Airway management in special scenarios

1. 1
AIRWAY MANAGEMENT IN SPECIAL SCENARIOS
I.E. CERVICALTRAUMA, AIRWAYTRAUMA,
CERVICAL SPINE DISEASE
--- DR ZIKRULLAH.

2. INTRODUCTION
 Injury is the third leading cause of death overall.
 WHO estimates that injury is the leading cause of death
worldwide for both men and women from 15 to 44 years
 Hypoxia and airway mismanagement are the predominant
cause of pre-hospital deaths (34%) in these patients
 Inability to oxygenate- permanent brain injury and death
within 5 to 10 minutes.
2

3. 3
 60% of patients with severe facial trauma have multisystem
trauma and the potential for airway compromise.
 20-50% concurrent brain injury.
 1-4% cervical spine injuries.
 Airway injuries occur in 1% of trauma patients. 78% of them die
within 1 hour if unattended hence the GOLDEN HOUR.
 The primary focus of ATLS is on the first hour of trauma
management - rapid assessment and resuscitation

4.  The initial assessment of the trauma patient should be done which
should take 2–5 min and consists of the ABCDE sequence of
trauma:
 Airway
 Breathing
 Circulation
 Disability
 Exposure.
 If the function of any of the first three systems is impaired,
resuscitation must be initiated immediately.

5. 5

6. 6

Life threatening airway obstruction:
 Inhalation of tooth fragments
 Accumulation of blood & secretions
 Loss of control of tongue in unconscious
 CLEAR AIRWAY: suction, remove foreign bodies such as a broken
denture or avulsed teeth, jaw thrust, cricoid pressure, nasal
airway,

7. 7
 A trauma patient is always considered to have a full stomach
and to be at risk for aspiration
 Is the patient conscious- If so, the use of sedation or analgesics
should be done cautiously since the airway can be lost following
injudicious use of such drugs
 Is the patient breathing spontaneously- If so, there is time to
arrive at the hospital, preferably to the operating room, and
manage the airway under the best conditions and by the most
experienced personnel
 Spontaneous breathing should be preserved

8. 8
 Prehospital management –
controling airway, external
hemorrhage, rapid transport
 All patients should be transported
initially with supplemental oxygen.
 Immobilization of the C-spine
combination of a hard collar and
sandbags on opposite sides of the
head

9. 9
 Prehospital airway management is a key component of emergency.
 Advanced airway management techniques involves placement of
oropharyngeal airways such as the Laryngeal Mask Airway or
endotracheal tube.
 Endotracheal tube placement success is a common measure of
out-of-hospital airway management quality.
 In studies demonstrating poor outcomes related to prehospital
attempted endotracheal intubation (ETI), both training and skill
level of the provider are usually often low.

10. 10
 Many systems may benefit from more input and guidance by the
anesthesia department, which have extensive training and
experience not just with training of airway management but also
with different airway management techniques and adjuncts.
 Establishing and maintaining an airway is always the first priority.
 Establishing verbal contact with the patient - clear phonation by the
patient establishes that the airway is patent.
 Further intervention depends on:
 neurologic stability
 adequacy of gas exchange and the potential for airway compromise

11. Simplemaneuverstomanageairwaycompromise
 Head tilt/chin lift
 Jaw thrust
 100% oxygen by face mask.
 Oral airway or nasopharyngeal
airway
11

12. 12
 Endotracheal intubation, whether performed in the prehospital
environment or in the ED, must be confirmed immediately by
capnometry.
 Esophageal intubation or endotracheal tube dislodgement are
common and devastating if not promptly corrected.
 Patients in cardiac arrest may have very low end-tidal CO2 values;
direct laryngoscopy should be performed if there is any question
about the location of the endotracheal tube

13. Neurological Stability
 brief neuro exam (done during the primary survey):
A - Alert
V - responds to Verbal stimuli
P - responds to Painful stimuli
U - Unresponsive
 Glasgow Coma Scale (GCS):
GCS < 8 requires definite airway intervention to prevent
aspiration pneumonitis, to insure adequate oxygen delivery
and to avoid hypercarbia.
13

14. 14Simplified approach to definitive airway management in trauma patients

15. CERVICAL SPINE INJURY
 2 to 4% of blunt trauma patients have cervical spine injuries.
 Common causes include high-speed motor vehicle accidents,
falls, diving accidents, and gunshot wounds.
 Head injuries, especially those with low GCS and focal
neurologic deficits, are likely to be associated with cervical
spine injuries
 About 2 to 10% of blunt trauma-induced cervical spine injury
patients develop new or worsening neurologic deficits after
admission
15

16. 16
 In conscious patients, neck pain, tenderness, and extremity
paresthesias are strong indicators of spine injury.
 Five criteria increase the risk for potential instability of the
cervical spine:
(1) neck pain,
(2) severe distracting pain,
(3) any neurological signs or symptoms,
(4) intoxication, and
(5) loss of consciousness at the scene.

