Airway and Ventilatory Management

AIRWAY

1. Problem Recognition
 “talking patient”provides momentary reassurance that the airway is patent and not compromised. Therefore, the most important early
assessment measure is to talk to the patient and stimulate a verbal response. A positive, appropriate verbal response with a clear voice
indicates that the patient’s airway is patent, ventilation is intact, and brain perfusion is sufficient.
 Failure to respond or an inappropriate response suggests an altered levelof consciousness that may be a result of airway or ventilatory
compromise, or both.
 Patients with an altered level of consciousness are at particular risk for airway compromise and often require a definitive airway.
 It is important to anticipate vomiting in all injured patients and be prepared to manage the situation. The presence of gastric contents in
the oropharynx presents a significant risk of aspiration with the patient’s next breath. In this case, immediately suction and rotate the
entire patient to the lateral position while restricting cervical spinal motion.

o Maxillofacial Trauma
 Fractures of the mandible,especially bilateral body fractures, can cause loss of normal airway structural support, and airway
obstruction can result if the patient is in a supine position

 Furthermore, providing general anesthesia, sedation,or muscle relaxation can lead to total airway loss due to diminished or absent
muscle tone.

o Neck Trauma
 Penetrating injury to the neck can cause vascular injury with significant hematoma, which can result in
 Displacement and obstruction of the airway.

o Laryngeal Trauma
 triad of clinical signs:
1. Hoarseness
2. Subcutaneous emphysema
3. Palpable fracture
 Complete obstruction of the airway or severe respiratory distress from partial obstruction warrants an attempt at
intubation. Flexible endoscopic intubation may be helpful in this situation, but only if it can be performed promptly. If
intubation is unsuccessful, an emergency tracheostomy is indicated, followed by operative repair.
 Surgical cricothyroidotomy,although not preferred in this situation, can be a lifesaving option.
 Penetrating trauma to the larynx or trachea can be overt and require immediate management. Complete
 tracheal transection or occlusion of the airway with blood or soft tissue can cause acute airway compromise requiring
immediate correction. These injuries are often associated with trauma to the esophagus, carotid artery, or jugular vein, as
well as soft tissue destruction or swelling.
 Noisy breathing indicates partial airway obstruction that can suddenly become complete, whereas the
 absence of breathing sounds suggests complete obstruction.When the patient’s level of consciousness is
 depressed, detection of significant airway obstruction is more subtle, and labored breathing may be the only clue to
airway obstruction or tracheobronchial injury.

2. Objective Signs of Airway Obstruction

 agitated (suggesting hypoxia)
 obtunded (suggesting hypercarbia).
 Cyanosis indicates hypoxemia from inadequate – use pulse oximeter in early airway assessment can detect inadequate oxygenation
before cyanosis
 Listen – Stridor associated with partial occlusion of larynx/pharynx, hoarsness(dysphonia) implies functional laryngeal obstruction

Ventilation

1. Problem Recognition

 Ventilation compromised - altered ventilatory mechanics, and/or central nervous system (CNS) depression.
 Injuries below the C3 level result in maintenance of the diaphragmatic function but loss of the intercostal and abdominal muscle
contribution to respiration. Typically these patients display a seesaw pattern of breathing in which the abdomen is pushed out with
inspiration, while the lower ribcage is pulled in. This presentation is referred to as “abdominal breathing” or “diaphragmatic
breathing.” This pattern of respiration is inefficient and results in rapid, shallow breaths that lead to atelectasis and ventilation
perfusion mismatching and ultimately respiratory failure.
 2. Objective Signs of Inadequate Ventilation

 Look - symmetrical rise and fall of the chest and adequate chest wall excursion. Asymmetry suggests splinting of the rib
cage, pneumothorax, or a flail chest. Labored breathing may indicate an imminent threat to the patient’s ventilation.
 Listen - movement of air on both sides of the chest
 Use a pulse oximeter to measure the patient’s oxygen saturation and gauge peripheralperfusion. Note, however, that this
device does not measure the adequacy of ventilation

