Difficult Airway Management in Trauma
Blair Munford
Outline
DIFFICULT AIRWAY MANAGEMENT IN TRAUMA
Blair Munford, FANZCA
Senior Specialist Anaesthetist
Liverpool Hospital, Sydney, Australia
&
Senior Flight Physician & Deputy Medical Director
NRMA CareFlight/NSW Medical Retrieval Service
Airway Control – Why?
A for Airway
Obstructed/at risk/soiled airway.
B for Breathing
e.g. Flail chest/high spinal deficit.
C for Circulation
e.g. Anaesthesia for laparotomy.
D for Disability
e.g. confused or paediatric patient for CT.
The winner, and still champion:
Endotracheal intubation (usually oral), remains the gold standard for trauma airway management, but . . .
Why not?
Because you should (almost) never see this view during intubation of a trauma patient.
Why not?
“Sometimes, you have to box clever”
- Anon
Classification of airways
Four short stories:
“Paint me warts and all”
-Oliver Cromwell
Case I:
29 year old male
3 days prior to Christmas
Intoxicated, involved in dispute
Hit in face
Le Fort III and mandibular #s
Case I: Airway management
Topical airway anaesthesia
with nebulised lignocaine – (then)
Fibreoptic assisted awake oral intubation attempted
unsuccessful because of bleeding/restlessness
Plan B: Rapid sequence induction
with head up position till induction
then Trendelenberg till airway secured
Case I: Take home message
Do what you do well
Have a backup plan
Blood in the airway & fibreoptic intubation don’t mix well.
Case II: There are old motorcyclists & bold motorcyclists – but no old bold motorcyclists.
54 yr old male Harley Davidson rider
Morbid obesity
Involved in MBA
Fractured ribs/pulmonary contusions
Borderline hypoxia
(SaO2 90-91% on high flow O2 via NRBM)
Suspected Cx/Tx spine #s
Case II: Airway management
Topicalisation of airway
Awake fibreoptic nasal intubation
Surgical insistence on supine posture due potential spinal #s.
Extremely technically difficult & patient hypoxic throughout procedure.
Improved after intubation & IPPV/PEEP.
Very nearly a failed intubation – then what?
Case II: Take home message
Airway comes before disability!!!
Sometimes you may be the only one who can see this.
If so, you need to be assertive.
If the protocol doesn’t fit the patient, you have to change the former .
Case III: When you race a train to a level crossing, coming first equal is not good.
MVA vs train, 32 yr old woman driver
Trapped by legs, inverted position
Partial impalement through abdomen
Progressive blood loss
Impaired & decreasing LOC.
T wave peaking on ECG
Case III: Airway management
Small dose of morphine – further decrease in LOC
Laryngeal mask placed, hand bag assisted ventilation where possible (CPAP/PSV)
After extrication, modified RSI
(no suxamethonium)
Concomitant treatment for hypovolaemia & crush injury syndrome
Case III: Take home message
The best airway is the one you can get!
Case IV: Double (jump) Trouble
16 year old motocross rider, went over handlebars landing from double jump, handlebar struck neck.
Brought in by private car (~25km)
X-ray at district hospital:
Extra-laryngeal/pharyngeal air
C1 & C2 fractures
Case IV: Airway management
Retrieval team called
Cx collar removed (!)
Immobilisation with sandbags/tape
Expedient transfer to regional trauma centre
Stable in transit
Backup plan: surgical cricothyrotomy
Had awake tracheostomy then delayed surgical stabilisation of vertebrae
Case IV: Take home message
(Sometimes):
“The best medical care is the delivery of as much nothing as possible”
-The Fat Man (in)
‘The House of God’
My top tips:
Be prepared
Use most experienced team possible
Time is important
Airway comes first
(This may be difficult)
Customise to patient
But do what you do well
Anatomy may be unfavourable
(Difficulty increases further)
Assume full stomach
Cooperation not assured
(Difficulty increases again)
Be flexible
Have a backup plan
Rapid sequence induction (1)
Most common airway technique in trauma
Needs up to four team members:
Preoxygenation/intubation
Drug administration
Cricoid pressure administration
Inline Cx spine immobilisation
Laryngoscopy with anterior jaw lift only.
Sometimes less is more:
Rapid sequence induction (2)
Use the least force that gives Grade 2-3 view
Pass a silicone bougie
“Railroad” (small-ish) ETT over the bougie
Confirm position with capnography & clinically
But what if this fails?
Failed intubation:
After two optimal attempts by most experienced operator available
Remember:
People don’t die of failure to intubate - but of failure to oxygenate
Supra-glottic airway options:
Initial step: BMV with oral &/or nasal airway.
Sub-glottic airway options:
Needle cricothyrotomy
Technique of choice in paediatrics
Tube cricothyrotomy
Technique of choice in adults
Tracheostomy
Only on television!
Alternative intubating devices
Making a decision
The choice will depend on:
The patient
The situation
What you think you are good at
Remember – it’s going to be your choice, so have a think about it.
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Ministry of Health
