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Airway and Ventilatory Management

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Objectives

Identify when airway compromise will occur Recognize acute airway obstruction Describe techniques to establish and maintain

patent airway Define definitive airway with c-spine

protection Demonstrate ventilatory techniques

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Airway Obstruction

Coma Aspiration Maxillofacial

trauma Neck trauma

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Airway Obstruction Recognition

Look Agitation / obtunded Air movement Retraction /”rocking” respirations Deformity Airway debris

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Airway Obstruction Recognition

Listen Normal speech → No obstruction Noisy breathing → Obstruction

• Gurgle

• Stridor

• Hoarseness

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Airway Obstruction Recognition

Feel Maxillofacial / laryngeal crepitus

fractures Tracheal deviation Hematoma

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Adequate Breathing

Provide supplemental oxygen Subtle deterioration of breathing

• Coma • Spinal cord injury • Direct chest traumaCaution

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Inadequate Breathing

Look Cyanosis in mental status Chest asymmetry Tachypnea Neck vein

distention Paralysis

Listen “I can‘t breathe !” Stridor, wheezes or absent breath

sounds

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Inadequate Breathing

Feel Subq. emphysema Chest wall

crepitus / tenderness Tracheal deviation

Adjuncts Pulse oximeter CO2 detector ABGs Chest x-ray

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Adequate Oxygenation

Requires Supplemental O2 Airway Maintenance techniques

or a definitive airway Ventilation

Protect

c-spineCaution

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Airway Maintenance

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Definitive Airway

Need for Airway Coma Maxillofacial injury Aspiration Airway injury

Definitive = Airway

Need For breathing Apnea Hypoxia Hypercarbia Brain Injury

Tube In trachea with cuff inflated

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Definitive Airway

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Right Bronchial Intubation

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Rapid Sequence Intubation

Be prepared for surgical airway Requires skill and training

Urgency must

justify risk !

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Surgical Airway Indications: Inability to intubate trachea

• Maxillofacial trauma

• Neck injury Methods

• Needle cricothyroidotomy with jet insufflation

• Surgical cricothyroidotomy

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Definitive Airway

Immediate Need : Apneic Patient Suspect c-spine injury Oxygenate and ventilate Orotracheal intubation, protect c-spine If unable to intubate → Surgical airway

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Definitive Airway

Immediate Need: Breathing Patient Suspect c-spine injury Oxygenate and ventilate as needed Oro- or nasotracheal intubation, protect

c-spine If unable to intubate → surgical airway

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Definitive Airway

Immedieate Need : Maxillofacial Trauma Suspect c-spine injury Oxygenate and ventilate as needed If unable to intubate → surgical airway

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Oxygenate and Ventilate

Goal: Achieve Maximal cellular O2

O2 at 10-12 liters / minute Tight-fitting oxygen reservoir mask Ventilate Avoid prolonged attempts at intubation

without oxygenation

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Monitor Oxygenation

Pulse Oximeter Measures O2

hemoglobin sat. Utility

• Difficult

intubation • During transport

Pa O2 O2 Hgb Sat

90 mm Hg 100%

60 mm Hg 90%

30 mm Hg 60%

27 mm Hg 50%

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O2 / Hgb Dissociation Cure

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Questions

?

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Summary

Suspect airway compromise Protect c-spine Open airway and ventilate If in doubt → Definitive airway

• Urgency of need

• Clinical judgment and skill Adequate O2 delivery