Airway management

 all of these actions potentially require neck motion, restriction of cervical spinal motion is necessary in all trauma
patients at risk for spinal injury until it has been excluded by appropriate radiographic adjuncts and clinical evaluation.
 cribriform plate fractures, and the insertion of any tube through the nose can result in passage into the cranial vault
 helmet- two-person procedure: One person restricts cervical spinal motion from below while the second person expands
the sides of the helmet and removes it from above. Then, clinicians reestablish cervical spinal motion restriction from
above and secure the patient’s head and neck during airway management. Using a cast cutter to remove the helmet while
stabilizing the head and neck can minimize c-spine motion in patients with known c-spine injury

 potential difficulties with airway maneuvers include:

1. •• C-spine injury
2. •• Severe arthritis of the c-spine
3. •• Significant maxillofacial or mandibular trauma
4. •• Limited mouth opening
5. •• Obesity
6. •• Anatomical variations (e.g., receding chin, overbite, and a short, muscular neck)
7. •• Pediatric patients
LEMON assessment

Airway Maintenance Techniques

 Chin-Lift Maneuver - tongue can fall backward and obstruct the hypopharynx. Maneuvers used to establish an airway
can produce or aggravate c-spine injury, so restriction of cervical spinal motion is mandatory during these procedures.
 Jaw-Thrust Maneuver

1. Nasopharyngeal Airway

Do not attempt this procedure in patients with suspected or potential cribriform plate fracture.

2. Oropharyngeal Airway
Do not use this method in children, because rotating the device can damage the mouth and pharynx. Instead, use a tongue blade to
depress the tongue and then insert the device with its curved side down, taking care not to push the tongue backward, which would
block the airway

3. Extraglottic and Supraglottic Devices

Laryngeal Mask Airway and Intubating LMA particularly if attempts at endotracheal intubation or bag-mask ventilation have
failed

4. Laryngeal Tube Airway and Intubating LTA

Multilumen Esophageal Airway airway devices to provide oxygenation and ventilation when a definitive airway is not feasible.

DEFINITIVE AIRWAYS
Cuffed tube in trachea

The criteria for establishing a definitive airway are based on clinical findings

• A —Inability to maintain a patent airway by other means, with impending or potential airway compromise (e.g., following
inhalation injury, facial fractures, or retropharyngeal hematoma)

• B —Inability to maintain adequate oxygenation by facemask oxygen supplementation, or the presence of apnea

• C —Obtundation or combativeness resulting from cerebral hypoperfusion

• D —Obtundation indicating the presence of a head injury and requiring assisted ventilation (Glasgow Coma Scale [GCS] score
of 8 or less), sustained seizure activity, and the need to protect the lower airway from aspiration of blood or vomitus

Endotracheal Intubation
Patients with GCS scores of 8 or less require prompt intubation. no immediate need for intubation, obtain radiological evaluation
of the c-spine.
However, a normal lateral c-spine film does not exclude the possibility of a c-spine injury Facial, frontal sinus, basilar skull, and
cribriform plate fractures are relative contraindications to nasotracheal intubation.
Evidence of nasal fracture,raccoon eyes (bilateral ecchymosis in the periorbital region), Battle’s sign (postauricular ecchymosis),
and possible cerebrospinal fluid (CSF) leaks (rhinorrhea or otorrhea) are all signs of these injuries.
As with orotracheal intubation, take precautions to restrict cervical spinal motion.
Cricoid pressure during endotracheal intubation can reduce the risk of aspiration, although it may also reduce the view of the
larynx
The presence of CO2 in exhaled air indicates that the airway has been successfully intubated, but does not ensure the correct
position of the endotracheal tube within the trachea
Proper position of the tube within the trachea is best confirmed by chest x-ray, once the possibility of esophageal intubation is
excluded.

Drug-Assisted Intubation – RSI

The technique for drug-assisted intubation is as follows:

1. Have a plan in the event of failure that includes the possibility of performing a surgical airway. Know where your rescue airway
equipment is located.
2. Ensure that suction and the ability to deliver positive pressure ventilation are ready.
3. Preoxygenate the patient with 100% oxygen.
4. Apply pressure over the cricoid cartilage.
5. Administer an induction drug (e.g., etomidate, 0.3 mg/kg) or sedative, according to local protocol.
6. Administer 1 to 2 mg/kg succinylcholine intravenously (usual dose is 100 mg).

