Airway and C-spine Flashcards
What structures in the oral cavity can play a role in airway obstruction?
- Teeth
- Gums
- Tongue - most important
- Soft palate
- Hard palate
Wht is the unconscious patient at risk of airway obstruction?
Previously thought to be posterior displacement of the tongue, but more recently shown to be a complex mechanism involving the tongue and epiglottis as the source of airway obstruction.
Key message - patency is controlled by soft structures which, when innervated, provide good tone. The absence of muscular stimulation allows a change in structure leading to obstruction of airway
What is the easiest way to assess someone’s airway?
Talk to them
If a patient is talking without any difficulty, what does this indicate about the patency of their airway?
No major obstruction at that point in time
What is meant by the term “open airway”?
You can see it is open
What is meant by the term “patent airway”?
Clinical signs of air passing in and out of the airway
What is meant by the term “maintained aiway”?
Upper airway reflexes are intact including the cough and gag reflex - “the patient is maintaining their own airway”
What is meant by the term “threatened airway”?
Clinical suspicion is that there may be imminent deterioration in airway patency
How would you assess someones airway?
Look, Listen, feel
- Look for obvious ventilation
- Look at airway - injuries, swelling, detritus, blocking*
- Look in the airway*
- Listen for signs of airway obstruction - partial/complete
- Feel for breath - feel chest rising, feel for breath on cheek
*Consider quick consciousness assesment - full sentences/phrases/single words/at all
https://www.youtube.com/watch?v=4xAM69MitzQ - Video time 1.15 -> 3.57
What are signs of airway obstruction?
- Absent breath sounds
- Added sounds of laboured breathing
- Paradoxical chest movements
- Use of accessory muscles
- Reduced consciousness
What added sounds might you hear in somoene with laboured breathing?
- Stridor
- Expiratory wheeze
- Gurgling
- Stertor
What is stridor?
Harsh, high-pitched sound heard in upper airway obstruction caused by turbulent airflow at the supraglottis, glottis, subglottis or trachea
If someone was making the following noise on breathing, what might it indicate?
Stridor - Significant airway obstruction
What can the following indicate in someone with laboured breathing?
Expiratory wheeze - lower airway obstruction
What might gurgling be a sign in a patient struggling to breath?
Fluids in the lung - blood, vomit
Why do paradoxical chest movements occur in someone with an airway obstruction?
With airway obstruction, air is unable to enter the thoracic cavity, meaning the negative pressure caused by the diaphragm causes the chest to be drawn inwards - This appears as abdominal expansion and chest sucking inwards - “see saw” movement
What does paradoxical chest movements indicate?
Complete airway obstruction
What does use of accessory muscles indicate?
Increased respiratory effort required due to obstruction
What are features of partial airway obstruction?
- Use of accessory muscles
- Tracheal tug
- Paradoxical chest movements (almost complete obstruction)
- Intercostal recession
- Tripoding stance
What are features of complete airway obstruction?
- Absent breath sounds
- Unable to talk
- Silent chest
- Paradoxical chest movement
What are common causes of airway obstruction in a pre-hospital setting?
- Loss of consciousness
- Foreign Body
- Trauma
- Aspiration - Blood, Saliva, Vomit
- Airway interventions
- Inhalational injury (Burns)
- Anaphylaxis
If you found someone who was sterterous, what airway intervention would you start with?
If C-spine is clear:
- Head tilt and chin lift
https://www.youtube.com/watch?v=4xAM69MitzQ - Video time 4.26 -> 5.17
What would you want to establish in someone before performing any airway maneuvre’s?
If they had a C-spine injury
If someone was sterterous and you suspected a C-spine injury, what intervention would you consider using first?
How does the head tilt-chin lift manoeuvre work?
Anterior displacement of the hyoid bone is key in restoring airway patency, and that this is achieved by a head tilt-chin lift.
When would you consider suction to manage someone’s airway?
- Audible secretions such as gugrling
- Noisy Crackles
- Ineffective cough with a physiological deterioration in a patient
https://www.youtube.com/watch?v=4xAM69MitzQ - Video Time - 5.20 -> 5.55
How might you position a patient to aid with suctioning?
On their side (if possible) as gravity aids drainage
How long should you suction for?
15 seconds maximum - any longer is associated with risk of hypoxia
What could you use to remove obstructions in the airway which are within view?