17. 17
 A cervical spine fracture must be assumed if any one of these
criteria is present, even if there is no known injury above the level of
the clavicle.
 Immobilization of the neck in neutral position is indicated in all
acute trauma patients suspected to have cervical spine injury based
on mechanism and clinical presentation
 Stabilization of the cervical spine will generally occur in the
prehospital environment
 eg, MILS, axial traction, sandbags, forehead tape, soft collar,
Philadelphia [hard] collar

18. 18
 Jaw-thrust maneuver is the preferred means of establishing an
airway, to avoid neck hyperextension.
 Oral and nasal airways may help maintain airway patency
 A patient who arrives in the hospital with a rigid collar and other
neck-stabilizing devices, but not in need of emergency airway
management, should be evaluated for cervical spine injury.
 Clearance of the neck should be performed at the earliest possible
time
 Not necessarily to facilitate airway management, but to minimize
the risk of pressure ulceration by the collar.

19. CERVICAL SPINE EVALUATION
 Clinical examination: NEXUS or Canadian criteria in awake
patients
 Radiological modalities: awake and low GCS
 X-ray: AP, open mouth view, Lateral
 CT
 MRI
19

20.  Early intubation is almost universally required for patients with
cervical spine fracture and quadriplegia.
 Ventilatory support is absolutely required for patients with a
deficit above C4
 Patients with levels fromC6 to C7 may still need support
 Spontaneous ventilation and extubation are possible after
surgical stabilization and resolution of neurogenic shock.

21. 21
 Unconscious patients with major trauma - increased risk for
aspiration,
 Secure airway as soon as possible
 Endotracheal tube orTracheostomy
 Avoid neck hyperextension and excessive axial traction
 Apply MILS

22. 22
When cervical spine instability present
 Minimize force applied across unstable segments
 Minimize cervical spine motion
 Maintain neck in neutral position

23. MANUALIN-LINESTABILIZATION
 Direct Laryngoscopy and orotracheal intubation with manual in-
line stabilization
 Best accomplished by having two operators in addition to the
physician managing the airway.
 The first operator stabilizes and aligns the head in neutral
position without applying cephalad traction, and the second
operator stabilizes both shoulders by holding them against the
table or stretcher.
23

24. 24
 The anterior portion of the hard collar, which limits mouth
opening, may be removed after immobilization
 Preoxygenation and cricoid pressure (“full stomach”)
 Sedatives/anesthetics & paralytics as indicated
 Assistant applies force(s) equal & opposite to those of DL to
keep the head/neck in neutral position

25. 25
CRICOID PRESURE
 Worsen the laryngoscopic view,
 Impair bag-valve mask (BVM) ventilation efficiency
 Not reduce the incidence of aspiration
 Removed as a level 1 recommendation
 Reduces successful insertion of LMA (94% to 67%)
 To be applied throughout induction and attempts at intubation in
trauma patients
 To be removed to ease intubation or insertion of LMA, should take
precedence over the potential risk of aspiration.

26. 26
• Acc. To recent studies,
• MILS Impaired glottic view  cause application of increased
pressure
 The pressure is transferred to the cervical tissues causing cranio-
cervical motion and instability of the pathologic cervical spine
 In patients with otherwise normal airways, MILS increases the
tracheal intubation failure rate and intubation time, and worsens
laryngeal visualization during direct laryngoscopy.

27. ROUTES OF INTUBATION: NASAL VS ORAL
 Some clinicians prefer nasal intubation in spontaneously
breathing patients with suspected CSI
 Easier path to intubation
 Higher risk of pulmonary aspiration.
 Avoided in patients with midface or basilar skull fractures
 Increased risk for sinusitis in the ICU if the patient is not
extubated at the end of the procedure.

28. 28
 Oral intubation is likely to be more challenging technically
 Better if the patient remains mechanically ventilated

29. 29
ALTERNATIVETECHNIQUES
 Awake fiberoptic intubation.
 Blind nasal intubation
 Transillumination with a lighted stylet,
 Intubating lma,
 GlideScope
 Bullard laryngoscope
 The clinician is advised to use the equipment and techniques that are
most familiar.

