Transcript Airway Management - NH-TEMS

Airway Management in the
Combat Casualty
CPT Allen Proulx, MPAS, PA-C
References
Tactical combat Casualty Care, Butler, Hagmann,
Butler, Association of Militray Surgeons of U.S., 1996
Emergency Medicine: A Comprehensive Study
Guide, Tintinalli, 6th ed, Mcgraw-Hill, 2004.
USMC FMSS.
C.M. Benson’s Anatomy Drawings (CD).
University of New Mexico.
McKinley County EMS.
Overview
Discuss why we would secure an airway in the
combat casualty
Discuss and analyze some options in
establishing an airway in the combat casualty
Review the use of the Combitube
Review the steps in performing a
cricothyroidotomy
Scenario
You are supporting a unit operating in
western Afghanistan when a soldier is
brought in s/p his vehicle hitting a landmine.
The vehicle exploded. The casualty is
unconscious and unresponsive and has 2nd
degree burns to the face and neck. You
perform your CBA initial assessment and
note no other injuries.
What do you do?
Secure the Airway
What questions need to be answered when
we plan for airway management?
– What is effective?
– What is easy and quick to use?
Consider yourself inexperienced
– What requires minimal equipment?
– What is my back-up?
The Nasopharyngeal Airway, Combitube and
Cricothyroidotomy are excellent choices!
Options
Endotracheal intubation in the hands of
an inexperienced provider, with a
controlled setting has about a 42%
success rate.
The Combitube has a 95% success rate
in the field.
Cricothyroidotomy has a 90% success
rate in inexperienced physicians and a
98% success rate with flight nurses.
Nasopharyngeal Airway (NPA)
1% of all combat
fatalities can be
salvaged by ensuring
the airway is patent
throughout evacuation.
All unconscious/altered
mental status
casualties should have
their airway secured
with a NPA.
Oropharyngeal airway
is a poor choice for
military.
Elbow deflector
Distal
cuff
Large (blue) syringe:
100 ml large balloon
Ringmarks
Oropharyngeal
ballon
Suction catheter
Small syringe:
20 ml distal cuff
Esophageal - tracheal
COMBITUBE
„Pharyngeal“
lumen No. 1
Perforations
„Esophagotracheal“
lumen No. 2
Distal
cuff
Oropharyngeal
balloon
Combitube
Specially useful:
Difficult intubation
Blind intubation
Difficult circumstances
(space, illumination)
Indications for
Combitube
Emergency intubation
Bleeding and vomiting
Immediate decompression
of esophagus and stomach
Note: The casualty must be
unconscious and have no gag
reflex
Merits of COMBITUBE
Low price, all-in-one device
Non invasive
No preparations necessary
Rapid and easy intubation
Immediate fixation
PREVENTION OF ASPIRATION
Complications
Aspiration
– Ensure there is no gag reflex
Esophageal perforation
Direct trauma to the larynx
The Basic Procedure
Head:
Neutral
position
Open
mouth,
press
away
tongue
The Basic Procedure
Flat
insertion
along
tongue
The Basic Procedure
Emergency:
Emergency:
No. 2: 10 ml
No. 1: 85 ml
(or more)
The Basic Procedure
Esophageal
position
Selffixation
Behind
hard palate
Ventilation
via longer
blue tube
No. 1
Active
decompression
The Basic Procedure
Tracheal
position
Ventilation
via shorter
clear
tube
No. 2
Laryngoscope May be Used
C:\Documents and
Settings\proulxca\Desktop\VIDEO_TS
Cricothyroidotomy
DEFINITION – An emergency surgical procedure where
an incision is made through the skin and
cricothyroid membrane which allows for
the placement of an endotracheal tube into
the trachea when airway control is not
possible by other methods.
Indications
Trauma to the head or neck which
would preclude the use of an ambubag, oropharyngeal airway,
nasopharyngeal airway, or
combitube/endotracheal tube insertion
Merits of the
Cricothyroidotomy
Provides a definitive airway for
ventilating the patient
Can be performed quickly and has few
complications associated with the
procedure
Contraindications
Massive trauma to the larynx or cricoid
cartilage:
– Damage to the affected structures will
make it impossible to perform the
procedure properly
Complications
Hemorrhage
Esophageal perforation
Tracheoesophageal fistula
Subcutaneous air
Basic Anatomy
Basic Anatomy
Anterior view of the
larynx to show the
median cricothyroid
ligament.
