MANAGEMENT OF A TRAUMA PATIENT'S AIRWAY Flashcards
What is the first step in assessing a patient?
Airway management
True or False
Supplemental oxygen must be administered to all trauma patients
True
What is an open pathway that leads atmospheric air through the nose, mouth, pharynx, trachea, and bronchi to the alveoli?
Airway system
The upper airway consists of what structures?
- Nasal cavity
- Pharynx (nasopharynx, oropharynx, hypopharynx)
- Larynx
The lower airway consist of what structures?
- Trachea, its branches, and the lungs
a. the trachea divides into the right and left mainstem bronchi
1. each of the mainstem bronchi subdivides into several primary bronchi and then into bronchioles
Airway
Neural control - Primary control centers come from where?
- Medulla
2. Pons
What is the primary involuntary respiratory center?
Medulla
The pons is connected to the respiratory muscles via the what?
Vagus nerve
What is the secondary control center if the medulla fails to initiate respiration?
Apneustic center
What controls expiration?
Pneumotaxic Center
Airway
Chemical Stimuli - Receptors for oxygen and carbon dioxide balance are located where?
Carotid bodies (carotid sinus) and aortic arch
What is the primary control of respiratory center stimulation?
Cerebrospinal (CSF) pH
CSF is affected by the amount of what in the body?
Carbon Dioxide
An increase in the partial pressure (Pa) of _____ results in a decrease of the cerebral spinal fluid pH (more acidic) which results in an increase in respirations
Carbon dioxide
What is a form of respiratory drive in which the body uses oxygen, uses chemoreceptors instead of carbon dioxide receptors to regulate the respiratory cycle?
Hypoxic drive
The hypoxic drive is a late homeostatic system designed to increase respiration rate and depth (tidal volume) when the body’s_______ decreases significantly
arterial oxygen levels (SaO2)
What is when there is no oxygen available at all?
Anoxia
What does SaO2 stand for?
Arterial Oxygen Saturation
What does PaO2 stand for?
Arterial Oxygen Tension
What is the fraction or percentage of oxygen in the space being measured, often used in medicine, this is used to represent to percentage of oxygen that the patient is breathing?
Fraction of Inspired Oxygen (FiO2)
What literally means “deficient in oxygen”, that is an abnormally low oxygen availability to the body or an individual tissue or organ?
Hypoxia
What is insufficient oxygenation; that is decreased partial pressure of oxygen in blood?
Hypoxemia
What is a non-invasive method allowing the monitoring of the saturation of a patients hemoglobin?
Pulse oximeter
What are the indications for O2 therapy?
- Cardiac and respiratory arrest
- Hypoxemia (pO2 < 58.5 mmHg, Sat < 90%)
- Hypotension (Systolic BP < 100 mmHg)
- Low Cardiac Output and Metabolic Acidosis (serum bicarbonate < 19 mmol/l)
- Respiratory distress (RR > 24/min)
What are some different types of oxygen delivery devices?
- Pocket Mask
- Nasal cannula
- Bag-Valve Mask
- Non-Rebreather Mask
- Ventilators
- Hyperbaric Oxygen
Nasal Cannula
Oxygen is supplied at rates of __ to __ liters/min resulting in inspired concentration of approximately ___ to ___ %
- 1-4 liters per minute
2. 25%-30%
A non-rebreather mask is utilized for patients with what conditions?
- Physical trauma
- Chronic airway limitation/chronic pulmonary diseases
- Cluster headache
- Smoke inhalation
- Carbon monoxide poisoning
What are the indications for hyperbaric oxygen?
- Decompression illness (the “bends”)
- CO poisoning
- Radiation necrosis
- Reconstructive surgery
- Some infection, wounds
What may result from the long-term exposure to partially reduced oxygen products which alter the metabolic function and structure of lung cells?
Oxygen toxicity
What are some things that increase respirations?
- Body temp
- Emotion
- Pain
- Hypoxia
- Acidosis
- Stimulants
What are some things that decrease respirations?
- Depressant drugs
- Sleeping agents
- Morphine
Hyperbaric Oxygen. 100% oxygen is given at an increased pressure of 3 atm. Since normal air is 20% oxygen, pure oxygen would be ___ times more oxygen, and at 3 times normal air pressure, a patient gets ___ times more oxygen than normal.
- 5 Times
2. 15 times
Management of what in trauma casualties takes precedence over all other procedures with the exception of massive bleeding?
Management of the airway
What is the first step in airway management?
