Prehospital Trauma Life Support: Airway Management and Ventilation

Prehospital Trauma Life Support
Lesson
Airway Management and Ventilation
PROVIDER COURSE
Copyright 2003, Elsevier Science (USA). All rights reserved.
Objectives
Identify patients in need of airway control Explain the need for increased oxygenation and ventilation in the critical trauma patient Discuss methods of manual and mechanical management of the airway Discuss common errors in ventilation of the trauma patient
4-2
Airway Management
Keys Tools
Observation Listening Auscultation
Failing to appropriately assess the airway Use of the wrong tool for the patients condition
4-3
Anatomy - Upper Airway

Tongue Noisy ventilations = obstructed airway
Gurgling and snoring Stridor and wheezing
4-4
Anatomy - Lower Airway

Conduction region
Trachea Bronchi
Exchange region
Terminal bronchioles Alveoli
4-5
Respiratory System
Ventilation
Delivers O2 to the alveoli Removes CO2 from the alveoli
Connective tissue
Capillary endothelium
CO2 O2 O2
Alveolar epithelium
Gas exchange
Across alveolarcapillary membrane
Capillary
Alveolus
4-6
You are dispatched to a motorcycle and vehicle collision. Bystanders report that the motorcycle was traveling at about 40 mph (65 km/h) when a car pulled in front of the motorcycle. You find the patient laying on the pavement 30 ft (9 m) away from the crash. His helmet is heavily damaged and has been removed by a bystander.
4-7
Findings
Gurgling ventilations Blood is seen in the upper airway Ventilations are rapid and labored Patient is cyanotic Is this airway compromised?
4-8
Management Options
Essential skills
Manual clearing Manual maneuvers Suctioning Basic adjuncts
4-9
Manual Maneuvers
Trauma jaw thrust Trauma chin lift
Attempting more invasive methods before essential skills have been applied
4-10
Suctioning
Used to remove secretions from the airway
Failing to suction when needed may cause a partial or complete airway obstruction Overaggressive use of suctioning may cause or worsen hypoxia
4-11
Basic Adjuncts
Oropharyngeal airway (OPA) Nasopharyngeal airway (NPA) Dual lumen airways (Combitube, PtL)
4-12
Oropharyngeal Airway (OPA)

Not indicated if gag reflex present Best used temporarily Does not protect the trachea
4-13
Nasopharyngeal Airway (NPA)
When would you use this device? What are its limitations?
4-14
Dual Lumen Airways

How do they work? What are the indications for use? What are the contraindications for use?
4-15
Endotracheal Intubation
Orotracheal intubation Nasotracheal intubation Digital intubation
Improper tube placement Hypoxia from improper technique
4-16
Intubation with Inline Stabilization

What are the indications for oral endotracheal tube placement? When do we use the inline technique?
4-17
Nasotracheal Intubation
When would you perform nasotracheal intubation?
Bleeding
4-18
You arrive on the scene of a single vehicle MVC. Your patient is a 25-year-old female who is trapped upright in the drivers seat. Her VR is 36 and she is cyanotic. Gurgling sounds do not improve with suctioning or manual maneuvers. The fire department estimates that it will be 10 minutes before she is extricated.
How would you manage her airway at this point?
4-19
Face-to-Face Intubation
Oral endotracheal intubation can be accomplished by using nontraditional methods

4-20
Your patient is a 35-year-old construction worker who fell 25 ft (7.6 m) and landed on his head. His GCS score is 3. He is apneic and is being ventilated with a BVM. Three attempts at orotracheal intubation are unsuccessful. What are the airway management options at this point?
4-21
Alternative Airway Procedures

Laryngeal mask airway (LMA) Digital intubation Retrograde intubation Percutaneous transtracheal ventilation (PTV) Surgical cricothyrotomy
4-22
Laryngeal Mask Airway

Advantages:
Blind insertion Available in a range of sizes
Disadvantages:
Aspiration can occur Limited prehospital research
4-23
Digital Intubation
Advantages:
Blind insertion Requires no specialty equipment
Disadvantages:
Requires unconscious patient Takes significant practice
4-24
Retrograde Intubation
Potentially useful in certain situations Requires tracheal puncture Needs specialized equipment Requires practice at manipulating guidewire Poor choice when anatomic distortion exists
4-25
Percutaneous Transtracheal Ventilation

