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Lesson 4
- 1.
- 2. Airway Anatomy • Upperairway – Nasal passage – Turbinates – Oral cavity – Epiglottis – Vocal cord – Esophagus
- 3. Anatomy of theGlottis • Posterior tongue • Epiglottis • Vocal cords – True – False • Esophagus • Prehospital care providers who perform endotracheal intubation must know this anatomy Courtesy of James P. Thomas, M.D., www.voicedoctor.net
- 4. Pediatric Airway Considerations •Larger head and tongue – Greater potential for airway obstruction – Special attention to proper positioning • Epiglottis – Proportionally larger – Floppier than adult • Trachea – Shorter and conical shape – Greater potential for main bronchus intubation
- 5. Airway Assessment (1of 5) • If the trauma patient is talking normally, the airway is open – Further assessment is still required • Assessment of the airway requires the provider to: – Look – Listen – Feel
- 6. Airway Assessment (2of 5) • Look for findings that may indicate airway obstruction or injury or may lead to pulmonary aspiration • Examples may include: – Blood and secretions – Fractured teeth – Foreign bodies
- 7. Airway Assessment (3of 5) • Examples may include (cont’d): – Vomitus – Hematomas/contusions (e.g., tongue, neck) – Gross subcutaneous emphysema Photograph provided courtesy of J.C. Pitteloud M.D., Switzerland
- 8. Airway Assessment (4of 5) • Listen for abnormal sounds indicating airway compromise • Examples include: – Snoring – Stridor (inspiratory) – Gurgling (expiratory) – Hoarseness
- 9. Airway Assessment (5of 5) • Feel for abnormal masses and signs of airway injury • Examples include: – Hematomas – Subcutaneous emphysema in the neck • Additional consideration – Measure oxygen saturation
- 10. Airway Obstruction (1of 2) • Causes of airway obstruction – Tongue • Most common cause • Falls back, obstructing the airway with decreased mental status • Snoring — clinical finding
- 11. Airway Obstruction (2of 2) • Causes of airway obstruction (cont’d) – Foreign body – Blood – Vomit – Teeth
- 12. Airway Trauma (1of 2) • Blunt injuries – Examples of findings may include: • Swelling and edema • Fractured larynx • Subcutaneous emphysema • Hematoma
- 13. Airway Trauma (2of 2) • Penetrating injuries – Examples of findings may include (cont’d): • Bleeding into the airway • Subcutaneous emphysema • Hematoma
- 14. Inhalation Injuries ofthe Airway • Examples of causes – Dry – Steam – Chemical • Signs and symptoms of airway burns – Swelling/edema – Stridor
- 15. Airway and SpineStabilization • Maintain cervical spine stabilization as indicated by mechanism of injury • Especially important when assessing and performing airway maneuvers
- 16. Airway Management (1of 3) • The goal in managing the trauma patient’s airway is to maintain a patent airway that allows for adequate breathing, ventilation, and oxygenation • Management progresses from essential to complex procedures and adjuncts
- 17. Airway Management (2of 3) • Prehospital care providers should be knowledgeable and skilled in multiple methods of ensuring a patent airway • Providing a patent airway entails anticipating difficulties and planning for alternate methods of airway control
- 18. Airway Management (3of 3) • Essential skills and interventions are applied first • Complex skills and interventions are performed only if needed • The choice of technique to manage the airway depends upon: – Knowledge and skills of the provider – Situation at the scene – Severity of the patient – Resources available
- 19. Methods and Categoriesof Airway Management (1 of 2) • Manual – Trauma jaw thrust – Chin lift • Simple – Oropharyngeal airway (OPA) – Nasopharyngeal airway (NPA)
- 20. Methods and Categoriesof Airway Management (2 of 2) • Complex – Supraglottic airways – Endotracheal intubation – Rapid sequence intubation (RSI) – Percutaneous airway – Surgical airway Courtesy of Ambu, Inc.
- 21. Trauma Jaw Thrustor Chin Lift (1 of 2) • Always the first airway maneuvers for the trauma patient • Performed while maintaining manual cervical stabilization
- 22. Trauma Jaw Thrustor Chin Lift (2 of 2) • Both techniques lift the mandible, elevating the tongue away from the posterior pharynx, opening the airway • Can be used for conscious or unconscious patients
- 23. OPA and NPA(1 of 2) • Both airway adjuncts mechanically elevate the tongue off the poster pharynx to maintain an open airway • Both airways require measurement (length) and sizing (diameter) prior to insertion.
