Airway Techniques for Management in Trauma Patients

1. AIRWAY AND
ANESTHETIC
MANAGEMENT OF THE
TRAUMATIZED PATIENT
Hadi Munib
Oral and Maxillofacial Surgery Resident

2. Outline
 Importance of Airway in maxillofacial Trauma
 Initial Airway Assessment
 History
 Physical Examination
 Anesthetic Strategies
 References

3. Importance of Airway in Maxillofacial Trauma
 The maxillofacial trauma patient can present with impending airway compromise.
 Patent airway is mandatory.
 Maxillofacial injuries can prevent the trauma surgeon from securing an airway.
 An airway obstruction can be due to:
 Foreign body
 Mandibular injury or maxillary injury
 Tracheal injury, laryngeal injury, or tongue injury
 Which can be compounded by hemorrhage or edema resulting from injuries to these or
associated structures.

4. Importance of Airway in Maxillofacial Trauma
 Great care must be taken to avoid excessive movement of the cervical spine.
 The patient’s neck should not be rotated, hyper-flexed, or hyperextended.
 In order to minimize iatrogenic injury, the patient’s neck should be immobilized until a
detailed cervical spine examination and complete cervical spine radiographic series
are performed and a cervical spine injury has been ruled out.
 A common error in trauma management during the primary survey involves delay in
securing the patient’s airway.
 Maxillofacial Injuries may complicate airway management: compromise airway
integrity, resulting in poor exchange or obstruction, and the soft tissue or skeletal injury
may make providing respiratory support difficult.

5. Importance of Airway in maxillofacial Trauma
 Gruen et al studied 2594 trauma mortality patients in order to identify patterns of errors
contributing to inpatient deaths.
 They found that failure to intubate, secure or protect the airway was the most common
factor related to patient mortality, responsible for 16% of inpatient deaths.

6. Initial Airway Assessment
 The airway should be assessed to ascertain patency.
 The well-established approach to the ABCs (airway, breathing, circulation) is the
standard approach.
 Is the patient able to communicate verbally?
 Is the patient breathing spontaneously?
 Does the patient have adequate oxygenation?
 A negative response to any of these questions will require emergent intervention to
secure adequate oxygenation and ventilation.
 The inability to obtain control of the airway can result in irreversible brain damage due to
hypoxia in as little as 4 minutes.
 Severe head-injury patients with a Glasgow Coma Scale (GCS) score of 8 or less
usually require the placement of a definitive airway.

7. Initial Airway Assessment
 Airway patency does not ensure adequate ventilation.
 Ventilation requires adequate gas exchange with adequate oxygenation with normal
function of the lungs, diaphragm, and chest wall.
 Chest auscultation and percussion can help in assessing the patency of oxygenation;
 Auscultation is the most important technique in assessing air flow through the
tracheobronchial tree.
 Breath sounds may be decreased when air flow is decreased (due to muscular
weakness) or when the transmission of sound is poor (due to pleural effusion or
pneumothorax).
 The chest wall should be visually inspected to rule out any chest injuries.
 Conditions such as flail chest or massive hemothorax, as well as tension or open
pneumothorax, can compromise ventilation and oxygenation and need immediate
attention.

8. Initial Airway Assessment
 Every trauma patient should receive supplemental oxygen.
 Maintaining good oxygen saturation and preventing hypercarbia are key factors.
 A pulse oximeter is essential in assessing adequate hemoglobin saturation.
 Potential for a false initial assessment for a patient who may have both normal
appearing skin tone and oxygen saturation secondary to carbon monoxide exposure.
 Capnography could be helpful in monitoring the concentration or partial pressure of
carbon dioxide (CO2).
 It is usually presented as a graph of expiratory CO2 plotted against time.
 The capnogram is a direct monitor of the inhaled and exhaled concentration or partial
pressure of CO2 and is actually an indirect monitor of the CO2 partial pressure in the
arterial blood.

10. Initial Airway Assessment
 Vital signs are an important part of the assessment.
 Hypotension is usually indicative of hypovolemia.
 Hemorrhage is the most common cause of shock after injury.
 Almost all trauma patients have an element of hypovolemia, which is indicative of
hemorrhagic shock.
 Cardiogenic shock due to myocardial dysfunction can occur in trauma patients,
especially if they sustain blunt cardiac injury, cardiac tamponade, or myocardial
infarction.
 Skin color could be an important tool in assessing perfusion and oxygenation.

11. Initial Airway Assessment
 Capillary refill; the rate at which blood refills empty capillaries;
 Capillary refill is usually 1.5 to 2 seconds.
 Prolonged capillary refill suggests diminished localized blood flow or dehydration.