After the patient relaxes:

7. Intubate the patient orotracheally.
8. Inflate the cuff and confirm tube placement by auscultating the patient’s chest and determining the presence of CO2 in exhaled
air.
9. Release cricoid pressure.
10. Ventilate the patient.

If endotracheal intubation is unsuccessful, the patient must be ventilated with a bag-mask device until the paralysis resolves;
long-acting drugs are not routinely used for RSI for this reason.

Surgical Airway
Cricothyroidotomy or tracheostomy
indicated in the presence of edema of the glottis, fracture of the larynx, severe oropharyngeal hemorrhage that obstructs the
airway, or inability to place an endotracheal tube through the vocal cords
A surgical cricothyroidotomy is preferable to a tracheostomy for most patients who require an emergency surgical airway because
it is easier to perform, associated with less bleeding, and requires less time to perform than an emergency tracheostomy

 Needle Cricothyroidotomy
short-term basis
large-caliber plastic cannula—12- to 14-gauge for adults, and 16- to 18-gauge in children—through the cricothyroid membrane
into the trachea below the level of the obstruction onnected to oxygen at 15 L/min (50 to 60 psi) with a Y-connector or a side hole
cut in the tubing between the oxygen source and the plastic cannula.
Intermittent insufflation, 1 second on and 4 seconds off, can then be achieved by placing the thumb over the open end of the Y-
connector or the side hole
The patient may be adequately oxygenated for 30 to 45 minutes using this technique. During the 4 seconds that the oxygen is not
being delivered under pressure, some exhalation occurs.
Because of the inadequate exhalation, CO2 slowly accumulates and thus limits the use of this technique, especially in patients
with head injuries.

 Surgical Cricothyroidotomy

skin incision that extends through the cricothyroid membrane
A. Palpate the thyroid notch, cricothyroid interval, and sternal notch for orientation.
B. Make a skin incision over the cricothyroid membrane and carefully incise the membrane transversely.
C. Insert a hemostat or scalpel handle into the incision and rotate it 90 degrees to open the airway.
D. Insert a properly sized, cuffed endotracheal tube or tracheostomy tube into the cricothyroid membrane incision, directing the
tube distally into the trachea.

Management of oxygenation

pulse oximetry must be used at all times.

It does not measure the partial pressure of oxygen (PaO2) and, depending on the position of the oxyhemoglobin dissociation
curve, the PaO2 can vary widely measured saturation of 95% or greater by pulse oximetry is strong corroborating evidence of
adequate peripheral arterial oxygenation (PaO2 >70 mm Hg, or 9.3 kPa).

requires intact peripheral perfusion

and cannot distinguish oxyhemoglobin from carboxyhemoglobin or methemoglobin, which limits its usefulness in patients with
severe vasoconstriction and those with carbon monoxide poisoning

PRIMARY SURVEY AND RESUSCITATION OF PA TIENTS WITH POTENTIALLY LIFE-

THREATENING EXTREMITY IN JURIES

Potentially life-threatening extremity injuries include

1. MAJOR ARTERIAL HEMORRHAGE

2. BILATERAL FEMORAL FRACTURES,
3 CRUSH SYNDROME.

Hemorrhage from long-bone fractures can be significant, and femoral fractures in particular often result in significant blood loss
into the thigh.
Appropriate splinting of fractures can significantly decrease bleeding by reducing motion and enhancing the tamponade effect of
the muscle and fascia.
fracture is open, application of a sterile pressure dressing typically controls hemorrhage
  Major Arterial Hemorrhage and Traumatic Amputation

Assessment

The ankle/brachial index is determined by taking the systolic blood pressure value at the ankle of the injured leg and dividing it by
the systolic blood pressure of the uninjured arm.

