• Identify the situations in which airway compromise can occur.
• Recognize signs and symptoms of acute airway obstruction.
• Recognize ventilatory compromise and signs of inadequate ventilation
• Techniques for maintaining and establishing a patent airway
• Confirmation of adequacy of ventilation and oxygenation by pulse
oximetry and end tidal CO2 monitoring
• Define definitive airway
• Indications for Drug assisted intubation
• Steps necessary for maintaining oxygenation before, during and after
establishing a definitive airway.
Lack of oxygenated blood is the quickest killer.
Supplemental oxygen must be administered to all severely injured
Death from airway problems
Failure to recognize
o the need for an airway intervention
o the need for alternative airway
o the need for ventilation
o incorrectly placed airway
Inability to establish an airway
The first step is to recognize objective signs of airway obstruction.
Identify any trauma or burn involving face , neck and larynx.
A talking patient provides momentary reassurance that airway is patent
and not compromised.
Verbal response with a clear voice indicates
o Patent airway
o Intact ventilation
o Adequate brain perfusion
Patients with an altered level of consciousness require definitive airway.
Maintaining oxygenation and preventing hypercarbia are critical in
managing trauma patients, especially in patients with sustained head
In patients with facial burns or potential inhalational injury preemptive
intubation should be considered due to risk of insidious respiratory
Aspiration after vomiting Ensure functional suction
equipment is available
Be prepared to rotate the patient
laterally while restricting cervical
spine motion when indicated.
It is important to anticipate vomiting and manage situation in all trauma
OBJECTIVE SIGNS OF AIRWAY OBSTRUCTION
• Agitation suggest hypoxia
• Obtund suggest hypercarbia
• Noisy breathing suggest obstruction
• Hoarseness implies functional laryngeal obstruction.
• Snoring, gurgling and crowing sounds suggest partial occlusion.
• Abusive and belingerent patients may be hypoxic ,don’t assume
Other conditions that can cause airway compromise are:
1. Maxillofacial trauma
2. Neck trauma
3. Laryngeal trauma indicated by a triad of clinical signs:
• subcutaneous emphysema
• palpable fractures.
Look for any objective signs of inadequate ventilation.
Ventilation can be compromised by:
Altered ventilatory mechanics as in chest trauma
Objective signs of inadequate ventilation
• Symmetrical chest rise and fall. Asymmetry suggests splinting of rib cage,
pneumothorax or a flail chest.
• Labored breathing
• Rapid RR
Failure to recognise inadequate
Monitor the patient’s respiratory
rate and work of breathing
Obtain arterial or Venus blood gas
Perform continuous capnography
Quick and accurate assessment of airway patency and adequacy of
ventilation by using pulse oximetry and capnography.
Take immediate measures to improve oxygenation and ventilation to
reduce risk of further ventilator compromise. These measures include
airway maintenance, definitive airway and methods of providing
Restriction of cervical spine motion is necessary in all trauma patients.
PREDICTING DIFFICULT AIRWAY
Severe arthritis of c-spine
Limited mouth opening
Anatomical variations in face and neck(e.g. receding chin, Overbite, and a
short muscular neck)
AIRWAY MAINTENANCE TECHNIQUES
Restriction of cervical spine motion is mandatory before using manoeuvres.
Extraglottic and supraglottic devices
• Laryngeal mask airway and intubating LMA
• Laryngeal tube airway and intubating LMA
• Multilumen esophageal airway
Criteria for establishing definitive airway:
A- Inability to maintain patent airway
B- Inability to maintain adequate oxygenation
C- cerebral hypo-perfusion
D- obtundation indicating head injury, sustained seizure activity and need
to protect airway.
TECHNIQUE FOR DRUG ASSISTED
It is indicated in patients who need airway control but have intact gag
reflex, especially in patients who have sustained head injury.
The technique for drug-assisted intubation is as follows:
• Have a plan in the event of failure that includes the possibility of
performing a surgical airway.
• Ensure that suction and the ability to deliver positive pressure ventilation
• Pre-oxygenate the patient with 100% oxygen.
• Apply pressure over the cricoid cartilage.
• Administer an induction drug (e.g., etomidate, 0.3 mg/kg) or sedative,
according to local protocol.
• Administer 1 to 2 mg/kg succinylcholine intravenously (usual dose is 100
After the patient relaxes:
Intubate the patient orotracheally.
Inflate the cuff and confirm tube placement by auscultation and
determining the presence of CO2 in exhaled air.
Release cricoid pressure.
Ventilate the patient.
o Through the cricothyroid membrane into the trachea in an emergency situation.
o Short-term ,until a definitive airway can be placed.
Large-caliber plastic cannula(12 to 14 gauge for adults, 16 to 18 gauge in
children) below the level of the obstruction.
Connected to oxygen at 15 L/min (50 to 60 psi) with a Y-connector or a side hole
cut in the tubing between the oxygen source and the plastic cannula.
Intermittent insufflation, 1 second on and 4 seconds off, can then be achieved by
placing the thumb over the open end of the Y-connector or the side hole.
The patient may be adequately oxygenated for 30 to 45 minutes using this
technique. During 4 seconds off , exhalation occurs.
Skin incision extends through the cricothyroid membrane . Insert a curved
hemostat or scalpel handle to dilate the opening, and then insert a small
endotracheal or tracheostomy tube (preferably 5 to 7 ID) or tracheostomy
tube (preferably 5 to 7 mm OD).
Care must be taken, especially with children, to avoid damage to the
cricoid cartilage, which is the only circumferential support for the upper
trachea. For this reason, surgical cricothyroidotomy is not recommended
for children under 12 years of age.When an endotracheal tube is used, it
must be adequately secured to prevent malpositioning, such as slipping
into a bronchus or completely dislodging.
In recent years, percutaneous tracheostomy has been reported as an
alternative to open tracheostomy. This procedure is not recommended in
the acute trauma situation, because the patient’s neck must be
hyperextended to properly position the head in order to perform the
MANAGEMENT OF OXYGENATION
Oxygenated inspired air is best provided via a tight-fitting oxygen
reservoir face mask with a flow rate of at least 10 L/min.
Pulse oximetry must be used at all times.
MANAGEMENT OF VENTILATION
Ventilatory assistance may be needed prior to intubation in many trauma patients.
Effective ventilation can be achieved by bag-mask technique.
Two person technique is more effective
Upon intubation of the trachea, use positive-pressure breathing techniques to
provide assisted ventilation.
Should be alert for pneumothorax
Avoid prolonged periods of inadequate or absent ventilation and oxygenation.
• Situations of airway compromise include head trauma, maxillofacial
trauma, neck trauma, laryngeal trauma, and airway obstruction due to
• Actual or impending airway obstruction should be suspected in all injured
• Recognition of ventilatory compromise and ensuring effective ventilation
are of primary importance.
• Techniques for establishing and maintaining a patent airway include the
chin-lift and jaw-thrust maneuvers, oropharyngeal and nasopharyngeal
airways, extraglottic and supraglottic devices, and endotracheal intubation.
• Cervical spinal motion must be restricted when injury is present or suspected.
• The assessment of airway patency and adequacy of ventilation must be
performed quickly and accurately. Pulse oximetry and end-tidal CO2
measurement are essential.
• Definitive airway should be placed early to prevent prolonged periods of
• Drug-assisted intubation may be necessary in patients with an active gag
• To maintain a patient’s oxygenation, oxygenated inspired air is best provided
via a tight-fitting oxygen reservoir face mask with a flow rate of greater than
10 L/min. Other methods (e.g., nasal catheter, nasal cannula, and non-
rebreathing mask) can improve inspired oxygen concentration.
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