This document discusses airway and ventilatory management in trauma patients. It emphasizes that the airway is the top priority in trauma resuscitation. Failure to recognize airway compromise or establish a definitive airway can lead to death. Signs of airway or ventilation problems are described. Methods for airway maintenance include positioning, oral/nasal airways, and extraglottic devices if intubation is not possible. Rapid sequence intubation is the preferred method when a definitive airway is needed. Surgical airways like needle cricothyroidotomy or surgical cricothyroidotomy are alternatives if intubation fails. Adequate oxygenation and ventilation are also discussed.

1. M. NONTHACOUPT
Airway and Ventilatory
Management in Trauma

2. Initial assessment & management
 Preparation
 Triage
 Primary survey (A-B-C-D-E)
 Resuscitation
 Adjunct to primary survey
 Secondary survey
 Postresuscitation monitoring
 Definitive care

3. Why first priority?
 “The quickest killer”
 Secondary insult of CNS
 Supplemental oxygen must be administered in
trauma patient

4. Death from airway problem
 Failure to recognize
 the need for airway intervention
 the need for alternative airway
 incorrectly placed airway
 the need for ventilation
 Inability to establish an airway
 Displacement
 Aspiration

5. Recognize airway problem
 Sudden/ Complete
 Progressive/ Partial
“Reassessment”

6. Recognize airway problem
 Changed voice quality
 Stridor (noisy = partial, absence = complete)
 Sore throat
 Dyspnea
 Agitate
 Tachypnea
 Abnormal breathing pattern
 Decreased O2sat (late sign)

7. Objective signs of airway obstruction
 Agitation  hypoxia
 Obtund  hypercarbia
 Cyanosis  hypoxemia (late sign)
 Retraction
 Stridor/ Hoarseness
 Trachea shift
 Patient behavior

8. Quickest way?
Check verbal response
 Positive, appropriate
Patent airway
Intact ventilation
Adequate brain perfusion
 Negative, inappropriate
AOC
Airway/ ventilatory compromise
Definitive airway

9. Definitive airway
“Tube placed in trachea with cuff inflated below the vocal
cords, connected to oxygen-enriched assisted ventilation,
Secured in place”

10. Definitive airway
Protect airway
Support ventilation
Maintain oxygenation
Prevent hypercarbia
Prevent Aspiration

11. Maxillofacial trauma
 Midface
Fracture/dislocation
Loss structural support of airway
Hemorrhage
Dislodge teeth

12. Neck trauma
 Penetrating injury
 Hematoma displace/obst airway
 Blunt injury
 Hematoma
 Hemorrhage into soft tissue
 Disruption of larynx/trachea
 Hemorrhage in tracheobronchial tree
Progressive
Airway compromise

13. Laryngeal injury
 Clinical
 Hoarseness
 Subcutaneous emphysema
 Palpable fracture
 Incomplete obstruction
 Complete obstruction
 only 1 attempt of ETT, if fail  tracheostomy (or
surgical cricothyroidotomy if profuse bleed)

14. Recognize ventilation problem
 Mechanical
 Direct chest trauma
 Preexisting pulmonary dysfunction
 CNS depression
 Intracranial
 Spinal cord

15. Objective signs of inadequate ventilation
 Chest rising
 Labored breathing
 Breath sound (decreased/absent)
 Rapid RR
 Pulse oximetry, ETCO2

16. AIRWAY MANAGEMENT

17. Initial airway management
 Monitor pulse oximetry, ETCO2
 Remove helmet (if present)
 Airway maintenance + C-spine protection
 Suction
 Supplemental ventilation
 High flow oxygen

19. Predict difficult airway
 L : Look externally
 E : Evaluate 3-3-2 rule
 M : Mallampati
 O : Obstruction
 N : Neck mobility

21. M: Mallampati
 I : soft palate, uvula, fauces,
pillar
 II: soft palate, uvula, fauces
 III: soft palate, base of
uvula
 IV: hard palate

22. Airway decision flow
Preoxygenate (position, O2 mask c bag, oral airway)
Able to oxygenate?
LEMON
Intubation (±drug/cricoid pressure)
Gum elastic bougie/LMA
Definitive/surgical airway
yes
no
Definitive/
surgical airway
difficult Call for assistance
Awake intubation
easy
fail

23. Airway maintenance
 By position
 Chin lift (should not hyperextend neck)
 Jaw thrust
 Manual in line immobilization first

24. Airway maintenance
 By device
Oropharyngeal airway
May Induce gag reflex & aspiration
If pt can tolerate, ETT is highly likely required
Tongue blade in children, No rotation
Nasopharyngeal airway
Nostril  oropharynx
Lubricated
Don’t attempt in suspected cribiform plate fx, Lefort
fx