12. Airway Assessment
 Identify the patient with a potentially difficult airway.
 History and Physical Examination
 A patient’s history should inquire as to difficulties with airway
management during previous anesthetics, presence of obstructive
sleep apnea (OSA), and previous surgeries on the airway.
page 12

13. Airway Assessment
 The physical examination focuses on several potentially contributing
anatomic abnormalities, which have been shown to correlate well with
increasing difficulty with intubation:
 Modified Mallampati test; based on the ability to visualize the uvula
and facial pillars with the mouth open wide, tongue maximally protruded,
neck extended forward into the sniffing position, while the patient
phonates
page 13

14. page 14

15. Airway Assessment
 Thyromental distance; a measurement from the mandibular menton to
the prominence of the thyroid cartilage, with the neck fully extended.
 The distance should be at least 6 cm or approximately three ordinary
fingerbreadths.
 A short thyromental distance equates with an anterior larynx that is at a
more acute angle and also results in less space for the tongue to be
compressed into by the laryngoscope blade
page 15

16. Thyromental Distance

17. Airway Assessment
 Mandibular retrognathia.
 Interincisal opening less than 3 cm (reduced temporomandibular joint [TMJ]
mobility, trismus, scarring, fibrosis).
 Short neck.
 Neck circumference greater than 17 cm.
 Enlarged tonsils (grade 3–4).
 Limited neck flexion or head extension (e.g., rheumatoid arthritis, ankylosing
spondylitis).
 Prominent upper incisors.
 Abnormal oropharyngeal/neck masses.
 Congenital, developmental, or acquired facial deformities (e.g., craniofacial
syndromes, burns to the head and neck).
page 17

18. page 18

19. Airway Assessment
 Five independent predictors have been associated with impossible mask
ventilation:
1. Neck radiation changes
2. Male sex
3. OSA
4. Mallampati 3 or 4
5. Presence of a beard.
 Certain features such as: obesity, snoring, and lack of teeth were reported
to potentially increase the difficulty of mask ventilation but could be
overcome using various maneuvers and were not found to be predictors of
impossible mask ventilation
page 19

20. LEMON Assessment

21. History
 In many acute trauma patients, history cannot be obtained from the patient.
 Pre-hospital personnel and family members may be helpful in providing some of this
relevant information.
 The AMPLE history is a quick mnemonic to use in evaluating the trauma patient:
 A: Allergies
 M: Medications (currently used)
 P: Pregnancy/Past illnesses
 L: Last meal
 E: Events/Environment related to the injury

22. History
 A patient who is on a beta blocker can have a “normal” heart rate even in hypovolemic
shock.
 Patients on anticoagulants are prone to severe bleeding and hemorrhage.
 With many elderly patients on anticoagulants, a neurologic hemorrhage must be ruled
out in this patient population.
 There is the potential for airway compromise associated with an increased risk of
aspiration, decreased functional residual volume, and increased difficulty in intubating
the airway.
 There are hemodynamic changes that impact fluid management, as well as the
pharmacokinetics and pharmacodynamics of anesthetic and emergency agents

23. History
 The mechanism of injury can provide the trauma surgeon with pertinent information
about the type of injuries sustained.
 Blunt injuries usually result from motor vehicle accidents (MVAs), falls, and occupation-
related injuries.
 Important prehospital information to obtain from MVA patients includes seat belt usage,
direction and type of impact, steering wheel deformation, and automobile damage.
 Rear impact in an MVA will probably result in cervical spine injury and/or soft tissue
injury to the neck.
 The extent of injury depends on the region of the body affected, the path of the
penetrating object, and the organs in proximity to the injury, as well as the velocity of
the missile.

24. Six Specific Situations Associated with Maxillofacial Trauma in
which these situations might affect the Airway
1. Posteroinferior displacement of a fractured maxilla parallel to the inclined plane of
the skull base may block the nasopharyngeal airway.
2. A bilateral fracture in the mandible (comminuted in anterior mandible/ Bilateral
Parasympheseal)
3. Fractured or exfoliated teeth, bone fragments, vomitus and blood as well as foreign
bodies – dentures, debris, shrapnel etc.
4. Hemorrhage, either from distinct vessels in open wounds or severe nasal bleeding
from complex blood supply of the nose, may also contribute to airway obstruction.
5. Soft tissue swelling and edema resulting from trauma to the head and neck may
cause delayed airway compromise.
6. Trauma to the larynx and trachea may cause swelling and displacement of
structures, such as the epiglottis, arytenoid cartilages and vocal cords, thereby
increasing the risk of cervical airway obstruction.

26. Physical Examination
 Airway patency can affect the ability to ventilate and intubate the patient.
 Part of a detailed trauma examination is to recognize the problem and manage it
appropriately.
 Airway compromise may be partial or complete.
 Signs such as stridor, dyspnea, tachypnea, and dysphagia may be indicative of airway
obstruction.
 Tachypnea could be an early sign of airway or ventilatory compromise.
 The patient with an altered level of consciousness is at high risk of airway compromise
and will require a secure airway.

