AW for Trauma

*Examples of inadequate respirations* C___ arrest R___ arrest (such as narcotic overdose) Respiratory failure (such as status a____) Severe lung injury (such as pulmonary c___) Traumatic respiratory d___

Cardiac Respiratory asthmaticus contusion distress

*LARYNGEAL INJURY DIAGNOSIS* clinical finding are usually sufficient to diagnose injury to larynx additional findings may be soft tissue air in the neck (but not c___) or deformity of the air column on l___ neck xray

chest lateral

*C OF ABC ASSESSMENT* C____ is there a p___? is c___ adequate? based on pulse rate, pulse fullness, blood pressure, other signs of peripheral perfustion ___cardia, weak or unpalpable p___ pulses, ___tension, pale/cool/cyanotic ____ may signal inadequate circulation 1st priority: stop b___ 2nd priority: replace i_____ volume

circulation pulse circulation tachy peripheral hypo extremities bleeding intravascular

*LARYNGEAL INJURY* The larynx may be fractured by c___ (i.e. w/ steering wheel in an MVA) Open injuries -Associated w/ bleeding from major neck vessels, obstruction from h___ or e___, subcutaneous e___, and cervical spine injuries Closed laryngeal trauma -Less obvious but can be present as neck c___, hematoma, dysphagia, h___, or poor phonation The airway is at r___, as bleeding into the larynx, hematoma, or swelling may occur Acute obstruction from upper airway trauma --emergent c___/t___

contact hematoma edema emphysema crepitations hemoptysis risk cricothyrotomy tracheostomy

*SEVERE FACIAL FRACTURES TX* If trauma involves both the mandible and upper face, and the C-spine is still at risk, you are probably better off performing c___ If the C-spine is OK, o___ intubation may be attempted first Nasal intubation may cause complications such as e___ into open fractures, and may restart b___ into the airway Gastric tubes may be passed o___ in the presence of facial trauma If trauma is not too severe, a ___ airway can be inserted to guide a nasally-inserted NG tube downward —the nasal airway prevents the NG from entering into tissue tears such as an open c___ plate fracture

cricothyroidotomy oral entry bleeding orally nasal cribriform

*AW BURNS* -most likely to occur in e___ space burn injuries -not as likely, but must be screened for, in "f___" burns, such as when gas in a carburetor flares into face -once swelling begins, may progress rapidly that i___ becomes extremely difficult, normally within ___hrs

enclosed flare up intubation 24

*AW BURNS CONT* Assume the airway is burned if there are burns within the mouth, nose or throat, or if the victim had significant time in an enclosed-space f___ or e___ s___, h___, facial burns, singed nasal hairs or eyebrows, soot in sputum or in the oropharynx, respiratory distress; red, tender o___ membranes; or obvious intraoral or pharyngeal burns indicate likely airway burn diagnosis: based on h____ and clinical exam tx: if AW burn suspected, i___ pt at the first opportunity

fire explosion Stridor hoarseness oral history intubate

*INDICATIONS FOR SURGICAL AW* -can't i___, can't v____ -a__ with suspected cspine injury -f___ trauma with suspected cpsine injury -severe f___ and n__ trauma, altered anatomy

intubate ventilated apneic facial facial neck

*SEVERE FACIAL FRACTURES* --oral and nasal airways may help in the immediate situation however subsequent i___ will be necessary --risk of AW compromise from: b___, e___, h__ formation --pts will normally have other head injuries = decreased L___ --n___ fractures also common --facial fractures sufficient to put the AW at risk will almost always be u___ --palpate the j___ for crepitance and instability --grasp the upper teeth between thumb and knuckle of index finger to test for m___ instability --bilateral eyelid swelling and sunken facial appearance suggest a c____ fracture

intubation bleeding edema hematoma LOC neck unstable jaw maxillary cranio-facial

EXAMPLES OF AW TRAUMA: stab wound to n____ self inflicted G___ to head

neck GSW

*CSPINE PRECAUTIONS* -assume cspine injury until prove otherwise TOP PRIORITY: ____ can complicate a___ c___ is contraindicated --move minimally, only to close m___, do not put pt in s___ position jaw thrust: dislocated T___ to open AW 2 or 3 person intubation is ___ --1. stabilize c spine (M___) --2. l____ (with i___ immobilization) --3. for c___ pressure l___ roll to move

do not move neck AW chin lift mandible sniffing TMJ MANDATORY MILS laryngoscopist in line cricoid log

*LARYNGEAL INJURY TX* In the multiply-injured patient, i___ should be performed on any patient suspected to have laryngeal injury If the injury is isolated, and judged not to be s___, the patient may be o___ (while prepared to intubate if signs of airway encroachment develop)

intubation severe observed

*BLUNT TRAUMA* -inability to l___ injury precisely -usually more d___ -e___ AW management indicated when there is evidence of significant blunt injury to the neck -pts with blunt a___ neck trauma must be presumed to have cspine injury (up to 50%)

localize diffuse early anterior

Dermatomes T4 = ____ T10 = ____ C6 = ___ C8 =____

nipple line belly button thumb pinky

What is always the 1st priority?

bag mask ventilation

In which 2 zones would emergency airway management likely be required for sustained injuries?

