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Airway obstruction (Principles (Clear, maintain and protect airway …
Airway obstruction
Principles
Clear, maintain and protect airway
(without exacerbating any neck trauma)
Ensure adequate ventilation
Give O2 high conc as possible
Ensure O2, suction and airway equiptment near
Escalate to senior ED/ICU/anaesthetist if serious
Aetiology
Coma
Airway obstruction,
loss of protective reflexes
Bodily fluids
Blood, vomit
Trauma
Face/neck trauma
FB inhalation
Inflammation
Oedema, haematoma
Management
1. Basic measures
Look in mouth (FBs, blood, vomit)
Remove liquid with suction, remove FBs with Magill's forceps
Assess gag reflex (dictates adjunct to use)
Head tilt, chin lift (opens airway when no c-spine injury)
Jaw thrust (1L in trauma; opens upper airway with minimal impact on C-spine; Forefingers of both hands behind angle of mandible, push anterior; tongue lifted anterior and away from posterior pharyngeal wall
2. Airway
adjuncts
Nasopharyngeal airway
Indication: gag reflex intact
CI: severe head/facial injury i.e. basal skull fracture
MOA: Select right size (incisors to tragus; adult M=7; adult F=6), lubricate (water/water soluble lube), Insert tip into one nostril, direct posterior, aiming tip at tragus of ear, tip should reach the pharynx, end should abut the nostril; re-check airway and breathing and provide O2
Oropharyngeal airway (Guedel)
Indication: absent/poor gag reflex
MOA: select right size (incisors to angle of mandible; average=3), open mouth, suction any fluid, insert upside down halfway then turn 180 as insert, recheck airway/breathing, give high-flow O2
SEs: vomit/gag if gag reflex intact
Laryngeal mask airway (LMA)
Indication: elective surgery (avoid damage to teeth and vocal cords); ALS (temporarily maintain an airway before intubate)
MOA: Lubricate cuff and slide over the palate to sit over larynx, Inflate the cuff and tie in place, If an i-gel, cuff does not need to be inflated
3. Tracheal
intubation
Indications
Injured patient with no gag reflex (risk vomit/aspirate)
Difficult airway (apnoea, resp inadequacy)
Prevent obstruction (burns, oedema)
Manipulate ventilation in patients with raised ICP
Emergency anaesthesia (RSI)
Muscle relaxant (suxamethonium), but NOT if cardiac arrest (takes too long)
Apply cricoid pressure, Position patient with head and neck extended
Slide laryngoscope blade down R side of the tongue to the venacular (space btw tongue and epiglottis) while protecting teeth
Lift the laryngoscope blades and visualise the cords
Pass lubricated ET tube between the vocal cords
Remove laryngoscope, inflate the cuff
Confirm tracheal
placement
Tube passes via cords
Symmetrical chest movement
Auscultate axilla for breath sounds
Confirm with end-tidal CO2 monitoring
4. Surgical
airway
Indication
Emergency surgical airway (complete obstruction not
relieved by tracheal intubation)
Needle cricothyroidectomy
Indication: temporary measure while prep
for surgical, or in children
MOA: large bore cannula (12/14G), via cricothyroid membrane (betw thyroid and cricoid cartilages), Connect cannula to O2
Surgical cricothyroidectomy
MOA: Clean area and use LA, transverse incision through
skin and cricoid membrane; tracheal dilator to open hole
in the trachea; Insert lubricated tracheostomy tube; remove introducer, inflate cuff, connect to catheter mount and ventilation bag; Confirm correct placement (end tidal CO2)
Percutaneous tracheostomy (PT)
Indication
Bypassing upper airway obstruction
Prolonged mechanical ventilation (easier to wean patients off)
Need airway protection and frequent suctioning
Method
Seldinger technique
Dilation of trachea between cartilage
rings before passing ET tube
Advantages
Patient can phonate (if fenestrated tube used)
Less sedation needed
Nursing care easier (mobility, mouth care, sedation)
Complications
Early: bleeding, hypoxemia, loss of airway, trauma to posterior tracheal wall, pneumothorax
Late: dislodgement/obstruction, tracheooesophageal fistula, tracheal stenosis, swallow dysfunction
Assessment
Talk to patient
(Lucid = patent airway, breathing
and sufficient brain oxygenation)
Protect c-spine
Check breathing
Complete obstruction
(paradoxical chest/abdo movement,
no breath sounds)
Partial obstruction
(Gurgling, snoring, stridor)
Choking on a FB
Clinical features
Sudden onset respiratory distress
Cough, gag, stridor
Management
Concious, effective cough
Encourage coughing
Observe in case cough becomes ineffective
Concious, ineffective cough
Initial 5 back blows (heel of hand betw shoulder blades)
Children <1y, 5 chest thrusts (per CPR position) Children>1y or adults, 5 abdo thrusts (fist between umbilicus and xiphisternum, thrust inward and upwards)
Repeat abdo/chest thrusts
Unconcious
Look in mouth forobvious FB
Remove with finger sweep or Magill forceps
Open airway with 5 rescue breaths (check if chest rising)
CPR if no response (compression:ventilation 15:2)
Surgical airway
Definition
Blockage of the airway,
preventing normal ventilation
and risking hypoxic injury
Reassess at each stage
If airway now patent and breathing,
ventilate with high-flow O2
(15L/m non-rebreathe resevoir mask)
If airway patent but breathing is inadequate,
ventilate with bag, valve and mask