Emergency Airway Access

8/7/2019 Emergency Airway Access

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Ensuring an adequate airway is the firstpriority in the primary survey.In general

patients who are conscious and have anormal voice do not require early attentionto their airway.Patients who have anabnormal voice or altered mental status

require further airway evaluation. Options for airway access include

nasotracheal,orotracheal and surgical.


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The most widely used route is orotracheal, in which an endotrachealtube is passed through oral cavity.In a nasotracheal procedure, anendotracheal tube is passed through thenose.

Other methods of intubation involvesurgery and include theI. cricothyroidotomyII. tracheostomy


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T

racheal intubation is indicated in patients with:

Actual or impending airway obstruction due to Foreign body common in infants and toddlers. Severe blunt orpenetrating injury to the face

or neck may be accompanied by swellingand an expanding hematoma, or

Injury to the larynx, trachea or bronchi. It is also common in people who have suffered

smoke inhalation or burns within or near theairway.

Sustained generalized seizure activity and angioedema


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Defined as decreased oxygen content and oxygen saturation of the bloodcaused due to hypoventilation) suspended (apnea), or when the lungsare unable to sufficiently transfer gasses to the blood.

Examples of such conditions include

cervical spine injury,

multiple rib fractures,

severe pneumonia,

acute respiratory distress syndrome (ARDS), or

near-drowning.

Specifically, intubation is considered if the arterial partial pressure of

oxygen (PaO2) is less than 60 millimeters of mercury (mm Hg) whilebreathing an inspired O2 concentration (FIO2) of 50% or greater. Inpatients with elevated arterial carbon dioxid

e, an arterial partialpressure of CO2 (PaCO2) greater than 45 mm Hg in the setting ofacidemia would prompt intubation, especially if a series ofmeasurements demonstrate a worsening respiratory acidosis.


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Depressed level of consciousness due toa) Administration of general anaesthesiab) Strokec) Non-penetrating head injuriesd) Poisoning

e) Intoxication

f) when depressed level of consciousnessbecomes severe to the point of stupororcoma (defined as a score on the GlasgowComa Scale of less than 8)


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Diagnostic or therapeutic manipulation of the

airway (such as bronchoscopy, lasertherapy orstenting of the bronchi) mayintermittently interfere with the ability tobreathe.


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Relative contraindications include

maxillo facial trauma

laryngeal injury

cervical spine injuries


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PRE REQUISITESPre oxygenation with a bag valve mask apparatus and100%oxygen,suction,adequate sedation and muscle relaxationan appropriately sized ETT tube and a functional laryngoscope

are required

With the physician at the patients head,the head is so positionedthat the pharyngeal and laryngeal axes are in alignment.

The patients head and neck are fully extended. With the non dominant hand,the physician opens the mouth

with the thumb and index finger on pts lower and upper teeth.

The oropharynx is inspected and foreign bodies or secretions areremoved,blade of the laryngoscope is introduced andadvanced with gentle traction upward and towards the patientsfeet.


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oOnce the epiglottis is visualized the tipof the blade is positioned in thevaleculla.the glottic opening and

vocal cords are visualized, the ET tubeis advanced under direct vision until

the cuff passes through the vocalcords.

oCuff is inserted roughly 2cm past the

vocal cords and the patients incisorsshould rest between the 19 and 23 cm

markings on the tube.

oThe cuff is inflated and proper positionis confirmed by auscultating bilateral

breath sounds.An anteroposterior chestx ray is obtained to confirm

position.Ideallly the tip of the ET tubeshould be 2 to 4 cm above the carina.


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Chipped teeth

Emesis and aspiration

Vocal cord injury

Laryngospasm

Soft tissue injury to the oropharynx


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Advantages include

Direct visualization of the vocal cords

Ability to use larger diameter

endotracheal tubes

Applicability to apneic patients

Familiarity to most physicians Demerits

require neuromuscular blockade or

deep sedation


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A cricothyrotomy is an incision made through the skin andcricothyroid membrane to establish a patent airway

INDICATIONS include

Life-threatening situations, such as airway obstruction by aforeign body, angioedema, or massive facial trauma.

