All patients should have high-flow oxygen administered using a mask with a reservoir bag. There are a range of techniques used to open the airway, and it is important that simple airway techniques are attempted first.
Airway with cervical spine control 179
Airway positioning
Where there is no evidence of a neck injury, the manoeuvre of choice is head-tilt and chin-lift (Figure 14.1). This realigns the soft tissues to provide an open airway. Where a neck injury is suspected, a head-tilt should not usually be performed. The only exception to this rule is where the patient has an obstructed airway and all other interventions have been unsuccessful. In this situation, the odds of the patient dying from an obstructed airway far outweigh the risks associated with a gentle, slow head-tilt until airway patency is achieved.
The jaw-thrust is an alternative airway manoeuvre that does not involve any movement of the neck. It is highly effective and involves lifting the soft tissues of the anterior pharyngeal wall upwards to provide an airway. The disadvantage is that it is effective only while the res- cuer is performing the manoeuvre. If the rescuer moves on to perform another task, the airway will obstruct again.
Clearance of foreign bodies
Foreign bodies can be removed under direct vision. Rigid suction is used to remove fluid in the oropharynx (e.g. blood, vomit) but should be used only as far as can be visualised in order to avoid further trauma to the airway. Solid and some semisolid foreign bodies can be removed with forceps.
Airway adjuncts
Oropharyngeal
The oropharyngeal airway is used in unconscious patients as an airway adjunct. Its use is not advised in conscious or semiconscious patients as it may stimulate the gag reflex and precipi- tate vomiting. Caution should be used in the patient with maxillofacial trauma as insertion may precipitate bleeding, leading to further airway compromise.
The airway is inserted in adults upside-down and rotated through 180 degrees (Figure 14.2). In children, it is inserted the correct way round with the assistance of a spatula.
Nasopharyngeal
The nasopharyngeal airway (Figure 14.3) is used in conscious or semiconscious patients, but it can also be used in unconscious patients. Caution should be used in patients with basal skull Figure 14.1 ● Airway-positioning manoeuvres (head-tilt, chin-lift and jaw-thrust).
MANAGEMENT OF SEVERELY INJURED PATIENTS 180
fracture, as aggressive insertion may lead to perforation of the cribriform plate. The airway should be lubricated before insertion in order to avoid epistaxis.
Advanced airway options
If simple airway manoeuvres and/or adjuncts are not successful, then the patient will need an advanced airway manoeuvre. In general, a clinician with advanced airway training performs this. There are two main options:
● Laryngeal mask airway (LMA): this device sits in the back of the oropharynx and overlies the larynx. The tip provides some occlusion to the oesophagus. The level of skill needed to insert an LMA is less than that needed to perform tracheal intubation.
Figure 14.2 ● Sizing and insertion of oropharyngeal airway.
Figure 14.3 ● Insertion of nasopharyngeal airway.
Breathing with assisted ventilation
● Tracheal intubation: this technique provides full airway protection due to the presence of a cuffed tube in the trachea. The patient is more likely to need a rapid sequence intubation.
Surgical airway options
If none of the above procedures is successful, then a surgical airway can be life-saving. There are two main options:
● Needle cricothyroidotomy: a needle is inserted through the cricothyroid membrane and oxygen is insufflated under pressure into the lungs. This immediately life-saving technique provides oxy- genation but not ventilation. It is only temporarily beneficial (< 30 min) and the patient will subsequently need to undergo a formal surgical airway.
● Surgical cricothyroidotomy: a cuffed tube (either commercially available equipment or a tracheal tube) is placed through an incision in the cricothyroid membrane under local anaesthetic. This enables formal ventilation and access for tracheal suctioning.
Tracheostomy requires skill and is time-consuming. It is therefore not the technique of choice in an emergency.
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BREATHING WITH ASSISTED VENTILATION
The maintenance of breathing is the second priority in the management of any critically unwell patient. Early management of inadequate breathing will prevent an already unwell patient from deteriorating any further.
Symptoms and signs of impaired breathing include the following:
● Tachypnoea
● Shortness of breath, anxiety and irritability
● Decrease in level of consciousness
● Absent or decreased air entry on auscultation
● Altered percussion note – dull with fluid, resonant with air
● Deviated trachea – indicative of mediastinal shift (e.g. tension pneumothorax)
● Cyanosis (late sign).
Breathing problems in the trauma patient may be due to the following causes:
● Airway compromise: this should be addressed as a priority.
● Decreased respiratory drive: e.g. central nervous system depression.
● Decreased respiratory effort: e.g. chest wall damage, burns, spinal injury.
● Lung disorder: e.g. haemothorax, pneumothorax.
The immediate management of the patient should be to ensure that the airway is open. High-flow oxygen should be administered and ventilatory support given if necessary. In the first instance, this can be accomplished by use of a self-inflating bag–valve–mask device. Early con- sideration should be given to tracheal intubation. Any underlying cause of breathing problems should be treated where possible.