U.S. ARMY MEDICAL DEPT.

CENTER & SCHOOL CORRESPONDENCE PHASE 91B BNCOC TECHNICAL TRAINING Initial Airway Management I. REFERENCE.

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Campbell, J.E. (Ed.), Basic Trauma Life Support (Advanced). (3rd Ed.) Englewood Cliffs, N.J.: PrenticeHall, Inc. 1995. II. OBJECTIVES. A. Terminal Learning Objective. Given a patient with airway trauma, assess and treat the patients airway using appropriate adjuncts IAW cited reference. B. Enabling Learning Objectives. 1. 2. 3. 4. 5. 6. 7. III. Given a list, match the airway anatomical terms with their descriptions IAW cited reference. Given a simulated patient, describe Sellicks maneuver and identify when it should and should not be used IAW cited reference. Given a list, select the correct definition for airway management terms IAW cited reference. Given an list, identify the essential contents of an airway kit IAW cited reference. Given a simulated patient, identify the procedures associated with maintaining a patent airway IAW cited reference. Given a list, select the methods to deliver supplemental oxygen to the trauma patient IAW cited reference. Given a list, identify the methods, advantages, and disadvantages of ventilation techniques IAW cited reference.

EXPLANATION. Given a list, match the airway anatomical terms with their descriptions IAW cited reference. Given a simulated patient, describe Sellicks maneuver and identify when it should and should not be used IAW cited reference.

Objective 1. Objective 2.

M C2000191 0797 A. Anatomy. 1. 2. Alveolarcapillary membrane - end of the airway through which gas exchange occurs between the air sacs of the lung (the alveoli) and the lungs capillary network. Nasal cavity and oropharynx - respiratory tract beginning. Lined with moist mucous membranes which warms and filters inhaled gases. The respiratory tract lining is delicate and highly vascular. Prevent undue trauma to the lining by using highly lubricated tubes. Teeth - first obstruction in the oral part of the airway. Tongue - second potential obstruction in the airway path. Tongue muscles are attached to the jaw anteriorly, and to the hyoid bone through a series of muscles and ligaments. The hyoid bone is under the chin from which the cartilage skeleton (the larynx) of the upper airway is suspended. Epiglottis - a main anatomic landmark in the airway and connected to the hyoid. Elevating the hyoid will lift upward on the epiglottis and further open the airway. The epiglottis can fall down against the glottic opening and prevent ventilation in a supine unconscious patient. Vocal cords - protected by the thyroid cartilage. A C-shaped structure which can be seen on the anterior surface of the neck as the laryngeal prominence. The cords can close entirely in laryngospasm, producing complete airway obstruction. Cricoid - portion of the larynx inferior to the thyroid cartilage. Palpated as a small bump on the anterior surface of the neck inferior to the laryngeal prominence. Pressure on the cricoid at the front of the neck will close off the esophagus (Sellicks maneuver) which is found behind the posterior wall of the cricoid cartilage. This action reduces gastric regurgitation during the process of intubation, and prevents insufflation of air into the stomach during positive pressure ventilation (mouth-to-mouth, bag-valve mask, demand valve).

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WARNING: DO NOT use the Sellicks maneuver when there is danger of cervical spine injury. Pressure applied to the neck may cause too much movement in an unstable cervical spine. 8. Pyriform fossa - recess and located on either side of the epiglottis. An endotracheal tube can catch in either one. Forcing the tube may perforate the mucosa - a disastrous complication of careless intubation. An endotracheal tube placement in the Pyriform fossa can be identified easily by tenting of the skin on either side of the superior aspect of the laryngeal prominence (Adams apple). Cricothyroid membrane - landmark to gain direct access to the airway below the cords. Palpate by finding the most prominent part of the thyroid cartilage, slide down until you feel a second bump (just before you finger palpates a last depression prior to the sternal notch). The final bump is the cricoid cartilage. The upper edge of the cricoid cartilage is the cricothyroid membrane. Sternal notch - the point at which the cuff of an endotracheal tube should lie. Palpated at the junction of the clavicles with the upper edge of the sternum. 2

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M C2000191 0797 11. Tracheal rings - C-shaped cartilaginous supports for the trachea which continue beyond the cricoid cartilage. The left and right mainstem bronchi is divided by the Trachea (point of division is called carina). The right mainstem bronchus is at an angle that is slightly more in line with the trachea. Tubes or foreign bodies that are poked or trickle down the airway usually end up in the right mainstem bronchus. When performing an endotracheal intubation avoid a right mainstem bronchus intubation. Landmark measurements - be aware of how far these landmarks are from the teeth. Remember 3 numbers, 15, 20, and 25 - allows detection of a tube that is too far into the airway, or not in far enough. a. b. c. For an average adult, fifteen centimeters is the distance from the teeth to the vocal cords.. The sternal notch is twenty centimeters. The carina is twenty five centimeters.