27. Physical Examination
 Soft tissue: A detailed soft tissue examination must be performed.
 Significant tissue avulsions or injuries may result in an inability to secure a mask and
provide ventilatory support.
 Avulsion
 Laceration
 Abrasion
 Puncture
 Contusion

29. Soft Tissue Injury

30. Physical Examination
 Hemorrhage: can lead to airway irritation, aspiration, and laryngospasm.
 Pressure packing may be needed to control the bleeding.
 If the bleeding does not stop, surgical exploration or interventional radiology might be
indicated (especially in neck trauma).
 Hemorrhage can result in an expanding hematoma that can compromise airway
integrity.
 Securing an airway either via intubation or tracheotomy may be required

33. Physical Examination
 Skeleton
 (a) Mandibular fractures are common in trauma patients.
 Bilateral mandibular fractures can lead to a flail mandible; upper airway obstruction
due to posterior movement of the tongue. Lying supine can further aggravate the
obstruction.
 Airway adjuncts (e.g., nasopharyngeal airway) may assist in supporting and
maintaining airway patency.

35. Physical Examination
 (b) Trauma to the midface can result in injuries to the nasopharynx and oropharynx.
 These fractures could be associated with hemorrhage, dislodged teeth, or unstable
segments (maxilla or midface), any of which could lead to airway compromise.
 Posterior and downward displacement of a Le Fort fracture can result in an open bite
and difficulty with mask ventilation.
 Displacement of a Le Fort II/III fracture can result in obstruction of the nasopharynx

37. Physical Examination
 (c) Nasal fractures can lead to posterior bleeding and aspiration and thus to
nasopharyngeal obstruction.
 Nasal intubation is relatively contraindicated in midface fractures because of the risk of
the endotracheal tube entering either the cranium or the orbit.
 A hematoma in the oropharynx or nasopharynx can lead to partial or complete airway
obstruction.
 A nasal septal hematoma can lead to nasopharyngeal obstruction.
 An urgent surgical airway may be needed if endotracheal intubation is not possible.

38. Physical Examination
 Laryngeal trauma:
 Laryngeal trauma is associated with the triad of hoarseness, subcutaneous
emphysema, and a palpable fracture.
 Patients with arytenoid injury are at higher risk of aspiration.
 Some of the symptoms of arytenoid injury include hoarseness, dysphagia, sore throat,
dyspnea, vocal fatigue, loss of vocal control, and cough.
 A flexible endoscopically guided intubation may be helpful in laryngeal trauma.
 Early diagnosis of tooth aspiration in the multi-trauma patient can be difficult because
aspiration is rarely considered in the absence of an acute clinical presentation.
 Accounting for teeth is an important aspect of the maxillofacial exam.

40. Injuries Affecting Airway: Cervical Spine Injury
 Cervical spine injury must be presumed in any patient with maxillofacial or head
trauma.
 The incidence of cervical injury in the presence of facial fractures has been reported to
be 1% to 6%.
 Cervical spine injuries tend to occur in patients between 15 and 45 years of age and
are seen more commonly in males (7:3).
 The most common level of fracture is C2
 Dislocations occur most commonly at the C5/6 and C6/7 levels.
 The exclusion of cervical spine injuries, or “clearance,” requires the exclusion of both
bony and ligamentous injuries.

41.  They suggest injuries to upper cervical spine segments are associated with lower third
facial fractures, principally mandibular fractures
 Injuries to the lower cervical spine segments are associated with middle third facial
fractures.
 Our study lends some support to this model in that three of the four cases of CSI
associated with isolated mandibular fractures occurred at C2 and the remaining case
at C1

43.  Examination of the neck includes inspection, palpation and auscultation.
 The standard three-view plain film series for a c-spine evaluation includes lateral,
anteroposterior, and open-mouth view.
 The lateral cervical spine film must include the base of the occiput and the top of the
first thoracic vertebra.
 The lateral view alone is inadequate and will miss up to 15% of cervical spine injuries.
 The lower cervical spine may be difficult to examine, and caudal traction on the arms
should be used to improve visualization.
 If the lower cervical spine is not visualized, a computed tomography (CT) scan of the
region is indicated
Injuries Affecting Airway: Cervical Spine Injury

44.  Thin cut (2-mm) axial CT scanning of specific bone windows, with sagittal and coronal
reconstruction, should be used to evaluate abnormal, suspicious, or poorly visualized
areas on plain radiology.
 With technically adequate studies and experienced interpretation, the combination of
plain radiology and directed CT scanning provides a false-negative rate of less than
0.1%.
 Magnetic resonance imaging (MRI) is the gold standard for clearing the cervical spine
in a clinically suspicious or unresponsive trauma patient.
 In most trauma centers, cervical fixation is usually maintained until the patient is awake
and can respond to command.
Injuries Affecting Airway: Cervical Spine Injury