1 and 2

T/F Intubation for a normal sized pt. who was stabbed in the abdomen and was placed in a C-spine collar by emergency medical services but has little likelihood of a neck injury would routinely warrant a laryngoscopic attempt

True

T/F An assault pt. requiring strict C-spine precautions because of a dislocated jaw and active upper airway bleeding would be a contraindication to performing DL

True

*LEMON* Identification of one or more requires consideration of management of the patient as a difficult ___ L: look e___ E: evaluate __-__-__ (helps ensure view of VC by ___) M: M____ O: O___ (stridor, altered voice, subQ air, neck hematoma, direct penetrating or blunt injury) N: n___ mobility (pts in whom c spine injury is not issue)

airway externally 3-3-2 DL mallampati obstruction neck

*A OF ABC ASSESSMENT* A_____ is there an o___: talking vs unconscious signs: s____, g___, s____ and paradoxical c___ movement is the airway at r___ advanced management (ETT, cricothyrotomy, tracheostomy) indicated if: a____, persistent obstruction, severe head i____, m____ trauma, penetrating neck injury with expanding h____, major c___ injuries

airway obstruction snoring gurgling stridor chest risk apnea injury maxillofacial hematoma chest

*3 fundamental questions to determine the decision to undertake emergency intubation* 1. if there a failure to maintain or protect ___? 2. is there failure of o___ or v___? 3. is there a need for i____ based on the anticipated clinical course?

airway oxygenation ventilation intubation

*B of ABC ASSESSMENT* B____ Look: c____, a___ muscle usage, f___ chest, chest i___ Listen: presence, absence, or diminution of b___ Feel: subq e____, t___ shift, broken r___ use FiO2 of ___

breathing cyanosis accessory flail injuries breath sounds emphysema tracheal ribs 1.0

*INDICATIONS OF HEAD INJURY* s___ wound f___ s___/b___ loss of c____ n___ discharge stiff n___

scalp fracture swelling bruising consciousness nasal neck

*SEVERE FACIAL FRACTURES DIAGNOSIS* The diagnosis of risk to the airway is made based on the finding of significant fracturing and s___ tissue injury The a___ is the critical issue —the nature of the fracturing can be determined at leisure once the airway is safe

soft airway

*PENETRATING TRAUMA* s___ or p___ wounds, major lacerations, missile injuries (low and high v____) three zones: zone 1 --c___ to c__ cartilage --dominated by major v___ structures --often require e___ AW management --less the __% of penetrating neck injuries zone 2 --c___ cartilage to line drawn through the angles of the m___ --most c___ --require emergency AW intervention in 1/__ of cases --major vascular structures, hypopharynx, e____, l___, t___ zone 3 --above the angles of the m___ --less than __% of penetrating neck injuries

stab puncture velocity clavicles cricoid vascular emergency 10 cricoid mandible most common 1/3 esophagus larynx trachea mandible 10

zone 1 contains the ___

trachea

*LEFORT CLASSIFICATION OF MIDFACIAL FRACTURES* I: t___ fracture of m___ II: p___ fracture III: c____ dysjunction nasal intubations are contraindicated in LeFort __ and __ secondary to possible basal skull fx and a potential passage into s___ or c___ vault

transverse maxilla pyramidal craniofacial 2 and 3 sinus cranial

*CSPINE INJURY* -the c spine is considered injured in all t___ victims until proven otherwise. in the multiply-injured or intoxicated pt, absence of p___ or t___ doesn't exclude cervical fracture -presence of a s___ deformity may indicated a fracture or dislocation -complete spinal cord injury will result in a flaccid a____, flaccid s___ and d___ breathing -pt may be able to f___, but not extend the arms -painful stimulation may be felt only above the c___ -n___ shock results from loss of sympathetic nerve stimulation of blood vessels and heart diagnosis: by cross table cspine ____ tx: tx of life threatening injuries continues with precautions to continue cervical p____, g___ w____ tongs may be applied in the ER for pts who are to undergo sx, obtain a n___ consult, give immediate high dose s___, new tx include immediate hypothermia to about __-__C

trauma pain tenderness step off areflexia sphincters diaphragmatic flex clavicle neurogenic xray protection gardner wells neurosurgical steroids 32-34

*Examples of inadequate protection* Prolonged u____ Inadequate g____ (such as drug overdose) Airway e___ (such as burn or bleeding)

unconsciousness gag reflex encroachment

*DIRECT AW TRAUMA* PENETRATING OR BLUNT --maxillofacial trauma: compromise the ___ aw --direct injury to the neck: compromise upper aw from h____ to t___ --chest injury: disrupt lower t___, main stem b___, other lesser bronchi AW MANAGEMENT APPROACH DICTATED BY: --clinical presentation of the p___ --best judgement of the o____

upper hypopharynx trachea trachea bronchi patient operator

Which zone of the neck is the most common location for penetrating neck injuries?

zone 2