Trauma - airway/breathing

AIRWAY

1. 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

1. 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

1. 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"

1. 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