- 24. OPA and NPA(2 of 2) • Improperly sized or improperly inserted airways can cause obstruction by pushing the tongue against the posterior pharynx • OPA insertion requires an absent gag reflex – Insertion technique is based on age of patient • NPA insertion requires the use of a water-soluble lubricant
- 25. Supraglottic Airways (1of 2) • Blind insertion technique • Less complex technique than endotracheal intubation – Less initial training – Easier to maintain proficiency • Requires an absent gag reflex Courtesy of Ambu, Inc.
- 26. Supraglottic Airways (2of 2) • Supraglottic airways occlude the pharynx to limit regurgitation but do not prevent aspiration • Some supraglottic airways are available in pediatric sizes • Examples of supraglottic airways include the laryngeal mask airway (LMA), Combitube, and King LT airway
- 27. Endotracheal Intubation (1of 6) • Complex technique • Requires: – Significant initial training – Multiple pieces of equipment – Substantial ongoing training to maintain proficiency Courtesy of AMBU
- 28. Endotracheal Intubation (2of 6) • Placement options – Oral • Pharmacologically assisted intubation • Rapid-sequence intubation (RSI) • Nonpharmacologic – Nasal
- 29. Endotracheal Intubation (3of 6) • Assess need for intubation based on: – Inability to maintain a patent airway – Decreased LOC – Upper airway burns – Signs of impending airway obstruction • Endotracheal intubation may also be considered when alternate methods of airway management are deemed inadequate or inappropriate based on the situation and severity of injuries
- 30. Endotracheal Intubation (4of 6) • Before attempting intubation: – Anticipate potential difficulties • Trauma-related – Disrupted/displaced anatomy • Pre-existing conditions – Small mouth/mandible – Short neck – Obesity
- 31. Endotracheal Intubation (5of 6) • Before attempting intubation (cont’d): – Prepare an alternate (backup) plan for airway management in the event of unsuccessful endotracheal tube placement – Have all necessary equipment immediately at hand
- 32. Endotracheal Intubation (6of 6) • Important considerations – Essential airway skills are often sufficient to provide a patent airway – If intubation is required: • Preoxygenate to maximize oxygen saturation • Reoxygenate patient in between intubation attempts • Monitor oxygen saturation (e.g., pulse oximetry) throughout the procedure – Following intubation, verify proper tube placement
- 33. Surgical Airways (1of 3) • Complex technique • Requires: – Significant initial training – Multiple pieces of equipment – Substantial ongoing training to maintain proficiency Courtesy of Peter T. Pons, MD, FACEP. Courtesy of Peter T. Pons, MD, FACEP.
- 34. Surgical Airways (2of 3) • Potential for: – Multiple complications – Damage to nearby anatomic structures
- 35. Surgical Airways (3of 3) • May be considered for: – Massive facial trauma that prevents endotracheal intubation – Upper airway obstruction unrelieved by other techniques – Failed intubation and alternative airway methods are unavailable or unsuccessful
- 36. Confirmation of Tube Placement(1 of 2) • Should include at least one physiological and one mechanical method • Physiological – Breath sounds – Chest rise – Change in skin color – Pulse rate • Continually monitored and reassessed
- 37. Confirmation of Tube Placement(2 of 2) • Mechanical – End tidal CO2 • Colorimetric • Capnometry • Wave form capnography – Pulse oximetry • Continually monitored and reassessed Courtesy Masimo
- 38. Airway Protocol (1of 3)
- 39. Airway Protocol (2of 3)
- 40. Airway Protocol (3of 3)
- 41. Summary • Goal isto secure and maintain a patent airway • Assess airway by looking, listening, and feeling • Maintain manual stabilization of the head and spine as indicated • Apply essential airway maneuvers first • Utilize complex airway techniques only when required • Anticipate difficulties and plan and prepare for alternate methods of airway control
- 42.
Editor's Notes
- #2 Instructor Notes Lesson 4 will provide participants with an overview on how to manage an airway in a trauma patient. Remember, management of the airway is paramount in the successful resuscitation of the trauma patient. Without a patent airway, all is lost. However, the best airway for a particular patient may not be an advanced airway or endotracheal tube.
