Airway Management

Scenario

You receive a call as the SHO on call for general surgery to evaluate a 40-year-old male who sustained multiple facial injuries after a fall. He's conscious but struggling to maintain his airway, with a GCS of 7. Despite receiving oxygen at 40% via a non-rebreather mask, his oxygen saturation remains low at 88%. He presents with audible stridor and obvious facial trauma

Observations

Respiratory rate 16/ min

Oxygen saturation 98%

Blood pressure 115/89mmHg

Heart rate 98 bpm

Temperature 36.3 C

GCS 7 (E2 / V2 / M3)

How would you assess this patient's airway within the emergency department?

In this scenario, it's crucial to follow the ATLS (Advanced Trauma Life Support) algorithm to ensure timely and appropriate assessment and treatment. Given the severity of the patient's injuries and the potential for airway compromise, you should highlight your airway concerns and state you would follow ATLS Algorithm.

C-Spine

• Ensure C-spine immobilisation with collar, blocks, and tape due to fall with dangerous mechanism.

• Proceed to assess airway while maintaining C-spine immobilization.

Airway Assessment - “Look, Listen, Feel” Approach

• Look: Visually inspect the patient's airway for any signs of obstruction, such as swelling, foreign objects, or trauma. Look for any visible signs of respiratory distress, such as cyanosis or use of accessory muscles.

• Listen: Listen for abnormal breath sounds, such as stridor (indicating upper airway obstruction), wheezing (indicating lower airway obstruction), or absent breath sounds (suggesting complete airway obstruction).

• Feel:  Feel for any breathing efforts on your cheek or back of hand

If patient is not talking, making snoring noises, and has reduced GCS or poor respiratory effort, immediately shout for help and put out 2222 call (need anaesthetist on call urgently)

How would you immediately manage the patient if you were concerned about their airway within the emergency department?

Airway Assessment

If patient is not talking, making snoring noises, and has reduced GCS, immediately shout for help and bleep anaesthetist on call

• Begin by airway manoeuvres:

  • Head tilt and chin lift (if no c-spine injury) / Jaw thrust

  • Whilst applying oxygen via NRBM

  • And suctioning any debris form airway via yanker suction

• Then consider an airway adjunct:

  • Oropharyngeal airway

  • Nasopharyngeal airway

  
  

Note: It is crucial to progress from simpler interventions to more complex ones while managing the airway.

Airway manoeuvres --> simple adjuncts --> supraglottic airways --> definitive airway --> surgical airway

How is an oropharyngeal airway size measured and how would you insert it?

Sizing

• To ensure proper sizing of the oropharyngeal airway (OPA), measurements are taken from the corner of the patient's mouth to the angle of the jaw or the earlobe.

• This distance should correspond roughly to the length of the airway.

Insertion

• Preparation involves ensuring the cleanliness and integrity of the OPA and lubricating it with a water-soluble lubricant for ease of insertion.

• During insertion, the airway is held with the tip directed toward the hard palate and inserted into the patient's mouth with the curved tip facing the roof. Once in the posterior pharynx, the airway is rotated 180 degrees to align with the tongue's contour, ensuring the flange rests against the lips for proper placement.

How is a nasopharyngeal airway measured?

A nasopharyngeal airway (NPA) is measured from the tip of the patient's nose to the angle of the jaw or the earlobe to ensure proper sizing. Alternatively, the size can be estimated by comparing the airway to the patient's little finger, with the tip of the airway ideally reaching the base of the fifth finger when positioned alongside it.

Are there any contra-indications to the use of a nasopharyngeal airway?

Signs of or diagnosed:

• Basal skull fracture

• Cribriform plate fracture

What are the potential causes of airway obstruction in this scenario?

• Facial trauma - leading to soft tissue swelling or hematoma

• Fractures of the facial bones - such as the nose, jaw, or maxilla

• Displaced or broken teeth - causing an obstruction

• Fluids / Foreign Bodies - Accumulation of blood, secretions, or foreign objects in the oral cavity or upper airway

• Oedema or inflammation - of the pharynx or larynx due to injury

• Loss of consciousness - with relaxation of the tongue or soft tissues into the airway

• Aspiration - of vomit, blood, or other fluids due to reduced consciousness or impaired protective airway reflexes

With a Glasgow Coma Scale (GCS) score of 7 (E2 / V2 / M3), what functions is the patient capable of doing?

• Eyes - The patient can open eyes in response to pain (E2).

• Verbal - The patient can only produce incomprehensible sounds (V2).

• Motor - The patient can only demonstrate abnormal flexion in response to pain (M3).

Glasgow Coma Scale

What GCS would require immediate intubation?

GCS <8

What is a definitive airway?

A definitive airway is an established passage for breathing, typically created by inserting a cuffed tube below the vocal cords into the trachea. This tube is secured and inflated to maintain an unobstructed airflow, ensuring effective ventilation and oxygenation.

What can be performed if endotracheal intubation is unsuccessful?

Surgical airway - Emergency cricothyroidotomy or tracheostomy to create a secure airway directly into the trachea in cases of complete airway obstruction or inability to intubate.

What is the difference in a tracheostomy and a cricothyrotomy?

Cricothyrotomy

• Placed into cricothyroid membrane

• Between cricoid and trachea

Tracheostomy

o   Performed lower down

o   Between the 2nd-5th tracheal rings

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