Goal: Maintain EtCO2 of 35 mmHg. Capnography also indirectly

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Chapter 4 Initial Airway Management
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Initial Airway Management
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Overview

• Respiratory anatomy and physiology
• Importance of observation
• Supplemental oxygen, various airway adjuncts
• Indications, contraindications, advantages,
  disadvantages
• Predictors of difficulty
• Mask ventilation and endotracheal intubation
• Sellick maneuver
• Essential components of airway kit

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Initial Airway Management

• Most important trauma care task
• Challenging in field
• Frequently time critical
• Unpredictable
• Need options and alternatives
• Always start with basics

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Anatomy and Physiology
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Anatomy and Physiology

• Nasopharynx
• Delicate
• Turbinates
• Oropharynx
• Hyoid bone
• Hypopharynx
• Epiglottis

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Anatomy and Physiology

• Larynx
• Laryngeal prominence
• Vocal cords
• Thyroid cartilage
• Cricoid cartilage
• Sellick maneuver
• Cricothyroid membrane

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Anatomy and Physiology

• Trachea, bronchi
• Carina
• Mainstem bronchi
• Protective reflexes
• Lungs
• Pleural space
• Alveolocapillary membrane

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Average Adult

• Distances can vary by several cm.
• 22.5 cm movement in flexion/extension

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Patent Airway

• Without a patent airway,
• all other care is of little use.

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Patent Airway

• Continual observation
• Suction with large-bore tubing
• Airway adjuncts
• Nasopharyngeal airway
• Oropharyngeal airway
• Blind insertion airway device (BIAD)
• Endotracheal intubation

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Difficult Airway

• Rapid sequence intubation (RSI)
• BVM ventilation and immediate transport
• Assessment of difficult airway
• Remember MMAP
• M Mallampati
• M Measurement 3-3-1
• A Atlanto-occipital extension
• P Pathology

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MMAP Mallampati Score
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MMAP

• Measurement 3-3-1
• Chin to hyoid bone
• Opening of mouth
• Lower-jaw protrusion
• Atlanto-occipital extension
• Only if cervical-spine injury not suspected
• Pathology
• Anatomic airway obstructions

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Patent Airway

• Noisy breathing
• is obstructed breathing.

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Normal Perfusion

• Normal oxygenation
• PaO2 100 mmHg
• Pulse oximetry
• Goal maintain SpO2 gt95
• Monitor SpO2 with all trauma patients
• Monitor SpO2 with any respiratory compromise

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Supplemental Oxygen
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Normal Ventilation

• Tidal volume (VT)
• Amount moved with each breath
• 400 to 600cc (adult)
• VT x breaths/minute Minute volume
• 500cc x 12 breaths/min 6 liters/min (adult)
• Fast, shallow 250cc x 24 breaths/min 6
  liters/min
• Slow, deep 750cc x 8 breaths/min 6 liters/min

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Normal Ventilation

• Normal ventilation
• Carbon dioxide in blood (pCO2) 3540 mmHg
• Abnormal ventilation
• Hypoventilation pCO2 above 40 mmHg
• Hyperventilation pCO2 below 35 mmHg
• Capnography
• End-tidal CO2 (EtCO2) relates directly to pCO2

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• When in doubt,
• give oxygen!

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Positive Pressure

• Ventilation rate
• 1012 per minute Non-intubated patient
• 810 per minute Intubated patient
• Supplemental oxygen essential
• Suction must be immediately available
• Avoid gastric distention
• Monitor lung compliance

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Perfusion and Ventilation

• Monitor effectiveness

• Pulse oximetry (SpO2)monitors oxygenation

• Capnography (EtCO2)monitors ventilation

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Difficult BVM Ventilation

• B Beards
• O Obesity
• O Older patients
• T Toothlessness
• S Snores or stridor

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Airway Kit

• Airway adjuncts
• Various adjuncts
• Intubation kit
• Rescue airway device
• Portable suction
• Monitoring devices
• SpO2
• EtCO2
• Oxygen cylinder

• Oxygen delivery
• Cannula and masks
• Pocket mask
• BVM with reservoir bag

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Summary

• Ensuring a patent airway is essential.
• Need a clear understanding of anatomy, tidal
  volume, minute volume, compliance.
• Must be proficient in various techniques.
• Equipment must be immediately available.
• When in doubtgive oxygen!

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Discussion