injury
Parasimphisis mandibula Fr.
Condylus mandibula Sin Fr.
Maxila L II-III Fr.
(Multi fragmented & floating mandibula)
Tibial plateu & cruris Sin CFr.

WHAT DO YOU THINK

WHAT WRONG WHAT CAN HAPPEN

HEAD INJURY, ICP
C-SPINE INJURY
MULTI TRAUMA
CHEST TRAUMA
PNEUMOTHORAX
HEMOTHORAX
FAIL CHEST
ABDOMINAL TRAUMA
ETC
• Some patients (e.g. with burns, cervical
hematoms, or chest wall injury) obviously will
require tracheal intubation and mechanical
ventilation.

• The majority of trauma patients do not

obviously require intubation, but a through on
going assessment of ventilatory status
must be made in every case.

• Pneumothorax and some types of airway

injury are most accurately diagnosed
radiographically. But tension pneumothorax
must be decompressed imediatelly
without radiological confirmation
 Diagnostic groups likely
to
require ventilation:
– Head injury
– Chest wall injury
e.g. pneumothorax, hemothorax, flail chest
– Other injuries, require mechanical ventilation,
develop pulmonary insufficiency
– Massive volume administration
– Injuries that may interfere with airway management
• Cervical spine injury
• Maxillofacial injury
• Airway injury
• Intrinsic : tongue, edema, blood,
dentures, food, vomit,
other foreign bodies
• Extrinsic : fractures, haematomas, head
and neck positioning
• Long term planning :
• Hospital location
• Ambulance service
• A & E department
• Trauma team
• Staffing & Training

• Short term planning :

– Dedicated resuscitation area equipped with
the appropriate equipment to deal with the
immediate management of injuries
• Facilities to supply supplemental oxygen to
spontaneously breathing patients (piped or wall supplied
oxygen, trauma mask with re-breathing bag), continuous
nasopharyngeal catheter oxygenation

• Airway adjuncts available to assist airway

maintenance in the comatose or semi – comatose
breathing patient (oropharyngeal and nasopharyngeal
airways)

• Advanced airway equipment and equipment to aid

tracheal intubation in a patient who is difficult to
intubate (equipment for tracheal intubation, laryngeal
mask airway-LMA)
…………………………… Check the Equipment and Drugs

• Equipment to remove foreign bodies from the

airway (yankauer sucker, suction catheter for
aspirating down nasopharyngeal airways or
down tracheal tubes, magills forceps for
removing solid material)

• Equipment for developing a surgical airway

(cricothyroid membrane puncture and jet
ventilation, tracheostomy)

• Ventilation equipment : ideally a fully stocked

anaesthetic machine (end-tidal CO2 monitoring,
self inflating bag, portable ventilator and
monitoring)
…………………………… Check the Equipment and Drugs

• Equipment and drugs specific to the details of

the injuries that are expected, e.g. anaesthetic
drugs for rapid sequence induction (RSI) of
anaesthesia if a patient with a head injury and
low glasgow coma scale (GCS) is expected or
chest drain equipment if a pneumothorax /
haemothorax is suspected

• Drug e.g. sedative, analgetic and drying agent

neuromuscular blocking agent
emergency drug
strictly dose and indication
• Remember you’re needed since onsite – during
transportation – referral hospital
• Can be more difficult when faced with a patient
in the emergency department, than in the
relative calmness of an anaesthetic room
• The senior help should be present to assist if
difficulties arise
• Don’t panic, call for help
• Soon
• Keep the airway clear, Cervical spine protection
• Ventilation support/oxygenation,
• Circulation support,
• Evaluation of disability
The Senior Help Should be Present to Assist if Difficulties Arise
• Because of potential cervical spine
instability, the patients neck movement may be
restricted to prevent spinal cord damage
• The patient may have a full stomach
• Inability to perform a complete airway
assessment if the patient is semi conscious
• Unfamiliar surroundings and staff, different
equipment or the lack of it. Limited space
around patient, especially at the head end
• “Adrenaline factor” in staff
 …………………………………………….The factor complicate airway

management in the emergency department

• Airway trauma will distort the normal anatomy

and blood in the airway will reduce the normal
visibility, while partial airway obstruction will
reduce the efficiency of pre oxygenation

• Undisclosed injuries, e.g. a simple

pneumothorax that will become a tension
pneumothorax when positive pressure
ventilation is started

• Un-cooperative patients (alcohol, head injuries

etc)
• All trauma patient must be assumed to
have a cervical spine injury until proved
otherwise

• The cervical spine must be maintained in a

neutral position to prevent causing damage
to the cervical cord

• Hold the head to prevent neck movement

 …………………Airway with cervical spine control

• The standard equipment to protect the

cervical spine consist of :
– A hard collar around the neck restricting
atlanto – occipital joint flexion and extension
– Sand bag or head box next to the head to
prevent lateral flexion and rotation, and
– Straps across the forehead and the chin to
prevent neck flexion
• Stridor, gurgling noise in throat or no inspiratory
noise
• Tachypnoea
• Use of accessory muscles of respiration
• Nasal flaring
• See – sawing of chest and abdomen
• Cyanosis
• Absence of water vapor in the facemask on
expiration
• Oropharyngeal & nasopharyngeal airways
can be used adjuncts to create a better
airway

• Do not use nasopharyngeal airway in a

head injury for fear of penetrating trauma
through the base of the skull
• Don’t panic, call for help
• Soon
• Keep the airway clear, Cervical spine protection
• Ventilation support/oxygenation, continuous nasopharyngeal
oxygenation
• Circulation support,
• Evaluation of disability
• Aspiration prevention, suction switch on. Make sure that
the table can be positioned head up-head down, simply !
• Cricoid pressure (Sellicks manouvre)
• Strictly drug usage – dose and indication
• Tracheal intubation
• Can be more difficult
• Trauma will disturb / destruct the normal anatomy
• Emergency equipment
• Oral intubation
– Trauma from laryngoscopy
– Excessive cervical spine motion
– Esophageal intubation
– Pneumothorax
– Damage to endotracheal tube
– Vomiting and aspiration
– Broken teeth
– Inadvertent extubation
– Laryngeal trauma
– Right main stem intubation
– Forcing debris in mouth down trachea
– Esophageal perforation
– Laryngotracheal disruption
– Blood clots obstructing tube
 ………………………….Complications of intubations
in trauma patients

• Nasal intubation
– All complications list above plus :
• False passage in posterior pharynx
• Air entry from paranasal sinuses into
subcutaneous tissue
• Nosebleed
• Prolonged intubation
– Sinusitis
– Necrosis of nose
• Expected – un expected difficult intubation
• Failure to intubation
– Digital intubation
– Lighted stylet
– Retrograde technique
– Percutaneous needle cricothyrotomy
– Percutaneous dilational tracheostomy
– Formal surgical tracheostomy
 …………………………………..Techniques for managing
the difficult airway and failed intubation

• Specialized intubation equipment

– Laryngeal mask airway
– Prisms and mirrors
– Bullard laryngoscope
– Augustine guide
– Mc Coy Laryngoscope
– Fibre optic intubation
– Endotrol endotracheal tube
• Airway and breathing problem will kill trauma patients
before other injuries

• All trauma patients may have full stomach

• All trauma patients have a cervical spine injury until

proved otherwise

• Prepare contingency plans and obtain appropriate

equipment

• Patient with pneumothoraces should have chest drains

inserted before intubation and positive pressure
ventilation

• Strictly drug usage, dose and indication

– Must be carefully titrated and levels of sedation and analgesia
frequently re – evaluated