25. Extraglottic, supraglottic devices
 Laryngeal mask airway
 Bridging, if ETT/mask c bag fail
 Laryngeal tube airway
 Doesn’t require significant manipulation of head & neck
 Multilumen esophageal airway
 Esophageal port, trachea port
 ETCO2

28. Indication for definitive airway
Need airway protection Need ventilation
Severe maxillofacial fx Inadequate respiratory effort
-tachypnea
-hypoxia
-hypercarbia
-cyanosis
Risk for obstruction
-neck hematoma
-laryngeal/tracheal injury
-stridor
Massive blood loss and need
for volume resuscitation
-anemia
Risk for aspiration
-bleeding
-vomiting
Severe closed head injury with
need for brief hyperventilation
if AOC
unconscious Apnea

29. Endotracheal intubation
 Clearance of C-spine, but don’t delay
 Manual in-line
 Nasotracheal
 Contraindicated in
Apnea
Facial, frontal sinus, basal skull, cribiform plate fx
 Pressure necrosis, sinusitis
 Orotracheal
Indicated in apnea patient

30. Orotracheal intubation
 2-person manual inline
 Laryngeal manipulation “BURP”
 Backward, Upward, Rightward Pressure
 Thyroid cartilage
 Direct laryngoscopy
 Gum elastic bougie

31. Infant endotracheal intubation
 Same size as infant’s nostril or little finger
 Uncuffed Tube = (Age / 4) + 4
 Cuffed Tube = (Age / 4) + 3
 Suitable for age 1-12 yr
 above 12, typically most adult sizes (6.5-8.0)
 Insert not more than 2 cm past the cords

32. Is the tube in place?
 Listen
 equal breath sound
 no borborygmi
 ETCO2
 CXR

33. Rapid sequence intubation (RSI)
 Anesthetic
 Sedative
 Neuromuscular blocking
 Always have Plan B (surgical airway)

34. Rapid sequence intubation (RSI)
1. Be prepared for surgical airway
2. Suction, PPV ready
3. Preoxygenate
4. Cricoid pressure
5. Administer induction drug/sedative
Etomidate 0.3 mg/k
6. Succinylcholine 1-2 mg/kg v
7. Intubate
8. Confirm tube placement
9. Release cricoid pressure
10. ventilate

35. Surgical airway
 Cricothyroidotomy/ tracheostomy
 Indication
 fail ETT
 Obstruction of upper airway (glottic edema, larynx fx, severe
oropharyngeal hemorrhage

36. Needle cricothyroidotomy
 Short term, bridging for definitive airway
 Jet insufflation
 Large caliber plastic canular
 12-14 adult
 16-18 children
 Through cricothyroid membrane into trachea
 Connect to O2 15 LPM
 Hole cut in tubing between
O2 source and cannula,
thumb over1 second,
off 4 seconds

38. complication
 Inadequate ventilation
 Blood aspiration
 Esophageal laceration
 Hematoma
 Posterior tracheal wall laceration
 Subcutaneous/mediastinal emphysema
 Thyroid perforation
 pneumothorax

39. Surgical cricothyroidotomy
 NOT recommended in children <12 y
 Skin incision extend through cricothyroid membrane
 Small ETT or tracheostomy (5-7mm OD) tube insertion
 Reapply cervical collar

41. complication
 Blood aspiration
 False tract
 Subglottic stenosis
 Laryngeal stenosis
 Hematoma
 Laceration of esophagus
 Laceration of trachea
 Mediastinal emphysema
 Vocal cord paralysis/ hoarseness

42. Management of oxygenation

43. Adequate oxygenation
 Tight sealed mask c bag > 11 LPM
 Pulse oximetry
 O2sat ≥ 95%  PaO2 >70%
 Require intact peripheral perfusion
 Can’t distinguish oxyhemoglobin/
carboxyhemoglobin/ methemoglobin

45. Approximate PaO2 vs O2Sat
PaO2 O2Sat
90 mmHg 100 %
60 mmHg 90 %
30 mmHg 60 %
27 mmHg 50 %

46. Management of ventilation

47. Adequate ventilation
 Bag-mask ventilation (1-2 person)
 Ventilate q 5 secs (RR 12)
 Volume/pressure regulated respirator
 Watch intrathoracic pressure
 Watch for tension PTX
 Secondary PTX from barotrauma

48. Gastric distention
 Secondary to bag-mask ventilation
 Vomit/ aspirate
 Stomach distention  vena cava pressure 
hypotension, bradycardia