Management

manual pressure to the wound

A pressure dressing is then

applied, using a stack of gauze held in place by a circumferential elastic bandage to concentrate pressure over the injury

If bleeding persists, apply manual pressure to the artery proximal to the injury
If bleeding continues, consider applying a manual tourniquet (such as a windlass device) or a pneumatic tourniquet
applied directly to the skin

If time to operative intervention is longer than 1 hour, a single attempt to deflate the tourniquet may be considered in an otherwise
stable patient.
The use of arteriography and other diagnostic tools is indicated only in resuscitated patients who have no
hemodynamic abnormalities;

Application of vascular clamps into bleeding open wounds while the patient is in the ED is not advised,
If a fracture is associated with an open hemorrhaging wound, realign and splint it while a second person applies direct pressure to
the open wound.
Joint dislocations should be reduced, if possible; if the joint cannot be reduced, emergency orthopedic intervention may be
required.

 Amputation - Replantation is usually performed on patients with an isolated extremity injury

thoroughly wash the amputated part in isotonic solution (e.g., Ringer’s lactate) and wrap it in moist sterile gauze. Then wrap the
part in a similarly moistened sterile towel, place in a plastic bag, and transport with the patient in an insulated cooling
chest with crushed ice – DO NOT FREEZE

 Bilateral Femur Fractures

 Crush Syndrome / Traumatic Rhabdomyolysis

clinical effects of injured muscle that, if left untreated, can lead to acute renal failure and shock

Assessment

Myoglobin produces dark amber urine that tests positive for hemoglobin Rhabdomyolysis can lead to metabolic acidosis,
hyperkalemia, hypocalcemia, and disseminated intravascular coagulation

Management

Initiating early and aggressive intravenous fluid therapy during resuscitation is critical to protecting the kidneys and preventing
renal failure in patients with rhabdomyolysis
Myoglobin-induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by intravenous
administration of bicarbonate, and osmotic diuresis.
Adjuncts to the primary survey of patients with musculoskeletal trauma
when fracture is suspected as a cause of shock ; Include
1. fracture immobilization
2. x-ray examination,

1. Fracture Immobilization

realign the injured extremity in as close to anatomic position as possible and prevent excessive motion at
the fracture site. Applying inline traction to realign the extremity and maintaining

traction with an immobilization device Proper application of a splint helps control blood loss, reduces pain, and prevents further
neurovascular compromise and soft-tissue injury

If an open fracture is present, pull the exposed bone back into the wound, because open fractures require surgicaldebridement.

Remove gross contamination and particulate matter from the wound administer weight-based dosing of antibiotics as early as
possible in patients with open fractures

If a closed reduction successfully relocates the joint, immobilize it in the anatomic position with prefabricated splints, pillows, or
plaster to maintain the extremity in its reduced position

If reduction is unsuccessful, splint the joint in the position in which it was found

Apply splints as soon as possible, because they can control hemorrhage and pain.

2. X-ray Examination

it may be undertaken during the primary survey when fracture is suspected as a cause of shock.

Limb-Threatening Injuries
1. open fractures
2. joint injuries
3. ischemic vascular injuries
4. compartment syndrome
5. neurologic injury secondary to fracture or dislocation

1. Open Fractures and Open Joint Injuries

 The presence of intraarticular gas on a CT of the affected extremity is highly sensitive and specific for identifying open
joint injury
 Treat all patients with open fractures as soon as possible with intravenous antibiotics using weight-based dosing
 Delay of antibiotic administration beyond three hours is related to an increased risk of infection.

2. Vascular Injuries
3. Compartment Syndrome

The absence of a palpable distal pulse is an uncommon or late finding and is not necessary to diagnose compartment
syndrome

 Capillary refill times are also unreliable for diagnosing compartment syndrome
 Weakness orparalysis of the involved muscles in the affected limb is a late sign and indicates nerve or muscle damage
 Tissue pressures of greater than 30 mm Hg suggest decreased capillary blood flow, which can result in muscle and nerve
damage from anoxia. Blood pressure is also important:
 The lower the systemic pressure, the lower the compartment pressure that causes a compartment syndrome
 ABDOMEN & PELVIS – ORGAN SPECIFIC

