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Airway management in polytrauma
The document discusses advanced airway management in polytrauma, emphasizing the need for maintaining a protected airway and adequate ventilation as paramount priorities. It outlines the signs of airway compromise, assessment techniques, and critical interventions for trauma patients, including specific scenarios and management pearls for conditions like traumatic brain injury and unstable cervical spine injuries. Additionally, it provides practical tips and guidelines for intubation, confirmation of tube placement, and the use of advanced airway devices in emergencies.
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Airway management in polytrauma
- 1. Airway Management in Polytrauma : Advanced version Dr.Venugopalan P P, DA,DNB,MNAMS,MEM(GW) Director and Lead consultant in Emergency Medicine Aster DM Healthcare ,India
- 2. Background Prevention of hypoxemiarequires a protected, unobstructed airway and adequate ventilation, which take priority over management of all other conditions.
- 3. This session... 1. Definedefinitive airway. 2. Recognize the signs and symptoms of airway obstruction and ventilatory compromise. 3. Describe the techniques for establishing and maintaining a patent airway. 4. Describe techniques for confirming the adequacy of ventilation and oxygenation 5. Explore the management pearls in specifice trauma scenarios
- 4. What are thePriorities in Polytrauma? 1. Airway and C-Spine protection 2. Breathing and Ventilation 3. Circulation and Hemorrhage control 4. Disability 5. Exposure and prevention of hypothermia A B C D E
- 5. Case scenario ● 34-year-oldmotorcyclist lost control and crashed into a fence ● Obvious facial trauma ● No helmet ● Smells of alcohol ● Belligerent at scene; now not communicating ● Pulse oximeter 85% Airway management
- 6. Airway assessment How doI know the airway is adequate? Airway management
- 7. How do Iknow the airway is adequate? • Patient is alert and oriented. • Patient is talking normally. • There is no evidence of injury to the head or neck. • You have assessed and re-assessed for deterioration Airway Assessment
- 8. Signs and symptomsof airway compromise • High index of suspicion • Change in voice / sore throat • Noisy breathing (snoring and stridor) • Dyspnea and agitation Airway Assessment
- 9. Signs and symptomsof airway compromise • Tachypnea • Abnormal breathing pattern • Low oxygen saturation (late sign) Airway Assessment
- 10. Remember …. ● Agitatedpatient ● Rule out Hypoxia ● Obtunded patient ● Rule out Hypercarbia Airway management
- 11. When to intervenein a patient with a patent airway? 1. Airway problem - Impending airway compromise 2. Breathing problem-Need for ventilation 3. Circulatory Problem-Intractable shock 4. Disability problem-Inability to protect the airway, Low GCS 5. Expected course : Transfer to Radiology , Transfer to another Institution Airway Assessment A B C D E
- 12. Dynamic Airway -Anticipatory Intubation ● Bullet ● Burn ● Bites 3 B’s in Head & Neck Airway management
- 13. How do Imanage the airway of a trauma patient? • Supplemental oxygen • Basic techniques • Basic adjuncts Airway management
- 14. When to intervenein a patient with a patent airway? Definitive airway • Cuffed tube in the trachea Airway Management
- 15. When to intervenein a patient with a patent airway? Difficult airway adjuncts • Unexpected difficult airway • Predicted difficult airway Airway management
- 16. Protect the cervicalspine during airway management! Airway Management
- 17. Cervical spine motionrestriction Airway management
- 18.
- 19. Basic Techniques Chin LiftHead tilt Airway Management
- 20.
- 21. Cervical collar withJaw thrust Airway Management
- 22. Basic Adjuncts 1. Oropharyngeal Airway- OPA 2. Nasopharyngeal Airway -NPA Airway Management
- 23. OPA - Usecorrect size ● Patients who can tolerate an oral airway will usually need intubation ● Buying time in emergency room ● Too large and Too small cause airway obstruction Airway Management
- 24.
- 25. Nasopharyngeal Airway ● Use correctsize ● Better tolerated ● Use most patent nose ● Avoid in midfacial injuries ● Avoid in fracture base of skull Airway Management
- 26. No NPA Airway Management Raccoon’s Eye Battle'ssign Midfacial fracture
- 27.
