dr. Prabowo Wicaksono Y.P.

, SpAn

BAGIAN/SMF ANESTESIOLOGI FK UNISSULA/RSI SULTAN AGUNG SEMARANG

INTRODUCTION
Early preventable deaths from air way problems after trauma often result from :
1. Failure to recognize the need for an airway. 2. Inability to establish an airway. 3. Failure to recognize an incorrectly placed airway. 4. Displacement of a previously established airway. 5. Failure to recognize the need for ventilation. 6. Aspiration of gastric contents.

Remember : Airway and ventilation are the first priorities.

AIRWAY OBSTRUCTION (SPLIT FRAME )

Left Frame Coma. Aspiration. Maxilofacial trauma Neck trauma.

AIRWAY OBSTRUCTION RECOGNITION LOOK

Agitation / obtunded Air movement Retraction / rocking respirations Deformity

Airway debris

AIRWAY OBSTRUCTION RECOGNITION LISTEN

Normal speech obstruction Noisy breathing obstruction Gurgle Stridor Hoarseness No

AIRWAY OBSTRUCTION RECOGNITION FEEL Maxillofacial / laryngeal crepitus fractures Tracheal deviation Hematoma

AIRWAY MAINTENANCE
ILLUSTRATION : Demonstrating 4 methods of airway Maintenance : Chin lift, jaw thrust,

Oral airway, and nasal airway

CHIN-LIFE

JAW-THRUST

PIPA OROFARINGS

PIPA NASOFARINGS

DEFINITIVE AIRWAY
NEED FOR AIRWAY Coma Maxilofacial injury Aspiration Airway injury NEED FOR BREATHING Apnea Hypoxia Hypercarbia Brain injury Definitive Airway = tube in trachea with cuff inflated

TABLE 1 INDICATIONS FOR DEFINITIVE AIRWAY Need for Airway Protection Unconscious Severe maxillofacial fractures Need for Ventilation Apnea Neuromuscular paralysis Unconscious Inadequate respiratory effort Tachypnea Hypoxia Hypercarbia Cyanosis Severe closed head injury with need for hyperventilation

Risk for aspiration Risk for obstruction Neck hematoma Laryngeal, tracheal injury Stridor

DEFINITIVE AIRWAY
ILLUSTRATION : Depicts 3 methods of establishing a definitive

Airway :
Orotracheal and nasotracheal intubation and surgical cricothyroidotomy

TEKNIK INTUBASI OROTRAKHEA

GB 15 A DAN B

TEKNIK INTUBASI OROTRAKHEA

GB 15 C

RIGHT BRONCHIAL INTUBATION

Illustration : X ray of right bronchial intubation

RAPID SEQUENCE
INTUBATION
Be Prepared for surgical airway Requires skill and training

Urgency Must Justify Risk

SURGICAL AIRWAY
Indications : Inability to intubate trachea Maxilofacial trauma Neck injury

Methods
Needle cricothyroidotomy with

jet insufflation
Surgical cricothyroidotomy

SURGICAL CRICOTHYROIDOTOMY

GB 16

SURGICAL CRICOTHYROIDOTOMY

GB 17

DEFINITIVE AIRWAY
Immediate Need : Apneic Patient

Suspect c spine injury

Oxygenate and ventilate

Orotracheal intubation, protect

c- spine

If unable

surgical airway

DEFINITIVE AIRWAY
Immediate Need : Breathing patient Suspect c spine injury Oxigenate and ventilate as needed Oro or nasotracheal intubation, protect c-spine If unable to intubate surgical airway

DEFINITIVE AIRWAY
Immediate Need : Breathing patient Suspect c spine injury Oxigenate and ventilate as needed Oro or nasotracheal intubation, protect c-spine

If unable to intubate

surgical airway

OXIGENATE AND VENTILATE

Goal : Achieve maximal celluler O2 O2 at 10 12 liters / minute

Tight fitting oxygen reservoir mask

Ventilate

Avoid prolonged attempts at intubation

without oxigenation

ALAT UNTUK PEMBERIAN OKSIGEN

1. OXYGEN MASKS 2. NASAL CATHETERS : ANTERIOR NARES 3. DOUBLE NASAL PRONGS 4. NASOPHARYNGEAL CATHETER 5. OXYGEN TENTS 6. INCUBATORS

MONITOR OXIGENATION (Split frame)

Pulse oximeter Measures O2 hemoglobin sat Utility Difficult intubation During transport Right frame shows comparison of Pao2 O2/Hgb Sat 90 mm Hg = 100% 60 mm Hg = 90% 30 mm Hg = 60% 27 mm Hg = 50%

FIGURE 1 AIRWAY ALGORITHM

IMMEDIATE NEED FOR DEFINITIVE AIRWAY Suspect Cervical Spine Injury

Oxigenate / Ventilate Apneic Orotracheal intubation With in-line manual Cervical immobilization Severe, maxillofacial injury Unable to intubate Unable to intubate Breathing Nasotracheal or Orotracheal intubation With in-line manual Cervical immobilization* Unable to intubate Pharmacologic adjunct

Orotracheal intubation Unable to intubate

Surgical Airway * Proceed according to clinical judgment and skill/experience level

TABLE 2 APPROXIMATE Pao2,VERSUS O2 HEMOGLOBIN SATURATION LEVELS

Pao2 Levels 90 60 30 27 mm Hg mm Hg mm Hg mm Hg

O2 Hemoglobin Saturation levels 100% 90% 60% 50%

SUMMARY
Suspect airway compromise
Protect c- spine

Open airway and ventilate

If in doubt Definitive airway

Urgency of need
Clinical judgment and skill

Adequate O2 delivery