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NOTE: Average distances and can vary within a few centimeters. Flexion or extension of the head may move the endotracheal tube up or down as much as 2 to 2.5 cm. Avoid and guard against movement. Objective 3. Given a list, select the correct definition for airway management terms IAW cited reference. B. Ventilation - the movement of gases or air in and out of the lungs. 1. 2. Tidal volume - adults at rest normally take in about 450 to 500 cc with each breath. A respirometer measures the volume. Minute volume - multiply tidal volume by the number of breaths per minute (respiratory rate). The amount of air breathed in and out each minute - normally 6 to 8 liters per minute. Hyperventilation - greater resting value of 6 to 8 liters per minute. Hypoventilation - lesser resting value of 6 to 8 liters per minute. Intermittent positive pressure ventilation - pumping in oxygen or air through the glottic opening. Know approximately how much volume is being delivered with each breath. Delivering over a liter of volume at a pressure of 60 cm H2O will almost guarantee gastric insufflation. When performing positive pressure ventilation with a mask: a. b. c. d. Provide supplemental oxygen. Suction must be available. Ventilation carefully to avoid gastric distension and to reduce the risk of regurgitation/aspiration. Estimate the minute volume being delivered. During an emergency, you may tend to ventilate at an increased rate and delivered volumes are often deficient. 3

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M C2000191 0797 Rate cannot compensate for inadequate volumes. 6. Compliance - the ability of the lungs and chest wall to expand and ventilate a patient supports whether or not you can adequately ventilate.

M C2000191 0797 Objective 4. C. Given an list, identify the essential contents of an airway kit IAW cited reference. Airway Equipment. 1. Necessary equipment for pre-hospital trauma patients: long backboard with attached head immobilization device, cervical immobilization device, airway kit, trauma box (bandage material, BP cuff, stethoscope), personal protection equipment (glasses or face shield, rubber gloves). Airway kit - contains everything needed to secure an airway in any patient. A lightweight airway kit should consist of the following: Oxygen D cylinder (preferably aluminum), portable, battery-powered or hand-powered suction unit, oxygen cannulae and masks, endotracheal intubation wrap, bag-valve-mask ventilating device, pocket mask with supplemental oxygen intake, translaryngeal oxygen cannula and manual ventilator.

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Objective 5. D.

Given a simulated patient, identify the procedures associated with maintaining a patent airway IAW cited reference. Patent Airway - Procedure for Establishing an Open Airway. 1. Quickly ensure open or patent airway - Hypoxia cannot be tolerated for more than a few minutes. First step in providing patent airway in an unconscious patient - ensure that the tongue and epiglottis are lifted forward (modified jaw thrust or jaw lift). Maintain in that position. Either maneuver will prevent the tongue from falling backward against the soft palate or posterior pharyngeal wall and will pull forward on the hyoid, lifting the epiglottis up out of the way. Essential maneuvers for basic and advanced airway procedures and when done properly, they will open the airway without the necessity of tilting the head backward or moving the neck. Maintaining patent airway - vigilance and care are required to maintain a patent airway. Essentials for this task: a. Constant observation of the patient.

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M C2000191 0797 b. c. 3. Adequate suction device with large-bore tubing and attachment. Airway adjuncts.

Suction - vomiting and aspiration is a serious threat to the patent airway. Portable suction devices should be considered basic equipment for field trauma care and should have the following characteristics: a. b. c. d. Carried in a kit with an oxygen cylinder and other airway equipment; not be separated or stored away from oxygen. Hand or battery powered rather than oxygen driven. Generate sufficient pressure and volume displacement to suction pieces of food, blood clots, and thick secretions from the oropharynx. Tubing of sufficient diameter (0.8 to 1 cm) to handle what is suctioned from the patient.

Objective 6.