45.  Rigid cervical collars (by themselves) limit rotation and lateral movement only to 50%
of normal and flexion and extension only to 30% of normal and do not provide
adequate stabilization.
 Complete dissection of the spinal cord above C3 will cause apnea and death, unless
the patient receives immediate intubation and ventilatory support.
 For lesions between C3 and C5, the degree of respiratory failure is variable.
 The vital capacity can be reduced to 15% to 20% of normal.
 These patients are at risk of increasing diaphragmatic fatigue due to slowly
progressive ascending injury resulting from cord swelling and edema.
 This usually leads to decompensation and retention of secretions on day 3 to 4 post
injury.
 Intubation and ventilation is needed to prevent respiratory failure.
Injuries Affecting Airway: Cervical Spine Injury

46.  Patients with high cervical spine lesions have increased bronchial secretions, possibly
due to altered neuronal control of mucous glands.
 Injuries at C5 or below spare the phrenic nerve and diaphragmatic breathing.
 Expiratory reserve may be impaired secondary to accessory muscle paresis
Injuries Affecting Airway: Cervical Spine Injury

47.  The decision to intubate depends on several factors,
 Loss of innervation of the diaphragm (e.g., phrenic nerve injury)
 Fatigue of muscles of respiration
 Failure to clear secretions
 Failure to maintain a patent airway
 History of aspiration
 Presence of other injuries (e.g., head, maxillofacial, and/ or chest injuries)
 Premorbid conditions, especially respiratory disease (chronic obstructive pulmonary
disease) and/or obesity
Injuries Affecting Airway: Cervical Spine Injury

48.  Injuries to the cervical airway may result from blunt or penetrating trauma.
 The incidence is usually rare.
 Blunt trauma to the airway either from a direct blow to the cervical airway or from
severe flexion/extension injuries may result in a thyroid or a cricoid cartilage fracture.
Injuries Affecting Airway: Cervical Airway Injury

49. Injuries Affecting the Airway: Thermal and Inhalation Injury
 Suspected in any patient presenting with a history of exposure to fire or smoke.
 CO Toxicity does not cause direct injury to the lungs.
 Its toxic effect results from a displacement of oxygen from hemoglobin-binding sites,
thereby decreasing the oxygen-carrying capacity of the blood.
 This causes a shift of the oxyhemoglobin dissociation curve to the left; tissue hypoxia.
 CO reacts with myoglobin to further impair oxygen uptake by decreasing facilitated
diffusion of oxygen into muscle.
 This leads to impaired tissue oxygen availability and delivery.
 Cyanide causes tissue asphyxiation through the inhibition of intracellular cytochrome
oxidase.

50.  It blocks the final step in oxidative phosphorylation and prevents mitochondrial oxygen
use.
 The organs most affected to cellular hypoxia include the central nervous system and
the heart
 Inhalation injury can occur with or without evidence of burns.
 Burns on the face and singed eyebrows and/or facial hair are indicative of smoke
inhalation.
 Patients with respiratory injury present with many symptoms, including minor eye
irritation, cough, dyspnea, hyperventilation, tachypnea, rales, wheezing, and facial
burns.
 This can lead to acute respiratory failure.
 These symptoms usually present within 6 to 24 hours post injury
Injuries Affecting the Airway: Thermal and Inhalation Injury

51.  Pulse oximetry is an accurate technique to monitor oxygen Saturation; it is falsely
elevated by CO.
 Arterial oxygen tension (partial pressure arterial oxygen [PaO2]) does not accurately
reflect the degree of CO poisoning or cellular hypoxia.
 The PaO2 level reflects the oxygen dissolved in blood that is not altered by the
hemoglobin-bound CO.
 PaO2 level within the reference range may lead to serious underestimation of the
decrement in tissue oxygen delivery and the degree of hypoxia at the cellular level that
occurs when CO blocks the delivery of oxygen to the tissues; dissolved oxygen makes
up only a small fraction of arterial oxygen content
 Arterial blood gas (ABG) measurements are still useful
Injuries Affecting the Airway: Thermal and Inhalation Injury

52.  Cyanide levels correlate closely with the level of exposure and toxicity; These levels
may not be readily available.
 Indications of Cyanide Poisoning:
 Persistent neurologic dysfunction
 Unresponsive to use of supplemental oxygen
 Cardiac dysfunction
 Severe lactic acidosis
 In a setting consistent with potential cyanide exposure, empiric therapy should be
started
Injuries Affecting the Airway: Thermal and Inhalation Injury

55.  Both direct laryngoscopy and fibreoptic bronchoscopy are both diagnostic and
therapeutic.
 Visualization of erythema, edema, ulceration, and soot deposition make bronchoscopy
useful in evaluating the extent of injury to the tracheobronchial tree.
 Fiberoptic bronchoscopy can facilitate endotracheal tube placement.
Injuries Affecting the Airway: Thermal and Inhalation Injury

56. Post-Operative Period
 The patient with a difficult airway is also at high risk for complications in the post-
operative period.
 Following surgery, mucous membranes are edematous, soft tissue is swollen and the
air pathway may be compressed.
 Neck expandability is relatively low and even a small hemorrhage in the region could
result in airway compromise.
 It was found that complications arose throughout the perioperative period:
 67% upon induction,
 15% during surgery,
 12% at extubation
 5% during recovery.

