Airway Assessment & Management

of Primary Trauma Survey

Associate Professor DR. YH

Emergency Physician & Medical Educationist
 1. Attention..lets get ready and roll
https://www.youtube.com/watch?v=9RlPGjBtHZk

ATLS – incorrect way

2. Objectives of today teaching & learning
At the end of the teaching and learning session, the learner should be able
to:

1. Evaluate and demonstrate Airway assessment & management per

primary trauma survey of ATLS as a tabletop exercise.

2. Evaluate and demonstrate breathing assessment & management per

primary trauma survey of ATLS as a tabletop exercise.

3. Recognize and formulate management of chest trauma per secondary

survey of ATLS.
 Bloom Taxonomy

Miller Pyramid
3. Pre-test
Regarding Primary trauma survey: T/F

A Correct sizing of oropharyngeal airway is measuring the distance from

corner of the patient’s mouth to the earlobe.

B Sequence of primary trauma survey is circulation assessment follow by

airway & breathing assessment.
C Laryngeal mask ventilation is a form of definitive airway.
D The big four of life threating chest trauma includes flail chest.
E The immediate intervention for stabilization of an open pneumothorax is
three-sided dressing application.
4. Why we train ourselves for caring of trauma
victims..

1) When the care of trauma starts?

2) What is Golden hour?

3) What is silver day?

4) What is the difference between trauma care & criminal justice

system?
 5. ATLS

5. Advanced Trauma Life Support

 Initial Assessment
Timing is crucial

rapid assessment of injuries

life preserving intervention

Systematic approach is essential which must be:

rapid
accurate
 Initial Assessment

Initial assessment includes the following elements:

1. Preparation
2. Triage
3. Primary survey (ABCDEs) with immediate resuscitation of patients
with life-threatening injuries
4. Adjuncts to the primary survey and resuscitation
5. Consideration of the need for patient transfer
6. Secondary survey (head-to-toe evaluation and patient history)
7. Adjuncts to the secondary survey
8. Continued post resuscitation monitoring and reevaluation
9. Definitive care
 Primary Survey with simultaneous resuscitation

It identifies life-threatening conditions by adhering to this

sequence:

1. Airway maintenance with restriction of cervical spine motion

2. Breathing and ventilation
3. Circulation with hemorrhage control
4. Disability(assessment of neurologic status)
5. Exposure/Environmental control
 Primary Survey with simultaneous resuscitation

Life-threatening conditions are identified and treated in a prioritized

sequence:

 based on the effects of injuries on the patient’s physiology, because at first

it may not be possible to identify specific anatomic injuries

 based on the degree of threat (the abnormality posing the greatest threat to
Life)

Note: ATLS describes the sequential steps in order of importance

and to ensure clarity.

In practice, these steps are frequently accomplished simultaneously by a

team of healthcare professionals
Airway
Management

Airway Management
 Airway Maintenance with
RESTRICTION OF CERVICAL SPINE MOTION
1.Airway Assessment

Self Identification/asking the trauma victim’s name/ Asking what

happened

Sir/Madam, I am doctor Khin. May I help you?

May I know what your name is?
What had happened to you?
 Airway Maintenance with
RESTRICTION OF CERVICAL SPINE MOTION

Appropriate Response Failure to response

(ability to speak clearly)

- no major airway compromise There is abnormalities in A, B, C, or

D that warrant urgent assessment
- breathing is not severely and management
compromised (i.e., ability to generate
air movement to permit speech)

- level of consciousness is not

markedly decreased
2.Opening of the airway
The tongue can fall backward and obstruct the hypopharynx in
patients who have a decreased level of consciousness.

chin-lift
jaw-thrust maneuvers

Caution:
The above maneuvers can produce or aggravate c-spine injury,
so restriction of cervical spinal motion is mandatory.
2A.Manual in-line stabilization

 Ask an assistant to perform

inline manual stabilization of
the neck of the unresponsive
trauma victim
Manual inline Stabilization
https://www.youtube.com/watch?v=PqiaHVYaK3c

Manual inline immobilization (start from 50s)

2B.Jaw-thrust & Trauma chin lift maneuvers
Jaw thrust

To perform a jaw thrust

maneuver, grasp the angles
of the mandibles with a hand
on each side and then
displace the mandible forward

Caution:
Be careful not to extend the
patient’s neck.
Trauma chin lift maneuver

Place the fingers of one hand under the mandible and then
gently lifting it upward to bring the chin anterior.
With the thumb of the same hand,
placed behind the lower incisors
while simultaneously lifting the chin gently.

