Airway assessment of the injured patient Airway management of the injured patient

1. Airway assessment of the injured patientAirway management of the injured patient www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Airway assessment Many vital structures: • Respiratory – larynx, trachea • Vascular – carotids, jugular veins • Digestive – pharynx, esophagus • Neural – brachial plexus, vagus etc

3. Airway assessment…contd • Starts with : Airway Breathing Circulation • Resuscitation • Secondary survey

4. Airway assessment…contd • Laryngotracheal trauma (LTT): rare, but life threatening spectrum of injuries • more than 50% pt’s: cardiopulmonary arrest • Associated injuries: cervico-thoracic vascular injuries, closed head injuries - emergency exploration

5. Airway assessment…contd • Presentation varies: -no visible external signs of trauma -abrasions and contusions -extensive lacerations • High index of suspicion: avoids catastrophic complications

6. Airway assessment…contd Signs and symptoms of LTT • s/c or mediastinal emphysema: may be the only signs in distal tracheal injuries • Hemoptysis • Local contusion • Change in voice • Inspiratory stridor, Resp distress

7. Airway assessment…contd • Respiratory distress: not the most prevalent symptom • s/c emphysema: most consistent physical finding. :periodic assessment of patient from neck to feet :may develop over a period of time

8. Airway assessment…contd Signs of severe injury • Airway related: sucking neck wound, respiratory distress, s/c emphysema • Vascular: active external bleed, expanding/ pulsatile hematoma, oropharyngeal bleed • Neurological: neurological deficits

9. Airway assessment…contd • EXPEDITIOUS AIRWAY MANAGEMENT IS TOP PRIORITY • A DEFINITIVE AIRWAY - Endotracheal intubation - Tracheostomy

10. Airway management Indications for emergency intubation • cardiac/ respiratory arrest • Severe respiratory insufficiency/ obstruction • Airway protection: bleeding into oral cavity

11. Airway management…contd Tracheostomy • Fundamental intervention for airway control • Under local anaesthesia • Concern with a combative patient • Consideration to conserve trachea for further management ( tracheal resection and repair )

12. Airway management Other indications for securing airway: • Patients with associated CNS injury, preventing aspiration • Associated thermal injuries involving face • Hemodynamic instability • For diagnostic work up

13. Airway management…contd • Group of pt’s: few minutes available to secure airway in a more systematic way • Should be shifted to OT • Monitors attached • Surgeon scrubbed and ready • Larynx, trachea identified, cleaned and draped.

14. Airway management • Equipment: full endoscopy cart with a monitor, VCR, picture capability- allows assessment by the entire team including anaesthesiologist, ENT surgeon, emergency physician

15. Airway management…contd • problems with blind endotracheal intubation: -further injury, complete obstruction -upper airway examination difficult -false passage -covert partial to a complete tear -burns: edema interferes with DL • Complications lethal, difficult to reverse

16. Airway management…contd • Desjardins et al, Ryder trauma centre: Resuscitation 2001 • Awake fiberoptic • Rapid sequence fiberoptic • Rapid sequence induction • Awake orotracheal intubation

17. Airway management…contd • Method determined by: - urgency of situation - patient cooperation - type of injury - significant bleed

18. Airway management…contd • Awake fiberoptic: safest, considered in all awake and cooperative patients • Awake, no severe distress: few minutes available • Full endoscopy cart • Topical anaesthesia: lidocaine spray • Advance FOB till carina: any evidence of injury: pass ETT under vision beyond defect

19. Airway management…contd • Thermal injuries: intra oral, laryngeal, tracheal assessment • Edema interferes with DL →role of FOB

20. Airway management…contd • Combative patient: rapid sequence FOB • Who do not appear difficult to intubate • Rapid sequence induction, in line immobilization ► standard laryngoscopy ► insert FOB beyond larynx to rapidly evaluate for injury

21. Airway management…contd • Four individuals • Practice in normal patients prior in routine OT before using this in emergency room

22. Rapid sequence fiberoptic

23. Airway management…contd • Awake orotracheal: expeditious approach for immediate control • Moribund or apneic patient • Massive upper airway bleed

24. Airway management…contd • Standard RSI: previous normal anatomy minimal injury high risk of bleeding if coughing or straining occurs • Last choice amongst the following: inability to visualize airway before insertion of ETT

25. Airway management…contd Whenever endotracheal intubation planned: • In an operating room setup • Monitored environment • Surgeon ready for tracheostomy • Restrict multiple attempts • Identify trachea and cricothyroid membrane

26. Airway management…contd no obvious resp distress, Patient stable, no signs/ symptoms of LTT: • Close monitoring of the patient • When planned for work up: e.g. CT scan- accompanied by anaesthesiologist, airway cart and monitoring facilities.

27. Pediatric airway Relatively uncommon: • Larynx higher in neck • Fewer motor vehicle accidents • Fewer interpersonal conflicts

28. Pediatric trauma…..contd Anatomical features: • Glottic aperture • Subglottic diameter • Loose laryngeal mucosa

29. Pediatric trauma…..contd • Management • Small children may not tolerate awake procedures • Consider inhalational anaesthesia: • Rigid bronchoscopy: can proceed to either ETT or tracheostomy

30. summary • Laryngotracheal injuries are life threatening • Symptoms can be subtle: abrasions, minor contusions • Awake intubation is a consideration • Cricothyroidotomy/ tracheostomy are life saving • Periodic assessment is mandatory: w/f subcutaneous emphysema

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