Emergency Airway Management Trauma and Burn

8/8/2019 Emergency Airway Management Trauma and Burn

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Prof.DrProf.Dr.. Koeshartono,SpAnK.IC.PGD.Pall.Med.ECUKoeshartono,SpAnK.IC.PGD.Pall.Med.ECULab.AnestesiologiLab.Anestesiologi && ReanimasiReanimasi

((KedokteranKedokteran GawatGawat DaruratDarurat))

FK.FK. UnairUnair / RSU Dr./ RSU Dr. SoetomoSoetomo

SurabayaSurabaya


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Injured Patient / Trauma - Burn


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By Passing Transtracheal Airway


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Difficult Airway / Mucosal Oedema


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Airway Management Can be More Difficult


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he Senior Help Should be Present to Assist if Difficulties Arise


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Potential Cervical Spine Instability

Hold the Head to Prevent

Neck Movement

A Head Collar Around The Neck Restricting Flexion and Extension

Sand Bag Preventing Laterel Flexion and Rotation


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Unlike the elective surgical patientUnlike the elective surgical patient

usually presents a complex scenariousually presents a complex scenariofor airway management :for airway management :

1. The patient must undergo multiple therapeutic anddiagnostic interventions while airway assessmentand management take place

2. Traumatic injuries themselves often interfere withroutine airway management techniques

3. Injuries and hemorrhage place increased oxygen

demands on the body, while other injuries mayinterfere with gas exchange

4. Unlike the airway in elective surgical patients, theairway in trauma patients often must be controlled

expeditiously by one means or another5. The patient must always be considered to have a fullstomach


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Although anesthesiologists tend to focus

on this last condition (aspirationprophylaxis), it is only one of the manyproblem associated with post traumatic

airway management

Comatose patient require tracheal

intubation to protect their airways fromaspiration and to allow mechanicalventilation that will reduce arterial

carbon dioxide pressure (PaCO2) andintracranial pressure (ICP). In othercases early mechanical ventilation may

reduce later morbidity and mortality.


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If manual attempts to open the airway andprovide mask ventilation are unsuccessful,immediate oral endotracheal intubationshould be attempted. In such cases all but the

most routine precautions to avoid injury duringthe intubation process.

Even experienced anesthetists are faced withpatients who cannot be managed by directoral intubation, such as those with blunt orpenetrating injuries of the trachea or severemaxillofacial trauma that distorts normalanatomic relationships. Provisions for anemergency cricothyrotomy or tracheostomyshould always be alvailable.


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WHAT WRONG WHAT CAN HAPPEN

WHAT DO YOU THINK

R female / 30 years old/ 50 kg

Dx : Head injury

Parasimphisis mandibula Fr.Condylus mandibula Sin Fr.

Maxila L II-III Fr.

(Multi fragmented & floating mandibula)

Tibial plateu & cruris Sin CFr.

HEAD INJURY, ICP

C-SPINE INJURYMULTI TRAUMA

CHEST TRAUMAPNEUMOTHORAXHEMOTHORAXFAIL CHEST

ABDOMINAL TRAUMAETC


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Some patients (e.g. with burns, cervical

hematoms, or chest wall injury) obviously willrequire tracheal intubation and mechanicalventilation.

The majority of trauma patients do notobviously require intubation, but a through ongoing assessment of ventilatory statusmust be made in every case.

Pneumothorax and some types of airwayinjury are most accurately diagnosedradiographically. But tension pneumothoraxmust be decompressed imediatelly

without radiological confirmation


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Head injury

Chest wall injury

e.g. pneumothorax, hemothorax, flail chest

Other injuries, require mechanical ventilation,develop pulmonary insufficiency

Massive volume administration

Injuries that may interfere with airway management Cervical spine injury

Maxillofacial injury

Airway injury

Diagnostic groups likely

torequire ventilation:


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Intrinsic : tongue, edema, blood,

dentures, food, vomit,

other foreign bodies

Extrinsic : fractures, haematomas, headand neck positioning


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Long term planning : Hospital location

Ambulance service

A & E department

Trauma team

Staffing & Training

Short term planning :

Dedicated resuscitation area equipped withthe appropriate equipment to deal with the

immediate management of injuries


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Facilities to supply supplemental oxygen tospontaneously breathing patients (piped or wall supplied

oxygen, trauma mask with re-breathing bag), continuousnasopharyngeal catheter oxygenation

Airway adjuncts available to assist airway

maintenance in the comatose or semi comatosebreathing patient (oropharyngeal and nasopharyngealairways)

Advanced airway equipment and equipment to aidtracheal intubation in a patient who is difficult tointubate (equipment for tracheal intubation, laryngealmask airway-LMA)


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Check the Equipment and DrugsCheck the Equipment and Drugs

Equipment to remove foreign bodies from theairway (yankauer sucker, suction catheter foraspirating down nasopharyngeal airways or

down tracheal tubes, magills forceps forremoving solid material)