Do not hyperextend the neck

while employing the
chin-lift maneuver.
https://www.youtube.com/watch?v=PdkgnRCoci4
Start from 1:55

https://www.youtube.com/watch?v=dkhhKrpMYnY
3. Clear the airway

Look for: Immediate intervention

Foreign bodies- glasses, grass, mud Suction with large bore rigid tip such
Blood & blood clots as Yankauer suction tube
Dentures & broken tooth
Lacerated tongue
If you see the Foreign Body,
you can remove by:

- Finger sweep method

- Magill forcep
 Safe use of suction
STEP 1.
Turn on the vacuum, selecting a midpoint (150 mm Hg) rather than full
vacuum (300 mm Hg).

STEP 2.
Gently open the mouth, inspecting for bleeding, lacerations or broken
teeth.
Look for the presence of visible fluid, blood, or debris.

STEP 3.
Gently place the suction catheter in the oropharynx and nasopharynx,
keeping the suction device (Yankauer) tip in view at all times.
4. Secure the airway
Oropharyngeal Airway

Different sizes of Oro Pharyngeal

Airway
STEP 1.
Select the proper size of airway.
A correctly sized OPA device extends
from the corner of the patient’s mouth to the earlobe.
STEP 2.
Open the patient’s mouth with
the crossed finger (scissors)
technique.
STEP 3.
Insert a tongue blade on top of
the patient’s tongue and
far enough back to depress
the tongue adequately.
Be careful not to cause
the patient to gag.
STEP 4.
Insert the airway posteriorly, gently sliding the airway over the
curvature of the tongue until the device’s flange rests on top of
the patient’s lips.
The device must not push the tongue backward and block the
airway.
Rotation method

- inserting the OPA

upside down so its tip is facing
the roof of the patient’s mouth.
As the airway is inserted,
it is rotated 180 degrees
until the flange comes to rest
on the patient’s lips and/or teeth.

Caution: This maneuver should not be

used in children because rotating
the device can damage the mouth
and pharynx.
STEP 5.
Remove the tongue blade.

STEP 6.
Reassess the patient to ensure that the airway is now patent.

https://www.youtube.com/watch?v=vgqOrmBskaw
Indications

 Patient who is unable to maintain his or her airway

 To prevent an intubated patient from biting an ET tube

Contraindications

 Patient who is conscious or semiconscious

Complications

- gagging, vomiting, aspiration, and laryngospasm

(Because it stimulates the gag reflex, use of the OPA may lead

to in patients who are conscious)

Caution

Patients who tolerate an oropharyngeal airway are highly likely to

require intubation
Nasopharyngeal Airway
Note: Do not use a nasopharyngeal airway in a patient with midface fractures or suspected basilar
skull fracture.

STEP 1.
Assess the nasal passages for any apparent obstruction (e.g., polyps, fractures, or
hemorrhage).

STEP 2.
Select the proper size of airway.
Look at the nostril diameter to determine the greatest size that will pass easily through the nostril.

STEP 3.
Lubricate the nasopharyngeal airway with a water-soluble lubricant or tap water.

STEP 4.
With the patient’s head in neutral position, stand to the side of the patient.
Holding the NPA like a pencil, gently insert the tip of the airway into the nostril and direct it
posteriorly and toward the ear.
STEP 5.
Gently insert the nasopharyngeal airway through the nostril into the
hypopharynx with a slight rotating motion, until the flange rests
against the nostril.

If during insertion the NPA meets any resistance, remove the NPA
and attempt insertion on the other side.

If the NPA causes the patient to cough or gag, slightly withdraw

the NPA to relieve the cough or gag and then proceed.

STEP 6.
Reassess the patient to ensure that the airway is now patent.
Nasopharyngeal airway insertion
https://www.youtube.com/watch?v=uALM3HqtTnI
Bag-valve-mask ventilation
One-person BVMV
STEP 1.
-Select the proper size of mask to fit the patient’s face
-The mask should extend from the proximal half of the nose to the
chin

STEP 2.
-Connect the oxygen tubing to the bag-mask device
-Adjust the flow of oxygen to 15 L/min

STEP 3.
Ensure that the patient’s airway is patent
(an oropharyngeal airway will prevent obstruction from the tongue)
 One-person BVMV

STEP 4.
Apply the mask over the patient’s nose and mouth with the dominant
hand, ensuring a good seal.