- 28. How do Ipredict a potentially difficult airway? Airway Management
- 29. Assess the difficultyat 4 level Airway Management 1. Difficulty for Bag Mask ventilation 2. Difficulty for Intubation 3. Difficulty for Supraglottic /Extraglottic airway Insertion 4. Difficulty for Surgical Airway
- 30. Bag Mask Ventilation AirwayManagement MOANS
- 31. Difficult airway BMV Trauma Related difficulty Approach LimitedJaw thrust Mandibular fracture Early use of SGA Poor seal Facial injuries with swelling , Disruption Early use of SGA Blood and Vomitus Facial injuries, Full stomach Delayed gastric emptying 2 suction/ SALAD approach FONA Penetrating or Blunt trauma neck Distorting subcutaneous emphysema,Disrupted airway Passive oxygen delivery/minimize Positive pressure ventilation
- 32. ● SALAD -Suction Assisted Laryngoscopy & Airway Decontamination ● FONA-Front Of Neck Airway Airway Management
- 33. SALAD : SuctionAssisted Laryngoscopy Airway Decontamination ● Use rigid large-bore suction to initially decontaminate ● Perform laryngoscopy keeping blade superior against tongue away from fluid ● Advance suction tip into upper esophagus then wedge in place to left of the laryngoscope
- 34. SALAD : SuctionAssisted Laryngoscopy Airway Decontamination ● Use second suction as needed ● Rotate laryngoscope blade 30 degrees to the left to open blade channel ● Place endotracheal tube (ETT), inflate the cuff
- 35.
- 36. Emergency perspective ofLEMON ● Look externally ● Evaluate 3- 3-2 rule ● Mallampati score ● Obstruction ● Neck mobility Unresponsive patients - You can’t do Mallampati LEONAirway Management
- 37. Trauma perspective ofLEMON ● Look externally ● Evaluate 3- 3-2 rule ● Mallampati score ● Obstruction ● Neck mobility Suspected C spine injury : U cant Do neck mobility LEO
- 38. Difficult airway DL Scopy TraumaRelated Difficulty Approach Limited Mouth opening/ Jaw displacement Collar/Improper MILS/ Trismus Open collar/ Ear Muff MILS Inability to position MILS BURP/GEB/VL Blood and Vomitus Facial injuries, Full stomach Delayed gastric emptying 2 suction/ SALAD approach FONA Penetrating or Blunt trauma neck Disrupted /Distorted airway Awake primary flexible fibero-scopic intubation,VL assisted intubation
- 39. Ear Muff MILSAirway Management
- 40.
- 41. Difficult airway TraumaRelated Difficulty Approach Blood and Vomitus Facial injuries, Full stomach Delayed gastric emptying 2 suction/ SALAD approach FONA Penetrating or Blunt trauma neck Disrupted /Distorted airway Direct visualization FIE/FONA, Low tracheotomy Airway Management Extraglottic airway
- 42.
- 43. Difficult airway TraumaRelated Difficulty Approach Penetrating or Blunt trauma neck Distorted/disrupted airway CTM not accessible or injury at or below CTM Low tracheotomy Airway Management FONA
- 44. Airway Management ● Is thisa difficult airway? ● How would you manage this patient?
- 45. What is meantby a Definitive Airway? A definitive airway is a tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to some form of oxygen-enriched assisted ventilation, and the airway secured in place with tape Airway Management
- 46. Definitive Airway -Easy • Oral intubation (medication assisted) • BURP, suction back-up • Maintain c-spine immobilization Anticipate difficult airway Airway Management
- 47. Rapid Sequence Intubation/Delayed Sequence Intubation Airway Management
- 48. ● Is thisa difficult airway? ● How would you manage this patient? Airway Management
- 49. Definitive Airway -Difficult ? • Get help • Be prepared • Rapid sequence vs. awake intubation • Maintain c-spine immobilization Airway Management
- 50. Definitive Airway -Difficult ? Using Paralytic Agents for Intubation will be suicidal Airway Management
- 51. Definitive Airway -Difficult ? • Consider use of: • Gum elastic bougie • Combitube • King’s Airway • (Intubating) LMA • Surgical airway • Other advanced techniques Airway Management
- 52. Gum Elastic bougieassisted intubation Airway Management
- 53. Definitive Airway -Difficult ? Rescue airway devices - Buying time Airway Management
- 54. Rescue airway devices-Buying time Intubating LMA Airway Management
- 55. Definitive Airway -Difficult ? Video Laryngoscopy is a choice ● Difficult airway ● Unstable C-spine injury ● Blood in oral cavity ??? Airway Management
- 56. Video Laryngoscopes :Types Macintosh video laryngoscope -standard geometry blade ● C-MAC (Mac Blade; Karl Storz, Tuttlingen, Germany) ● McGrath Mac (Mac blade; Medtronic, Minneapolis, MN) ● GlideScope Titanium Mac (GlideScope, Verathon, WA), ● Venner APA (Mac blade; Venner Medical, Singapore, Republic of Singapore).