57. Post-Operative Period
 In intubated maxillofacial trauma patients, extubation should be deferred until normal
anatomy is restored or at least until the edema subsides.
 During extubation the patient should be monitored closely and the care providers
should be prepared for the possibility of re-intubation.
 In a case of tracheotomy tube, the patient may be awakened and allowed to breathe
spontaneously through the tracheostomy tube for a few days, providing a safer
recovery.

58. Indications of Definitive Airway in Maxillofacial Injury

59. STRATEGIES OF GENERAL ANESTHESIA
IN THE TRAUMA PATIENT

60. Triage
 To classify patients into various categories, identifying the urgency of treatment.
 Traumatized patients are divided into two major categories:
 Those patients who require airway control as part of the resuscitation:
 Usually apneic or have total or near-total airway obstruction.
 They are identified during the primary survey and will require establishment of a patent
airway.
 The mouth must be inspected for the presence of any foreign material.
 Then administration of positive pressure ventilation by mask with 100% oxygen is
performed.

61. Triage
 If ventilation is unsuccessful, placement of an oropharyngeal or nasopharyngeal
airway may be used to facilitate mask ventilation.
 The oropharyngeal airway can induce gagging and coughing; may lead to increased
intracranial or intraocular pressure and/or vomiting.
 The nasopharyngeal airway can lead to epistaxis, and care must be used when using
it in a patient with a base-of skull fracture.
 If the patient cannot be effectively ventilated, laryngoscopy and intubation must be
attempted.
 An LMA (laryngeal mask airway) or a Combitube (double-lumen airway) may be
considered in these cases.

64. Combitube (double-lumen airway)

65. Triage
 Those patients who require semi-elective airway control at some time during
hospitalization for surgical management of the maxillofacial injury.
 Usually require elective intubation or, in selected situations, a tracheostomy.
 Intubation or a surgical airway in this situation:
 Provides a patent airway
 Protects against aspiration of secretions
 Allows positive pressure ventilation
 Decreases anatomic dead space
 Provides a potential emergency route for drug administration.

66. Basic Principles of Management - Prophylaxis Against Aspiration
 Trauma patients are always considered to have full stomach.
 This is due to multiple reasons including:
 Ingestion of food or liquids before injury
 Swallowed blood from oral or nasal injury
 Delayed gastric emptying
 Administration of liquid contrast medium

67.  Various actions are considered to prevent aspiration:
 Administer non-particulate antacid prior to induction
 Cricoid pressure/Sellick maneuver applied continuously during airway management
 Rapid-sequence induction (RSI)
 Avoidance of ventilation between administration of medication and intubation
 Awake intubation with or without topical or anesthetic blocks to the upper airway
Basic Principles of Management - Prophylaxis Against
Aspiration

68. Sellick’s Maneuver

69. Induction of General Anesthesia
 There is no ideal anesthetic drug for trauma patients with hemorrhagic shock.
 The key to safe anesthetic management is to administer small incremental doses of
whichever agents are selected.
 Titration of the general anesthetic is a key factor in preventing complications.
 Some of the induction agents are propofol, etomidate, ketamine, and
dexmedetomidine.

70. Propofol
 An ideal general anesthetic agent used in induction.
 It has a rapid onset of action as well as fast recovery from its sedative-hypnotic effects.
 Propofol has antiemetic effects that may be beneficial, especially for a patient who
may have maxilla-mandibular fixation.
 Has some unwanted side effects in trauma patients.
 It may potentiate profound hypotension due to its direct myocardial depression and
decrease in systemic vascular resistance.
 These effects can be potentiated in the elderly or cardiac patient and can be
exacerbated in the hypovolemic trauma patient

71. Etomidate
 Widely used in the trauma population because of its cardiovascular stability relative to
other induction agents.
 Etomidate provides advantages for induction of anesthesia in the setting of
hemorrhagic shock.
 Its pharmacodynamics and pharmacokinetics are minimally altered in contrast to other
anesthetic drugs.
 Etomidate may still produce profound hypotension due to its inhibition of
catecholamine release.
 It can cause adrenocortical suppression.
 Adrenal suppression was found to last 6 to 8 hours in patients following a single
induction dose of etomidate, and more than 24 hours following etomidate infusion.
 The impact of single-dose etomidate on outcomes in critically ill patients remains
unclear.

72. Ketamine
 Ketamine can be used for induction in trauma patients.
 It is most suitable in children who are hemodynamically unstable or hypovolemic.
 Ketamine is also helpful in asthmatic patients because of its broncho-dilating
properties.
 It can result in myocardial depression.
 In normal patients, the effects of catecholamine release usually will mask cardiac
depression and result in tachycardia and hypertension.
 In patients with severe hemorrhagic shock, the cardiac depression may be unmasked.
 This will lead to cardiovascular collapse.

