Air way management (ABCDE of trauma)

Goal is to determine in the initial assessment of those injuries that threaten patient's life.

Airway management.
Airway management is the first step in resuscitation of a critically ill patient. Make a rapid & complete assessment of the airway.

Airway assessment
Airway patency.( I ) Protective reflexes.( II ) Respiratory drive.( III ) Inspired oxygen concentration.( IV )

Airway patency
Airway obstruction.( I ) 1. reduced muscle tone allowing the tongue to fall backwards against the posterior pharyngeal wall, thus blocking the airway. 2. presence of blood, mucus, vomitus or foreign bodies in the oropharynx. 3. edema, swelling or inflammation of the tissue bordering the airway.

Signs of AO
Inspiratory stridor. Poor expired airflow. Indrawing of soft tissues. Increased respiratory distress & paradoxical rocking movements of the thorax & abdomen. In total airway obstruction there are no sounds of breathing due to complete lack of airflow through the larynx.

Difference b/n stridor & bronchospasm

Stridor is the term is used to describe an inspiratory noise which sounds similar to wheezes, it is due to partial upper airway obstruction for any cause e.g. foreign body, tumor in the airway, vocal cord edema or paralysis. Bronchospasm is predominantly an expiratory wheezing sound associated with bronchial narrowing e.g. asthma, COPD, or anaphylactoid reaction.

Protective reflexes .( II )
Patients who can swallow normally have intact airway reflexes. Normal speech makes absence of such reflexes unlikely but not impossible. If a patient tolerates an orophryngeal airway without gagging then the protective reflexes are either absent or decreased. Patients with decreased level of consciousness should be assumed to have inadequate protective reflexes until proven otherwise. PR is proper function of the epiglottis, vocal cords, & the sensory supply to the mucous membrane of the pharynx.

Respiratory drive ( III )

Respiratory center. - stimulated by arterial CO2 tension. - controls respiratory minute volume.

Hypoxemia ( IV ).
Reduced partial pressure of oxygen in the arterial blood. Central cyanosis due to the presence of deoxy-hemoglobine. May lead to agitation, confusion, drowsiness, as well as signs of sympathetic over activity & respiratory distress. If not corrected rapidly, it may lead to cardiac arrest, irreversible cerebral injury, organ dysfunction & death.

The primary survey should identify life threatening injuries such as Airway obstruction. Chest injuries with breathing difficulties. Sever external or internal haemorrhage. Other injuries.

What is ABCDE survey.

A = airway Asses the airway. Can the patient talk & breath freely ? If obstructed the steps to be considered are: Chin lift / jaw thrust. Suction. Application of airway. Intubation.

Contd
In assessing the airway, always recognize the potential for cervical spine injuries. Movement of the cervical spine should be avoided or at least minimized when performing airway maneuvers.

posture
Elevate the head 10 cm with a pillow under the occiput & extend the neck.

B= breathing.
Assessment of breathing. Is it adequate or not ? If inadequate, the steps to be considered are: Decompression & drainage of tension pneumothorax / haemothorax. Closure of open chest injuries. Artificial ventilation

C= circulation. Asses circulation if inadequate.

Stop external haemorrage. Establish 2 large- bore IV lines ( 14 or 16 G) Administer fluid or blood if available.

D = disability rapid neurological assessment.

A = awake. V = verbal response. P = painful response. U = unresponsive. E = exposure. Undress the patient & look for injury.

Respiratory failure.
Def. as the inability of the respiratory system to cope with the body's need of oxygen consumption & carbon dioxide elimination while breathing ambient air at rest.

Types of respiratory failure.

Type 1 results from inadequate gas exchange. Type 2 results from inadequate ventilation. 1. hypoxia partial pressure of oxygen < 60mmhg. 2. hypoventilation partial pressure of carbon dioxide > 50mmhg. 3. hyperventilation partial pressure of carbon dioxide < 30mmhg.

Type 1 respiratory failure

Also known as hypoxemic respiratory failure, because any significant acute lung pathology will impair oxygen diffusion. The cardinal feature is compensatory hyperventilation( have good respiratory drive) The patient will compensate by hyperventilation which results in washing out of carbon dioxide, which's diffusion capacity 20x more than that of oxygen. Most commonly results from = pneumonia. = pulmonary edema. = pulmonary hemorrhage = ARDS in all cases there is ventilation perfusion mismatch & shunt.

Type 2 respiratory failure.

Also known as hypercarbic RF. The patient is unable to ventilate efficiently this will lead to impaired gas exchange & results in hypoxia & retention of carbon dioxide. The cardinal feature is hypoventilation. Common causes are = neuromuscular diseases = drugs, head injury. = UAO. =COPD, asthma( respiratory muscle fatigue due to increased work load. . In all cases the MV is , PDS is increased as result alveolar ventilation is inadequate to meet metabolic demands.

intubation
1. 2. indication for intubation. General anesthesia. Respiratory failure to put the patients on mechanical ventilator. To protect the air way of comates patient To facilitate suctioning.

3. 4.

equipments which are using for air way management. 1.Endotracheal tube. 2. Airways two types ( oral & nasal). 3 laryngoscope. 4. Ambu ( resuscitation) bag. 5. Face masks. 6. Suction tube & suction machine. 7. Oxygen cylindr.