Quick visual inspection of the oropharyngeal cavity
What is the most common cause of airway obstruction?
Tongue
What are some manual maneuvers for opening an airway?
- Head tilt/chin lift
- Jaw thrust maneuver
- Sellick’s maneuver
- BURP maneuver
What manual airway maneuver is this?
- Used to relieve a variety of anatomic airway obstructions in casualties who are breathing spontaneously.
- The chin and lower incisors are grasped and then lifted to pull the mandible forward.
- The provider uses universal precautions (wears gloves) to avoid body fluid contamination.
Head Tilt/Chin Lift
What manual airway maneuver is this?
- In casualties with suspected head, neck, or facial trauma, the cervical spine is maintained in a neutral inline position.
- The trauma jaw thrust maneuver allows the provider to open the airway with little or no movement of the head and cervical spine.
Jaw thrust maneuver
What manual airway maneuver is this?
- Prevention of gastric aspiration is one of the key components in airway maintenance.
- Typically, the injured patient has either swallowed large amounts of air into their stomach, or air has been forcibly placed into the stomach during ventilation with a BVM.
- Use of this, particularly during BVM ventilation, aids in preventing aspiration
- The maneuver is accomplished by applying gentle posterior pressure to the
patient’s cricoid cartilage. - This pressure causes the cricoid cartilage to be displaced posteriorly thus effectively closing off the esophagus.
- The pressure is applied by a healthcare provider placing their thumb and index
anteriorly and laterally onto the cricoid cartilage near the midline of the
patient’s neck.
Sellick’s Maneuver
What manual airway maneuver is this?
- Backward, upward, and rightward pressure on the larynx.
- The maneuver improves the visualization of the larynx structures and eases
the intubation. - This procedure displaces the thyroid cartilage dorsally in such a way that the larynx is pressed against cervical vertebrae’s body, two centimeters in cephalic direction, until resistance appears.
- Subsequently, it should be displaced 0.5 cm -2.0 cm to the right.
BURP Maneuver
When manual airway maneuvers are unsuccessful or when continued maintenance of an open airway is necessary what is the next step?
Artificial airway
What is the most frequently used artificial airway device?
OPA
What kind of airway is a soft rubber or latex uncuffed tube that is designed to conform to a the patient’s natural nasopharyngeal curvature?
NPA
Designed to lift the posterior tongue off of the oropharynx
What are some advantages to the NPA?
- Ease and rapid insertion
- Patient tolerance and comfort
- Can be easily inserted when the patients teeth are clenched
What are some disadvantages of the NPA?
- Smaller size
- Risk of nasal bleeding during insertion
- Cannot be used if a basilar skull fracture is suspected
NPA
What nare is preferentially chosen, as it is typically larger?
Right
What is the preferred supraglottic airway because it makes it simpler to use and avoids the need for cuff inhalation and monitoring?
I-Gel
True or False
If a supraglottic airway with an air-filled cuff is used, the cuff pressure must be monitored to avoid over pressurization, especially during a potential TACEVAC on
an aircraft with the accompanying pressure change.
True
What are the indications for an I-Gel?
Unconscious patient without significant direct trauma to the airway/facial structures
What is the primary advantage of the I-Gel?
No need to fill the cuff with air and no need to monitor cuff pressure after inflation and with altitude changes
What is the correct size I-Gel for the typical adult and what is the size for an adult over 200 pounds?
- Size 4 for typical adults
2. Size 5 for big boys and gals
True or False
The majority of injured patients are able to undergo successful oral tracheal
intubation. According to ATLS preferred definitive airway is tracheal intubation
through the mouth using direct laryngoscopy.
True
What are some indication for an Endotracheal Intubation?
- Unable to protect airway
- Significant oxygenation problem, requiring administration of high concentrations of oxygen
- Significant impairment in ventilation requiring assisted ventilation
- Cardiac arrest
- Severe hemorrhagic shock
What are some contraindications for Endotracheal Intubation?
- Patient with epiglottitis
- Lack of training
- Lack of proper indications
- Obstruction of upper airway due to foreign objects
- Cervical Fractures
What is the “universally accepted” size of ET tube for an unknown victim?
7.5mm
- 8 may be used for men
- 7 may be used for women
The insertion of the ET tube should be no longer than ____ from the time you stop ventilating the patient until the time you remove the stylet
30 seconds
ET Tube
Ventilate the patient 1 breath every ___ seconds
5
What is also known as the double lumen airway, is a blind insertion airway device (BIAD) often used in the pre-hospital and emergency setting; It is designed to facilitate the placement of an advanced airway in a patient in respiratory distress by provider with minimal training; Its simplicity of placement is the main advantage over endotracheal intubation?