- 57. Video Laryngoscopes: Types HyperangulatedVL (also known as indirect VL) ● C-MAC (D-Blade) ● McGrath Mac (X blade) standard GlideScope ● King Vision (non channeled blade Ambu, Ballerup, Denmark) Data from Kovacs G, Law JA. Lights camera action: redirecting videolaryngoscopy. EMCrit. 2016. Available at: https://emcrit.org/blogpost/redirecting-videolaryngoscopy/. Accessed February 25, 2017
- 58. Video Laryngoscopes: Types Channeledblade VL ● King Vision ● Pentax AWS (Pentax, Tokyo, Japan) ● Airtraq (Teleflex Medical, Wayne, PA) for example, King Vision, Pentax AWS (Pentax, Tokyo, Japan) Data from Kovacs G, Law JA. Lights camera action: redirecting videolaryngoscopy. EMCrit. 2016. Available at: https://emcrit.org/blogpost/redirecting-videolaryngoscopy/. Accessed February 25, 2017
- 59. Definitive Airway -Difficult ? Superior Laryngeal nerve block Awake Intubation
- 60. Definitive Airway -Difficult ? RSAI
- 61. Definitive Airway: SurgicalAirway Cricothyroidotomy Needle- Buying time Surgical- Definitive Airway Management
- 62.
- 63.
- 64.
- 65. How do Iknow the tube is in the right place? Airway Management
- 66. Confirmation of tubepositions • Visualize it going through the cords • Watch the chest • Auscultation • CO2 detector / ETCO2 monitor • Pulse oximeter • X-ray Airway Management
- 67. ETCO2 : Colorimetric/Digital /Waveform Airway Management
- 68. USG to confirmtube position Airway Management
- 69. Esophageal Detector Device/ EDD Airway Management
- 70. Pulse oximeter/ XRay Chest in Tube positioning Airway Management
- 71. Pulse-Ox lag “By thetime peripheral oxygen saturation begins to fall, cerebral hypoxemia has already occurred, a phenomenon known as “pulse-ox lag”
- 72. Airway Management PaO2 Levels SpO2 90mm of Hg 100% 60 mm of Hg 90% 30 mm of Hg 60% 27 mm of Hg 50% Approximate PaO2 vs SpO2 Relations
- 73. Gold standard : FiberOptic confirmation, Visualization of tracheal rings Airway Management
- 74.
- 75. Focussed Management Pearls 1. Traumaticbrain injury 2. Unstable C Spine injuries 3. Contaminated Airway 4. Agitated trauma patient 5. Faciomaxillary injuries 6. Laryngotracheal injuries 7. Hemodynamic instability
- 76. Patients with TBI ●Hypoxemia and Hypotension during airway management significantly worsens outcomes in patients with TBI ● Airway management for airway protection should proceed only after adequate measures have been taken to prevent intubation related physiologic disturbances.
- 77. Patients with TBI ●Postintubation hypocapnia is associated with poor outcomes in patients with TBI and often the result of adrenaline induced overzealous postintubation ventilation ● Postinjury apnea requiring ventilation support does not necessarily predict poor outcome.
- 78. ❏ What arepoints to be taken care in airway management in patient with Traumatic brain injury? ● Avoid Hypoxia ● Avoid Hypotension ● Avoid airway Obstruction ● Pre Oxygenation ● Pre Treatment : Lignocaine/Opioid/Defasciculating agents ● Pre load : Fluid Pre-Intubation
- 79. ❏ What arepoints to be taken care in airway management in patient with Traumatic brain injury? DURING INTUBATION ● Appropriate selection of Drugs ● Use brain friendly agents ● Adequate reflex obtundation ● Do gentle laryngoscopy ● Use adjuncts appropriately ● Expert help as needed ● Avoid hyperventilation
- 80. ❏ What arepoints to be taken care in airway management in patient with Traumatic brain injury? 1. Avoid coughing ,bucking and Gagging 2. Avoid Tube bitting and Blockage 3. Avoid High PEEP 4. Avoid High PIP 5. Avoid Hyperventilation 6. Avoid Hypoventilation 7. Adequate sedation 8. Adequate paralysis 9. Avoid Jugular obstruction (C-Collar, ETT tieng tap) 10. Always check DOPE Post Intubation Ten As
- 81.
