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Airway and ventilation

  • The airway should be secured as the initial action in trauma resuscitation
  • A cervical spine injury should be assumed until proven otherwise
  • Oxygen should be delivered at high concentration
  • Hypercarbia should be prevented

Airway assessment

  • The patient should be asked a simple question
  • If he responds appropriately
    • The airway is patent
    • Ventilation is intact
    • The brain is being adequately perfused
  • Agitation is often a sign of hypoxia

Airway management

  • The aims of airway management are:
    • To secure an intact airway
    • To protect a jeopardised airway
    • To provide an airway when none is available
  • These can be achieved with basic, advanced and surgical techniques

Basic life support

  • Foreign bodies should be removed from the mouth and oropharynx
  • Secretions and blood should be removed with suction
  • Airway can usually be secured with a chin lift or jaw thrust
  • An oropharyngeal or nasopharyngeal airway may be required
  • Oxygen should be delivered at a rate of 10-12 l/min
  • Should be administered via a tight fitting mask with reservoir (e.g. Hudson mask)
  • An FiO2 of 85% should be achievable

Advanced measures

  • If absent gag reflex, endotracheal intubation is required
  • If no cervical spine fracture orotracheal intubation is preferred
  • If cervical spine injury can not be excluded consider nasotracheal intubation
  • The position of the tube should be checked
  • Complications include:
    • Oesophageal intubation
    • Intubation of right main bronchus
    • Failure of intubation
    • Aspiration

Surgical airways

  • If unable to intubate the trachea a surgical airway is required
  • There are few indications for an emergency tracheostomy
  • Surgical airway can be achieved with a needle or surgical cricothyroidotomy

Needle cricothyroidotomy

  • Cricothyroid membrane is punctured with a 12 or 14 Fr cannula
  • Connected to oxygen supply via a Y connector
  • Oxygen supplied at a rate of 15 l/min
  • Jet insufflation achieved by occlusion of Y connection
  • Insufflation provided one second on and four seconds off
  • Jet insufflation can result in significant hypercarbia
  • Should only be used for 30 - 40 minutes

Surgical cricothyroidotomy

  • Small incision made over cricothyroid membrane
  • 5 mm incision made in membrane
  • Small tracheostomy tube inserted
  • Complications of surgical airways include:
    • Aspiration
    • Haemorrhage / haematoma
    • Cellulitis
    • False passage
    • Subglottic stenosis
    • Mediastinal emphysema

Surgical cricothyroidotomy

Ventilation

  • In the non-intubated patient ventilation can be achieved with either
    • Mouth to face-mask
    • Bag-valve-face-mask
  • The later is more efficient if performed with a two person technique
  • One maintains face seal - other ventilates patient
  • If endotracheal intubation required
  • Should be performed with cricoid pressure
  • If rib fractures present need to insert chest drain on side of injury to prevent pneumothorax

Bibliography

Granholm T,  Farmer D L.  The surgical airway.  Respir Clin North Am 2001;  7:  13-23.

Schroeder A A.  Cricothyroidotomy: when, why and why not?  Am J Otolaryngol 2000;  21: 195-201.
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