1. Airway Management
for the Trauma
Provider
SarahBeth Hartlage, MD MS
Assistant Professor
Department of Anesthesiology and Perioperative Medicine
University of Louisville
10. Mallampati Score
โข Class I โ complete visualization of
soft palate, uvula, anterior and
posterior tonsillar pillars
โข Class II โ complete visualization of
soft palate, uvula; partial
visualization of tonsillar pillars
โข Class III โ complete visualization of
soft palate; partial visualization of
uvula
โข Class IV โ no visualization of soft
palate; hard palate and tongue only
visible structures
Evaluate the airway with the patient sitting
upright, with head in neutral position.
14. Planning and Preparation
โข Plan
โข Evaluate the patient for necessity of intubation
โข Examine the airway
โข Equipment
โข Suction, oxygen, monitors
โข Bag valve mask
โข Ancillary noninvasive devices โ oral and nasal airways
โข Laryngoscope handle and blade(s)
โข Endotracheal tube(s) and stylet(s)
โข Backup equipment โ bougie, LMA, surgical airway kit
โข Drugs
โข Relevant personnel
โข Physician, nurse, respiratory therapist
โข Defined roles for team members
โข Communication is key
19. Positioning
โข โSniffing Positionโ aligns oral / pharyngeal / laryngeal axes
โข Requires alignment of the tragus with the sternal notch
โข Typically the shoulders remain on the bed while the head is
lifted 3 or more inches
โข Obese patients may require ramping of the shoulders and
significantly more elevation of the head
โข Note that this is not simple โextension of the spineโ
โข Caution in patients with cervical spine injury or unknown
pathology
22. Preoxygenation
โข Used to โdenitrogenateโ the lungs and extend the safe apnea
period
โข Safe apnea = time until saturation falls below ~90%
โข 1-2 minutes if breathing room air
โข Up to 8 minutes if fully preoxygenated
โข Reduced in patients with decreased FRC (pregnancy, extremes of
age, obesity, ascites), increased O2 consumption (sepsis,
hypermetabolic state), shunt physiology, etc
โข If adequate respiratory effort, may use FiO2 100% fo 3
minutes of tidal breathing OR 8 vital capacity breaths
โข If patient unable to perform above, may โpreoxygenateโ with
positive pressure breaths
23. Preoxygenation
โข Useful in the optimal situation โ clearly not always the case
โข Do the best you can
โข Can also โpreoxygenateโ with bag-valve mask in some cases
25. Placement โ Technique
โข Position the patient
โข Open the mouth โ spread the molars with your right hand
โข Insert the laryngoscope with your left hand
โข Direct blade (Macintosh, Miller) โ insert on right of mouth, sweep
tongue to left
โข Indirect 60ยฐ video blade (Glide, D) โ insert down center of tongue
โข Remove right hand from mouth, may need for cricoid pressure
or other optimization of positioning
โข Advance blade, visualize epiglottis
โข Macintosh โ advance anterior to epiglottis, into vallecula
โข Miller โ advance posterior to epiglottis
โข Indirect โ advance anterior to epiglottis, into vallecula
26. Placement โ Technique
โข Lift epiglottis to reveal vocal cords โ lift up and away, never
back
โข Miller blade โ active lifting of epiglottis
โข Macintosh, indirect video blades โ passive lifting
โข Use right hand to place endotracheal tube between vocal
cords
โข After passing glottic opening, ask assistant to remove stylet
โข Advance tube to desired depth
โข Remove laryngoscope
โข Inflate ETT cuff
โข Ventilate
27.
28.
29. Proof of ETT Placement
โข Fog in tube
โข End Tidal CO2
โข POC detector changes from purple ๏ yellow when exposed to
CO2
โข Continuous capnography will show ventilatory pattern
โข Bilateral breath sounds
โข Stable / increasing SpO2
โข Tidal volumes / compliance
โข Chest X Ray
32. Difficult Airway
โข Bread and butter for anesthesiologists, but alsoโฆ
โข One of the most common causes of lawsuits in closed claims
analysis
โข Incidence of difficult intubation in OR 1.5-8%
โข Incidence of difficult intubation out of OR as high as 30%
โThe difficult airway is
anticipated; the failed airway is
experienced.โ
33. Difficult Airway
โ[โฆ]the clinical situation in which a conventionally trained
Anesthesiologist experiences difficulty with facemask
ventilation, difficulty in supraglottic device ventilation, difficulty
in tracheal intubation or all three.โ
- ASA definition
35. Signs of Difficult Intubation
Testing
โข Mallampati score โฅ3
โข Thyromental distance โค5cm
โข Upper lip bite test
โข Class I โ lower incisors reach
above vermillion border
โข Class II โ lower incisors reach
upper lip below vermillion
border
โข Class III โ lower incisors cannot
bite upper lip
โข Each has poor sensitivity with
decent specificity; improved
utility when used together
Other Exam Findings
โข Facial trauma, burns
โข Obstruction / foreign
body
โข Obesity
โข Secretions, blood,
edema in airway
โข Personal history of
difficult intubation
36. Signs of Difficult Mask Ventilation
โข Beard
โข Obesity
โข Edentulous
โข Elderly
โข Sleep apnea, diagnosed or suspected
40. Things to Remember in a
Difficult Airway Situation
โข When in doubt, give a shout
โข Call for help early
โข The harder I practice, the luckier I get
โข Your first experience shouldnโt be in an emergency
โข Doing the same thing and expecting different
results is insane
โข Do not keep repeating a failed technique
41. Nobody ever died from failure to
intubate, but patients die every day from
failure to oxygenate.