Lesson 4

PHTLS 8ªED

1. Lesson 4 Airway

2. Airway Anatomy Upper airway Nasal passage Turbinates Oral cavity Epiglottis Vocal cord Esophagus

3. Anatomy of the Glottis 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 (1 of 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 (2 of 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 (3 of 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 (4 of 5) Listen for abnormal sounds indicating airway compromise Examples include: Snoring Stridor (inspiratory) Gurgling (expiratory) Hoarseness

9. Airway Assessment (5 of 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 (1 of 2) Causes of airway obstruction Tongue Most common cause Falls back, obstructing the airway with decreased mental status Snoring — clinical finding

11. Airway Obstruction (2 of 2) Causes of airway obstruction (cont’d) Foreign body Blood Vomit Teeth

12. Airway Trauma (1 of 2) Blunt injuries Examples of findings may include: Swelling and edema Fractured larynx Subcutaneous emphysema Hematoma

13. Airway Trauma (2 of 2) Penetrating injuries Examples of findings may include (cont’d): Bleeding into the airway Subcutaneous emphysema Hematoma

14. Inhalation Injuries of the Airway Examples of causes Dry Steam Chemical Signs and symptoms of airway burns Swelling/edema Stridor

15. Airway and Spine Stabilization Maintain cervical spine stabilization as indicated by mechanism of injury Especially important when assessing and performing airway maneuvers

16. Airway Management (1 of 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 (2 of 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 (3 of 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 Categories of Airway Management (1 of 2) Manual Trauma jaw thrust Chin lift Simple Oropharyngeal airway (OPA) Nasopharyngeal airway (NPA )

20. Methods and Categories of 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 Thrust or Chin Lift ( 1 of 2) Always the first airway maneuvers for the trauma patient Performed while maintaining manual cervical stabilization

22. Trauma Jaw Thrust or 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 (1 of 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 (2 of 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 (1 of 6) Complex technique Requires: Significant initial training Multiple pieces of equipment Substantial ongoing training to maintain proficiency Courtesy of AMBU

28. Endotracheal Intubation (2 of 6) Placement options Oral Pharmacologically assisted intubation Rapid-sequence intubation (RSI) Nonpharmacologic Nasal

29. Endotracheal Intubation (3 of 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 (4 of 6) Before attempting intubation: Anticipate potential difficulties Trauma-related Disrupted/displaced anatomy Pre-existing conditions Small mouth/mandible Short neck Obesity

31. Endotracheal Intubation (5 of 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 (6 of 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 (1 of 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 (2 of 3) Potential for: Multiple complications Damage to nearby anatomic structures

35. Surgical Airways (3 of 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 CO 2 Colorimetric Capnometry Wave form capnography Pulse oximetry Continually monitored and reassessed Courtesy Masimo

38. Airway Protocol (1 of 3)

39. Airway Protocol (2 of 3)

40. Airway Protocol (3 of 3)

41. Summary Goal is to 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. Questions?