30. DirectLaryngoscopy
 Most rapid route
 DL invariably involves muscle relaxation (induced or
intrinsic), hypnotic induction and re-alignment of the
airway;
 Can all be profoundly dangerous in cases of extensive
maxillofacial trauma.
30

31. Aidstodirectlaryngoscopy
 Airway exchange catheter [AEC]or Jet stylet
 Serves dual function: to ventilate the lungs and to act as a
guide for reintubation.
 AEC [Cook’s] has been used:
 (1) to assist with endotracheal tube exchanges, difficult
intubations, and reintubation.
 (2) to monitor end-tidal CO2 levels after extubation.
 (3) to act as a conduit for jet ventilation and oxygen
insufflation.
31

32. Fiberopticintubation
Most useful instrument in skillful
hands.
 Pros:
• Good visualization
• Minimal neck motion
• Can be used in partially occluded
airway
 Cons:
• Availability
• Operator dependent
• Relatively slow
32

33. DifficultiesEncounteredduring FiberopticIntubation
 Lack of patient cooperation
 Acute airway obstruction/ distorted anatomy of airway
 Prescence of secretions and blood
 Extensive pharyngeal edema or tissue rearrangement
 Inadequate topical anaesthesia
 Fogging of the lens
 Difficulty advancing ETT into glottis despite fibreoptic in
trachea
33

34. VideolaryngoscopelikeMcGrath,Glidescope,C-Mac
 Pros:
• Minimizes neck movement
• Good at visualizing glottis when
neck unable to be moved or mouth
unable to be opened wide
 Cons:
• Difficult to pass tube
• Availability
34

35. C Mac Kings Vision Mcgrath
Glidescope
Mcgrath
Video Laryngoscopes

36. TheBullardLaryngoscope
36

37. The Bullard Laryngoscope
 Potential Advantages
 Can be faster than fiberoptics
 Neck can be maintained in neutral position
 Better glottic visualization with MILS
 Incorporates a working for oxygen insufflation/ suction
 Notes of Caution
 Not evaluated in patients with unstable spines
 Successful intubation not “a sure thing”
37

38. The WuScope
38
Potential Advantages
•Neck can be maintained in neutral
position
•Better glottic visualization with
MILS
Notes of Caution
•Not evaluated in patients with
unstable spines
•Not a “sure thing”

39. TheIntubatingLMA(ILMA)
39
•Can be inserted with head & neck
neutral
•Designed to allow rapid blind
orotracheal intubation
•Fiberoptic guided intubation also
possible

40. 40
 Allows ventilation during intubation.
 No or minimal movement of cervical spine.
 Can serve as a good conduit for fibreoptic intubation in patients
with blood/secretions
 Cannot be inserted if the inter dental distance is less than 2 cm.
 Can be inserted in lateral position.

41. LightedStylet(Light-GuidedIntubation)
 The term “lighted stylet” may be used to describe any device
that uses a bright light within the tip of a endotracheal tube as
a guide to facilitate tracheal intubation.
 The technique depends on interpretation of the light
transmitted through the skin of the neck to indicate the
position of the tip of the endotracheal tube.
 When the tip is at the larynx, the light should be in the midline,
and its position in the longitudinal plane indicates its position
in relation to the laryngeal cartilage.
41

42. 42
 As the light passes more
distally, a localized glow in the
center indicates a tracheal
position and a diffuse glow
indicates an esophageal
position.

43. Role of Supraglottic Airway Devices: CVCI
 Laryngeal Mask Airway
 Proseal Laryngeal Mask Airway
 Combitube
 LaryngealTube {King’s airway}

44. RETROGRADEINTUBATION
 pass a narrow flexible guide,
percutaneously, into the trachea
from a site below the vocal cords
and advance this guide through the
larynx and out the mouth or nose.
 In the basic technique, the tracheal
tube is then passed over the guide
into the upper part of the trachea,
the guide is removed, and the tube
is advanced into the trachea

44

45. SURGICAL AIRWAY
 Cricothyrotomy
 Tracheostomy

46. Cricothyrotomy
Surgical or needle technique
– Incision through cricothyroid
membrane
– Indicated when oral or
nasotracheal intuation by other
means fails and when BVM
ineffective
– facilitates rapid restoration of
ventilation and oxygenation in
the “cannot intubate, cannot
ventilate” situation.
46

47. 47

48. Risk-benefitanalysis
 Direct laryngoscopy with orotracheal intubation and
manual in-line stabilization
48
Risk of
exacerbating
cervical spine
injury
Risk of anoxic
brain injury
from failed
intubation
A failed airway is a bad outcome!