- 82. Patient with UnstableC spine injuries ● Imaging should not delay airway management and assume all trauma patients have unstable cervical spines. ● Optimally use the intubation device he or she is most experienced with. ● Be prepared for a poor view with direct laryngoscopy (DL) and always have a bougie ready for use.
- 83. Patient with UnstableC spine injuries ● Rigid cervical collars must be opened or removed and replaced by properly applied manual inline stabilization (MILS). ● Properly applied MILS should avoid immobilization of the mandible.
- 84. Patient with UnstableC spine injuries ● Use a hyperangulated video laryngoscope, a deliberate restricted glottic view may facilitate difficult ETT advancement
- 85.
- 86. Patient with contaminatedAirway ● Have at least 2 large-bore rigid suction catheters. ● Consider alternative options for hemorrhage control (sutures, packing, epistaxis kit). ● Minimize positive-pressure ventilation (PPV) and use a mono meter for provider feedback when mask ventilation is indicated. ● Look for epiglottis as an important landmark for glottis and have a bougie prepared for use with DL
- 87. Patient with contaminatedAirway ● VL is considered the best option, Macintosh VL may be the preferred device, as it may be used directly if contamination obstructs camera ● Consider esophageal ETT diversion connected to suction ● Suction-assisted laryngoscopy airway decontamination (SALAD) approach ● If intubation fails and patient is desaturating, front of neck airway (FONA) rescue oxygenation approach is indicated
- 88.
- 89. ● Agitation maybe a symptom of traumatic pathology ● Agitated patients may require facilitated cooperation to ensure adequate preoxygenation ● Ketamine is an appropriate agent to facilitate cooperation in agitated patients in preparation for airway management ● Always be prepared to provide definitive airway intervention before administering sedation. Agitated Trauma patients
- 90.
- 91. Patients with FaciomaxillaryTrauma ● Do careful assessment of damaged anatomy recognizing the unique airway complications associated with facial fractures. ● Both laryngoscopy and mask ventilation may be challenging ● Double set-up should be prepared for when rapid sequence intubation (RSI) is the chosen approach
- 92. Patients with FaciomaxillaryTrauma ● An awake approach, although not always practical, should be considered. ● Management of aggressive bleeding should be anticipated. ● Allow patients to assume a position of comfort when safe to do so.
- 94.
- 95. Patients with PrimaryAirway injury : Laryngo tracheal trauma ● Decompensation in the patient with a traumatized airway may be rapid and catastrophic. ● PPV should be avoided if possible. ● An awake approach with appropriate topicalization is the preferred approach. ● If an RSI is chosen, a double set-up with a FONA plan for accessing the trachea based on the level of the airway breach.
- 96. Patients with PrimaryAirway injury : Laryngo tracheal trauma ● ETT placement should ideally be performed with visualization of the airway using a flexible intubating endoscope (FIE). ● Advanced techniques using FIE either primarily in an awake patient or assisted by VL when an RSI is chosen are recommended when resources and skill are available.
- 98.
- 99. Peri Intubation hemodynamicinstability ● Resuscitation using blood products (packed red blood cells/massive transfusion) should be done early in the pre-intubation phase of trauma management ● Selected scenarios consider the use of vasopressors during the peri-intubation phase. ● Reduce the dose of all induction agents by at least 50% and increase the dose of the paralytic agents
- 100.
- 101. PreOxygenation : “TheRule of Two” ● Elevate the Head (ear to sternum) and the Bed greater than 20 (reverse Trendelenburg). ● Two sources of oxygen for all critically ill patients 1. High-flow nasal prongs !15 L/min 2. NRB/bag-mask ventilation !15 L/min. ● Two approaches for obstruction: OPA with a Jaw thrust for soft tissue obstruction
- 102. PreOxygenation : “TheRule of Two” ● Two attachments for your BVM: positive end-expiratory pressure valve and pressure manometer ● Two hands on all face masks: to ensure closed system oxygenation and ventilation and perform an aggressive jaw thrust ● Two providers: a tight mask seal and aggressive jaw thrust giving feedback to the provider squeezing the bag ● Avoid over ventilation and hyperventilation
- 103.