1. Thyroid lamina.
2. Arch of cricoid
cartilage.
3. Median
cricothyroid
ligament (cut here)
Required Equipment for
Emergency
Cricothyroidotomy
Quicktrach
Quicktrach
Nu-Trake
Required Equipment
#10 or 15 Scalpel
Endotracheal Tube
– Size 6 and Larger
10 cc Syringe
Stethoscope
Curved Kelly
Hemostat, Straight
will work
Ambu-bag
Sterile Dressing
Vaseline / Petroleum
Gauze
Betadine or Alcohol
Wipes
Required Equipment
(continued)
Sterile or Clean Gloves
Suture Material
Suction Device
Suture Scissors
Tape
Performing the
cricothyroidotomy
Determine that the patient requires an
emergency cricothyroidotomy.
Assemble required equipment, quickly.
– Use pre-established kits
Do it. Don’t hesitate
Position the patient’s head/neck
– The patient is placed in a supine or semirecumbant position
– The neck is placed in a neutral position
Performing the
cricothyroidotomy
Palpate the thyroid
and cricoid cartilage
for orientation
– A - Cricoid Cartilage
– B - Cricothyroid
Membrane
– C - Incision Site
– D - Thyroid Cartilage
Performing the
cricothyroidotomy
Locate the cricothyroid membrane
Stabilize the thyroid cartilage using your
non-dominant hand
– This is not as easy as it sounds!
Make a vertical vs horizontal incision
through the skin approximately 2-5 cm (1
inch+) long over the cricothyroid membrane
Visualize the cricothyroid membrane
Performing the
cricothyroidotomy
Make a transverse
incision into the
cricothyroid
membrane
– DO NOT make the
incision more than
1/2 inch deep or you
may perforate the
esophagus
Performing the
cricothyroidotomy
Insert the Curved Kelly Hemostat into
the incision and blunt dissect the
incision (turn the Curved Kelly
Hemostat or scalpel handle 90 degrees
to open up the incision)
Performing the
cricothyroidotomy
Insert the endotracheal tube (adult
6mm or Ped smaller? whatever will
fit), into the incision, directing the
tube distally down the trachea
Performing the
cricothyroidotomy
Ventilate the patient with two breaths
– Check for proper placement of the
endotracheal tube with these first two
ventilations by:
Observing the chest rise and fall with each
ventilation
Auscultate for bilateral breath sounds
Pulse Oximiter would be an excellent
assessment tool!!
Performing the
cricothyroidotomy
Bilaterally Absent Breath Sounds - the
endotracheal tube is not within the trachea
and has probably been placed within the
esophagus or subcutaneous tissue.
– Remove the tube and attempt to reinsert into the
trachea
Right main-stem placement is common.
Breath Sounds in the Right Lung Field - the
endotracheal tube has been placed too far
down the bronchial tree and is in the right
mainstem bronchus.
– Pull back the tube 1/4 to 1/2 inch or until bilateral
breath sounds have been established
Performing the
cricothyroidotomy
Auscultate over the epigastrium for gastric
sounds
– Placement of the endotracheal tube into the
esophagus will produce gurgling sounds in the
epigastric area with ventilations
Inflate the endotracheal tube’s cuff with 10
cc’s of air
– Inflation of the cuff serves two purposes:
Holds the endotracheal tube in place
Acts as a barrier and prevents fluids from entering
the lungs
Performing the
cricothyroidotomy
Apply petroleum gauze
dressing to insertion
site
Apply a dry, sterile
dressing to the
insertion site
Tape around the tube
then completely around
the neck.
Sutures not needed.
This is a temporary
airway!!
Performing the
cricothyroidotomy
Continue to ventilate the patient (1
breath every 5 seconds) and suction as
necessary.
– Loving Gentle Squeeze 2 in, 3 out.
Continue to monitor the patient for
changes
Performing the
cricothyroidotomy
Questions??