Airway Management Case Study 3

• May 15, 2008

Airway Management Case Study 3

A patient was involved in a motorcycle accident. He is lying approximately 25 feet from his bike with his full-face helmet still on. Upon initial assessment, you hear gurgling from his airway. His respiratory rate is 6 and irregular with a weak, rapid heart rate of 140. The patient is unconscious. As you glance at his body for obvious bleeding, you note the presence of a pinkish fluid draining from his nose.

1. How will you ensure the patency of this patient's airway?

After ensuring a patent airway, you insert an oropharyngeal airway and begin assisted ventilation with a bag-valve mask and 100% oxygen due to his unconsciousness and irregular respiratory rate of 6. You notice minimal chest wall movement with each ventilation.

2. What is the most likely cause for the minimal chest wall movement with assisted ventilation? How will you remedy this?
3. Why would a nasopharyngeal airway be contraindicated in this patient?

With good chest wall movement with each ventilation, you package the patient and begin to transport him to a trauma center. En route to the hospital, the patient becomes cyanotic, despite that fact that you are assisting ventilations.

4. Why would the patient suddenly become cyanotic? How will you troubleshoot this problem?

Case Study 3 Answers

Answer 1: There are several things that you will have to do in order to ensure a patent airway in this patient. First, the full-face helmet is hindering your ability to effectively manage the patient's airway, so it must be removed. This must be accomplished with simultaneous c-spine control. Once the helmet has been removed, the airway must be maintained with a jaw thrust. Gurgling respirations indicate the presence of fluid, probably blood and/or vomitus in the patient's mouth therefore; immediate suction is needed.

Answer 2: The most common problem encountered when using a bag-valve mask device is difficulty in maintaining an airtight seal. To remedy this, you must re-evaluate the mask to ensure that it is the correct size. The best method for placing the mask on the patient's face is to lock the mask under the patient's chin, and secure the bridge of the mask over the bridge of the patient's nose. If you are still unable to effectively ventilate the patient with the BVM, you will have to switch to a pocket mask with supplemental oxygen.

Answer 3: Nasopharyngeal airways are contraindicated when the patient has obvious nasal trauma or if there is drainage from the nose. In this particular patient, the pinkish fluid is most likely cerebrospinal fluid, which indicates skull fracture. If you place a nasal airway, inadvertent placement of the airway directly into the cranium may occur. Since the patient is unconscious, the oropharyngeal airway is the adjunct of choice.

Answer 4: If a patient suddenly becomes cyanotic during assisted ventilation, you must determine why. In many cases, you will find that the oxygen tubing has become disconnected from the oxygen source or the oxygen tank has depleted. These problems must be corrected immediately. Critical patients will not fare well with 21% oxygen. They need 100% oxygen in order to survive. Other cause for this sudden onset of cyanosis include airway obstruction by blood and/or vomitus or the patient's airway needs to be re-evaluated to make sure that it is still in the correct position, which in this case, should be the neutral in-line position.

Case Study 3 Synopsis

This patient was in critical condition and required immediate assisted ventilation however, in order to effectively accomplish this, patency of the airway must be assured first. His full-face helmet was hampering your ability to do this, so you removed it. Assisting ventilations in a patient with blood and/or vomitus in the mouth will force the fluid into the lungs and will be of no benefit to the patient; therefore, immediate suction to clear the airway must be performed. You must ensure a patent airway before you can effectively manage it.

The minimal chest movement with assisted ventilation as well as the development of cyanosis are perfect examples of why you must continually re-assess the airway while management is in progress. Even though the fixes for these problems are relatively simplistic, failure to troubleshoot and correct them will result in worsened hypoxia in the patient therefore; you cannot expect the patient to improve, let alone survive.

When providing assisted ventilation to a patient, signs that the patient may be improving include the following:

• Improvement in heart rate
• Remember that children respond to hypoxia with bradycardia
• Improvement in color (if previously cyanotic)
• Improvement in level of consciousness (not likely with this patient, due to his injuries)