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

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* Rapid sequence fiberoptic Airway assessment Many vital structures: Respiratory larynx, trachea ... contd problems with blind endotracheal intubation: ... – PowerPoint PPT presentation

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Title: 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.in anaesthesia.co.in_at_gmail.c
om
2
Airway assessment
  • Many vital structures
  • Respiratory larynx, trachea
  • Vascular carotids, jugular veins
  • Digestive pharynx, esophagus
  • Neural brachial plexus, vagus etc

3
Airway assessmentcontd
  • Starts with Airway
  • Breathing
  • Circulation
  • Resuscitation
  • Secondary survey

4
Airway assessmentcontd
  • Laryngotracheal trauma (LTT) rare, but life
    threatening spectrum of injuries
  • more than 50 pts cardiopulmonary arrest
  • Associated injuries cervico-thoracic vascular
    injuries, closed head injuries - emergency
    exploration

5
Airway assessmentcontd
  • Presentation varies
  • -no visible external signs of trauma
  • -abrasions and contusions
  • -extensive lacerations
  • High index of suspicion avoids catastrophic
    complications

6
Airway assessmentcontd
  • 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 assessmentcontd
  • 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 assessmentcontd
  • 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 assessmentcontd
  • 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 managementcontd
  • 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 managementcontd
  • Group of pts 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 managementcontd
  • 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 managementcontd
  • Desjardins et al, Ryder trauma centre

  • Resuscitation 2001
  • Awake fiberoptic
  • Rapid sequence fiberoptic
  • Rapid sequence induction
  • Awake orotracheal intubation

17
Airway managementcontd
  • Method determined by
  • - urgency of situation
  • - patient cooperation
  • - type of injury
  • - significant bleed

18
Airway managementcontd
  • 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 managementcontd
  • Thermal injuries intra oral, laryngeal, tracheal
    assessment
  • Edema interferes with DL ?role of FOB

20
Airway managementcontd
  • 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 managementcontd
  • Four individuals
  • Practice in normal patients prior in routine OT
    before using this in emergency room

22
Rapid sequence fiberoptic
23
Airway managementcontd
  • Awake orotracheal expeditious approach for
    immediate control
  • Moribund or apneic patient
  • Massive upper airway bleed

24
Airway managementcontd
  • 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 managementcontd
  • 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 managementcontd
  • 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

31
Thank you
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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