Given a list, select the methods to deliver supplemental oxygen to the trauma patient IAW cited reference. 4. Airway adjuncts - insertion of airway devices must be reserved for patients whose protective reflexes are sufficiently depressed to tolerate them. Avoid provoking vomiting or gagging. a. Nasopharyngeal airways - appropriate length and soft. Better tolerated than the oropharyngeal. Designed to prevent the tongue and epiglottis from falling against the posterior pharyngeal wall. Mild hemorrhage from the nose after insertion is not an indication to remove it. The nasopharyngeal airway should be kept in place so as not to disturb the clot or reactivate the bleeding. Oropharyngeal airways - designed to keep the tongue off the posterior pharyngeal wall and help maintain a patent airway.

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M C2000191 0797 c. Esophageal obturator airways (EOA) - designed to be inserted into the esophagus at a level beyond the carina. Inflate the cuff to reduce the likelihood of gastric distension or regurgitation during demand-valve or bag-valve mask ventilation. Pharyngotracheal (PTL) airway - combination of an endotracheal tube and EOA. Attempts to solve the problem of possible intratracheal placement of the EOA as well as attempting to provide for tracheal ventilation should blind insertion result in intratracheal positioning. Endotracheal intubation - the best airway care in patients who cannot protect their airways or in those needing assistance in breathing. The selection of an intubation method should be suited to the patient - patients with a low risk of Cspine injury can be intubated using a laryngoscope; the nasotracheal route, the tactile or transillumination methods, or a combination of the two should be reserved for patients with specific indication for alternative techniques. Oxygenation - injured patients require supplemental oxygen, especially if they are unconscious. (1) Supplemental O2 can be supplied by: (a) (b) Simple face mask run at 10 to 12 L/min. Patient is provided with about 40% to 50% oxygen. Non-rebreathing masks with a reservoir bag with oxygen flow rates into the bag of 12 to 15 L/min can provide 60 to 90% oxygen to the patient. Nasal cannulae - tolerated well by most patients, but provides only about 25 to 30% oxygen to the patient.

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M C2000191 0797 (2) During mouth-to-mouth ventilation oxygenation must be supplemented by running oxygen at 10 to 12L/min through oxygen nipple attached to most masks. Increase oxygen percentage by placing a nasal cannula on yourself. This increases the delivered oxygen percentage from 17% to about 30%. Resuscitator bags require an oxygen flow rate of at least 15L/min to increase the delivered oxygen from 21% (air) to 40 or 50%. Oxygen percentage will depend on rate of ventilation and refilling time of the bag. Oxygen-powered demand valves - advantage of delivering 100% oxygen to the patient (older models do so at very high flow rates, i.e. 100 L/min). Using these high-pressure devices can result in gastric distention and a potential for complications. Bag-valve-mask devices, or resuscitator bags - fixed-volume ventilators delivering a volume of about 600 to 800ccs when squeezed with an adult hand. Resuscitator bags have the advantage of a better appreciation of the patients compliance and are recommended as the device to use if an endotracheal tube is in place.

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Objective 7. E.

Given a list, identify the methods, advantages, and disadvantages of ventilation techniques IAW cited reference. Ventilation Techniques - Methods. 1. Mouth to mouth - most effective method of ventilation. Requires no equipment with a minimum of experience and training. Delivered volumes are consistently adequate since mouth seal is effectively and easily maintained. Compliance can be felt more accurately, and high oropharyngeal pressures are therefore less likely. The disadvantages of mouth to mouth are: a. b. c. 2. 3. Only 17% oxygen is delivered without placing nasal cannula on yourself. Many patients have copious secretions, gastric regurgitation, bleeding, or a combination of these. Disease transmission possibility.

Mouth to mask - placing a face mask between your mouth and that of the patient. Some commercially designed pocket masks provide a side port for supplemental oxygen. Demand valve - in the past, high pressure demand valves were considered too dangerous to use in multiple-trauma patients. Newer demand valves that meet American Heart Association guidelines (oxygen flow rate of 40L/min at a maximum pressure of 50 + 5 cm H20), suggest that these may now be the equal of bag-valve devices for ventilation. Because it is more difficult to feel lung compliance when ventilating with the newer demand valves, there is still some controversy about their use.

M C2000191 0797 NOTE: Follow your medical directors advice on the use of demand valves. 4. Bag-valve mask - fixed-volume ventilator with 700 cc average delivered volume. With a two-handed squeeze, over 1L can be delivered to the patient. Allowing the bag to refill slowly (over 2 to 3 seconds) will greatly increase the percentage of oxygen when no reservoir is used. Problems associated with bag-mask devices are mask leak and volumes delivered.