Advantages:
Ease of access Ease of insertion Minimal equipment required No surgical procedures necessary Minimal education required Hypercarbia not a problem for short-term use in first 45 minutes
4-26
Surgical Cricothyrotomy
Airway of LAST RESORT Requires extensive training, knowledge of neck anatomy, and ongoing QI/QA Complications:
Hemorrhage Damage to vocal cords
4-27
At a college baseball game a 22-year-old third baseman is struck in the head by a line drive. Upon your arrival his GCS score is 7 (E-1, V-1, M-5). His teeth are clenched and he is vomiting. How would you manage his airway?
4-28
Pharmacologically Assisted Intubation (PAI)

PAI includes the use of sedation, narcotics, and paralytic agents RSI involves the use of a paralytic agent Benefits must outweigh the risk Back-up airway techniques must be anticipated and available Current research does not conclusively demonstrate improved outcome
4-29
PAI
Indications:
Patient requiring secure airway with uncooperative behavior
Relative contraindications:
Alternative airway available Severe facial trauma Neck deformity or swelling Known allergy to indicated medications, medical problems that preclude use of medications
4-30
Drugs Used in PAI

Pretreatment
Oxygen Lidocaine or atropine
Sedatives
Midazolam, fentanyl, etomidate
Paralytics
Succinylcholine, vecuronium, pancuronium
4-31
Oxygen
All trauma patients should receive supplemental oxygen The goal is to maintain an SpO2 95% If in doubt, use a device that will deliver a concentration of at least 85% (FiO2 of 0.85) Failing to recognize and treat hypoxia
4-32
Minute Volume
Normal minute volume (MV)
500 mL(VT) x 12 bpm (VR) = 6000 mL air/min (MV)
Normal MV 6000 -7500 mL
What happens when VT decreases to 250 mL?
4-33
Minute Volume
First patient breathing
VT = 500 mL VR = 12 bpm MV = 6000 mL
Second patient breathing

VT = 250 mL VR = 30 bpm MV = 7500 mL
4-34
What About Deadspace?

Deadspace = VD First patient breathing
VT VD = 500 mL 150 mL = 350 mL VR = 12 Air reaching alveoli = 4200 mL
Second patient breathing

VT VD= 250 mL 150 mL = 100 mL VR = 30 Air reaching alveoli = 3000 mL DEADSPACE MATTERS!
4-35
Minute Volume
Alveolar ventilation is usually inadequate in patients who breathe slower than 12 bpm or faster than 30 bpm. These trauma patients will require assisted ventilations.
4-36
Assisted Ventilation
Goal is to improve MV (alveolar ventilation) and oxygenation Devices:
BVM is the most commonly used device Oxygen-powered demand valve Transport ventilators
4-37
Bag-Valve-Masks (BVM)
Minimum of 800 mL per breath 95% to 100% oxygen (FiO2 0.95 1.0) May require two or three providers Maintain stabilization of cervical spine
4-38
Summary
Essential Skills
Manual techniques Suctioning Basic adjuncts
Endotracheal Intubation remains the gold standard Options

Dual Lumen Airways LMA Retrograde Intubation
PTV and surgical cricothyrotomy

4-39
Summary
Aggressive management of the airway, ventilations, and oxygenation improves patient outcomes.
4-40
Prehospital Trauma Life Support

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4-41

Prehospital Trauma Life Support: Airway Management and Ventilation

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Prehospital Trauma Life Support

Airway Management and Ventilation

Anatomy - Upper Airway

Anatomy - Lower Airway

Oropharyngeal Airway (OPA)

Nasopharyngeal Airway (NPA)

Dual Lumen Airways

Intubation with Inline Stabilization

How would you manage her airway at this point?

Oral endotracheal intubation can be accomplished by using nontraditional methods

Alternative Airway Procedures

Laryngeal Mask Airway

Percutaneous Transtracheal Ventilation

Pharmacologically Assisted Intubation (PAI)

Drugs Used in PAI

Normal MV 6000 -7500 mL

What happens when VT decreases to 250 mL?

Second patient breathing

What About Deadspace?

Second patient breathing

Endotracheal Intubation remains the gold standard Options

PTV and surgical cricothyrotomy

Prehospital Trauma Life Support

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