Airway management in ATLS patient

The airway is assessed clinically through the following examinations:

1. Inspection: Observe the mouth, nose and jaw for any abnormalities. Look for symmetry, loose teeth, swelling, masses, etc. Observe the neck for mobility, tracheal tugging or deviation which can indicate airway obstruction.

2. Palpation: Palpate the trachea for position and mobility. Normally midline and moves slightly side to side. displacement or reduced mobility indicates obstruction or tracheal injury. Palpate the cricothyroid membrane in midline between the thyroid cartilage and cricoid cartilage. Important for emergency cricothyrotomy if intubation is not possible.

3. Movement: Ask the patient to protrude their tongue, open and close their mouth, and swallow. This assesses tongue mobility and strength, jaw movement, palate elevation. Inability or asymmetry can indicate nerve damage or obstruction.

4. Measurement of jaw protrusion/ mallampati score: Measure distance between upper and lower incisors at maximal mouth opening. A greater degree of protrusion >3 fingerbreadths is better for intubation. The mallampati score classifies view of posterior pharynx:

Class I: Uvula, tonsils, soft palate  visible
Class II: Uvula, tonsils visible
Class III: Only base of uvula visible
Class IV: Only hard palate visible

Higher scores indicate more difficult intubation.

5. Head tilt/Chin lift: Tilt the head back and lift the chin to align the airway for breathing. Unable to extend the neck sufficiently indicates possible cervical spine injury. The “sniffing position” with head extended and facing upwards also helps open the airway.

6. Auscultation: Use a stethoscope to listen for air movement, wheezing or stridor which can indicate airway obstruction. Listen over the trachea and at the mouth/nose.

7. Peak flow: If awake and cooperative, use a peak flow meter to assess maximum expiratory flow rate. Reduced peak flow can indicate airway inflammation or bronchoconstriction.

8. Chest x-ray: If airway obstruction or injury is suspected from the above assessments, a chest radiograph is taken to check for mediastinal widening, tracheomalacia, foreign body, pleural effusions, etc.

In summary, clinical airway assessment provides a quick overview and screening for any obvious abnormalities or difficulties with ventilation or intubation by evaluating both anatomy and function. Changes from normal in any aspect warrant further workup using direct visualization or imaging.

Head tilt/chin lift:

– Place one hand on the patient’s forehead and two or three fingers under the chin.

– Tilt the head back gently while lifting the chin forward.

– This maneuver aligns the pharynx and opens the airway by relieving obstruction from the tongue and epiglottis.

– Used for unconscious or unresponsive patients. Maintains airway patency for rescue breathing or bag-valve-mask ventilation.

Jaw thrust:

– Place the first two fingers behind the angles of the mandible while leaving the thumbs to grasp the chin.

– Lift the jaw upward to bring the lower teeth away from the upper teeth. 

– This produces airway opening by displacing the mandible forward and away from the tongue base.

– Preferred over head tilt/chin lift if cervical spine injury is suspected since it produces less neck movement.

– Can be performed on patient in supine or lateral positions.

Bag-valve-mask (BVM) ventilation:

– A hand-operated device with a self-inflating bag, valve to control air flow, and face mask to direct air into the patient’s airway.

– Gently apply the face mask over the patient’s mouth and nose to create an adequate seal for ventilation.

– Ventilate by compressing the self-inflating bag using both hands in a rhythmic manner, pausing briefly between compressions.  

– Watch for chest rise as a sign of adequate ventilation. Make mask adjustments as needed to optimize seal and gas exchange. 

– Provides rescue breathing in cases of apnea or hypoventilation. Goal is to provide oxygenation and ventilation until advanced airway placed (intubation) or spontaneous breathing resumes.

Endotracheal intubation:

– Placement of a breathing tube through the mouth into the trachea for definitive airway management. 

– Orotracheal (through mouth) intubation is most common. Nasotracheal (through nose) intubation is an alternative.

– Allows for controlled mechanical ventilation and protection from aspiration.

– Performed using a laryngoscope to visualize glottic opening and pass the endotracheal tube through the cords into the trachea. Correct position confirmed using physical exam and device like end-tidal CO2 monitor.

– Considered the “gold standard” for emergency airway management but requires significant training and practice to perform.

– Can be performed on patient in direct laryngoscopy (sniffing position) or by video laryngoscopy using a camera to visualize airway structures.

Nasopharyngeal airway : check for right nostril patency, attach safety pin to end of tube (if needed) and lubricate the tip, insert it bevel end first and perpendicular to orifice (towards the ear). Once in place, reassess the airway according to Look, Listen and Feel.

