1) The patient, a 28-year old man involved in a motorbike accident, has an impaired airway as evidenced by snoring, rapid breathing, and low oxygen saturation. 2) The top priority is securing the patient's airway. Basic airway maneuvers and adjuncts like chin lift, jaw thrust, oropharyngeal airway are appropriate first steps given intact reflexes. 3) If the airway cannot be maintained or there is impending compromise, more invasive techniques like intubation may be needed while protecting the cervical spine. Assessing risk factors can help predict difficult airways requiring specialized equipment or procedures like surgical airway.

1. Airway solutions in an acute
trauma scenario
Dr.Venugopalan.P.P
DA;DNB;MNAMS;MEM[GWU]
Director ; Emergency Medicine
Aster DM Health Care Ltd
Deputy Director ;MIMS Academy
Founder and executive director -ANGELS

2. Focus
• Why?
• When?
• How?
• What is different?
• What is new ?

3. Case Scenario
What is your first priority?
28year old man was
brought to ED
following a motor
bike accident , Pulse
112,BP 110/60,Rapid
breathing , Snoring+
SpO2 87 in room air
and CGS 8/15. Smell
of alcohol +

4. Priority –One
• Airway is the first system to be taken care in
any trauma victim
• Compromised airway will endanger the
patient life more rapidly than any other
system compromise

5. Airway Assessment
How do I know 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
reassessed for deterioration.

6. Airway Assessment
Signs and symptoms of airway compromise
● High index of suspicion
● Change in voice / sore throat
● Noisy breathing (snoring and stridor)
● Dyspnea and agitation

7. Airway Assessment
Signs and symptoms of airway compromise (cont.)
● Tachypnea
● Abnormal breathing pattern
● Low oxygen saturation (late sign)

8. Airway Assessment
When to intervene when the airway is patent
● Inability to protect the airway
● Impending airway compromise
● Need for ventilation

9. Trauma :Definitive airway
• Apnoea
• Glasgow Coma Scale < 8 or sustained seizure activity.
• Unstable mid-face trauma.
• Airway injuries.
• Large flail segment or respiratory failure.
• High aspiration risk.
• Inability to otherwise maintain an airway or
oxygenation.

10. Airway Assessment
Impending Airway Obstruction

11. Airway Management
How do I manage the airway of a trauma patient?
● Supplemental oxygen
● Basic techniques
● Basic adjuncts
● Definitive airway
● Cuffed tube in the trachea
● Difficult airway adjuncts
● Unexpected difficult airway
● Predicted difficult airway

12. Airway Management
Protect the cervical spine during airway
management!
Caution

13. Obstructed airway ?
• Tongue and Epiglottis
• Any Foreign materials ?
Clear it
Noisy breathing ?

14. Tongue obstructing
Airway

15. Airway Management
Basic Techniques
Chin-lift Maneuver

16. Jaw thrust

17. Trauma ?

18. Airway
Not – Maintainable ?
Adjuncts

19. Airway Management
Basic Adjuncts
Oropharyngeal airway
● Patients who can tolerate an oral airway will
usually need intubation.
Nasopharyngeal airway
● Often well tolerated

20. • Airway Reflexes ? …..No !
Choice –OPA !

21. O P A

22. Sizing - oropharyngeal airway

25. • OPA is not tolerating ?
• Airway reflexes retained ?
• Inability to open mouth ?
N P A

26. N
P
A

28. • Facial and Maxillary injury
• Fracture Base of skull
Caution
Raccoons' eye Battles sign

29. Airway Management
How do I predict a potentially difficult airway?
● Maxillofacial trauma and deformity
● Mouth opening
● Anatomy
● Beard
● Short, thick neck
● Receding jaw
● Protruding upper teeth

30. Airway Management
Is this a difficult airway?
How would you manage this
patient?

31. Airway Management
Definitive Airway – Easy
● Oral intubation (medication assisted)
● Cricoid pressure, suction, back-up
● Maintain c-spine immobilization
● Plan for failure:
● Gum elastic bougie
● LMA / LTA
● Needle cricothyroidotomy
● Surgical airway

32. RSI: “7 P’s”
1. P = Preoxygenation
2. P = Preparation
3. P = Pretreatment
4. P = Paralysis with induction
5. P = Protection
6. P = Placement of the tube
7. P = Post-Intubation management

33. RSI: Timeline
T – 10 minutes Prepare
T – 5 minutes Preoxygenate
T – 3 minutes Pretreat
T = 0 Paralysis with
induction
T + 30 seconds Protection
T + 45 seconds Placement
T + 90 seconds Post-Intubation
management

34. Airway Management
Definitive Airway – Easy
● Preoxygenate
● Cricoid pressure
● Sedate (midazolam)
● Paralytic (succinylcholine)
● Intubate
● Confirm (Auscultate, CO2)
● Release cricoid pressure and ventilate

35. Airway Management
Is this a difficult airway?
How would you manage this
patient?

36. Airway Evaluation
Problem Airway
epiglottis Vocal cords

37. Difficult Airway Assessment
• 4 D’s
– Distortion, Disproportion, Dysmobility, Dentition
• BONES
– Beard, Obese, No teeth, Elderly, Snores (sleep apnea)
• SHORT
– Surgery (head/neck/jaw), Hematoma, Obese,
Radiation, Tumor
• LEMON
• MALLAMPATI
• Always have a “Rescue Airway” technique ready

38. MALLAMPATI SCORE
Class I Class II Class III Class IV

39. Anticipate the worst !!!

40. 60-SECOND EXAM “LEMON”
• Look for external difficulty
• Evaluate using 3=3=2 rule
• Mallampati (Class I & II)
• Obstruction
• Neck Mobility
 3 fingers fit in mouth
 3 fingers fit from mentum
to hyoid cartilage
 2 fingers fit from mandible
to top of thyroid cartilage

41. McIntyre; The difficult tracheal intubation

42. Airway Management
Definitive Airway – Difficult
● Get help
● Be prepared
● Consider rapid sequence intubation vs. awake
intubation
● Maintain c-spine immobilization
● Consider use of:
● Gum elastic bougie
● LMA / LTA
● Surgical airway
● Other advanced airway techniques, eg, fiberoptic
intubation

43. Gum elastic bougie

44. LMA

46. Igel

47. Intubating LMA

50. Kings LT airway

51. Video Laryngoscope

52. Video Assisted Laryngoscope

53. Other methods
Useful in semi elective scenarios
• Fiberoptic intubation

54. Airway Management
Definitive Airway
● Surgical airway
● Cricothyroidotomy
Needle
Surgical

55. Always
Do confirm tube positions !!

56. Airway Confirmation
How do I know the tube is in the right place?
● Visualize it going through
the cords
● Watch the chest
● Auscultation
● Pulse oximeter
● CO2 detector
● Radiology

57. Rule out wrong tube position

58. End tidal CO2 detection

59. Esophageal Detector Devices
(EDD)

60. Recognize Adequacy of Ventilations
Pulse oximeter

61. Approximate Blood oxygen level !
SpO2 100% = PaO2 100mm of Hg
SpO2 90%= PaO2 60mm of Hg
SpO2 60%= PaO2 30mm of Hg
SpO2 50%= PaO2 27mm of Hg

62. Airway Decision Scheme

63. Airway
can be
tricky
always

64. www.drvenu.net
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