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AIRWAY AND VENTILATORY MANAGEMENT OF TRAUMA PATIENTS 1 -.pptx

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AIRWAY AND VENTILATORY MANAGEMENT OF TRAUMA PATIENTS 1 -.pptx

  1. 1. . AIRWAY AND VENTILATORY MANAGEMENT OF TRAUMA PATIENTS PRESENTED BY Dr. MOHIT GARG
  2. 2. AIRWAY AND VENTILATORY MANAGEMENT
  3. 3. OBJECTIVES • Identify the situations in which airway compromise can occur. • Recognize signs and symptoms of acute airway obstruction. • Recognize ventilatory compromise and signs of inadequate ventilation • Techniques for maintaining and establishing a patent airway • Confirmation of adequacy of ventilation and oxygenation by pulse oximetry and end tidal CO2 monitoring • Define definitive airway • Indications for Drug assisted intubation • Steps necessary for maintaining oxygenation before, during and after establishing a definitive airway.
  4. 4. INTRODUCTION  Lack of oxygenated blood is the quickest killer.  Supplemental oxygen must be administered to all severely injured trauma patients.  Death from airway problems Failure to recognize o the need for an airway intervention o the need for alternative airway o the need for ventilation o incorrectly placed airway Inability to establish an airway Displacement Aspiration
  5. 5. AIRWAY (PROBLEM RECOGNITION)  The first step is to recognize objective signs of airway obstruction.  Identify any trauma or burn involving face , neck and larynx.  Sudden/complete  Progressive/Partial  A talking patient provides momentary reassurance that airway is patent and not compromised.  Verbal response with a clear voice indicates o Patent airway o Intact ventilation o Adequate brain perfusion  Patients with an altered level of consciousness require definitive airway.
  6. 6.  Maintaining oxygenation and preventing hypercarbia are critical in managing trauma patients, especially in patients with sustained head injuries.  In patients with facial burns or potential inhalational injury preemptive intubation should be considered due to risk of insidious respiratory compromise.
  7. 7. Pitfalls Prevention  Aspiration after vomiting  Ensure functional suction equipment is available  Be prepared to rotate the patient laterally while restricting cervical spine motion when indicated. It is important to anticipate vomiting and manage situation in all trauma patients .
  8. 8. OBJECTIVE SIGNS OF AIRWAY OBSTRUCTION • Agitation suggest hypoxia • Obtund suggest hypercarbia • Noisy breathing suggest obstruction • Hoarseness implies functional laryngeal obstruction. • Snoring, gurgling and crowing sounds suggest partial occlusion. • Abusive and belingerent patients may be hypoxic ,don’t assume intoxication.
  9. 9.  Other conditions that can cause airway compromise are: 1. Maxillofacial trauma 2. Neck trauma 3. Laryngeal trauma indicated by a triad of clinical signs: • Hoarseness • subcutaneous emphysema • palpable fractures.
  10. 10. VENTILATION (PROBLEM RECOGNITION)  Look for any objective signs of inadequate ventilation.  Ventilation can be compromised by: Airway obstruction Altered ventilatory mechanics as in chest trauma CNS depression
  11. 11. Objective signs of inadequate ventilation • Symmetrical chest rise and fall. Asymmetry suggests splinting of rib cage, pneumothorax or a flail chest.  Breath sounds • Labored breathing • Rapid RR  Pulse oximetry  Capnography.
  12. 12. Pitfall Prevention  Failure to recognise inadequate ventilation  Monitor the patient’s respiratory rate and work of breathing  Obtain arterial or Venus blood gas measurements  Perform continuous capnography
  13. 13. AIRWAY MANAGEMENT  Quick and accurate assessment of airway patency and adequacy of ventilation by using pulse oximetry and capnography.  Take immediate measures to improve oxygenation and ventilation to reduce risk of further ventilator compromise. These measures include airway maintenance, definitive airway and methods of providing supplemental ventilation.  Restriction of cervical spine motion is necessary in all trauma patients.
  14. 14. PREDICTING DIFFICULT AIRWAY  C-spine injury  Severe arthritis of c-spine  Maxillofacial trauma  Limited mouth opening  Obesity  Pediatric patients  Anatomical variations in face and neck(e.g. receding chin, Overbite, and a short muscular neck)
  15. 15. AIRWAY DECISION SCHEME
  16. 16. AIRWAY MAINTENANCE TECHNIQUES  Restriction of cervical spine motion is mandatory before using manoeuvres.  Chin-lift Manoeuver  Jaw-Thrust Manoeuver  Oropharyngeal airway  Nasopharyngeal airway  Extraglottic and supraglottic devices • Laryngeal mask airway and intubating LMA • Laryngeal tube airway and intubating LMA • Multilumen esophageal airway
  17. 17. DEFINITIVE AIRWAYS  Criteria for establishing definitive airway: A- Inability to maintain patent airway B- Inability to maintain adequate oxygenation C- cerebral hypo-perfusion D- obtundation indicating head injury, sustained seizure activity and need to protect airway.
