Airway management

Airway management is one of the key components of emergency care. Its primary objective is to diagnose an obstructed or potentially obstructed airway, to clear the obstruction and keep the airway patent. No medical emergency, short of a complete cardiopulmonary arrest, is more immediately life-threatening than the loss of an adequate airway. Failure to adequately manage airway patency and ventilation has been identified as a major cause of preventable death in trauma (27-30).

In the initial assessment and management of any critically ill patient, the airway, breathing and circulation (ABC) are the first steps. The response to any acutely ill or injured patient must be met using a systematic approach, with the airway being the first priority. If any abnormalities are detected, measures to intervene are instituted immediately. The skills to assess a patient for obstruction of the airway, to establish and maintain a patent airway, and to ensure adequate ventilation and oxygenation of the patient, are therefore essential.

At all levels of the health care system, it is deemed essential that health care personnel know the signs of airway obstruction and are skilled in manual manoeuvres to keep an airway patent while maintaining cervical spine protection. The probability of success of airway management is increased by the provision of specific equipment and the skills to utilize it properly and safely. This includes equipment and skills for basic airway management, including oral or nasal airway, suction and bag-valve-mask. These are deemed essential at hospital-level facilities. The probability of success in airway management is further increased by the provision of equipment and skills for advanced airway management, including endotracheal intubation and cricothyroidotomy. These are deemed essential at specialist-staffed hospitals. At each level, the probability of success in airway management is increased. However, both the need for resources (both equipment and training) and the potential for harm are increased. Environments in which more resources are available, and/or in which there is a greater than average trauma volume in specific facilities, may wish to change the "desirable" designation to essential at some or all facilities of a given level.

At whatever level of the health care system it is decided to provide advanced airway capabilities (e.g. endotracheal intubation with or without cricothyroido-tomy, with or without tracheostomy—see end of section 5.I),1 several safety assurances should be in place. This includes the provision that the equipment is readily available in whatever area receives the injured patient (casualty ward or emergency department). This is aided by having the necessary equipment in pre-assembled packs (where appropriate and feasible), stocked in the emergency area. Safety assurance also mandates that staff performing the various procedures be adequately trained to perform them successfully, with an acceptable rate of complications. This includes both the training received in basic education (e.g. medical or nursing or other professional school) and whatever continuing education might be required to maintain the skills. Given the potential for harm (in the form of oesophageal intubation) with advanced airway management, inexpensive materials to assist in the clinical assessment of endotracheal tube placement should be provided whenever endotracheal intubation is performed. This includes principally an oesophageal detector device (either bulb or syringe). Finally, given this potential for harm associated with advanced airway manoeuvres, a quality assurance mechanism should be in place to track adverse events such as oesophageal intubations. Further details can be found in the chapter on quality assurance.

By way of further explanation of some of the equipment listed in the table, suction is an extremely important component of airway management. It can be provided at a low cost by manual and foot pump devices. These should be considered essential in any hospital. Likewise, a stiff suction tip (Yankauer or equivalent) is an essential component of an adequate suction set up. The term "basic trauma pack" implies a kit with a few basic instruments and supplies, including a scalpel, clamps, scissors, gauze, suture, syringe and needles. These represent a component of the minimum of physical resources needed to perform certain smaller procedures in the casualty ward/emergency department setting. Such pro

1 Cricothyroidotomy is generally considered to be the surgical airway of choice in emergency situations and can be performed in several seconds. If needed for a prolonged period, it is usually converted to a tracheostomy after a few days.

cedures include cricothyroidotomy in Table I.They also include some procedures mentioned later, such as chest tube insertion in Table 2. The basic trauma pack is considered essential at all hospital levels.

These guidelines indicate the use of cricothyroidotomy when a surgical airway is indicated. In general, this is performed more quickly and safely than a tracheostomy, especially by non-specialists (31).

Further details of airway equipment are included in Annex I.

TABLE I Airway management

Facility level1

Airway: knowledge & skills

Basic

GP

Specialist

Tertiary

Assessment of airway compromise

E2

E

E

E

Manual manoeuvres (chin lift, jaw thrust,

E

E

E

E

recovery position, etc.)

Insertion of oral or nasal airway

D

E

E

E

Use of suction

D

E

E

E

Assisted ventilation using bag-valve-mask

D

E

E

E

Endotracheal intubation

D

D

E

E

Cricothyroidotomy (with or without tracheostomy)

D

D

E

E

Airway: equipment & supplies

Oral or nasal airway

D

E

E

E

Suction device: at least manual (bulb) or foot pump

D

E

E

E

Suction device: powered: electric/pneumatic

D

D

D

D

Suction tubing

D

E

E

E

Yankauer or other stiff suction tip

D

E

E

E

Laryngoscope

D

D

E

E

Endotracheal tube

D

D

E

E

Oesophageal detector device

D

D

E

E

Bag-valve-mask

D

E

E

E

Basic trauma pack

D

E

E

E

Magill forceps

D

D

E

E

Capnography

I

D

D

D

Other advanced airway equipment (Annex 1)

I

D

D

D

1 In this and subsequent resource matrices, the following key is used to indicate different levels of facilities: Basic: outpatient clinics, often staffed by non-doctors; GP: hospitals staffed by general practitioners; Specialist: hospitals staffed by specialists, usually including a general surgeon; Tertiary: tertiary care hospitals, often university hospitals, with a wide range of specialists.

2 Items in the resource matrices are designated as follows:

E: essential; D: desirable; PR: possibly required; I: irrelevant (not usually to be considered at the level in question, even with full resource availability).

1 In this and subsequent resource matrices, the following key is used to indicate different levels of facilities: Basic: outpatient clinics, often staffed by non-doctors; GP: hospitals staffed by general practitioners; Specialist: hospitals staffed by specialists, usually including a general surgeon; Tertiary: tertiary care hospitals, often university hospitals, with a wide range of specialists.

2 Items in the resource matrices are designated as follows:

E: essential; D: desirable; PR: possibly required; I: irrelevant (not usually to be considered at the level in question, even with full resource availability).

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