In this video, Dr. Ludmer at UChicago Medicine describes the airway assessment for a trauma patient.
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Hi everybody, I'm Dr. Nicholas Ludmer. I'm one of the emergency medicine doctors here at the University of Chicago. Today, I'm going to be talking you guys through the basics of the airway assessment in the setting of a trauma patient. So every patient that comes into the University of Chicago under trauma, we treat basically through the ATLS treatment algorithm. ATLS is the advanced trauma life support. And what it does is it outlines a common approach to trauma patients when they come into our emergency department. It outlines a steady structure of sort of airway, breathing, circulation, disability, and exposure. And what that does is it helps us with two things. First is it helps us not to miss any injuries. It also helps us to intervene on what's going to kill the patient the fastest. So the way that ATLS is arranged with airway first, breathing second, circulation third, disability fourth, and then exposure fifth, is that is kind of the order in which problems with the patient are going to kill the patient fastest. So, the problems with the airway are generally going to kill the patient faster than problems with breathing. And then problems with breathing generally are going to kill the patient faster than problems with circulation. So that's why it's arranged the way it is. So the airway assessment is one of the key parts of the ATLS guidelines, and one of the most important when you need to intervene on the fastest. So what I'm going to do is take you through our basic assessment of the patient's airway when they come in during a trauma.
First most important thing is to determine whether the airway is open, whether the patient is able to move air in and out through their airway. And the fastest way to do that is really just to talk to the patient. So you say, "Hey, bud, what's your name?" Nikita. Nikita, okay? And if Nikita can speak, that means that he's able to move air in and out through his airway well, okay? So we say the airway is patent. The airway is open. And that reassures the entire team that we don't need to do, we may not need to do any immediate intervention right now, okay? It's still important to complete an assessment of the airway. Because even though he's talking now, he may have some injuries that might be obstructing his airway or getting in the way of his airway, all right? And there may be other interventions that we need to do to make sure that Nikita's airway stays open, all right? So in addition to talking to the patient, and making sure that he can speak, we're also going to listen for any abnormal sounds. We're going to listen to the quality of his speech. So if he speaks, and there's sort of gurgling sounds, or there's coarse sounds in the airway, that may mean that maybe he's got some fluid in the airway, maybe he's got some swelling, okay, that may become a problem and cause issues with his airway in the immediate future, okay? So we're going to listen for any abnormal sounds: gurgling, coarse sounds, stridor, which is sort of a high-pitched sound as air moves in and out past a narrow opening. So like - [breathes deeply and loudly] is stridor. And that can be indicative of airway swelling or impending airway closure, okay? In which case we may need to intervene on his airway.
So in addition to listening to the patient speak and making sure their airway is patent, as well as listening to the quality of their voice for any abnormal sounds, we're also going to do a visual inspection of the airway. Remember, the airway is composed of the nares, which are the nostrils, the nasal cavity, which is the space just behind those. The nasopharynx, which is even further back. The mouth, which is the oral cavity, okay? And the oropharynx, which is the back of the throat. And then finally, the structures in the neck: the larynx and the trachea. We're going to do a visual inspection of all of it, okay? So you're going to take a light, usually an otoscope, oftentimes with a speculum, which is the little cone part you put on front, and we're going to take a look in the patient's nose. So we're just going to shine a light up. See if there's any evidence of injury, okay, bleeding, any evidence of facial fracture that might obstruct his airway or block his airway, all right? We're going to ask the patient to open their mouth. So would you open your mouth wide? You're going to shine the light in, and again, we're looking at everything. You're looking for - is the tongue swelling? Are there any injuries to the tongue? Is there any other swelling in the mouth that's going to end up blocking his airway? Is there any fluids that we need to suction? Is the patient bleeding? Did they vomit, okay? Do we need to suction the patient's airway? Are there any signs of injuries that might block it? So any loose teeth that the patient could accidentally get into their windpipe or get into their airway that we need to take care of. Once you've examined the nasopharynx and the nasal cavity as well as the oral cavity - the mouth and the oropharynx, you also want to be able to take a look at the anterior neck, the front part of the neck, all right? Because the airway also involves the larynx and the trachea, which make up your windpipe right here in the front, all right? So in order to do that - that can be a little bit more difficult in a trauma patient. Oftentimes, people who are in traumas will come in with a cervical collar in place and may often also be on a backboard, all right? Because one of the special considerations we worry about in trauma is - does this patient have a cervical spine injury, an injury to their spinal cord, that we don't want to make worse by doing our evaluation, okay? So once we've taken a look inside the nose, we've taken a look inside the mouth, we also want to examine the front of the neck. And to do that, we're going to ask one of our other colleagues, one of our other coworkers to actually hold the patient's head still, okay? Where it's called manual inline stabilization, okay? They're going to hold the patient's neck still to prevent any injury to his cervical spine, to his neck, while we take the collar off and actually examine the front of the neck, okay? So because we're limited in personnel, we're not going to have somebody hold it for the sake of this video. But in real life, and what you'll see in some of the cases, is that whenever you remove this collar, somebody is going to be holding manual inline stabilization. They're going to hold the neck still, all right? But for the sake of the video - say somebody is holding inline stabilization, you can remove the front of the collar so that you can complete your visual inspection of the airway, you can complete your evaluation of the larynx and the trachea, which basically compose the windpipe, right in the middle. So I'll actually have you sort of lean your head back. And again, you wouldn't do this in a trauma setting. You wouldn't have the patient move their neck, but just for the sake of visualization you're going to take a look at the patient's neck. And there are a few things you're going to look for. First, you're going to examine and make sure that the patient's airway, their windpipe, is in the middle of the neck right where it should be, okay? You want to make sure that's in the middle. If it's off to one side or it looks deviated, is what we call it, that can be a sign of an injury to the trachea or an injury to the larynx - an airway injury, which is something we may need to intervene on quickly, okay? So you look to make sure that the airway is midline, okay? You also look for other injuries around the neck that might compromise the airway. So maybe he's got a foreign body in his neck. Maybe he was stabbed in the neck, something else that might impede on the airway or cause an impending injury to the airway. Sometimes trauma can also cause bleeding in this area. And so you can get expanding collections of blood, or what we call hematomas. So you want to make sure that there's no swelling in the neck, around the neck that might push on the airway and compromise the airway. So you want to complete your visual inspection. You can often also sometimes just feel and press the skin lightly and see if there's any air under the skin that might indicate that the trachea, or the windpipe, has been injured, okay? So sometimes injuries to the windpipe can cause air to release under the skin, and you'll get this Rice Krispies Treat type feeling. If you press on it, it'll kind of crinkle and crunch, kind of like you're pressing on Rice Krispies, all right? Or like crepitations, okay?
So you're going to do your - talk to the patient, make sure that their airway is patent, listen to the quality of the airway sounds. Are there any abnormal sounds? Stridor, gurgling, coarse sounds, okay? You're going to look in the nares, in the oral cavity, in the oropharynx, and you're going to look at the anterior neck, okay? And then you can also feel for any signs of bony fracture, deformity, and also any signs of air in the neck that might suggest a tracheal injury. All right? And once you're done with your examination, you're going to replace the patient's collar, all right? And your coworkers can then release inline stabilization once the collar is secure. All right? That's the basics of the airway evaluation in trauma. If you find something wrong, you intervene before moving on to the next examination. So if we find something wrong with the airway, we fix it before we move on to examining breathing, okay? And we're going to talk about some of those interventions in the subsequent videos.