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Advanced Prehospital Airway Management Techniques

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Advanced Prehospital Airway Management Techniques EUROPEAN JOURNAL OF EMERGENCY MEDICINE, 2002,9,298^302 EXTENDED ABSTRACTS FROM INVITED SPEAKERS AT THE 1ST MEDITERRANEAN CONGRESS ON EMERGENCY MEDICINE, STRESA, 2–5 SEPTEMBER 2001 Advanced prehospital airway management techniques A.R. THIERBACH Department of Anaesthesiology, Johannes Gutenberg-University, Mainz, Germany Keywords: airway management intubation; endotracheal intubation; flexible fibre optic combitube; oesophageal tracheal; laryngeal mask airways; algorithm; emergency airway INTRODUCTION patient before every non-emergency endotracheal intubation. Approximately 2–3% of patients have Complications related to airway management in the anatomical features that make tracheal intubation prehospital setting are frequent and, because of the difficult. Table 2 lists those findings that suggest that importance and vulnerability of the ventilatory endotracheal intubation may be difficult. system, can be life threatening within a very short time. Therefore, airway management is perhaps the Time priorities key component in the treatment of any patient in a critical condition. The urgency of airway management is divided into four categories, as outlined in Table 3. EVALUATION TECHNIQUES Perhaps most importantly of all, the emergency care provider must be able to recognize those patients in Airway management involves far more than just whom airway management may be difficult and be proficiency with tracheal intubation techniques. able to formulate and implement alternative plans in Clearly there are several techniques available and various situations. the method chosen will depend on the availability of equipment, the level of training and expertise, and the Patients who have suffered major trauma or life- patient’s specific injury or disease. threatening diseases can present the most complex airway management problems, especially in the Standard monitoring should be employed, includ- prehospital setting. Because the treatment is time- ing electrocardiography, non-invasive automated critical, evaluation is usually incomplete at the time blood pressure monitoring, pulse oximetry and airway management is undertaken. capnography. Trauma Alternative techniques include mask ventilation to ensure immediate oxygenation, the oesophageal Direct airway trauma may involve actual damage to tracheal Combitube and various laryngeal mask the airway or any kind of injury to nearby structures airways. Modifications of laryngoscopic blades (e.g. that distorts the anatomy of the airway. Indirect or Henderson, McCoy) and fibreoptic intubation tech- associated airway trauma affecting airway manage- niques (e.g. Bonfils, Bullard) may offer alternatives to ment will be considered to be those injuries that limit the expert even in the prehospital environment. The or influence the techniques available for airway needle or surgical cricothyrotomy is rarely required, management. Table 1 lists the injuries that may cause but remains the ‘ultima ratio’ in airway problems direct or indirect airway trauma. when all other techniques fail. Difficult anatomy Orotracheal intubation A comprehensive physical examination of the dental Endotracheal intubation represents the most common system and airway should be performed in each technique for securing the airway and provides the & 2002 Lippincott Williams & Wilkins. ADVANCED PREHOSPITAL AIRWAY MANAGEMENT TECHNIQUES 299 Table 1. Direct and indirect trauma to the airways Table 4. General indications for endotracheal intubation Direct airway trauma Resuscitation (optimized ventilation and oxygenation) Mandibular fractures Respiratory insufficiency of any reason (e.g. high spinal Maxillary fractures cord injuries, drug overdose) Penetrating wounds (e.g. gun shot, stab injury) of neck or Multi-traumatized patients and patients in shock face Glasgow coma score o8 Indirect airway trauma Risk of aspiration (e.g. protection against gastric contents or Cervical spine injury blood) Bleeding into soft tissues of neck or face Provision of surgical anaesthesia Air emphysema and oedema of soft tissues of neck or face Pneumothorax Burns of neck and upper chest Table 5. Benefits of endotracheal intubation Protection against aspiration Provision of a route to administer drugs even without intravenous access (e.g. adrenaline, lignocaine, atropine, naloxone) Table 2. Findings that suggest a difficult intubation using Application of facilitated assisted or controlled mechanical standard direct laryngoscopy ventilation and positive end expiratory pressure Allows endotracheal suctioning and bronchial toilet Small mouth, inability to open mouth, temporomandibular joint abnormalities Narrow receding mandible Protuberant maxilla (overbite) When