49. ATLS
Airway C-spine
control
Priority
Loss of an airway kills more quickly than does the
loss of the ability to breathe or circulatory problems

50. AIRWAY TRAUMA
 Death from trauma has a trimodal
distribution:
 seconds to minutes
minutes to hours
GOLDEN HOUR
several days or weeks
50

51. DIRECT AIRWAY TRAUMA
 Direct trauma to the airway can be classified into broad
categories of blunt and penetrating trauma
 Each of these can be considered in the context of direct
injury to the airway itself versus compromise or threat to
the airway caused by the proximity of the injury in the
neck.
51

52. Penetrating Neck Trauma
 For the purposes of classification of penetrating injury, the
neck is divided into three zones.
52

53. 53
 Zone 1 injuries are relatively infrequent (less than 10% of
penetrating neck injuries) but are often associated with major
vascular injuries or injuries to the dome of the lung
 Zone 2 is a most common location for penetrating neck injuries.
 Zone 2 injuries require emergency airway intervention in
approximately one third of cases, with a large proportion of the
remainder undergoing subsequent intubation related to
evaluation or surgical repair.
 Zone 3 injuries are uncommon (less than 10% of all penetrating
neck injuries)

54. Blunt Neck Trauma
 Inability to localize injury precisely and the injury is usually
more diffuse.
 Initial evaluation of the patient with blunt neck trauma should
include identification of any bruising or ecchymosis related to
the external injury.
 The oropharynx should be inspected to ensure that there is no
injury to the tongue or dentition.
 The external neck should then be palpated carefully from the
mandible to the clavicle.
54

55. 55
 Infrequently, direct blunt neck trauma can cause laryngeal fracture
or tracheal transsection.
 Bag-mask ventilation may produce profound subcutaneous
emphysema and accelerates the patient's deterioration.
 Prompt transfer to the operating room for surgical exploration of
neck and establishment of the airway by tracheostomy distal to the
transection.
 Often, however, airway management must be undertaken before
the surgery.

56. Maxillofacial trauma
 Fractures of the facial skeleton are commonly seen after
assault, road traffic accidents, falls, and sporting injuries
in a ratio of
mandibular : zygoma : maxillary- 6 :2 : 1.1
56

57. 57
FRACTURES OF THE FACIAL SKELETON
 Divided into:
Upper third( above the eyebrow)
Middle third( above the mouth)
Lower third( the mandible)

58. THEMIDDLETHIRD
 Three predominant types were
described.
 Le Fort I :usually involves the
inferior nasal aperture
 Le Fort I I :usually involve the
inferior orbital rim
 Le Fort I I I: along the floor of
the orbit along the inferior
orbital fissure
58

59. Mandibular dislocation
 The mandible can be dislocated:
 Anterior 70%
 Posterior
 Lateral
 Superior
 Dislocations are mostly bilateral.
59

60. 60
 Coronal CT is the investigation of choice for facial injuries
 Plain radiograph with waters view and submental-vertical view
can also be done
 OrthoPentoGram (OPG) is done for mandibular fractures
Advanced airway management (such as endotracheal intubation,
cricothyrotomy, or tracheostomy) is indicated if there is
 cardiac arrest,
 apnea,

61. 61
 persistent obstruction,
 severe head injury,
 maxillofacial trauma,
 a penetrating neck injury with an expanding hematoma,
 or major chest injury(flail chest),
 inability to maintain spo2 >90% by facemask

62.  Oral and nasal airways may help maintain airway patency.
 Unconscious patients are at risk for aspiration
 airway must be secured as soon as possible - endotracheal tube or
tracheostomy.
 Nasal intubation should be avoided in patients with midface or
basilar skull fractures.
 Laryngeal trauma makes a complicated situation worse.

63.  Open injuries may be associated with bleeding, obstruction,
subcutaneous emphysema, and cervical spine injuries.
 Closed laryngeal trauma is less obvious but can present as neck
crepitations, hematoma, dysphagia, hemoptysis, or poor
phonation.
 An awake intubation under direct laryngoscopy or fiberoptic
bronchoscopy with topical anesthesia, if the larynx can be well
visualized and patient is cooperative.
 If facial or neck injuries preclude endotracheal intubation,
tracheostomy under local anesthesia should be considered.

