Common cause of avoidable mortality is not securing the airway
- recognise the need for an airway
- secure the airway.
- recognise an incorrectly placed or a displaced airway
- recognise the need for ventilation
- prevent aspiration
Compromise may be
- sudden and complete
- insidious and partial
- progressive and/or recurrent.
--> frequently reassess.
Unconscious are at particular risk of hypoxia and hypercarbia
- intubation provides an airway, delivers O2, supports ventilation
and prevents aspiration.
Aspiration should be anticipated
--> immediate suction, role entire patient to lateral position.
Signs Remove the helmet. Talk to the patient first
- a positive and appropriate response indicates a patent ventilating
airway with brain perfusion.
- otherwise there is airway/ventilation compromise or altered
Obtunded (hypercarbia), agitated (hypoxia - don't presume
Refusing to lie down.
Accessory muscle use.
Noisy breathing is obstructed.
Snoring, gurgling crowing (stridor) - partial occlusion.
Hoarseness - dysphonia - functional laryngeal obstruction.
Neck haematomas - can obstruct
Material in mouth - blood, teeth, vomitus Palpate
Ensure trachea is midline
Mid-face #/dislocation compromises the naso & oropharynx.
- associated haemorrhage, secretions and teeth cause additional
Mandibular #s (esp bilateral) causes loss of support
--> obstruction in the supine position
trauma Penetrating injury
- can cause haemorrhage, airway displacement & obstruction
--> urgent surgical airway required.
--> operative control may be required.
C-spine immobilization unnecessary in penetrating trauma; may delay
correct care Laryngeal/trachea disruption
Initially these pts may maintain patency & ventilation
- can be accompanied by bleeding into the tracheobroncheal tree
- if compromise suspected --> definitive airway
- can be obstructed from outset --> urgent definitive airway.
Insert the ET tube cautiously else the existing injury may extend.
- if patency being lost, a surgical airway is usually indicated.
trauma Noisy breathing indicates
Absence suggests obstruction.
In an unconscious patient, laboured resps may be the only feature. Laryngeal fracture
Rare but can be life threatening.
- triad of hoarseness, subcutaneous emphysema, palpable fracture.
If totally obstructed
--> attempt intubation, flexible endoscopic guidance if
--> if unsuccessful, emergency tracheostomy (difficult and may
invoke bleeding and take time)
--> surgical cricothyroidotomy may be life-saving, although not
CT can identify subtle larynx fractures. Penetrating trauma
Requires immediate attention due to risk of transection or occlusion
- oesophageal, carotid and jugular injury may be associated.
Securing an Airway
1. Provide supplemental oxygen before and after airway
2. Maintain C-spine protection Recognise difficulty
Beard, poor dentition, short mandible, tooth loss
Poor mouth opening / poor view
- Mallampati designed for pts sitting up spontaneously opening
- readily corrected with chin lift and
- maintain with oropharyngeal or
Multilumen oesophageal airways are sometimes used by
- one communicates with trachea (ventilated), one with oesophagus
- remove it after appropriate assessment.
- similarly check position
of any tube placed in the field, after transport.
Laryngeal masks Are not a
- difficult without training and role in trauma not defined.
- if in place, decide whether to continue or remove & intubate.
Definitive Airway Tubed with
cuff inflated and oxygen-rich assisted ventilation, secured with
1. Orotracheal intubation
2. Nasotracheal intubation
- requires breathing
- avoid in pts with Battle sign, raccoon eyes rhinorrhea, otorrhoea,
3. Surgical airways (see below)
Once placed supplemental sedation, analgesics and muscle relaxants
may be required. C-spine injury is of major
concern during intubation.
May need rapid sequence
intubation in the awake patient in an acute setting.