This is done by creating a ‘C’ with the thumb and index finger while
lifting the mandible into the mask with other three fingers of the
dominant hand.
 One-person BVMV

STEP 5.
Initiate ventilation by squeezing the bag with the non-dominant
hand.

STEP 6.
Assess the adequacy of ventilation by observing the patient’s
chest movement.

STEP 7.
Ventilate the patient in this manner every 5 seconds.
2-person BVMV

STEP 1. Select the proper size of mask to fit the patient’s face.

STEP 2. Connect the oxygen tubing to the bag-mask device and adjust the flow of oxygen to 15
L/min.

STEP 3. Ensure that the patient’s airway is patent (an oropharyngeal airway will prevent obstruction
from the tongue).

STEP 4. The first person applies the mask to the patient’s face, performing a jaw-thrust maneuver. Ensure a tight
seal with
both hands.

STEP 5. The second person initiates ventilation by squeezing the bag with both hands.

STEP 6. Assess the adequacy of ventilation by observing the patient’s chest movement.

STEP 7. Ventilate the patient in this manner every 5 seconds.

BVM Ventilation

https://www.youtube.com/watch?v=rOZVljYnmxc
C- Collar application
Introduction

Cervical spine stabilization is a part of airway management in

primary survey of advanced trauma life support.

In other words, you have to stabilize the cervical spine while you
are assessing and managing the airway.
Indications for cervical collar application

 
Injury above the clavicle Altered mental state

High impact injury Intoxication

Neurological deficit Distracting injuries

Spine tenderness
Steps in application of cervical collar
 
- Maintain manual in-line stabilization of the head & neck by first trauma care provider
 
- The second trauma care provider uses his or her fingers to measure the patient's neck between the
patient's lower jaw and shoulder.
 
- Unlock the two buttons on the adjustable cervical collar
 
- Adjust the adjustable cervical collar to the correct size by using the measurement just being done
 
- Lock the adjustable cervical collar
 
- The second trauma care provider applies the properly sized collar while the first trauma care provider
continues to maintain the neutral in-line head and neck stabilization.

-After applying and securing the cervical collar, manual in-line stabilization of the head and neck is
maintained until the patient is secured to an immobilization device.
 
- Check the carotid pulse
Conclusion

-Rigid cervical collars alone do not provide adequate immobilization.

They simply aid in
supporting the neck and promote a lack of movement.

-Properly sized rigid cervical collars limit flexion by about 90% and
limit extension, lateral bending, and rotation by about 50%.

-An ill-fitting, improperly sized cervical collar will not help the patient
and may be detrimental if an unstable spinal column is present.
 Conclusion

- A rigid cervical collar is an important adjunct to immobilization but

must always be used with manual stabilization or mechanical
immobilization provided by a suitable spine-immobilization device.

- Lastly, there have also been reports of increased intracranial

pressure associated with cervical collar use in patients with
traumatic brain injury.

- If the patient shows obvious signs of increasing intracranial

pressure, loosening or opening the collar should be considered to
provide some relief.
https://www.youtube.com/watch?v=hHHy1mc7sqY
Quizz

Quizz
1 The followings are true: T/F

A Primary trauma surveys aim to assess the life-threatening injuries

of the victim sustains.
B The sequence of primary trauma survey is Airway, Breathing &
cervical collar application, and Circulation.
C The first step in airway management starts with jaw thrust
maneuver.
D Manual in-line stabilization can be suspended when attempting
intubation.
E Jaw-thrust maneuver is to open the upper airway.
1 The followings are true: T/F

A Primary trauma surveys aim to assess the life-threatening injuries T

of the victim sustains.
B The sequence of primary trauma survey is Airway, Breathing & F
cervical collar application, and Circulation.
C The first step in airway management starts with jaw thrust F
maneuver.
D Manual in-line stabilization can be suspended when attempting F
intubation.
E Jaw-thrust maneuver is to open the upper airway. T
2 The followings are true: T/F

A Head tilt & chin lift maneuver is preferred in primary trauma survey.
B Clear the airway starts with finger sweep maneuver.
C Large bore suction tube can be use for clearance of airway.
D Oropharyngeal airway should be removed if the patient is biting it.
E Correct sizing of the cervical collar is measuring the distance
between base of the chin and shoulder.
2 The followings are true: T/F