Equipment for developing a surgical airway(cricothyroid membrane puncture and jetventilation, tracheostomy)

Ventilation equipment : ideally a fully stockedanaesthetic machine (end-tidal CO2 monitoring,self inflating bag, portable ventilator and

monitoring)


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Check the Equipment and DrugsCheck the Equipment and Drugs

Equipment and drugs specific to the details ofthe injuries that are expected, e.g. anaestheticdrugs for rapid sequence induction (RSI) ofanaesthesia if a patient with a head injury andlow glasgow coma scale (GCS) is expected orchest drain equipment if a pneumothorax /haemothorax is suspected

Drug e.g. sedative, analgetic and drying agent

neuromuscular blocking agentemergency drugstrictly dose and indication


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Remember youre needed since onsite during

transportation referral hospital Can be more difficult when faced with a patient

in the emergency department, than in therelative calmness of an anaesthetic room

The senior help should be present to assist ifdifficulties arise

Dont panic, call for help

Soon Keep the airway clear, Cervical spine protection

Ventilation support/oxygenation,

Circulation support,

Evaluation of disability


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he Senior Hel Should be Present to Assist if Difficulties Ari


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Because of potential cervical spineinstability, the patients neck movement may berestricted to prevent spinal cord damage

The patient may have a full stomach

Inability to perform a complete airwayassessment if the patient is semi conscious

Unfamiliar surroundings and staff, different

equipment or the lack of it. Limited spacearound patient, especially at the head end

Adrenaline factor in staff


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.The factor complicate airway.The factor complicate airway

management in the emergency departmentmanagement in the emergency department

Airway trauma will distort the normal anatomy

and blood in the airway will reduce the normalvisibility, while partial airway obstruction willreduce the efficiency of pre oxygenation

Undisclosed injuries, e.g. a simplepneumothorax that will become a tensionpneumothorax when positive pressure

ventilation is started

Un-cooperative patients (alcohol, head injuries

etc)


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All trauma patient must be assumed to

have a cervical spine injury until provedotherwise

The cervical spine must be maintained in aneutral position to prevent causing damageto the cervical cord

Hold the head to prevent neck movement


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Airway with cervical spine controlAirway with cervical spine control

The standard equipment to protect the

cervical spine consist of : A hard collar around the neck restricting

atlanto occipital joint flexion and extension

Sand bag or head box next to the head toprevent lateral flexion and rotation, and

Straps across the forehead and the chin toprevent neck flexion


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Stridor, gurgling noise in throat or no inspiratory

noise Tachypnoea

Use of accessory muscles of respiration

Nasal flaring

See sawing of chest and abdomen

Cyanosis

Absence of water vapor in the facemask onexpiration


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Oropharyngeal & nasopharyngeal airways

can be used adjuncts to create a betterairway

Do not use nasopharyngeal airway in ahead injury for fear of penetrating trauma

through the base of the skull


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Dont panic, call for help Soon

Keep the airway clear, Cervical spine protection Ventilation support/oxygenation, continuous nasopharyngeal

oxygenation Circulation support,

Evaluation of disability Aspiration prevention, suction switch on. Make sure thatthe table can be positioned head up-head down, simply !

Cricoid pressure (Sellicks manouvre)

Strictly drug usage dose and indication Tracheal intubation Can be more difficult Trauma will disturb / destruct the normal anatomy

Emergency equipment


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Oral intubation Trauma from laryngoscopy

Excessive cervical spine motion Esophageal intubation Pneumothorax Damage to endotracheal tube

Vomiting and aspiration Broken teeth Inadvertent extubation Laryngeal trauma Right main stem intubation

Forcing debris in mouth down trachea Esophageal perforation Laryngotracheal disruption Blood clots obstructing tube


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.Complications of intubations.Complications of intubations

in trauma patientsin trauma patients

Nasal intubation

All complications list above plus : False passage in posterior pharynx Air entry from paranasal sinuses into

subcutaneous tissue

Nosebleed Prolonged intubation Sinusitis Necrosis of nose


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Expected un expected difficult intubation Failure to intubation

Digital intubation

Lighted stylet

Retrograde technique

Percutaneous needle cricothyrotomy

Percutaneous dilational tracheostomy

Formal surgical tracheostomy


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..Techniques for managing..Techniques for managing

the difficult airway and failedthe difficult airway and failed intubationintubation

Specialized intubation equipment

Laryngeal mask airway

Prisms and mirrors

Bullard laryngoscope Augustine guide

Mc Coy Laryngoscope

Fibre optic intubation

Endotrol endotracheal tube


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Airway and breathing problem will kill trauma patientsbefore other injuries

All trauma patients may have full stomach

All trauma patients have a cervical spine injury untilproved otherwise

Prepare contingency plans and obtain appropriateequipment

Patient with pneumothoraces should have chest drains

inserted before intubation and positive pressureventilation

Strictly drug usage, dose and indication

Must be carefully titrated and levels of sedation and analgesiafrequently re evaluated


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Emergency Airway Management Trauma and Burn

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