Oropharyngeal airway : open the mouth employing basic airway manoeuvres. Suction out debris and insert it upside down (curved side pointing to the palate). Rotate it 180° between the hard and soft palate and seat the flattened section between the gums and teeth.OPA should be measured so that it stretches from the corner of the mouth to the angle of the mandible

Ventilations are delivered at 8 to10 per minute(1ventilation every 6-8seconds)

Surgical airway: performed when other methods are not possible or have failed. Three techniques:

– Needle cricothyrotomy: Needle inserted through cricothyroid membrane to provide oxygenation. Temporary measure.

– Cricothyrotomy: Incision made through cricothyroid membrane to place breathing tube directly into trachea.

– Tracheostomy: Opening created in trachea below the larynx to place breathing tube. Performed by surgeon, can be temporary or permanent.

Indications for surgical airway include:

– Failed intubation: Unable to place endotracheal tube for oxygenation/ventilation.

– Facial/oral trauma: Unable to access airway through normal means due to trauma, fractures or bleeding. 

– Obstruction above glottis: Foreign body, angioedema or other obstruction preventing passage of endotracheal tube.

– Inability to ventilate/oxygenate with BVM: Exhausting basic and advanced methods, surgical airway is life-saving last resort.

– Prolonged ventilation needed: For long-term management, tracheostomy preferred over prolonged intubation for patient comfort and mobility. 

– Facial/neck burns: direct access below burn sites allows for maintenance of airway in otherwise difficult to manage airways.

Surgical airways provide access to the trachea below the larynx. The three main techniques for surgical airway are:

1. Cricothyrotomy: An incision is made through the cricothyroid membrane (between cricoid cartilage and thyroid cartilage) to gain access to the trachea. A cricothyrotomy airway device, such as a cricothyrotomy kit or endotracheal tube, is inserted through the incision into the trachea. This provides an temporary emergency airway.

2. Tracheostomy: An opening is made in the trachea, in the midline between the 2nd and 4th tracheal cartilage rings. A tracheostomy tube is placed into the trachea through this opening to provide an airway. This can be either a temporary or permanent tracheostomy. Temporary tracheostomies are often performed in emergency or OR, while permanent tracheostomies are usually surgically created in OR.

3. Transtracheal jet ventilation: A large bore needle, such as a 14-gauge needle, is inserted through the cricothyroid membrane into the trachea. Oxygen is delivered under high pressure through the needle using a jet ventilator device. This provides temporary oxygenation and ventilation, but does not provide a secure airway since the airway is not actually visualized or opened. It is mainly used as a life-saving measure until a more definitive airway can be established.

So in summary:

– Cricothyrotomy: Through cricothyroid membrane, provides temporary tracheal access.

– Tracheostomy: Through anterior trachea between 2nd to 4th cartilage rings, can be temporary or permanent.

– Transtracheal jet ventilation: Transcutaneous tracheal access using needle for temporary oxygenation until definitive airway placed.

Surgical airways provide access to the trachea when endotracheal intubation is difficult or impossible due to anatomy or trauma. They are truly lifesaving techniques, though do require training to perform, particularly tracheostomy. They allow clinicians to gain access to the trachea and provide effective oxygenation and ventilation in emergency situations.

1. Assess the patient’s neck for any obvious injuries or deformities before sizing and applying the collar. Perform a jaw thrust or head tilt as needed to open the airway, while maintaining inline stabilization of the spine.

2. Size the collar by placing your extended fingers along the side of the patient’s neck. Your pinky finger should rest on the shoulder. Note which of your fingers lines up with the bottom of the patient’s chin. Count the number of fingers needed to reach the chin – this determines the correct collar size.

3. Ensure the back and front halves of the collar are the proper size before application. The collar size should fit snugly but still allow 2 fingers to slide under. Have an assistant continue manual inline stabilization of the spine during sizing and fitting. 

4. Slide the back half of the collar under the patient’s neck until the edge is just visible. Ensure proper alignment and position.

5. Firmly slide the front half of the collar up and attach to the back half, securing all straps and screws. Ensure there are no loose areas and that the collar is snug around the circumference of the neck. 

6. Ensure the patient’s chin is in contact with the chin piece of the collar before securing the straps. If not in contact, the collar is not fitted properly and needs adjustment.

7. Secure the collar straps starting from the top, applying firm pressure. Recheck the snugness and alignment of the entire collar. Readjust as needed under inline manual stabilization.

8. Once fully secured, manually test the rigidity and alignment of the collar to ensure maximum immobilization and stability of the cervical spine. Loosen and reapply if instability detected.

9. Apply additional immobilization using head blocks, straps and tape for maximum protection during patient movement and transport. Reassess airway, breathing, circulation and neurological status frequently.

10. The collar should be kept in place until cervical spine injury has been ruled out or definitive treatment/surgery has been performed by a physician. Only loosen or remove under medical direction while maintaining spine precautions.

Strict adherence to proper sizing, application and securing of cervical collars is vital to effective spinal immobilization and preventing further injury. Close monitoring and frequent reassessment of the patient is also needed due to the risk of airway or circulatory compromise from over-tight collars.