INDICATIONS FOR LAPAROTOMY

1. Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal bleeding, or
without another source of bleeding
2. Hypotension with an abdominal wound that penetrates the anterior fascia
3. Gunshot wounds that traverse the peritoneal cavity
4. Evisceration
5. Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma
6. Peritonitis
7. Free air, retroperitoneal air, or rupture of the hemidiaphragm
8. Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle
injury, or severe visceral parenchymal injury after blunt or penetrating trauma Blunt or penetrating abdominal trauma
with aspiration of gastrointestinal contents, vegetable fibers, or bile from DPL, or aspiration of 10 cc or more of blood in
hemodynamically abnormal patients

1. Duodenal Injuries
 A bloody gastric aspirate or retroperitoneal air on an abdominal radiograph or CT should raise suspicion for this injury.
An upper gastrointestinal x-ray series, double-contrast CT, or emergent laparotomy is indicated for high-risk patients.

2. Pancreatic Injuries
 An early normal serum amylaselevel does not exclude major pancreatic trauma
 Double-contrast CT may not identify significant pancreatic trauma in the immediate postinjury period (up to 8 hours).
 Surgical exploration of the pancreas may be warranted following equivocal diagnostic studies.

3. Genitourinary Injuries
 Contusions, hematomas, and ecchymoses of the back or flank are markers of potential underlying renal injury and
warrant an evaluation
 Gross hematuria is an indication for imaging the urinary tract An abdominal CT scan with IV contrast can document the
presence and extent of a blunt renal injury, which frequently can be treated nonoperatively.
 Thrombosis of the renal artery and disruption of the renal pedicle secondary to deceleration are rare injuries in which
hematuria may be absent, although the patient can have severe abdominal pain. - With either injury, an IVP, CT, or renal
arteriogram can be useful in diagnosis

 An anterior pelvic fracture usually is present in patients with urethral injuries.

 Urethral disruptions are divided into those above (posterior) and below (anterior) the urogenital diaphragm.
 A posterior urethral injury is usually associated with multisystem injuries and pelvic fractures
 Anterior urethral injury results from a straddle impact and can be an isolated injury

4. Solid Organ Injuries

 Injuries to the liver, spleen, and kidney - that result in shock, hemodynamic abnormality, or evidence ofcontinuing
hemorrhage are indications for urgent laparotomy
 Solid organ injury in hemodynamically normal patients can often be managed nonoperatively\

5. Pelvic Fractures and Associated Injuries

commonly involve disruption of the posterior osseous ligamentous complex (i.e., sacroiliac, sacrospinous, sacrotuberous, and
fibromuscular pelvic floor), evidenced by a sacral fracture, a sacroiliac fracture, and/or dislocation of the sacroiliac joint.

four types

1. AP compression –
 produces external rotation of the hemipelvis with separation of the symphysis pubis and tearing of the posterior
ligamentous complex .
 The disrupted pelvic ring widens, tearing the posterior venous plexus and branches of the internal iliac arterial system.
Hemorrhage can be severe and life threatening.
 2. Lateral compression –
 Hemipelvis rotates internally reducing pelvic volume and reducing tension on the pelvic vascular structures
 This internal rotation may drive the pubis into the lower genitourinary system, potentially causing injury to the bladder
and/or urethra
 these patients require early hemorrhage control techniques such as angioembolization

3. Vertical shear
 disrupts the sacrospinous and sacrotuberous ligaments and leads to major pelvic instability
 A fall from a height greater than 12 feet commonly results in a vertical shear injury.

4. Combined mechanism

MANAGEMENT
1. Management of hypovolemic shock - rapid hemorrhage control and fluid resuscitation
2. Hemorrhage Control
 Mechanical stabilization of the pelvic ring and external counter pressure.

 Injuries associated with major hemorrhage externally rotate the hemipelvis, internal rotation of the lower limbs may
assist in hemorrhage control by reducing pelvic volume

 A sheet, pelvic binder, or other device can produce sufficient temporary fixation for the unstable pelvis when applied at
the level of the greater trochanters of the femur

 In cases of vertical shear injuries,longitudinal traction applied through the skin or the skeleton can also assist in providing
stability
 External pelvic binders are a temporary emergency procedure - Angiographic embolization is frequently employed to
stop arterial hemorrhage related to pelvic fractures

 Preperitonealpacking is an alternative method to control pelvic hemorrhage when angioembolization is delayed or

unavailable.