THE GENERAL METHOD FOR AIRWAY OBSTRUCTION

DIAGNOSIS

Try to diagnose that a patient’s airway is obstructed early. Watch for noisy breathing, restlessness and confusion, cyanosis of his mucous membranes (often a difficult sign to detect), sweating and hypertension (caused by carbon dioxide retention), a fast pulse (later becoming slow as his myocardium fails), forceful movements of his chest wall, and intercostal and subcostal indrawing.

If he makes wet bubbling sounds, there is fluid in his respiratory tract, which needs removing.

If he has respiratory stridor, his larynx is probably obstructed.

If he has to–and–fro stridor, his trachea is probably obstructed.

CAUTION! Airway obstruction can be completely silent.

PREVENTION

Make sure that the ambulance men transport him in the recovery position (A, Fig. 52-1).

THE TREATMENT OF AIRWAY OBSTRUCTION

Extend the patient’s neck and draw his jaw forwards (B, Fig.52-1). Remove pieces of vomit or foreign bodies from his pharynx with your finger (C). Insert an oropharyngeal airway (D).

If he Is noisy, restless, and is struggling for breath, you can Intubate him while he is still awake or partly conscious as described below (E).

If he is unconscious, you can intubate him as if he were anaesthetized (A 13.2).

CAUTION ! (1) If you suspect that a patient has a spinal injury, extending his neck to pass a tracheal tube may injure his spinal cord if you are not careful. Fortunately, most cervical spine injuries are flexion ones, and the little extension or even the neutral position required for intubation is not dangerous—provided you remember to avoid too much extension. (2) Nasotracheal intubation is more difficult, and there will not be a cuff on the tube.

If Intubation fails or is impractical, do a laryngotomy with a needle (F), or a knife (G), or do a tracheostomy (H). Unfortunately, a temporary laryngotomy is difficult to manage.

If a patient has a maxillofacial injury (62.1), you may need to pull his tongue forward with forceps or a stitch (I), or pass a nasotracheal catheter (J), or give him a nasotracheal airway (K), or apply a postnasal pack (L). Sometimes he may need bronchoscopic aspiration (M).

THE AWAKE INTUBATION OF A SEVERELY INJURED PATIENT

SEDATION

If a patient is conscious, give him an opioid, intravenously or intramuscularly. The intravenous morphine that he may already have had may be enough. If he is moribund, no sedation is necessary.

METHOD

If possible, and especially if a patient is not fully conscious or is a child, try to intubate him without using a local anaesthetic. This will take some minutes to act, and will delay the return of his protective reflexes.

If necessary, draw 5 ml of 4% lignocaine into a syringe and needle. Ask him to open his mouth and spray 1 to 1.5 ml of solution onto and over the back of his tongue.

Ask him to close his eyes and breathe deeply. Reassure him, and then gently introduce a well lubricated laryngoscope over his tongue until you see the tip of his epiglottis. Then spray a further 1 to 1.5 ml of solution onto it.

When you see his vocal cords, spray the remaining 2–3 ml into his upper larynx and between his cords.

When his cords are widely abducted, pass the tracheal tube into his trachea and inflate the cuff. He will cough a little, but he will soon tolerate the tube. With his airway isolated, you can, if necessary, induce him intravenously.

CAUTION! Don’t let a patient’s tracheal tube remain in place for more than 48 hours with the cuff inflated. Deflate the cuff as soon as is safe, or it will ulcerate his tracheal mucosa. Tracheal tubes vary, and you can leave some in longer than others. Even if you have been successful in intubating him, he may still need a tracheostomy later.

IF YOU CANNOT INTUBATE, DO A LARYNGOTOMY. DON’T LET A TRACHEAL TUBE STAY IN PLACE MORE THAN 48 HOURS