Airway and Ventilatory Management

Question 1

True or false: Supplemental oxygen must be administered to all severely injured trauma patients.

Answer 1

True!

Question 2

What is the most important early assessment measure to ensure airway patency in a trauma patient?

Answer 2

Talk to the patient and stimulate a verbal response

a positive appropriate verbal response with a clear voice indicates that the patient’s airway is patent, ventilation is intact, and brain perfusion is sufficient

Question 3

What is the definition of a definitive airway? (3 components)

Answer 3

1. Endotracheal tube placed in the trachea with the cuff inflated and below the vocal cords
2. The ETT is attached to an oxygen enriched assisted ventilation device
3. Airway secured in place with appropriate stabilizing method

Question 4

What is the triad of clinical signs suggesting laryngeal fracture?

Answer 4

1. Hoarse voice
2. Subcutaneous emphysema
3. Palpable fracture

Question 5

In terms of ventilation issues, what do injuries below the C3-C5 level result in?

Answer 5

Diaphragmatic function is maintained but you have loss of the intercostal and abdominal muscle contribution to respiration

-remember “C3-C5 keeps you alive” - phrenic nerve originates at C3-C5 and innervates the diaphragm

Question 6

What are 7 factors that indicate a potential difficult airway?

Answer 6

1. Pediatric patient
2. Obesity
3. Limited mouth opening
4. Maxillofacial or mandibular trauma
5. Anatomical variants - receding chin, short muscular neck, overbite
6. C-spine injury
7. Severe arthritis of the C-spine

Question 7

Describe the LEMON assessment for difficult intubation

Answer 7

1. Look - look for any external features of difficult airway: receding chin, overbite, short muscular neck, facial trauma, small mouth
2. Evaluate the 3-3-2 rule:
   - 3 finger breadths between top and bottom incisors
   - 3 finger breadths between tip of chin to hyoid bone
   - 2 finger breadths between floor of mouth to thyroid notch
3. Mallampati score:
   - Class 1: able to visualize soft palate, uvula, fauces, pillars entirely
   - Class 2: soft palate, uvula, fauces partially visible
   - Class 3: soft palate, base of uvula visible
   - Class 4: only hard palate visible
4. Obstruction - look for any condition that can cause obstruction of the airway
5. Neck mobility - in non-traumatic injuries, can get patient to flex neck to place his/her chin on chest and then extend the neck to look towards the ceiling. In trauma patients, you will have zero neck mobility since you will be providing C spine immobilization

Question 8

Describe the 3-3-2 rule for assessment of difficult airway

Answer 8

• 3 finger breaths between top and bottom central incisors (assesses mouth opening)
• 3 finger breaths between tip of chin to hyoid bone
• 2 finger breaths between floor of mouth to thyroid notch

Question 9

Describe the Mallampati Score

Answer 9

Class 1: Soft palate, uvula, fauces all visible

Class 2: Soft palate, uvula, fauces partially visible

Class 3: Soft palate, base of uvula visible

Class 4: Only hard palate visible

Question 10

How can you correct airway obstruction from the tongue in a patient with decreased level of consciousness?

Answer 10

1. Chin-lift or jaw-thrust
2. Insert an oropharyngeal airway or nasopharyngeal airway

Question 11

What is the proper technique of inserting an oropharyngeal airway in older children/adults?

Answer 11

Insert the oral airway upside down with its curved part directed upward until it touches the soft palate. Then rotate the device 180 degrees so the curve faces downward and slip it into place over the tongue

***do not use this in younger kids since it might damage their mouth/pharynx. Instead can use a tongue depressor, then insert it directly with the curved side down

Question 12

When should you consider extraglottic/supraglottic airway devices?

-examples of supraglottic airway devices?

Answer 12

Consider in patients who require an advanced airway adjunct but in whom intubation has failed or is unlikely to succeed

• Examples include:
  1. Laryngeal mask airway (LMA)
  2. Intubating laryngeal mask airway (ILMA) - allows for intubation through the LMA
  3. Laryngeal tube airway (LTA)
  4. Multilumen esophageal airway

Question 13

What are the indications for establishing a definitive airway?

