1. Airway Management
for the Trauma
Provider
SarahBeth Hartlage, MD MS
Assistant Professor
Department of Anesthesiology and Perioperative Medicine
University of Louisville
10. Mallampati Score
• Class I – complete visualization of
soft palate, uvula, anterior and
posterior tonsillar pillars
• Class II – complete visualization of
soft palate, uvula; partial
visualization of tonsillar pillars
• Class III – complete visualization of
soft palate; partial visualization of
uvula
• Class IV – no visualization of soft
palate; hard palate and tongue only
visible structures
Evaluate the airway with the patient sitting
upright, with head in neutral position.
14. Planning and Preparation
• Plan
• Evaluate the patient for necessity of intubation
• Examine the airway
• Equipment
• Suction, oxygen, monitors
• Bag valve mask
• Ancillary noninvasive devices – oral and nasal airways
• Laryngoscope handle and blade(s)
• Endotracheal tube(s) and stylet(s)
• Backup equipment – bougie, LMA, surgical airway kit
• Drugs
• Relevant personnel
• Physician, nurse, respiratory therapist
• Defined roles for team members
• Communication is key
19. Positioning
• “Sniffing Position” aligns oral / pharyngeal / laryngeal axes
• Requires alignment of the tragus with the sternal notch
• Typically the shoulders remain on the bed while the head is
lifted 3 or more inches
• Obese patients may require ramping of the shoulders and
significantly more elevation of the head
• Note that this is not simple “extension of the spine”
• Caution in patients with cervical spine injury or unknown
pathology
22. Preoxygenation
• Used to “denitrogenate” the lungs and extend the safe apnea
period
• Safe apnea = time until saturation falls below ~90%
• 1-2 minutes if breathing room air
• Up to 8 minutes if fully preoxygenated
• Reduced in patients with decreased FRC (pregnancy, extremes of
age, obesity, ascites), increased O2 consumption (sepsis,
hypermetabolic state), shunt physiology, etc
• If adequate respiratory effort, may use FiO2 100% fo 3
minutes of tidal breathing OR 8 vital capacity breaths
• If patient unable to perform above, may “preoxygenate” with
positive pressure breaths
23. Preoxygenation
• Useful in the optimal situation – clearly not always the case
• Do the best you can
• Can also “preoxygenate” with bag-valve mask in some cases
25. Placement – Technique
• Position the patient
• Open the mouth – spread the molars with your right hand
• Insert the laryngoscope with your left hand
• Direct blade (Macintosh, Miller) – insert on right of mouth, sweep
tongue to left
• Indirect 60° video blade (Glide, D) – insert down center of tongue
• Remove right hand from mouth, may need for cricoid pressure
or other optimization of positioning
• Advance blade, visualize epiglottis
• Macintosh – advance anterior to epiglottis, into vallecula
• Miller – advance posterior to epiglottis
• Indirect – advance anterior to epiglottis, into vallecula
26. Placement – Technique
• Lift epiglottis to reveal vocal cords – lift up and away, never
back
• Miller blade – active lifting of epiglottis
• Macintosh, indirect video blades – passive lifting
• Use right hand to place endotracheal tube between vocal
cords
• After passing glottic opening, ask assistant to remove stylet
• Advance tube to desired depth
• Remove laryngoscope
• Inflate ETT cuff
• Ventilate
27.
28.
29. Proof of ETT Placement
• Fog in tube
• End Tidal CO2
• POC detector changes from purple yellow when exposed to
CO2
• Continuous capnography will show ventilatory pattern
• Bilateral breath sounds
• Stable / increasing SpO2
• Tidal volumes / compliance
• Chest X Ray
32. Difficult Airway
• Bread and butter for anesthesiologists, but also…
• One of the most common causes of lawsuits in closed claims
analysis
• Incidence of difficult intubation in OR 1.5-8%
• Incidence of difficult intubation out of OR as high as 30%
“The difficult airway is
anticipated; the failed airway is
experienced.”
33. Difficult Airway
“[…]the clinical situation in which a conventionally trained
Anesthesiologist experiences difficulty with facemask
ventilation, difficulty in supraglottic device ventilation, difficulty
in tracheal intubation or all three.”
- ASA definition
35. Signs of Difficult Intubation
Testing
• Mallampati score ≥3
• Thyromental distance ≤5cm
• Upper lip bite test
• Class I – lower incisors reach
above vermillion border
• Class II – lower incisors reach
upper lip below vermillion
border
• Class III – lower incisors cannot
bite upper lip
• Each has poor sensitivity with
decent specificity; improved
utility when used together
Other Exam Findings
• Facial trauma, burns
• Obstruction / foreign
body
• Obesity
• Secretions, blood,
edema in airway
• Personal history of
difficult intubation
36. Signs of Difficult Mask Ventilation
• Beard
• Obesity
• Edentulous
• Elderly
• Sleep apnea, diagnosed or suspected
40. Things to Remember in a
Difficult Airway Situation
• When in doubt, give a shout
• Call for help early
• The harder I practice, the luckier I get
• Your first experience shouldn’t be in an emergency
• Doing the same thing and expecting different
results is insane
• Do not keep repeating a failed technique
41. Nobody ever died from failure to
intubate, but patients die every day from
failure to oxygenate.