- #3 Instructor Notes Expand on the following points: Briefly review the anatomy of the upper airway and its relationship to airway management. A patent airway is the first component in the delivery pathway of oxygen to the cells. Oxygen is needed for cellular metabolism and energy production. The tongue is the most common cause of airway obstruction. The components of the upper airway include: Nasal passage Turbinates Oral cavity Epiglottis Vocal cord Esophagus
- #4 Instructor Notes Expand on the following points: The figures on screen illustrate the laryngoscopic view of the glottis. Prehospital care providers who perform endotracheal intubation must know the anatomy of the glottis, including: Posterior tongue Epiglottis Leaf-shaped structure Acts as a gate or flapper valve Directs air into the trachea and solids and liquids into the esophagus Vocal cords True Folds of tissue that meet in the midline False Also called vestibular folds Direct the airflow through the vocal cords Esophagus
- #5 Instructor Notes Expand on the following points: Review the differences in the anatomy of the pediatric patient and potential areas of difficulty in maintaining a patent airway. Pediatric airway considerations include: A larger head and tongue as compared to an adult There is a greater potential for airway obstruction in a pediatric patient. Special attention to the proper positioning of the pediatric patient is required to maintain a patent airway. The epiglottis is proportionally larger and floppier than in an adult. The trachea is shorter and conical shape, which leads to a greater potential for main bronchus intubation.
- #6 Instructor Notes Expand on the following points: Even if the trauma patient is talking normally, still assess the airway. While the talking patient is demonstrating that the airway is open now, further assessment is still required. The assessment of the airway requires the prehospital care provider to: Look, listen, and feel This technique will be discussed in the following slides.
- #7 Instructor Notes Expand on the following points: During the airway assessment, look for findings that may indicate airway obstruction or injury or may lead to pulmonary aspiration. Examples may include: Blood and secretions Fractured teeth Foreign bodies
- #8 Instructor Notes Expand on the following points: During the airway assessment, look for findings that may indicate airway obstruction or injury or may lead to pulmonary aspiration. Examples may include (continued): Vomitus Hematomas/contusions (e.g. tongue, neck) Gross subcutaneous emphysema The photo on this screen illustrates contusion over the trachea and gross subcutaneous emphysema (note the air-filled swollen eyelids) in a patient with a ruptured trachea. It is courtesy of J. C. Pitteloud, MD, PHTLS Switzerland.
- #9 Instructor Notes Expand on the following points: Listen for abnormal sounds indicating airway compromise. Examples include: Snoring Stridor (upon inhalation) Gurgling (upon exhalation) Hoarseness Of all of the abnormal airway sounds, stridor is the most concerning because it indicates a high degree of airway obstruction and the need for immediate intervention.
- #10 Instructor Notes Expand on the following points: Feel for abnormal masses and signs of airway injury. Examples include: Hematomas It is critical to note the presence of an expanding hematoma involving the neck. May distort the normal anatomy and compromise the ability to manage the airway if necessary Subcutaneous emphysema in the neck The presence of subcutaneous emphysema indicates disruption of the pulmonary system. The exact location of the air leak may not be apparent in the field. Additional consideration during this phase: Measure oxygen saturation.
- #11 Instructor Notes Expand on the following points: Causes of airway obstruction: Tongue The tongue obstructing the airway is the primary reason for death in the head-injured patient prior to EMS arrival. With decreased mental status, the tongue falls back, obstructing the airway. Snoring is a clinical finding indicating this obstruction.
- #12 Instructor Notes Expand on the following points: Additional causes of airway obstruction in the trauma patient are (continued): A foreign body Blood Vomit Teeth
- #13 Instructor Notes Expand on the following points: Examples of clinical findings of blunt trauma may include: Swelling and edema Fractured larynx Subcutaneous emphysema Hematoma Note that this list is not inclusive of all possible findings.
- #14 Instructor Notes Expand on the following points: Examples of clinical findings of penetrating trauma may include (continued): Bleeding into the airway Subcutaneous emphysema Hematoma Note that this list is not inclusive of all possible findings.
- #15 Instructor Notes Expand on the following points: Inhalation injuries of the airway may be the result of smoke inhalation (dry), steam, or chemicals. The signs and symptoms of airway burns include swelling/edema and stridor. While the burn is of concern, the primary risk is the development of tissue edema obstructing the airway. Early and aggressive management of the burned airway is recommended before swelling develops and further complicates airway management. If the prehospital care provider cannot secure an airway, the patient needs to be immediately transported to a facility that can provide the needed airway. This facility may not necessarily be a trauma or burn center since the patient can be transferred as appropriate after the airway has been managed. The use of supraglottic airways in these cases may not secure the airway due to the increase in swelling of the upper airway. Endotracheal intubation and rarely surgical airway management techniques are required.
