Editing Trauma - airway/breathing

== AIRWAY ==

# Problem recognition

* Tachypnoea (consider pain/anxiety)
* Talking patient is reassuring
* Some patients may need definitive airway
** Unconscious with head injury
** Less responsive due to drugs
** Thoracic injuries
** Burns patients
** Definitive airway is a tube placed in the trachea with the cuff inflated below the vocal cords, attached to ventilation, and airway secured in place
* Vomitus in oropharynx needs to be suctioned immediately
** Rotate entire patient to lateral position with secured C-spine
* Maxfacs trauma
** Mandible - can cause loss of normal airway structural support - especially in supine position
** Midface fractures
** Associated with haemorrhage, oedema, loss of teeth, increased secretions
* Neck trauma
** Penetrating injury - haematoma - tracheal compression
*** Can need surgical airway
** Blunt trauma can also be an issue
* Laryngeal trauma
** Laryngeal fracture - hoarseness, subcutaneous emphysema, palpable fracture
*** Attempt intubation
*** If unsuccessful, emergency tracheostomy or cricothyroidotomy
*** If findings are more subtle, CT will be helpful

# Objective signs of airway obstruction

* Inspection
** Agitation/obtunded
** Cyanosis - nail beds/circumoral skin - late finding
** Accessory muscles/subcostal recession
** Pulse oximetry
* Sounds
** Noisy breathing is obstructed
** Snoring, gurgling, crowing = pharynx/larynx
** Hoarseness - larynx, probably functional
* Behaviour
** Belligerent/aggressive patients might by hypoxic

== VENTILATION ==
Move onto ventilation once airway has been cleared.

Can be compromised by airway obstruction, altered ventilatory mechanics, or CNS depression

# Problem recognition

* Direct trauma to chest causes pleuritic pain - poor ventilation - rapid, shallow breathing
* Intracranial injury - abnormal breathing patterns
* C-spine injury - paralysis/paresis
** Injuries below C3 will leave diaphragm intact but compromise intercostal/abdo muscle contribution
*** Seesaw pattern - abdomen pushed out with inspiration, lower ribcage pulled in
*** "abdominal breathing" or "diaphragmatic breathing"

# Objective signs of inadequate ventilation

* Look for symmetry
** Asymmetry - splinting of rib cage, PTX, flail chest
* Listen for movement of air on both sides
* Use pulse oximeter
** Consider hypoperfusion or shock with low sats
* Use capnography when intubated


Airway decision scheme:


== AIRWAY MANAGEMENT ==

* Ensure continued oxygenation while restricting spinal movement
* Manoeuvres
** Chin-lift
** Jaw-thrust
** Be careful not to extend neck
** NPA
*** Beware patients with suspected midface fracture
** OPA
*** If patient tolerates this, they are highly likely to require intubation
** If intubation fails or is unlikely to succeed, try LMA
*
* GCS of 8 or less requires prompt intubation

Intubation

* Drugs
** Indicated for patients that need airway control, but have intact gag reflexes
** Complication occurs if you can't then establish an airway - need to bag-valve mask until paralysis wears off
** Induction agent
*** ATLS recommends etomidate 0.3mg/kg
** Muscle relaxant
*** Succinylcholine 1-2mg/kg (often 100mg)
* Insert laryngoscope
* Pass bougie blindly beyond oesophagus, with angled tip positioned anteriorly
* Confirm tracheal position by feeling clicks as distal tip rubs along cartilaginous ribs of trachea
* Pass endotracheal tube over bougie
** If held up at arytenoids or aryepiglottic folds, withdraw slightly and turn counter-clockwise 90 degrees
* Remove bougie and confirm tube position with auscultation of breath sounds and capnography
* Inflate cuff and institute assisted ventilation

Surgical airway

* Cricothyroidotomy or tracheostomy
** Cricothyroidotomy is preferable in emergency
* Indications
** Oedema of glottis
** Fracture of larynx
** Severe oropharyngeal haemorrhage
** Inability to intubate vocal cords
* Needle cricothyroidotomy
** 12-14 gauge canula through cricothyroid membrane
** Can then be connected to oxygen with a Y-connector
** Can be adequately oxygenated for 30-45 mins, but CO2 slowly builds up
*

[[Category:Trauma]]