clinical home > primary survey


Airway (with cervical spine control if needed)

Remember in victims of trauma there is a need to protect the cervical spine as well as to manage the airway, though the airway is the prioirity.
Cervical spine injury should be assumed in all trauma patients with trauma above level of clavicle or decreased level of consciousness.
In the primary survey determine if the airway is patent, at risk or obstructed.
Patent
Able to talk & no upper airway/facial injuries
At risk
Talking impaired but breathing normally at present OR upper airway/facial injuries present that may cause obstruction later
Obstructed
Talking impaired and abnormal noises (e.g. gurgling or stridor) - these suggest partial obstruction
- or absence of noises which suggests complete obstruction
Airway management comprises:
  1. Assessment of the airway
  2. Basic manoeuvres to open airway
  3. Use of adjuncts to maintain patient airway
  4. Advanced manoeuvres (intubation without drugs in a remote setting is rarely, if ever, of benefit)
  5. Surgical airway manoeuvres

Assessment of the airway

Step 1: Ask the patient his / her name. If the patient fails to respond appropriately (i.e. vocalise, eyes open and look towards the doctor) then such patients are immediately identified as high risk. Then assess airway with LOOK - LISTEN - FEEL approach.
Step 2: If the patient responds appropriately, he / she should be asked to take a deep breath. Observe and listen for evidence of upper airway obstruction (tracheal tug, use of accessory muscles, inability to perform manoeuvre adequately, presence of stridor, etc). Look for chest expansion abnormalities (one side hyperinflated with poor expansion suggesting pneumothorax, in-drawing suggesting obstruction, paradoxical movement suggesting high cervical spine injury, flail segment, etc).

LOOK LISTEN FEEL

Before opening the airway look in the mouth and remove any solid foreign bodies.
Then open the airway (head tilt & chin lift or jaw thrust) and
LOOK for chest movement (if absent suggests breathing is inadequate; if present do not assume is is associated with air movement)
LISTEN for breath sounds and added noises. Breathing should be just audible with your ear by their mouth. Noisy breathing suggests partial obstruction, added noises such as gurgling) indicates other problems with the airway. The absence of noise suggests either complete airway obtruction or lack of ventilation (both a bad).
FEEL, if necessary, for exhaled iar on the side of your face.

Basic manoeuvres

After trauma, the head tilt chin lift may be harmful (if unstable neck injury) so the jaw thrust is the basic manoeuvre used then.
Neither of these basic manoeuvres will work if connections between the tongue and the mandible are lost (for example in comminuted mandibular fracture). In this instance traction to the tongue itself may be needed.
Blind finger sweeps are avoided but visible foreign bodies are removed.

Head tilt chin lift

Tongue-blocking-airways.png
back of the tongue is moved away from the airway


In the head tilt chin lift manoeuvre, one hand is placed on the casualty's forehead and extends the neck. The index and middle finger of the other hand are placed under the tip of the chin and the mandible pulled upwards.
It is important to avoid compressing the soft tissues under the chin - this can obstruct the airway.
The thumb can be used to pull down the lower lip if necessary.



Jaw thrust

The jaw thrust is the preferred manoeuvre in trauma that may be assoicated with a neck injury.
It is vital to remember, though, that an obstructed airway is invariably fatal - it is better to extend the neck a little to obtain a patent airway than for the casualty to die - probably without any injury to their neck.


Portable suction

Gurgling indicates the presence of fluid in the upper airway. In the absence of suction remember rolling the patient in the recovery position should allow fluids to fall out of the mouth.
There are a number of devices available for “portable suction”. Those that rely on electricity or a gas to drive them cannot be relied upon in the field. Vitalograph devices do work but are hard work and when the container is full whatever you suck up is squirted out of the back of the device (usually over your front). The “Suction Easy” device is a cheap, easy to use portable device that is very effective.
suction_easy.jpg

Adjuncts

Oropharyngeal and nasopharyngeal airways do not replace basic manoeuvres - they augment them.
Though there are ways of estimating the right size to use, it is more important to reassess the airway after insertion to ensure they are helping maintain airway patency.
Oropharyngeal airways are generally more effective, but will not be tolerated unless the casualty is unconscious. Nasopharyngeal airways can be tolereated by less unconscious casualties.