Magill forceps - used to remove foreign bodies and aid delivery of ET tube
https://www.youtube.com/watch?v=4xAM69MitzQ - Video time 5.39 -> 5.55
If an initial head-tilt, chin lift/jaw thrust failed to maintain a good airway, what would be your next step in establishing a good airway?
- Oropharyngeal airway
- Nasopharyngeal airway
What is the function of an oropharyngeal airway?
Inserted to prevent the tongue from covering the epiglottis maintaing the patency of the airway
How would you size an oropharyngeal airway?
Measure with the flange at the front teeth and the tip should reach the angle of the mandible
Why is sizing important when measuring an oropharyngeal airway for use?
If the adjunct is too large there is a risk of closing the glottis or damage to local structures
How would you insert an oropharyngeal airway in an adult?
- Initial Insertion - concave part pointing towards hard palate
- Rotate 180o on insertion
- Fully insert - flange flush with the mouth
https://www.youtube.com/watch?v=4xAM69MitzQ - Video time 6.00 -> 6.52
How would you insert an oropharyngeal airway in a child?
Insert directly with no rotation - gentle displacement of tongue (blade or laryngoscope) may help
When is an oropharyngeal airway indicated for use?
Unconscious patients only - due to gag reflex -> vomiting, or laryngospasm
What are contraindications for oropharyngeal airway use?
- Mandibular fractures
- Major oral trauma
- Trismus (lockjaw)
When would you consider using a nasopharyngeal airway over an oropharyngeal airway?
- Those who are not deeply unconscious - intact gag reflex
- Contraindications to OP airway - mandibular fracture, major oral trauma, trismus
How does a nasopharyngeal airway work?
Creates conduit between nose and nasopharynx, bypassing obstructions at the level of nose or tongue - lies just above epiglottis, preventing tongue from falling back onto posterior pharyngeal wall
How would you size a nasopharyngeal airway in a female?
- Small - size 6 + safety pin
- Average - size 6
- Large - size 7
What can occur if a nasopharyngeal airway is too long?
- Stimulate laryngeal/glossopharyngeal reflexes -> spasm/vomiting
- Cause obstruction - enters space between the epilgottis and tongue
How would you size a nasopharyngeal airway on a male?
- Small - size 6
- Average - size 7
- Large - size 8
How would you insert a nasopharyngeal airway?
Insert with bevel towards the septum, advancing straight forward following the floor of the nose
https://www.youtube.com/watch?v=4xAM69MitzQ - Video time 6.56 -> 7.39
If someone is breathing normally, but is unwell, what should be the default position that you put someone in?
Recovery position
What should you always do after each step in the airway ladder?
-
Test ventilation
- If worse - Go back to previous
- If unchanged - proceed to next step
What is a general rule of thumb with nasopharyngeal airways?
If they need an NPA, they probably need 2
What are examples of supraglottic airway devices?
- I-gel
- Laryngeal Mask Airway
- Laryngeal tube
- Oesophageal tracheal Combitube
What is an I-gel?
Most commonly used!!
SGA device consisting of a soft non-inflatable cuff made out of a gel-like substance to give a tight seal around the laryngeal inlet. The gel design means that no inflation is necessary potentially speeding up the process of insertion and causing decreased compression and trauma in the airway.
https://www.youtube.com/watch?v=4xAM69MitzQ Video time - 7.45 -
What is a laryngeal mask airway?
A wide bore tube with an inflated cuff. It is designed to form a seal around the laryngeal opening. It is used as an alternative to endotracheal intubation due to the failure rates associated with intubation, and studies have shown it to be both safe and effective
What is a laryngeal tube?
There are multiple variations of the laryngeal tube, some with a suction tube and some without. The standard tube consists of an airway tube with a distal and a proximal cuff that is located in the middle of the tube. The device is inserted until the teeth are in line with the black line on the device and the cuffs are inflated.
What is an oesophageal tracheal combitube?
A two-barrelled device that can be placed in the trachea or oesophagus. It isolates the oesophagus from the trachea, minimizing aspiration risk and has minimal c-spine movement on insertion. The combitube can be placed blindly, meaning direct laryngoscopy is not needed and has been shown to be as effective during resuscitation as an endotracheal airway.
What does an I-gel not stop?
Aspiration - only provides a partial seal
Which is regarded as more imoprtant than the other - airway or c-spine?
Airway is more important than C-spine
If you were still finding it difficult to establish a good airway using a supraglottic airway device, what would you think of using next?