  18. 18. TECHNIQUE FOR DRUG ASSISTED INTUBATION  It is indicated in patients who need airway control but have intact gag reflex, especially in patients who have sustained head injury.
  19. 19. The technique for drug-assisted intubation is as follows: • Have a plan in the event of failure that includes the possibility of performing a surgical airway. • Ensure that suction and the ability to deliver positive pressure ventilation are ready. • Pre-oxygenate the patient with 100% oxygen. • Apply pressure over the cricoid cartilage. • Administer an induction drug (e.g., etomidate, 0.3 mg/kg) or sedative, according to local protocol. • Administer 1 to 2 mg/kg succinylcholine intravenously (usual dose is 100 mg).
  20. 20. After the patient relaxes: Intubate the patient orotracheally. Inflate the cuff and confirm tube placement by auscultation and determining the presence of CO2 in exhaled air. Release cricoid pressure. Ventilate the patient.
  21. 21. SURGICALAIRWAY  Needle Cricothyroidotomy o Through the cricothyroid membrane into the trachea in an emergency situation. o Short-term ,until a definitive airway can be placed.  Large-caliber plastic cannula(12 to 14 gauge for adults, 16 to 18 gauge in children) below the level of the obstruction.  Connected to oxygen at 15 L/min (50 to 60 psi) with a Y-connector or a side hole cut in the tubing between the oxygen source and the plastic cannula.  Intermittent insufflation, 1 second on and 4 seconds off, can then be achieved by placing the thumb over the open end of the Y-connector or the side hole.  The patient may be adequately oxygenated for 30 to 45 minutes using this technique. During 4 seconds off , exhalation occurs.
  22. 22. COMPLICATION  Inadequate ventilation  Tension pneumothorax  Posterior tracheal wall laceration  Barotrauma
  23. 23. Surgical Cricothyroidotomy  Skin incision extends through the cricothyroid membrane . Insert a curved hemostat or scalpel handle to dilate the opening, and then insert a small endotracheal or tracheostomy tube (preferably 5 to 7 ID) or tracheostomy tube (preferably 5 to 7 mm OD).  Care must be taken, especially with children, to avoid damage to the cricoid cartilage, which is the only circumferential support for the upper trachea. For this reason, surgical cricothyroidotomy is not recommended for children under 12 years of age.When an endotracheal tube is used, it must be adequately secured to prevent malpositioning, such as slipping into a bronchus or completely dislodging.
  24. 24.  In recent years, percutaneous tracheostomy has been reported as an alternative to open tracheostomy. This procedure is not recommended in the acute trauma situation, because the patient’s neck must be hyperextended to properly position the head in order to perform the procedure safely.
  25. 25. MANAGEMENT OF OXYGENATION  Oxygenated inspired air is best provided via a tight-fitting oxygen reservoir face mask with a flow rate of at least 10 L/min.  Pulse oximetry must be used at all times.
  26. 26. MANAGEMENT OF VENTILATION  Ventilatory assistance may be needed prior to intubation in many trauma patients.  Effective ventilation can be achieved by bag-mask technique.  Two person technique is more effective  Upon intubation of the trachea, use positive-pressure breathing techniques to provide assisted ventilation.  Should be alert for pneumothorax  Avoid prolonged periods of inadequate or absent ventilation and oxygenation.
  27. 27. SUMMARY • Situations of airway compromise include head trauma, maxillofacial trauma, neck trauma, laryngeal trauma, and airway obstruction due to other reasons. • Actual or impending airway obstruction should be suspected in all injured patients. • Recognition of ventilatory compromise and ensuring effective ventilation are of primary importance. • Techniques for establishing and maintaining a patent airway include the chin-lift and jaw-thrust maneuvers, oropharyngeal and nasopharyngeal airways, extraglottic and supraglottic devices, and endotracheal intubation.
  28. 28. • Cervical spinal motion must be restricted when injury is present or suspected. • The assessment of airway patency and adequacy of ventilation must be performed quickly and accurately. Pulse oximetry and end-tidal CO2 measurement are essential. • Definitive airway should be placed early to prevent prolonged periods of apnea. • Drug-assisted intubation may be necessary in patients with an active gag reflex. • To maintain a patient’s oxygenation, oxygenated inspired air is best provided via a tight-fitting oxygen reservoir face mask with a flow rate of greater than 10 L/min. Other methods (e.g., nasal catheter, nasal cannula, and non- rebreathing mask) can improve inspired oxygen concentration.
  29. 29. THANK YOU

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