73. Dexmedetomidine
 An agonist of Alpha-2-adrenergic receptors in certain parts of the brain.
 It is indicated for sedation of critically ill or trauma patients in an intensive care unit
setting.
 Dexmedetomidine may also be used to provide sedation for an awake intubation.
 Clinically it provide sedation and analgesia.
 It does so with minimal respiratory compromise.
 Dexmedetomidine is administered via a slow bolus supplemented with a continuous
infusion.
 It is not administered with incremental boluses because of concerns about peripheral
Alpha-2-receptor stimulation, with resulting hypotension and bradycardia.
 Intravenous infusion is commonly initiated with a 1 mcg/kg loading dose, administered
over 10 minutes, followed by a maintenance infusion of 0.2 to 1.0 mcg/kg/hour.

74. Succinylcholine
 Remains the neuromuscular blocker with the fastest onset (30 seconds) and shortest
duration of action
 It is the agent of choice for RSI.
 It is especially indicated in trauma patients presenting for an emergency procedure
with a potentially full stomach or who have recently eaten.
 Succinylcholine may be contraindicated in selected trauma patients:
 Burn Patients; After the first 24 hours due to raised Pottassium
 Crush Injury: Risk of Hyperkalemia
 Ocular Injury: due to increased IOP, within 1 minute of induction, peak at 2-4 minutes
and subsides at 6 minutes
 Intracranial Injury: ICP

75. Rocuronium
 Rocuronium can be also used safely during RSI (1 mg/kg), with an onset of relaxation
of 60 seconds.
 At this dose the duration of action will be 1 to 2 hours.
 Sugammadex is an agent for reversing the neuromuscular blockade caused by a non-
depolarizing agent such as rocuronium.
 Its main advantage is reversal of neuromuscular blockade without relying on the
inhibition of acetylcholinesterase.
 Its administration is associated with much greater cardiovascular and autonomic
stability than the traditional reversal agents.

76. Advanced Airway Technique
 Two-handed mask ventilation:
 Bag-mask ventilation is the cornerstone of basic airway management.
 When a second person is available to provide ventilations by compressing the bag, a
two-hand technique can be used.
 The surgeon creates opposing semicircles with the thumb and index finger of each
hand to form a ring around the mask connector and hold the mask on the patient’s
face.
 Then, the mandible can be lifted with the remaining digits

77. C-E

79. Without Assistance

80. Advanced Airway Technique
 Combitube (double-lumen)
 A blind insertion airway device (BIAD) used in the prehospital and emergency setting.
 It is ideal to provide an airway for the trauma patient in respiratory distress.
 The simplicity of placement is a major advantage over endotracheal intubation.
 This technique has some serious but rare complications, including:
 Aspiration
 Esophageal perforation
 Facial nerve dysfunction

81. Combitube (double-lumen airway)

82. ( A ) right-sided Robertshaw double-lumen tube
( B ) left-sided Rusch double-lumen tracheostomy tube.

83. Advanced Airway Technique
 LMA: The laryngeal mask airway (LMA) is an easy way to ventilate a trauma patient.
 It is a supraglottic airway device and is a good alternative to bag-valve-mask
ventilation (freeing the hands of the provider with the benefit of less gastric distention).
 The LMA is actually placed into the back of the mouth following the curve of the
tongue.
 The rate of complications is rare (0.15%).
 These complications include:
 Aspiration of gastric contents, local irritation, pressure-induced lesions, facial nerve
palsies, mild sympathetic response, obstruction, and laryngospasm.

84. LMA

85. LMA

86. Laryngoscope

88. Advanced Airway Technique
 The laryngoscope is a useful technique to visualize the vocal cords and the glottis.

89. Advanced Airway Technique
 Videolaryngoscope:
 The failure of direct laryngoscopy to provide an adequate view for tracheal intubation
led to the development of videolaryngoscopy.
 The first camera screen laryngoscope was developed by Berall in 1998.
 Currently, there are several manufacturers of video laryngoscopes.
 These laryngoscopes employ a variety of features, such as a monitor on the handle
and/or channels, to assist in guiding the endotracheal tube into the trachea.
 The superior performance of video laryngoscopy in airway management where
cervical spine injury is suspected.

90. Videolaryngoscope

91. Videolaryngoscopy

92. Advanced Airway Technique
 Retrograde intubation is another alternative to secure an airway in the trauma patient.
 Under local anesthesia, a cannula is inserted through the cricothyroid membrane into
the trachea, and a guide wire is then passed through the needle upward through the
vocal cords into the oral cavity.
 The wire is then used to guide an ET tube through the vocal cords.