Only if appropriately trained
Provision of definitive airways - Intubation, then cricothyroid/tracheostomy if critical
If you were trying to manage someones airway using the airway ladder, and neither OPA or NPA had established a good airway, what would be the next step?
Supraglottic airway device
What are indications for the provision of a definitive airway?
- Presence of apnea
- Need for airway protection from aspiration: vomitus, bleeding.
- Unconsciousness: Glasgow Coma Scale (GCS) <8*
- Severe faciomaxillary fractures
- Risk for obstruction: neck haematoma, laryngeal/tracheal injury
- Impending or potential airway compromise: upper airway burn
What GCS is score is used as a cut-off for the provision of a definitive airway?
GCS <8 - however studies have demonstrated that oropharyngeal reflexes still remain intact at GCS <8, so this should not be an automatic procedure, and should be taken in context of other factors
What are the two forms of intubation used in trauma life support?
- Orotracheal/Endotracheal tube
- Nasotracheal tube
What is the most common form of intubation used in the UK?
ET tube
What are complications of orotracheal tube insertion?
- Oesophageal intubation -> hypoxia
- Vomiting -> aspiration
- Laryngospasm
- Bronchospasm
- Trauma to local structures
What are contraindications to intubation?
C-spine injury - relative contra - need to ensure strict in-line stabilisation
What are complicaitons that can occur in cricothyrotomy?
- Haemorrhage
- Miscplacement
- Damage to local structures
What are signs of mild choking?
Ask are you choking?
- Speaks and answers yes
- Able to speak, cough, and breathe
What are severe signs of someone choking?
Ask are you choking?
- Unable to speak
- Respond by nodding
Other signs
- Unable to breath
- Wheeze
- Silent cough
- Unconsciousness
- Clutching at neck
How would you manage mild choking?
Encourage coughing but no other action necessary
How would you manage severe choking?
- Lean patient forward and give 5 back blows
- 5 abdominal thrusts - if back blows fail
How many rounds of back blows and abdominal thrusts should you do before calling an ambulance?
3 rounds/cycles
If an adult was chocking and became unconscious, what would you do?
Start CPR
How would you manage an infant who was severely choking?
- Give up to five back blows firmly on the back while holding the baby face down along your thigh with the babies’ head lower then the bottom.
- Give up to five chest thrusts, turning the baby over and placing two fingers on the sternum pushing inwards and upwards
- If this does not dislodge the object repeat steps one and two, phoning for an ambulance after three cycles.
https://www.youtube.com/watch?v=h4uS5EmpeEs
If a child/infant became unconscious from choking, what would you do?
5 rescue breaths, then start CPR
When would you suspect a c-spine injury?
- Strong mechanism of injury
- Clinical findings of neck injury
What criteria could you use to exclude a C-spine injury?
NEXUS criteria
- No midline tenderness
- No focal neurological deficit
- No loss of consciousness
- No intoxication
- No painful distracting injury
What are the criteria for the Canadian C-spine rule (CCSR)?
High risk factors
- >65
- Paraesthesia
- Mechanism of injury
Low risk
- Absence of spinal tenderness
- Neck rotation through 45o
What should take highest priority if it is impossible to manage c-spine and airway?
Airway
What is the standard initial management of a suspected c-spine injury?
Manual in-line stabilisation
What is manual inline stabilisation?
Technique which provides a degree of stability before triple immobilisation can be carried out. The head is supported by the hands, and the one managing the c-spine uses their elbows for stabilisation on either the ground if lying down or knees if sitting up. This prevents arm movement by the responder when fatigue sets in. Using your knees is sometimes a handy method when there are limited responders as it frees your hands to auscultate the chest for example.
What are advantages of manual inline stabilisation?
-
Person at head can also:
- Manage airway airway
- Monitor consciousness
- Maintain rapport with the patient - keep patient informed of what is happening and helping relax them
Responder at head can advise if there is any change, thus guiding clinical decision making
How would you size a cervical collar?
- Neutral alignment
- Imaginary horizontal line from base of the mandible to angle of the trapezius
- Measure the number of fingers distance between
- Size your fingers against the collar
- Place number of fingers previously measured from the bottom of the plastic to the red sizing dot. Then push to lock.
If someone had a head injury, why might you be reluctant to use a cervical collar?
Has been shown to raise ICP
What is triple immobilisation?
Hard collar, head blocks and tape