64. 64
 Acute obstruction from upper airway trauma may require
emergency cricothyrotomy or percutaneous or surgical
tracheostomy .
 RSI is reserved for an uncooperative patient needing definitive
airway management
 Equipment to facilitate difficult intubation should be readily
available wherever emergency airway management is performed
 The gum elastic bougie, or intubating stylet, is an inexpensive and
easily mastered adjunct for management of a difficult airway.

65. 65

66. 66

67. CERVICALSPINEDISEASE
It includes
 Rheumatoid arthritis of cervical spine
 Ankylosing spondylitis of cervical spine
67

68. Rheumatoidarthritis
 Rheumatoid arthritis (RA) is a chronic inflammatory form
of arthritis, which affects about 1% of adults
 RA is characterized by persistent joint synovial tissue
inflammation leading to bone erosion, destruction of
cartilage, and loss of joint integrity
 The diagnosis of RA is primarily clinical. Patients
commonly present with pain and stiffness in multiple
joints.
68

69. 69
 Airway management can be particularly challenging in RA
patients because of involvement of cervical spine,
temporomandibular joints and cricoarytenoid joints.
 Arthritis of the cervical spine is common in patients with RA
nearly 85 % in long standing cases.
 Anterior subluxation of C1 on C2 (atlantoaxial subluxation)
may occur in 40% of patients with RA, with symptoms of
progressive neck pain, headaches, and myelopathy .

70. 70
 Flexion of the head in the presence of atlantoaxial instability
could result in the displacement of the odontoid process into the
cervical spine and medulla and compression of the vertebral
arteries .This may precipitate quadriparesis, spinal shock, and
death.
 TMJ is affected in nearly 50% patients.
 Synovitis of theTMJ may significantly limit mandibular motion
and mouth opening in these patients.
 Cricoarytenoid joints involvement occur in about 60 % patients.

71. Atlantoaxial
dislocation. Lateral view
of the cervical spine
71

72. 72
 Arthritic damage to the cricoarytenoid joints may result in
diminished movement of the vocal cords, resulting in a narrowed
glottic opening; this is manifested preoperatively as hoarseness
and stridor.
 During laryngoscopy, the vocal cords may appear erythematous
and edematous, and the reduced glottic opening may interfere
with passage of the endotracheal tube.
 There also is an increased risk of cricoarytenoid dislocation with
traumatic endotracheal intubations

73. 73
 Awake fibreoptic intubation with MILS for cervical spine
stablization is the technique of choice for airway management.
 Involvement of other systems may also add to the difficulty in
management
Other means of securing airway in these patients are
 ILMA
 Videolaryngoscope

74. 74
 Bullard laryngoscope/Airtraq
 Conventional laryngoscopy with MILS
 Retrograde intubation
 Intubation with lightwand
 Cricothyrotomy/Tracheostomy

75. 75
 Restrictive lung changes due to costochondral joint involvement
may lead to ventilation perfusion mismatch with the resultant
decreased arterial oxygenation.
 These patients may show rapid desaturation during
laryngoscopy despite adequate preoxygenation.
 Pericarditis , arteritis of coronary arteries , pericardial
effusion,cardiac valve fibrosis may complicate the management.

76. Ankylosingspondylitis
 Ankylosing spondylitis is a chronic inflammatory arthritic
disease that results in fusion of the axial skeleton.
 Ankylosing spondylitis involves ossification of the axial
ligaments progressing from the sacral lumbar region cranially,
resulting in a significant loss of spinal mobility.
 Reduced movement of their cervical spines and theirTMJ.
 In most cases, awake fiberoptic endotracheal intubation is
required for general anesthesia.
76

77. 77
 Other means of securing airway in these patients are
 ILMA
 Videolaryngoscope
 Bullard laryngoscope
 Conventional laryngoscopy with MILS
 Retrograde intubation
 Intubation with lightwand
 Cricothyrotomy/Tracheostomy

78. lateralviewoftheuppercervicalspineinankylosingspondylitis
patient(arrow).Thisisveryearlysyndesmophyteformation.
78

79.  Strict attention to intraoperative positioning is needed to
avoid fracture of the fused spine with concomitant spinal
cord trauma.
79

81. • Extubation should be deferred until normal anatomy is restored
or at least until the edema subsides.
• Close and continuous monitoring.
• Preparation for re-intubation.
• Steroids.
• Wire cutters.

85. 85
Thank You