A Head tilt & chin lift maneuver is preferred in primary trauma survey. F
B Clear the airway starts with finger sweep maneuver. F
C Large bore suction tube can be use for clearance of airway. T
D Oropharyngeal airway should be removed if the patient is biting it. T
E Correct sizing of the cervical collar is measuring the distance T
between base of the chin and shoulder.
Advanced level…
 Red flags

Rapid Problem identification Rapid intervention for

immediate stabilization
Acute upper airway obstruction

Trachea-bronchial disruption
Acute upper airway obstruction

Facial burns
Inhalational injuries
Maxillo-facial trauma
Neck trauma
Laryngeal trauma
Hoarseness of voice
Subcutaneous emphysema
Palpable fracture
 Acute upper airway obstruction

Look- Listen-Feel
Look

Agitation hypoxia
Obtunded hypercarbia
Cyanosis hypoxemia

Retractions and the use of accessory muscles of ventilation

Pulse oximetry

Listen

Hoarseness (dysphonia) implies functional aryngeal obstruction.

Abnormal sounds
Noisy breathing
Snoring, gurgling, and crowing sounds (stridor)
Laryngeal Mask
Laryngeal Mask Airway

effective in the treatment of patients

with difficult airways, particularly
if attempts
at endotracheal intubation or
bag-mask ventilation have failed

Not a definitive airway

Proper placement of this device is difficult without appropriate

training
Intubating Laryngeal Mask Airway

The ILMA is an enhancement of

the device that allows for
intubation through the LMA

When a patient has an LMA

or an ILMA in place on arrival
in the ED,
clinicians must plan for
a definitive airway.
https://www.youtube.com/watch?v=i4TKzIy5GjQ
STEP 1.
Ensure that adequate ventilation and oxygenation are in progress and that
suctioning equipment is immediately available in case the patient vomits.

STEP 2.
Choose the correct size of LMA: 3 for a small female, 4 for a large female or
small male,
and 5 for a large male.

STEP 3.
Inspect the LMA to ensure it is sterile and has no visible damage; check that
the lumen is clear.
STEP 4.
Inflate the cuff of the LMA to check that it does not leak.

STEP 5.
Completely deflate the LMA cuff by pressing it firmly onto a flat surface. Lubricate it.

STEP 6.
Have an assistant restrict motion of the patient’s cervical spine.

STEP 7.
Hold the LMA with the dominant hand, as you would hold a pen, placing the index
finger at the junction of the cuff and the shaft and orienting the LMA opening over the
patient’s tongue.
STEP 8.
Pass the LMA behind the upper incisors, keeping the shaft parallel to the patient’s
chest and the index finger pointing toward the intubator.

STEP 9.
Push the lubricated LMA into position along the palatopharyngeal arch while using the index
finger to maintain pressure on the tube and guide the LMA into final position.

STEP 10.
Inflate the cuff with the correct volume of air (indicated on the shaft of the LMA).

STEP 11.
Check placement of the LMA by applying bag ventilation.

STEP 12.
Confirm proper position by auscultation, chest movement, and ideally verification of CO2 by
capnography.
https://www.youtube.com/watch?v=NVD18kBjMyQ
Orotracheal Intubation
STEP 1.
Ensure that adequate ventilation and oxygenation are in progress and that
suctioning equipment is immediately available in case the patient vomits.

STEP 2.
Choose the correctly sized endotracheal tube (ETT).

STEP 3.
Inspect the ETT to ensure it is sterile and has no visible damage. Check
that the lumen is clear.

STEP 4.
Inflate the cuff of the ETT to check that it does not leak.
STEP 5.
Connect the laryngoscope blade to the handle and check the light bulb for
brightness.

STEP 6.
Assess the patient’s airway for ease of intubation, using the LEMON
mnemonic.
STEP 7.
Direct an assistant to restrict cervical motion.
The patient’s neck must not be hyperextended
or hyperflexed during the procedure.

STEP 8.
Hold the laryngoscope in the left hand.
(regardless of the operator’s dominant hand).

STEP 9.
Insert the laryngoscope into the right side of the patient’s mouth,
displacing the tongue to the left.
STEP 10.
Visually identify the epiglottis and then the vocal cords.
External laryngeal manipulation with backward, upward, and
rightward pressure (BURP) may help to improve visualization.

STEP 11.
Gently insert the ETT through the vocal cords into the trachea to the
correct depth without applying pressure on the teeth, oral tissues or lips.