performing orotracheal intubation in patients Large tongue or one whose mobility is limited Less than 6 cm distance between mandible and thyroid with potential injury of the cervical spine, manipula- prominence tions of the cervical spine must be minimized, and an Inability to place the head in the ‘sniffing’ position, e.g. assistant should always apply manual axial in-line cervical spine trauma stabilization (MIAS), being careful to leave the neck in Short, full or bull neck, or the presence of a neck mass a neutral position. Immobilization of the cervical spine may also be accomplished by using other techniques such as a rigid collar or head rolls and tape. Table 3. Relative time priorities of airway management MIAS should always be combined with cricoid 1. Immediate intervention in apnoeic patients pressure applied after the patient loses consciousness. 2. Emergency intervention in patients with respiratory By placing the thumb and index finger on the cricoid distress cartilage and exerting pressure in an anteroposterior 3. Urgent intervention in patients currently stable but with direction, the oesophagus is occluded. Proponents of increased risk of aspiration due to bleeding after the ‘bimanual technique’ have the assistant place one maxillofacial trauma, or airway swelling due to smoke inhalation and airway burns hand behind the patient’s neck, flexing it into the 4. Delayed intervention in all other patients with a high risk ‘sniffing’ position, while applying conventional cri- of developing pulmonary problems such as adult coid pressure with the other hand. respiratory distress syndrome Cricoid pressure to prevent regurgitation and aspira- tion is maintained until proper placement of the most secure protection against aspiration of foreign endotracheal tube is confirmed (by visualizing the material. It is indicated in a variety of acute medical tube passing through the glottis) and the endotracheal conditions as well as trauma (Table 4). Securing of the tube cuff has been inflated. Prematurely releasing the airway with an endotracheal tube and inflated cuff cricoid pressure prior to confirming the correct offers several benefits for the treatment of patients in a placement of the tracheal tube is a common error, critical condition, as listed in Table 5. and places the patient at huge risk of aspiration if accidental oesophageal intubation has occurred. Cri- In patients with an immediate need for ventilation coid pressure must be released immediately should and to secure the airway, there are few contraindica- active vomiting occur, otherwise there is danger of tions to careful orotracheal intubation. In some oesophageal rupture. situations orotracheal intubation is relatively contra- indicated or not easy to carry out, such as in patients The duration of attempts to intubate the patient’s with massive facial trauma and laryngeal or tracheal trachea without interposed ventilation via a mask injuries. should not exceed 30–45 s. Experience has shown that EUROPEAN JOURNAL OF EMERGENCY MEDICINE (2002) 9(3) 300 THIERBACH patients die of hypoxia during extended unsuccessful thread on the endotracheal tube once the FFB is attempts to intubate, who could have been ventilated positioned in the trachea because of the acute angle and oxygenated via mask. formed between the oropharynx and the trachea. Retraction of the tongue and anterior displacement of Visualization of the endotracheal tube entering the the mandible can usually overcome this problem. larynx, auscultation of the chest for breath sounds and Nasotracheal intubation is often easier to perform of the epigastrium for absence of air entry into the with the FFB because the natural curve of the stomach, and observation of chest motion during nasopharynx guides the tube into the larynx. ventilation are common methods of ascertaining proper endotracheal tube placement. Detection of Fibreoptic intubating laryngoscopes expired carbon dioxide provides the most reliable evidence of tracheal rather than oesophageal intuba- Fibreoptic modifications of the laryngoscope such as tion. the Bonfils or the Bullard not only improve the view of the larynx, especially in patients with difficult Flexible fibreoptic intubation anatomy, but also permit tracheal intubation with less head and cervical spine extension than are required Although the experienced endoscopist makes the for conventional laryngoscopy. Success with these procedure appear simple, flexible fibreoptic intuba- devices, however, requires experience and proficiency tion (FFI) requires skill and practice. This technique with the emergency airway. requires more time than conventional direct laryngo- scopy, even when performed by an expert. For these Oesophageal tracheal Combitube (ETC) reasons, and the fact that the equipment is rarely available in true emergencies outside the operating The
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