- #16 Instructor Notes Expand on the following points: Maintain cervical spine stabilization as indicated by the mechanism of injury. This is especially important when assessing and performing airway maneuvers in a trauma patient.
- #17 Instructor Notes Expand on the following points: The goal in managing the trauma patient’s airway is to maintain a patent airway that allows for adequate breathing, ventilation, and oxygenation. The management of an airway progresses from essential maneuvers to complex procedures and adjuncts. For example, progressing from the trauma jaw thrust to suctioning to ventilation with a bag-mask device to endotracheal intubation
- #18 Instructor Notes Expand on the following points: Prehospital care providers should be knowledgeable and skilled in multiple methods of ensuring a patent airway. Providing a patent airway entails anticipating difficulties and planning for alternate methods of airway control.
- #19 Instructor Notes Expand on the following points: When managing the airway of a trauma patient: Essential skills and interventions are applied first. Essential skills include manual airway opening techniques and simple devices such as oropharyngeal airways and nasopharyngeal airways. Complex skills and interventions are performed only if needed. Complex skills and interventions are those that require significant initial training and skills maintenance. Complex skills include devices and techniques such as endotracheal intubation, supraglottic airways, rapid sequence intubation (RSI), percutaneous airways, and surgical airways. The choice of technique to manage the airway depends upon: The knowledge and skills of the prehospital care provider The situation at the scene The severity of the patient The resources available
- #20 Instructor Notes Expand on the following points: The methods and categories of airway management are: Manual Trauma jaw thrust Chin lift Simple Oropharyngeal airway (OPA) Nasopharyngeal airway (NPA) The techniques listed will be covered in subsequent slides.
- #21 Instructor Notes Expand on the following points: The methods and categories of airway management are (continued): Complex Supraglottic airways Endotracheal intubation Rapid sequence intubation (RSI) Percutaneous airway Surgical airway The techniques listed will be covered in subsequent slides.
- #22 Instructor Notes Expand on the following points: The trauma jaw thrust or chin lift is always the first airway maneuver for the trauma patient. These techniques are performed while maintaining manual cervical stabilization. They require NOTHING other than your hands to perform.
- #23 Instructor Notes Expand on the following points: Both techniques lift the mandible, elevating the tongue away from the posterior pharynx, and opening the airway. They can be used for conscious or unconscious patients. Remind participants that the tongue is attached directly to the mandible, thus explaining why both techniques are efficacious.
- #24 Instructor Notes Expand on the following points: Both types of airway adjuncts mechanically elevate the tongue off of the poster pharynx to maintain an open airway. Both types of airways require measurement (length) and sizing (diameter) prior to insertion. Review the measuring, sizing, and insertion techniques of both types of adjuncts with participants. See the Specific Skills section at the end of the Airway and Ventilation chapter of PHTLS: Prehospital Trauma Life Support, Eighth Edition. Oropharyngeal Airway Nasopharyngeal Airway Note that head injury is not an absolute contraindication to the use of an NPA.
- #25 Instructor Notes Expand on the following points: Improperly sized or improperly inserted airways can cause obstruction by pushing the tongue against the posterior pharynx. OPA insertion requires an absent gag reflex. The insertion technique is based on the age of patient. OPA insertion in the pediatric patient requires the use of a tongue blade and de-rotation of the airway device in comparison to the technique utilized for adult patients. NPA insertion requires the use of a water-soluble lubricant.
- #26 Instructor Notes Expand on the following points: Supraglottic airways require the blind insertion technique. This is a less complex technique than endotracheal intubation. It requires less initial training. It is easier to maintain proficiency in this technique. Supraglottic airways require an absent gag reflex. See the Specific Skills section at the end of the Airway and Ventilation chapter to review specific supraglottic airway skills.
- #27 Instructor Notes Expand on the following points: Supraglottic airways occlude the pharynx to limit regurgitation, but do not prevent aspiration. Some supraglottic airways are available in pediatric sizes. Examples of supraglottic airways include the laryngeal mask airway (LMA), Combitube, and King LT airway Not all manufacturers of supraglottic airways provide pediatric sizes.