STEP 12.
If endotracheal intubation is not accomplished before the SpO2 drops
below 90%, ventilate with a bag-mask device and change the
approach[equipment, i.e., gum elastic bougie (GEB) or personnel].
STEP 13.
Once successful intubation has occurred, apply bag ventilation.
Inflate the cuff with enough air to provide an adequate seal.
Do not overinflate the cuff.

STEP 14.
Visually observe chest excursions with ventilation.

STEP 15.
Auscultate the chest and abdomen with a stethoscope to
ascertain tube position.
STEP 16.
Confirm correct placement of the tube by the presence of CO2.
A chest x-ray exam is helpful to assess the depth of insertion of the tube
(i.e., mainstem intubation), but it does not exclude esophageal intubation.

STEP 17.
Secure the tube. If the patient is moved, reassess the tube placement.

STEP 18.
If not already done, attach a pulse oximeter to one of the patient’s fingers
(intact peripheral perfusion must exist) to measure and monitor the
patient’s oxygen saturation levels and provide immediate assessment of
therapeutic interventions.
Orotracheal intubation

https://www.youtube.com/watch?v=imYps3orGtc
 Surgical Cricothyrotomy
STEP 1.
Place the patient in a supine position with the neck in a neutral position.
Have an assistant restrict the patient’s cervical motion.

STEP 2.
Palpate the thyroid notch, cricothyroid cartilage, and sternal notch for orientation.

STEP 3.
Assemble the necessary equipment.

STEP 4.
Surgically prepare and anesthetize the area locally, if the patient is conscious.

STEP 5.
Stabilize the thyroid cartilage with the nondominant hand and maintain stabilization until the trachea is
intubated.
 Surgical Cricothyrotomy

STEP 6.

Make a 2- to 3-cm vertical skin incision over the cricothyroid membrane and, using the
nondominant hand from a cranial direction, spread the skin edges to reduce bleeding.

Reidentify the cricothyroid membrane and then incise through the base of the
membrane transversely.

Caution: To avoid unnecessary injury, do not cut or remove the cricoid and/or thyroid
cartilages.

STEP 7.

Insert thermostat or tracheal spreader or back handle of scalpel into the incision and
rotate it 90 degrees to open the airway.
 Surgical Cricothyrotomy

STEP 8.
Insert a properly sized, cuffed endotracheal tube or tracheostomy
tube (usually a size 5–6) through the cricothyroid membrane
incision, directing the tube distally into the trachea.

If an endotracheal tube is used, advance only until the cuff is no

longer visible to avoid mainstem intubation.

STEP 9.
Inflate the cuff and ventilate.
STEP 10.
Observe lung inflation and auscultate the chest for adequate ventilation
Confirm the presence of C02
Obtain a chest x-ray.

STEP 11.
Secure the endotracheal or tracheostomy tube to the patient, to prevent dislodgement.

Surgical cricothyrotomy
https://www.youtube.com/watch?v=4gNgiaXDZwI

Needle Cricothyrotomy
https://www.youtube.com/watch?v=F_PV7N2c2pQ
QUIZZ Time
The followings are true or false: T/F
A If oxygen saturation falls below 95% during attempted
intubation, you must abort your procedure and bag the patient.
B External laryngeal manipulation with backward, upward, and
rightward pressure (BURP) may help to improve visualization.
C The best way of confirming ETT in correct place is by noting the
fogging of the tube by ventilation.
D Definitive air way must be instituted after laryngeal valve mask
insertion.
E Surgical cricothyrotomy is performed through thyrohyoid
membrane.
QUIZZ Time
The followings are true or false: T/F
A If oxygen saturation falls below 95% during attempted F
intubation, you must abort your procedure and bag the patient.
B External laryngeal manipulation with backward, upward, and T
rightward pressure (BURP) may help to improve visualization.
C The best way of confirming ETT in correct place is by noting the F
fogging of the tube by ventilation.
D Definitive air way must be instituted after laryngeal valve mask T
insertion.
E Surgical cricothyrotomy is performed through thyrohyoid F
membrane.
Tabletop Resus Exercise

A 25-year-old motorcyclist was on high speed about 140KM per hour when he
collided with a cow. He was thrown out about 10 meters where he laid
unconscious.
He was brought in by an ambulance carrying with a rigid spinal board, but no
treatment was given on the way.
You are at the red zone of Emergency Department.

Patient is lying on the trolley…

Perform primary trauma survey…

-Assess airway
-manual inline stabilization
-open the airway: jaw thrust
-Secure the airway: OPA
-C collar
-ETT
-Cricothyrodotomy
End of Airway assessment of primary trauma survey

END