Decision to place depends on: 1.
of the doctor
2. Need for protection
- impending or potential compromise
- eg inhalation / facial injury, sustained seizures
- eg blood / vomit aspiration risk
- eg retropharyngeal haematoma, larynx/trachea injury, stridor
3. Need for ventilation
- apnoea (paralysis, unconscious GCS<=8)
- inadequate respiration (tachypnoea, hypoxia, hypercarbia,
4. Clinical findings
urgency, need and type dictated by scenario
- pulse oximeter may help
- so might this algorithm:
Indications for definitive airway
Severe maxillofacial trauma
- can obstruct, bleed into airway, distort anatomy complicating
Thermal airway injury
- suspect in all burns
- esp if singed nasal hairs, carbonaceous sputum, face burns.
- intubate, do not wait until progression of oedema, hoarseness and
- rule of 3: if physically or verbally assaults the team 3 times,
Large / expanding neck haematoma
Penetrating airway injury
Severe maxillofacial injury
--> surgical airway if unable
Orotracheal intubation with in-line immobilization
--> surgical airway if unable.
Nasotracheal / orotracheal intubation with in-line immobilisation
--> pharmocologic adjunct if unable
--> surgical airway if still unable
- does not protect airway
- may be useful temporizing measure when intubation unsuccessful
- do not use when massive maxillofacial trauma or pregnancy >16w
- fibreoptic visualization of pathway
- less movement of c-spine
- useful in the morbidly obese; limited neck mobility; any difficult
Flexible fibreoptic bronchoscopic-assisted intubation
- advanced technique
- ETT preloaded over flexible bronchoscope, intubated
Surgical Airways Indicated when unable to intubate the trachea
- eg glottis oedema, fracture of the larynx, severe oropharyngeal
Surgical cricothyroidotomy is usually preferred to tracheostomy
- less bleeding & quicker. 1. Jet insufflation
- can be useful short-term in emergency situations
- not if pt has abnormal pulmonary function or significant chest
- lower flow to prevent barotrauma in persisting foreign body
obstruction of the glottic region.
- never seen it done though... 2. Cricothyroidotomy
- may need to briefly remove collar and immobilise neck during
3. Emergency tracheostomy - less commonly used
- may be necessary if tracheal disruption, direct airway injury /
- preferable in children as cricothyroidotomy can damage larynx.
- highly selective, only by those with substantial non-urgent case
- otherwise best to use open techniques with optimal control in
emergency. Airway Decision Scheme
2. If showing respiratory effort
--> pass a nasotracheal tube (? - really?; never seen it) If not
--> endotracheal tube under in-line immobilisation
3. If unable to intubate /
1. Does patient need to be intubated?
2. How quickly?
3. Will it be challenging?
4. What is the best method?
5. What is the back-up plan if it fails?
Tight fitting O2 reservious face mask
- flow rate 11L/min.
Nonrebreather masks can improve concentation.
Especially important for transport, or difficulties with airway
Ventilation depends on the airway, ventilatory mechanics and the
If clearing the airway does not help breathing, find another source.
--> pain with rapid shallow resps and hypoxia.
--> especially dangerous in those with preexisting chest
--> abnormal breathing patterns.
--> diaphragmatic breathing and hypoxia
--> or paralysis requiring assisted ventilation.
Difficult to bag-valve mask if:
- facial hair
- midface #s
- combative pt
--> secure airway
Asymmetrical chest excursion
- eg flail splinting (immediate threat)
Tachypnoea may represent 'air hunger'. Auscultate
Decreased or absent breaths
- eg intrathoracic injury Pulse oximetry
Helps know sats, perfusion, but does not assure adequate
Management 2 person bag-valve-masking
is better than one.
- one person holds with jaw thrust for a good seal
- another squeezes bag every 5 seconds with both hands.
- flow rate 12L/min
- assess success by chest expansion. Intubated ventilation
- proceed with positive pressure breathing.
- either volume or pressure regulated respirator.
- be alert for complications (eg pneumothorax).
· ¯ LOC (<10)
· Chest injury
v Use drugs only if
confident of controling airway & ventilation