93. Retrograde Intubation

94. Retrograde Intubation

95. Submental Intubation

96. Retromolar Intubation

97. Surgical Airway
 Emergency airway management in the trauma patient often involves a combination of
factors that increase the technical difficulty of intubation and increase patient risk.
 These factors include:
 Dynamically deteriorating clinical situation in the unstable patient
 Respiratory and ventilatory compromise
 Impaired ventilation and oxygenation
 Full stomach (increased risk of regurgitation, vomiting, aspiration)
 Increased secretions, blood, vomitus, and potential for foreign body
 Distorted anatomy
 If intubation is not possible, a surgical airway is advised.

98. Tracheostomy

99. Tracheostomy
 A surgical procedure which consists of making an incision on the anterior aspect of the
neck and opening a direct airway through an incision in the trachea
 The resulting stoma can serve independently as an airway or as a site
for tracheostomy tube to be inserted
 This tube allows a person to breathe without the use of the nose or mouth.
 There are four main indications:
 Emergency airway access
 Airway access for prolonged mechanical ventilation
 Functional or mechanical upper airway obstruction
 Decreased/incompetent clearance of tracheobronchial secretions

100. Tracheostomy
 There are no absolute contraindications to tracheostomy except for active cellulitis of
the anterior neck skin

101. An outer cannula (top item) with inflatable cuff (top right), an
inner cannula (center item) and an obturator (bottom item)

102. Complications
Complications
Early Late

103. Early Complications
 Bleeding
 Pneumothorax
 Subcutaneous Emphysema
 Injury to Recurrent Laryngeal Nerve
 Blocked Tracheostomy Tube
 Accidental Displacement of Tracheostomy Tube
 Infection

104. Bleeding
 Most likely cause of fatality after a tracheostomy.
 Injury to the anterior jugular venous system is a typical source of bleeding, which if
encountered is ligated and divided
 It usually occurs due to a Tracheoarterial Fistula, an abnormal connection between the
trachea and nearby blood vessels, and most commonly manifests between 3 days to 6
weeks after the procedure is done.
 Fistulas can result from incorrectly positioned equipment, high cuff pressures causing
pressure sores or mucosal damage, a low surgical trachea site, repetitive neck
movement, radiotherapy, or prolonged intubation.
 Use of the bronchoscope can help with proper placement of instruments and better
visualization of anatomical structures.
 Bleeding can also occur from frequent or improper suctioning; Use of a red rubber
suction may reduce any trauma from suctioning.

105. Pneumothorax
 Collapsed Lung; Partial or complete
 17% incidence; Increased incidence in children possibly due to the higher position of
the pleural dome
 Pneumothorax is a potentially life threatening complication and can occur from direct
injury to the pleura or the cupola of the lung (especially in children) or from high
negative inspiratory pressures of patients who are awake and distressed on
mechanical ventilation.
 Patients with chronic obstructive pulmonary disorder (COPD) are at particularly high
risk because intrinsic air-trapping causes their chest to be barrel shaped, and the apex
of the lung is much higher in the chest cavity.
 Chest X-ray

106. Subcutaneous emphysema
 The result of air or gas trapped under the skin, typically seen in the chest walls and
neck regions.
 It can develop rapidly, and may be the first clinical sign of a pneumothorax.
 It can result from trauma during the tracheotomy procedure or tracheal intubation.
 The most common sign is swelling around the neck and chest pain.
 Other signs and symptoms include tender sore throat, aching neck, difficulty in
swallowing, breathlessness, wheezing, and distension.
 Subcutaneous emphysema has a characteristic crackling feel when palpating the skin,
which is termed subcutaneous crepitation

107. Recurrent Laryngeal Nerve Injury
 Damage to the recurrent laryngeal nerve resulting in vocal cord paralysis, is also a
potential immediate complication of tracheostomy.
 Damage can cause hoarse or breathy vocal quality, dysphagia and aspiration
pneumonia.
 If midline is properly maintained during dissection, the nerves should not be
encountered, except for cases where significant misplacement of the tracheostomy
tube has occurred.
 Tracheostomy itself may be needed when bilateral recurrent laryngeal nerve injury has
occurred during another procedure (ie., total thyroidectomy).
 Bilateral recurrent laryngeal nerve injury results in the vocal folds paralyzed medially,
causing difficulty breathing past the closed vocal folds, requiring emergent intubation
or tracheostomy.

108. Blocked Tracheostomy Tube
 A blocked tracheostomy tube is typically secondary to a mucus plug or blood clot.
 This can be prevented with proper suctioning of the airway, adequate humidification,
and frequent changing or cleaning of the inner cannula when working with a double
lumen tube.
 The use of dual cannula tubes lessens the potential of mucus plugging because the
inner cannula can be removed for cleaning while the outer cannula safely maintains
patency of the fresh tract.
 Inner cannulas should be cleaned daily if non-disposable, or changed daily if
disposable in order to avoid mucous plugging.
 Partial blockage is indicated by resistance to the passage of a suction catheter over
the first 10 cm or when the inside of the tracheostomy tube feels roughened by
accumulated, dried secretions.
 A completely blocked tube is indicated by the inability to pass a suction catheter down
the tracheostomy tube.