Answer 13

1. Inability to maintain a patent airway by other means, with impending or potential airway compromise (inhalation injury, facial fractures, retropharyngeal hematoma)
2. Inability to maintain adequate oxygenation by facemask oxygen supplementation or the presence of apnea
3. Obtundation or combativeness resulting from cerebral hypoperfusion
4. Obtundation indicating the presence of a head injury and GCS 8 or less, sustained seizure activity, need to protect the lower airway from aspiration of blood or vomitus

Question 14

What are the contraindications to nasotracheal intubation?

Answer 14

1. Facial fractures
2. Basal skull fractures
3. Cribiform plate fractures
4. Frontal sinus fractures

***look for nasal fracture, raccoon eyes, battle’s sign, CSF leaks (rhinorrhea or otorrhea) - these are all signs of these injuries

Question 15

What is the purpose of cricoid pressure in intubation? What about BURP maneuver?

Answer 15

Cricoid pressure: can reduce the risk of aspiration by compressing the esophagus

BURP: backward, upward, rightward pressure on the thyroid cartilage can aid in visualizing the vocal cords

Question 16

How do you use a gum-elastic bougie to assist in intubation?

Answer 16

With a laryngoscope in place, place the GEB blindly beyond the epiglottis with the angled tip positioned anteriorly

• confirm tracheal position by feeling clicks as the distal tip rubs along the cartilaginous tracheal rings (presnet in 65-90% of GEB placements)
• a GEB passed into the esophagus will pass its full length without resistance
• after confirming the position of the GEB, pass a lubricated ETT over the bougie beyond the vocal cords. If the endotracheal tube is held up at tthe arytenoids or aryepiglottic folds, withdraw the tube slightly, turn it counter-clockwise 90 degrees to facilitate advancement beyond the obstruction. Then remove GEB and confirm endotracheal intubation

Question 17

How do you confirm adequate placement of an ETT tube?

Answer 17

1. Listen for bilateral breath sounds and chest rise
2. CO2 detector
3. End tidal CO2 monitoring
4. CXR to assess tube placement

Question 18

When should you consider drug-assisted intubation (ie. rapid sequence intubation)?

Answer 18

Indicated in patients who need airway control but have intact gag reflexes, especially in patients who have sustained head injuries

Question 19

What are the steps for drug-assisted intubation?

Answer 19

1. Have a plan in the event of failure that includes the possbility of performing a surgical airway and know where your rescue airway equipment is located
2. Ensure that suction and ability to develop PPV is ready
3. Preoxygenate the patient with 100% oxygen
4. Apply pressure over the cricoid cartilage
5. Administer induction drug
6. Administer neuromuscular blocking agent
7. Intubate the patient orotracheally
8. Inflate the cuff and confirm tube placement
9. Release cricoid pressure
10. Ventilate the patient

Question 20

What is the most dangerous complication of using sedation and neuromuscular blocking agents in intubation?

-how long does succinylcholine take for onset and what is its duration of action?

Answer 20

Inability to establish an airway

• if endotracheal intubation is unsuccessful, the patient must be ventilated manually with a bag-mask device until the paralysis resolves
• this is why long-acting drugs are not used for RSI
• succinylcholine: takes < 1 minute for onset of neuromuscular blockage and lasts approximately 5 minutes

Question 21

What are contraindications to using succinylcholine in RSI?

Answer 21

1. Severe crush injuries
2. Major burns
3. Electrical injuries
4. Chronic kidney disease
5. Chronic paralysis
6. Chronic neuromuscular disease

***Basically any injuries that can give you hyperkalemia from muscular breakdown/rhabdomyolysis

Question 22

What are the two types of surgical airways?

-indications for placing a surgical airway (4)

Answer 22

1. Cricothyroidotomy - preferred since it takes less time, causes less bleeding, easier to perform
2. Tracheostomy

Indications for placing a surgical airway:

1. Inability to pass an ETT through the vocal cords
2. Glottic swelling
3. Oropharyngeal hemorrhage obstructing the airway
4. Laryngeal fracture

Question 23

How long can a patient be adequately oxygenated for using percutaneous transtracheal oxygenation (PTO) with a needle cricothyroidotomy?

-what is the inspiration:expiration ratio?

Answer 23

A patient can be oxygenated for approximately 30-45 minutes using this technique

-intermittent insufflation is needed: 1 second on for inspiration and 4 seconds off for expiration

Question 24

How old does a child need to be before you can perform a surgical cricothyroidotomy?

Answer 24

Need to be at least 12 years old!!!!!