- #28 Instructor Notes Expand on the following points: All prehospital care providers should know and understand the skill of endotracheal intubation, as they may be called to either assist or perform the procedure. Endotracheal intubation is a complex technique that requires: Significant initial training Multiple pieces of equipment Substantial ongoing training to maintain proficiency
- #29 Instructor Notes Expand on the following points: Several methods are available for performing endotracheal intubation. Orotracheal intubation Pharmacologically assisted intubation Rapid-sequence intubation (RSI) Nonpharmacologic Nasotracheal intubation
- #30 Instructor Notes Expand on the following points: Assess for the need for endotracheal intubation based on: The inability to maintain a patent airway A decreased level of consciousness (LOC) Upper airway burns Signs of impending airway obstruction Endotracheal intubation may also be considered when alternate methods of airway management are deemed inadequate or inappropriate based on the situation and severity of injuries.
- #31 Instructor Notes Expand on the following points: Anticipation and preparation are key to successful airway management. Anticipated difficulties as well as the alternate plan will dictate what equipment should be out and readily available prior to any intubation attempt. Before attempting intubation: Anticipate potential difficulties: Trauma-related Disrupted/displaced anatomy Pre-existing conditions Small mouth/mandible Short neck Obesity
- #32 Instructor Notes Expand on the following points: Anticipation and preparation are key to successful airway management. Before attempting intubation (continued): Prepare an alternate (backup) plan for airway management in the event of unsuccessful endotracheal tube placement. Have all necessary equipment immediately at hand.
- #33 Instructor Notes Expand on the following points: Important considerations when performing endotracheal intubation: Essential airway skills are often sufficient to provide a patent airway. If endotracheal intubation is required: Preoxygenate to maximize oxygen saturation. Reoxygenate patient in between intubation attempts. Monitor oxygen saturation (e.g., pulse oximetry) throughout the procedure. Following intubation, verify proper endotracheal tube placement.
- #34 Instructor Notes Expand on the following points: A surgical airway utilizes a complex technique and requires: Significant initial training Multiple pieces of equipment Substantial ongoing training to maintain proficiency
- #35 Instructor Notes Expand on the following points: With surgical airways, there is a potential for: Multiple complications Damage to nearby anatomic structures Surgical airways in most cases are not the first choice for obtaining a patent airway.
- #36 Instructor Notes Expand on the following points: Surgical airways may be considered for: Massive facial trauma that prevents endotracheal intubation Upper airway obstruction unrelieved by other techniques Failed intubation and alternative airway methods are unavailable or unsuccessful However, massive facial injury does not always prevent the use of endotracheal intubation. Just because your protocols say you may perform a surgical airway does not mean that you should.
- #37 Instructor Notes Expand on the following points: Confirmation of tube placement should include at least one physiological and one mechanical method: Physiological Breath sounds Chest rise Change in skin color Pulse rate The patient’s airway should be continually monitored and reassessed.
- #38 Instructor Notes Expand on the following points: Confirmation of tube placement should include at least one physiological and one mechanical method (continued): Mechanical End tidal CO2 Colorimetric Capnometry Wave form capnography Pulse oximetry Wave form capnography is the preferred method for monitoring tube placement in complex airways. The patient’s airway should be continually monitored and reassessed.
- #39 Instructor Notes Expand on the following points: Use of this airway management algorithm presents a logical approach to a difficult or failed airway. Review the first section of the airway management algorithm with the participants. Not all devices or procedures may be allowed or available within an individual EMS system.
- #40 Instructor Notes Expand on the following points: Use of this airway management algorithm presents a logical approach to a difficult or failed airway. Review the second section of the airway management algorithm with the participants. Not all devices or procedures may be allowed or available within an individual EMS system.
- #41 Instructor Notes Expand on the following points: Use of this airway management algorithm presents a logical approach to a difficult or failed airway. Review the third section of the airway management algorithm with the participants. Not all devices or procedures may be allowed or available within an individual EMS system.
- #42 Instructor Notes Expand on the following points: The goal is to secure and maintain a patent airway. Assess the airway by looking, listening, and feeling. Maintain manual stabilization of the head and spine as indicated. Apply essential airway maneuvers first. Utilize complex airway techniques only when required. Anticipate difficulties and plan and prepare for alternate methods of airway control.
- #43 Instructor Notes Allow time for a question and answer session to answer any questions about the topics presented in the lesson.