- 104. Pre Intubation checklist One Emerg MedClin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Team Ready ? ❏ EP Aware / Experienced airway staff present ❏ Do we need additional help? ❏ Assign roles: Lead / MILS/BVM/Drugs/ETI Trauma -Airway Management
- 105. Pre Intubation checklist Two Trauma -Airway Management PatientReady ? ❏ Monitor(Pulse OX,ECG,BP,EtCO2) ❏ Reverse Trendelenburg 30 degree ❏ Ramp if obese Dual pre Oxygenation ❏ Nasal Cannula@15+LPM AND ❏ NRBM@15 flush LPM or If Sats less than 96% ❏ BVM/PEEP 5-10 cm(Passive) ❏ NIV Fluid bolus Pressor support ( Consider if SI more than .8) Emerg Med Clin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
- 106. Pre Intubation checklist Three Emerg MedClin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Equipment ready? ❏ BVM with PEEP/Pressure manometer ❏ DL/Mac VL, Stylet 30-40 degree + Bougie ❏ HA-VL ETT stylet 60-70 degree ❏ Suction (1-2) ❏ SGA sized ❏ Bougie cric equip available ❏ Ventilator/RT support Trauma -Airway Management
- 107. Intubation checklist One EmergMed Clin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Airway assessment & Plan ❏ Estimated Level of Difficulty Laryngoscopy/BMV/SA/Surgical (Circle ) Low,Moderate,High,Very High ❏ Consider Dangerous Physiology Low BP/Low Sat/Low pH,RV Strain ❏ RSI vs Awake approach, ❏ Medications -RSI Induction/NMBA doses -Awake, Ligno 4% or 10% spray -Ketamine -Post intubation Sedation Trauma -Airway Management
- 108. Intubation checklist Two PlanA-B- C- D Emerg Med Clin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ❏ Plan A - Primary - DL,Mac VL+ Bougie pr HA -VL ❏ Plan B - ReOx/w ETI OPA/2 Hand BVM ❏ Plan C Alternative ETI approach ❏ Plan D - Rescue Ox SGA/ bougie cric Trauma -Airway Management
- 109. Intubation checklist Three EmergMed Clin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Intubation ❏ Time out - ‘’All ready?” “Give drugs” ❏ Post RSI meds 45 sec countdown ❏ Passive BVM+Vent prn ❏ Prob solve ETT advancement -ETT turn left over bougie -Stylet with VL ETT turn right ❏ EtCO2(Waveform) Trauma -Airway Management
- 110. Post Intubation checklist One Emerg MedClin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Post Intubation ❏ Continuous Waveform Capnography ❏ Cycle pressures q3min ❏ Sedation/Analgesia orders ❏ Consider ongoing NMBA ❏ OG Tube placement prn ❏ CXR ❏ Restraints Prn ❏ Review ventilator settings Trauma -Airway Management
- 111. Post Intubation checklist Two Emerg MedClin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Debrief 1) What went well?------------------------------------------ ------------------------ 2) What could be strengthened and How?----------------------------------------- ---------------------------- Trauma -Airway Management
- 112. Post Intubation checklist Three Emerg MedClin N Am 36 (2018) 61–84 https://doi.org/10.1016/j.emc.2017.08.006 emed.theclinics.com 0733-8627/18/a 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Difficulty Rating (Post intubation)- (Circle)Low, Moderate , *High , *Very High *For “High and Very High” Difficulty Ratings ❏ Directly communicate to CC staff ❏ Document on chart What made the Airway difficult?---------------------------------- ------------------------------------------ Trauma -Airway Management
- 113.
- 115. Be prepared ● Oxygen ●Suction ● OPA ● NPA ● GEB ● LMA ● Combitude ● Kings Airway ● Needle & Surgical Cric set ● VL ● ETT different sizes ● Pulse Ox ● ETCO2 ● Drugs Help Trauma -Airway Management
- 116. Pre Oxygenate O2 +/-,OPA +/-, NPA =/- Able to Oxygenate ? No Definitive airway /Surgical Airway Yes Assess Airway Anatomy, Predict Ease of Intubation( LEMON) Easy Difficult Trauma -Airway Management
- 117. Intubation/-, Drug assisted intubation,Cricoidpressure Call for assistance Unsuccessful Consider Adjuncts( LMA, Kings Airway,GEB) Consider Awake Intubation Definitive Airway/ Surgical Airway Trauma -Airway Management
- 119.