A cricothyrotomy is nearly always performed as a lastresort in cases where orotracheal and nasotrachealintubation are impossible or contraindicated.

Advantages include Cricothyrotomy is easier and quicker to perform than

tracheotomy, does not require manipulation of thecervical spine and is associated with fewer complications.[


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The thyroid cartilage is easilyidentified in the midline of theneck.The cricoid is the onlycomplete cartilaginous ring ,isthe first ring inferior to thethyroid cartilage.Thecricothyroid membrane joinsthese two cartilages and is anavascular membrane.Inferiorto the cricoid and straddlingthe trachea is the isthmus ofthe thyroid gland.The thyroidlobes lie lateral to the tracheaand the superior poles canextend to the level of thethyroid cartilage.


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If time permits the area is prepared,draped and anesthetized with 1%lidocaine.

A vertical skin incision is made. The cricoid is identified and held firmly and

circumferentially in the physicians non dominant hand until the end of the

procedure.

With a no.11 or 15 blade, a small 3 to 5 cm transverse incision is made over

the cricothyroid membrane.The incision is carried deep to the until theairway is entered through the cricothyroid membrane.

The tract is widened using a clamp ,tracheal dilator or end of the scalpelhandle.

The tracheostomy tube is inserted along its curve into the trachea,the cuff is

inflated and bilateral breath sounds are confirmed.

If breath sounds are confirmed ,the tracheostomy is secured to the skin by

suturing the tabs to the skin with heavy ,non absorbable,monofilamentsuture.

A chest x ray is obtained to document the location of the tracheostomytube.

Traditionally cricothyroidotomy was converted to formal tracheostomy

.However it has been suggested that a cricothyroidotomy maybe used long

term without an increase in acute complications.


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Creation of a false passage when inserting tracheostomytube is most common complications. Others include

Subcutaneous emphysema

Pneumothorax Injury to surrounding structures such as

thyroid,parathyroids,esophagus,anterior jugular veins,andrecurrent laryngeal nerves can occur in situations of urgency.

Subglottic stenosis and granuloma formation are potential

long term complications.


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Tracheotomy consists of making an incisionon the front of the neck and opening adirect airway through an incision in the

trachea. The resulting opening can serveindependently as an airway or as a site fora tracheostomy tube to be inserted; thistube allows a person to breathe without theuse of their nose or mouth. The opening

may be made by a knife or a needle(referred to as surgical andpercutaneous[72] techniques respectively)and both techniques are widely used incurrent practice.


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In the acute setting, indications fortracheotomy are similar to those for

cricothyrotomy. In the chronic setting, indications for

tracheotomy include the

o need for long-term mechanical

ventilation and removal of trachealsecretions (e.g., comatose patients, or

o extensive surgery involving the headand neck).


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The patient is laid supine with padding placed under theshoulders and neck extended.

A vertical midline incision is made from the inferior aspectof the thyroid cartilage to the suprasternal notch and

continued down between the infrahyoid muscles. In extreme urgency,a further vertical incision straight into

the trachea at the level of the second,third and fourth ringshould be made immediately without regard to thepresence of thyroid isthmus.

The knife blade is rotated through 90 ,thus opening the

trachea. Any form of available tube is inserted into the trachea as

soon as possible and blood and secretion sucked out.

Once an airway is established hemostasis is thensecured.With the emergency under control,thetracheostomy should be refashioned as soon as possible.


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INTRAOPERATIVE

Hemorrhage

Injury to para tracheal structures

injury to trachea

EARLY POST OP

Apnea caused by a fall in pCO2Hemorrhage

Subcutaneous emphysema,pneumomediastinum and pneumothorax

accidental extubation

anterior displacement of the tube

obstruction of the tube lumen

occlusion against tracheal wall

LATE POST OP

Difficult decannulation

Tracheocutaneous fistula

Tracheo-esophageal fistula

Trachea stenosis


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Although emergent tracheostomy has fallen into disfavor because of itstechnical difficulties it may still be necessary in cases of laryngotracheal

separation orlaryngeal fractures,where cricothyroidotomy may cause further

damage or result in complete loss of the airway.


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Emergency Airway Access