Airway and Ventilatory Management

Question 1

Laryngeal trauma

Answer 1

Hoarseness, subcutaneous emphysema, palpable fracture

Question 2

Objective signs of airway obstruction

Answer 2

Agitation (hypoxia), obtunded (hypercarbia)
Cyanosos - nail beds and circumoral skin
Retraction and accessory muscle use

Listen for abnormal sounds - noisy breathing, snoring, gurgling and crowing
- Hoarseness implies functional laryngeal obstruction

Behaviour - abusive and belligerent may be hypoxic

Question 3

Ventilation

Answer 3

Troubleshooting:
Airway obstruction
Direct trauma
Intracranial injury
C3 level cause diaphragm to be injured (see-saw pattern of breathing)

Objective findings:
Symmetrical rise and fall, adequate chest wall excursion
- asymmetry - splinting, pneumothorax or a flail chest

Listen for movement of air on both sides

Pulse oximeter - not adequacy of ventilation

Capnography - to see if ventilation is adequate

Question 4

Airway management

Answer 4

Restriction of C spine - two person procedure for removing motorcycle helmet
High flow oxygen

Question 5

Difficult airway predictors

Answer 5

C spine injury
Severe arthritis
Significant maxillofacial trauma
Limited mouth opening
Obesity
Anatomical variations
Paediatric patients

LEMON

• Look externally
• Evaluate 3-3-2
• Mallampati - entire pillars visible, fauces partially visible, base of uvula visible, hard palate only visible
• Obstruction
• Neck mobility

Question 6

Airway maintenance techniques

Answer 6

RESTRICT C SPINE AT ALL TIMES

Chin lift
Jaw thrust
Nasopharyngeal airway - not to do this if potential cribriform plate fracture
Oropharyngeal airway
- Upside down (curved part directed upward –> until it touches soft palate –> then rotate 180 degrees so it faces downward) - can’t use this method in children
Extraglottic and supraglottic - LMA etc.

Cricoid pressure during intubation can reduce aspiration (but may reduce the view of the larynx)

Question 7

Definitive airways

Answer 7

A - Inability to maintain a patent airway by other means
B - Inability to maintain adequate oxygenation by facemark oxygen supplementation (or presence of apnoea)
C - Obtundation or combativeness
D - Obtundation - indicating presence of head injury, sustained seizure activity, need to protect the lower airway from aspiration, blood or vomitus

Question 8

Indications for definitive airway

Answer 8

For airway protection
Maxillofacial fractures - raccoon eyes and battle’s sign
- CSF leaks indicated by rhinorrhea or otorrhea
Neck injury
Head injury

For ventilation or oxygen:
Inadequate respiratory efforts 
Accessory muscle use
Respiratory muscle paralysis
Abdominal breathing
Progressive change
Acute neurological deterioration
Apnoea

Question 9

Drug assisted intubation

Answer 9

Have a plan in case of failure
Suction
Preoxygenate
Pressure over cricoid cartilage
Induction drug or sedative
Succinylcholine - be careful in burns, electrical and crush injuries due to hyperkalaemia

THEN
Intubate
Inflate cuff
Release cricoid pressure
Ventilate patient

Question 10

Surgical airway

Answer 10

Preferred in oedema of glottis, fracture of larynx, severe oropharyngeal haemorrhage, or inability to intubate

Needle cricoid - only 30-45 minutes of oxygenation