Oropharyngeal (Guedel) airway



Nasopharyngeal airway




I-Gel

User guide

Advanced manoeuvres

Tracheal intubation.

The value of prehospital intubation without drugs is very little (if not zero).
Intubation with the use of drugs (rapid sequence induction) does have a role in "normal" prehospital medicine (e.g. at RTCs) but it is difficult to envisage doing this, usefully, in a significantly remote environment; it is demanding in expertise, time and equipment.

Interesting approach to what to do before a surgical airway and also when to do one:

Needle cricothyroidotomy

This is a temporary solution when a definitive airway is established but cannot be obtained quickly. A large bore (12 or 14 gauge in an adult) cannula is inserted through the cricothyroid membrane (see below for landmarks) into the trachea. The cannula is inserted angled 45 degrees towards the feet and care must be taken not to transfix the trachea.

Once the metal needle has been removed high flow oxygen (15 L/min - for this reason this technique may have a limited role in the wilderness setting) is attached.

There needs to be a means of venting this oxygen so that the patient receive oxygen for 1 second and then none for the next 4 seconds. A Y connector or three way tap can be used, a hole can be cut in the side of the oxygen tubing (do this BEFORE connecting the tubing to the cannula in the patient), or a 2ml syringe can be connected to the cannula, the plunger removed and the end of the oxygen tubing pushed in (for those who have green oxygen tubing the varies in calibre along its length, the wide part is the part that will fit into the syringe.

Ventilating the patient this way ("jet insufflation") will not work well if there is significant pre-existing lung disease and/or significant chest trauma. It is not ideal in patients with a significant head injury as it is not effective and removing CO2 from the body.

Surgical airways

Surgical airway
Right-handed operator stands on casualty’s right side (facing casualty head not feet). The patient’s head should be in the midline and, if spinal injury is not a concern, extended. Prepare the skin. The thyroid cartilage is stabilised with the left hand as the right hand makes the incision. The first incision is 3cm long vertical incision through the skin overlying the cricothyroid membrane (closer to the cricoid cartilage than the thyroid cartilage). The second pass of the scalpel is transverse, through the cricothyroid membrane into the airway. With the scalpel blade protruding into the airway, it is rotated 90 degrees so that it is now longitudinal, holding the two edges of the incised membrane apart.
The left hand now releases the thyroid cartilage and picks up artery forceps. The artery forceps are placed into the airway, through the exposed gap, and opened so as to take over from the scalpel as the means of holding the incised edges apart (in the sagittal plane not transversely). The scalpel can now be removed and placed in the sharps tray. The right hand then picks up the endotracheal tube or tracheostomy tube and inserts it into the airway, directed towards the chest. The best size ET tube for an adult cricothyroidotomy is a size 6.0.
After confirming adequate position, the tube should be secured and suctioned. A definitive airway will be required as soon as the patient is stable, fully assessed and appropriate interventions have been performed.
Needle cric video:


Surgical airway video (NB many would make a second horizantal incision through the membrane rather than use the haemostat):

Airway management
Major maxillofacial injuries and the airway

The neck

The neck contains the trachea and carotid arteries (amongst other things) - problems with these will often have a major effect on airway, breathing or circulation. Assess the neck after assessing the upper airway using the TWELVE mnemonic:
T = trachea (for deviation)
W = wounds (causing life threatening haemorrhage)
E = emphysema (surgical emphysema should be regarded as indicating a upper airway trauma or pneumothorax until excluded)
L = larynx
V = veins (distended neck veins + shock suggest one or more of: tension pneumothorax, cardiac tamponade, massive PE)
E = examine the neck before you apply a collar

Recommended book

The Manual of Emergency Airway Management

Mastery quiz