Esophageal Tracheal Combitube Airway
What airway should be done when you are unable to perform endotracheal intubation and the casualty cannot be ventilated using a BVM device?
Laryngeal Mask Airway (LMA)
What are some complications for an ET tube?
- Hypoxemia from prolonged intubation attempts.
- Trauma to the airway with resultant hemorrhage.
- Right mainstem bronchus intubation.
- Esophageal intubation.
- Vomiting leading to aspiration.
- Loose or broken teeth.
- Injury to vocal cords.
- Conversion of a cervical spine injury without neurologic deficit to one with
neurologic deficit.
What are some indications for a Combitube?
- Ventilation in normal and abnormal airways.
- Failed intubation.
- Airway management in trapped patients.
What are some contraindications for a Combitube?
- Patients with intact gag reflexes.
- Patients with known esophageal pathology.
- Used in patients under 5 feet with standard Combitube™, under 4 feet with
Combitube™ SA (small adult).
What are some complications of the Combitube?
- Combitube™ includes an increased incidence of sore throat, dysphagia and
upper airway hematoma when compared to endotracheal intubation and LMA. - Esophageal rupture is a rare complication but has been described.
- These complications may be partially preventable by avoiding over-inflation of the distal and proximal cuffs.
True or False
ET Tube
If the tube is placed too far down the tracheal tree, a right mainstem
intubation can occur; this prevents air from going into the left lung. To correct this problem, continue to ventilate patient and slowly withdraw endotracheal tube ¼ - ½ inch or until bilateral breath sounds are heard.
TRUE
What is the indication for a Laryngeal Mask Airway (LMA)?
When unable to perform endotracheal intubation and the casualty cannot be
ventilated using a BVM device.
What are the contraindications for a Laryngeal Mask Airway (LMA)?
- When endotracheal intubation can be performed
2. Insufficient training
What are some complications of an LMA?
- Aspiration, because LMA does not completely prevent regurgitation and protect the trachea.
- Laryngospasm.
- Sore throat.
What is the optimal position for the insertion of the LMA?
Sniffing position
What is a supraglottic away device with capabilities similar to those of the LMA to provide successful patient ventilation; this is not a definitive airway and plans to provide a definitive airway are necessary; like the LMA, this is placed without direct visualization of the glottis and does not require significant manipulation of the head and neck for placement?
Laryngeal Tube Airway (LTA)
The indications (and contraindication) of the laryngeal tube airway is generally the same as for the ______ or a face mask. These include anesthesia for operations on the extremities, minor urological and gynecological procedures, and surface operations of the trunk.
LMA
What are some complications of the Laryngeal Tube Airway (LTA)?
- Laryngeal tube may be displaced during repositioning the patient’s head and neck for operation
- Aspiration
- Poor seal with inability to ventilate
What involves the creation of a surgical opening in the cricothyroid membrane, which lies between the larynx (thyroid cartilage) and the cricoid cartilage?
Surgical Cricothyrotomy
What is the most important instrument for surgical Cricothyrotomy ?
Scalpel
What airway technique should be used as a “last resort” ?
Cricothyrotomy
True or False
Surgical Cricothyrotomy should never be the initial airway control method unless the patient has suffered from C Spine injury and/or mid face injury.
True
What are the two basic types of cricothyroidotomy?
- Needle
2. Surgical
What are the indications for a Surgical Cricothyrotomy?
- Massive midface trauma precluding the use of BVM device.
- Inability to control the airway using less invasive maneuvers.
- Ongoing tracheobronchial hemorrhage.
What are the contraindications for a Surgical Cricothyrotomy?
- Any casualty who can be safely intubated, either orally or nasally.
- Casualties with laryngotracheal injuries.
- Children under 10 years of age.
- Casualties with acute laryngeal disease of traumatic or infectious origin.
- Insufficient training
What are the complications of a Surgical Cricothyrotomy?
- Prolonged procedure time
- Hemorrhage
- Aspiration
- Misplaced or false passage of the ET tube
- Injury to neck structures or vessels
- Perforation of the esophagus
- Longer the period of use the greater the risk of complications
A surgical cricothyroidotomy can be left in place for about _____ hours but should be replaced within that time period by a formal tracheotomy performed in a higher level of care.
24 hours