109. Signs of Blocked Tracheostomy Tube

110. Late Complications
 Tracheal Stenosis
 Tracheomalacia
 Tracheoesophegeal Fistula
 Tracheoinnominate Fistula
 Pneumonia

111. Tracheal Stenosis
 An abnormal narrowing of the trachea that can develop from prolonged intubation
causing scarring due to pressure injury.
 It can also occur due to high cuff pressures from either the tracheostomy tube or the
endotracheal tube cuff.
 Tracheal stenosis commonly develops at the stoma site or at the level of the cuff.
 When stenosis occurs at the stoma, it is usually due to bacterial infection and
chondritis.
 Granulation tissue can develop at the stoma site and may obstruct the airway at the
stoma site.
 The tissue can cause difficulty with replacing the tracheostomy Tube
 Diagnosis of tracheal stenosis is often delayed;
 Approximately 3 to 12% of all patients will develop clinically significant stenosis that
will require intervention; Extra-long Tracheostomy Tube

112. Tracheomalacia
 Weakening of the tracheal wall.
 In adults, this is usually secondary to trauma of some kind to the tracheal wall,
including recurrent infections, where the tube and/or cuff rubs against it, or with over
inflation of the cuff.
 Signs and symptoms of tracheomalacia include: shortness of breath, hoarse voice,
chronic cough, difficulty swallowing, recurring respiratory tract infections, and, during
mechanical ventilation there is often the presence of a cuff leak, or the need to over-
inflate the cuff in order to maintain control of mechanical ventilation
 If tracheomalacia is suspected, bronchoscopy or a dynamic CT scan of the trachea
can reveal excessive expiratory collapse of the trachea.
 Treatment options depend on the severity and include insertion of a longer
tracheostomy tube to bypass the region of trachomalacia or double cuffed
tracheostomy tubes.

113. Care of Tracheostomy
 Caring for a tracheotomy mostly includes
 Suctioning to prevent occlusions
 Replacing supplies, such as replacement of the inner cannula and/or suction devices.
 Risks include hypoxia and so suctioning is limited to 10 to 20 seconds at a time and
the patient is hyper-oxygenated just before and after suctioning.
 Risks also include atelectasis, or collapsing lung tissue from high suction pressure,
and so pressure is limited to 80–120 mm Hg.
 Risks also include tissue damage.
 The suction catheter is inserted no more than 1 cm past the length of the tube to avoid
contact with trachea tissue.

114. Tracheostomy
 Horizontal skin incisions are cosmetically superior to vertical incisions.

115. Tracheostomy Procedure

116. Emergency Cricothyrotomy
 Emergency cricothyrotomy is one of the last-resort and potentially life-saving procedures
for maxillofacial trauma patients who cannot be intubated or ventilated.
 A surgical airway has been established by making an incision through the skin and the
cricothyroid membrane into the tracheal lumen, through which an endotracheal tube is
inserted.
 In recent years, a number of commercial kits that include all of the necessary equipment to
establish a surgical airway have reached the market.
 The surgeon must be familiar with the kit used at his or her trauma center.
 The tube can stay in place for up to 3 days.
 In surgical cricothyrotomy, a scalpel is used to make a horizontal incision over the lower
half of the cricothyroid membrane.
 The only absolute contraindication to surgical cricothyrotomy is age.

117. Cricothyrotomy
 Some general indications for this procedure include:
 Inability to intubate
 Inability to ventilate
 Inability to maintain SpO2 >90%
 Severe traumatic injury that prevents oral or nasal tracheal intubation

118. Cricothyrotomy
 Contraindications
 Inability to identify landmarks (cricothyroid membrane)
 Underlying anatomical abnormality such as a tumor or severe goiter
 Tracheal transection
 Acute laryngeal disease due to infection or trauma
 Small children under 12 years old (a 10–14 gauge catheter over the needle may be
used)
 In patients below this cutoff age, needle cricothyrotomy is indicated because infants
and children younger than 12 years usually have a smaller cricothyroid membrane as
well as a more funnel-shaped, rostral, and compliant larynx

121. Cricothyrotomy

122. Cricothyrotomy Procedure

124. References
 Fonseca; Volume 2; Airway and Anesthetic Management of the Traumatized Patient
 Peterson’s Principles of Oral and Maxillofacial Surgery; Chapter 4 Outpatient
Anesthesia
 Complications of Tracheostomy;
https://www.tracheostomyeducation.com/blog/complications-of-
tracheostomy/#:~:text=termed%20subcutaneous%20crepitation.-
,Injury%20to%20the%20Recurrent%20Laryngeal%20Nerve,quality%2C%20dysphagia
%20and%20aspiration%20pneumonia.
 Maxillofacial Trauma Patient: Coping with Difficult Airway

125. References

126. THANK YOU!