5 tips for securing a patient's airway
You are on scene with a patient who has suffered significant facial trauma; what are some strategies to improve your ability to manage his airway?
One of the first concerns an EMS provider should have about a patient with significant facial trauma is whether the patient has a patent airway and will be able to maintain that airway. Bleeding, soft tissue swelling, broken teeth and other fractures can all create partial or complete obstruction to the patient’s airway.
Care must be paid to how the airway is managed in these patients to strike a balance between managing the airway and potentially exacerbating other injuries. Follow these five steps to manage a difficult airway:
1. Bring suction to the patient
Many roadway trauma calls allow the responding crews to park near the patient. That said, it is still important to bring portable suction from the vehicle to the patient’s side. As portable suction is not routinely used on many calls, crews may form a habit of leaving this piece of equipment in the vehicle.
As trauma patients with airway compromise may require aggressive airway management – including suction – time is of the essence. Bringing suction equipment directly to the patient is particularly important when the patient is located some distance away from a staging or parking location. Sending a responder back to obtain a suction device also takes valuable personnel away from a resource-intensive patient.
2. Proper airway management preparation
Treating a critical patient with a compromised airway is not a time to be fumbling with poorly organized airway adjuncts. Take the time to set up and store equipment in a logical fashion to help ensure that time is not lost on scene attempting to locate an adjunct or piece of equipment.
Ideally, agencies should have a single layout for airway and other kits but at the very least supplies and equipment should be placed in the same basic area of dissimilar bags. Beyond that, partnering with other local agencies can extend this standardization to an entire system allowing responders from different agencies to know their way around most – or all – of the bags in a system.
3. Have a patient assessment plan
Many EMS providers develop a flow to their calls over time. Providers will perform an assessment the same way, ask questions about a patient’s medical history in the same order and write most of their patient care reports in a similar fashion. This approach to the practice of medicine helps ensure that steps are not missed. By performing a task in the same order or the same way each time, providers can free themselves up to focus on what is different or unique about a call.
Airway management can be approached in a similar way. EMS providers can develop a flow to how they manage a patient’s airway. After assessing a patient and finding an inadequately managed airway, start with positioning, then suction if needed, reassess the patient’s airway and breathing, and begin an intervention if either is inadequate.
Some EMS systems are beginning with a basic airway adjunct and only moving to more invasive measures if the others are inadequate. Following your protocols or medical director guidelines, develop a standardized plan for airway management. It will be one less thing to think about on what may be a hectic and difficult call.
4. Have a back-up trauma plan
Sometimes plans work exactly as intended. Other times they don’t. Managing an airway on a complicated trauma patient may be one of the times that your well-designed plan falls apart. In these cases, it’s important to have a back-up plan or plans identified.
In some cases, simply escalating to a more invasive and/or secure airway might be the first logical backup plan. More and more states are adding supraglottic airway adjuncts to the BLS or even MFR scope of practice.
It may be that a complicated patient with a partial airway obstruction from bleeding or swelling may benefit from one of these. Also consider requesting an advanced provider to the scene if your system does not automatically send ALS resources or ask for an intercept while transporting. It may be that a need for more aggressive airway management is a criterion for requesting aeromedical resources in your system.
Finally, if you simply cannot secure an airway for a patient, consider immediately transporting to the nearest emergency department, whether it is a trauma center or not. In many systems, there is a protocol in place allowing patients with an unmanageable airway to be taken to the nearest facility for stabilization then transfer to definitive care.
Whatever your plan, know your other options in case the patient’s airway remains unmanaged.
5. Consider a pediatric BVM
The tidal volume – or the amount of air displaced by one breath – for an average adult is approximately 500 mL. Bag mask volumes vary but a typical adult bag holds somewhere between 1000 and 1500 mL. If the bag is emptied each time it is squeezed, the patient will be chronically over-ventilated.
Once the lungs are full and more air is forced into the airway, air can go down the esophagus and fill the stomach instead. Over time, the stomach becomes distended and further over-ventilation can cause stomach contents to move up and then be forced down into the lungs.
A typical pediatric bag mask holds approximately 500 mL of air. As this matches the tidal volume of an average adult, using a pediatric bag mask may be a safer way to deliver ventilations. It is possible to deliver only the amount of air needed to produce chest rise with an adult bag mask but it is also far to easier to over-ventilate your patient.
While proper tidal volume isn’t technically an airway management technique, preventing aspiration is. Check with your medical director first, but consider whether a pediatric bag mask may be appropriate for your adult patients.
After quickly assessing your patient, you determine that his airway is not adequately controlled. You direct your partner to suction his airway and quickly visualize the now clear oropharynx.
There is no obvious trauma in the patient’s mouth and the blood appears to have been from a laceration on his tongue which is no longer actively bleeding.
You direct your partner to place an oropharyngeal airway and to monitor the patient should he need further suctioning. With an airway adjunct in place, the patient does have spontaneous respirations, but they are slow and appear shallow.
You direct another responder to begin bag mask ventilations. She reports that bagging the patient is easy and you see adequate chest rise. You load the patient for transport and call to request an ALS intercept on the way to the trauma center.