What maneuver is used to open the airway when there is no cervical spine injury?
|
Where there is risk of c-spine injury, such as a patient who is unconscious as a result of a head injury, the airway should be opened using a maneuver that does not require neck movement. The jaw thrust is performed by having the physician stand at the head of the patient looking down at the patient. The middle finger of the right hand is placed at the angle of the patient's jaw on the right. The middle finger of the left hand is similarly placed at the angle of the jaw on the left. An upward pressure is applied to elevate the mandible which will lift the tongue from the posterior pharynx. Show
The jaw-thrust maneuver is a first aid and medical procedure used to prevent the tongue from obstructing the upper airways. This maneuver and the head-tilt/chin-lift maneuver are two of the main tools of basic airway management, and they are often used in conjunction with other basic airway techniques including bag-valve-mask ventilation. The jaw-thrust maneuver is often used on patients with cervical neck problems or suspected cervical spine injury.[1] The maneuver is used on a supine patient. It is performed by placing the index and middle fingers to physically push the posterior aspects of the lower jaw upwards while their thumbs push down on the chin to open the mouth. When the mandible is displaced forward, it pulls the tongue forward and prevents it from obstructing the entrance to the trachea.[2] Traditionally, the jaw-thrust maneuver has been considered the better alternative (rather than the head-tilt/chin-lift maneuver) when a first aider suspects that the patient may have a spinal injury (especially one to the neck portion of the spine). The International Liaison Committee on Resuscitation has reviewed various studies that found no spine-protecting advantage to the jaw-thrust maneuver.[3] Its "Treatment Recommendation" under "Opening the Airway" says, "Rescuers should open the airway using the head tilt–chin lift maneuver."[3] If the patient is in danger of pulmonary aspiration, he or she should be placed in the recovery position, or advanced airway management should be used.[citation needed] An injured child who cannot easily breathe, cough, cry, or speak has upper airway obstruction until proven otherwise. The airway must be opened and repositioned, with a modified jaw thrust maneuver and bimanual cervical spine stabilization. The quality of any abnormal sounds heard will dictate the correct initial treatment. Snoring suggests soft tissue obstruction for which airway opening and repositioning alone should be sufficient, followed in the absence of a gag reflex by insertion of an oropharyngeal airway that reaches from the mental foramen to the angle of the mandible. Gurgling suggests abundant pharyngeal secretions, which must be cleared through aggressive but gentle use of a large-bore oropharyngeal suction device. Stridor suggests a laryngeal foreign body, such as fractured dental fragments or small intraoral playtoys, that may require extraction under direct laryngoscopy using pediatric Magill or Rovenstine forceps, if a directly observable fingersweep is unsuccessful. Hoarseness suggests blunt laryngeal injury that may require medical or, rarely, surgical cricothyroidotomy if airway opening maneuvers fail, followed by definitive surgical repair if laryngeal fracture is present, a diagnosis that is made by computed tomography once definitive airway control has been obtained. Endotracheal intubation using an uncuffed endotracheal tube will in due course be required for injured children under 8 years of age who present in respiratory failure, decompensated shock, or traumatic coma, or who cannot protect their own airway. An uncuffed tube is preferred for such children, not because of the “physiologic” mucosal “cuff” that is the serendipitous benefit of the funnel-shaped upper airway, the narrowest point of which is at the subglottic level of the cricoid ring, but because the larger outer diameter created by the plastic “balloon” cuff necessitates use of a tube with a smaller inner diameter than is ideal, thereby predisposing the tube to earlier obstruction from bloody or mucousy secretions than a tube of larger inner diameter. However, the tube need not be inserted the moment the need for it is recognized, so long as the airway can be temporarily maintained by other means. This gives time for the treating physician to rapidly assess the child for conditions such as tension pneumothorax that may worsen if the child is tracheally intubated before they are addressed. Orotracheal intubation is the preferred approach in injured children requiring definitive airways. This is because the anterior, cephalad location of the larynx in children under 8 years of age precludes nasotracheal intubation in most emergent situations, while attempts at nasotracheal intubation may cause profuse adenoidal bleeding. In rare circumstances, tracheal intubation may not be possible due to laryngeal injury. Needle cricothyroidotomy followed by needle jet ventilation is preferred for such patients, since the hyoid bone is often more prominent than the thyroid cartilage in infants and young children, a fact that may predispose to misidentification of anatomic landmarks, which can lead to improper placement of the surgical cricothyroidotomy incision. Rapid sequence intubation, using etomidate and succinylcholine after an adequate interval of suction and preoxygenation, is preferred for injured children requiring tracheal intubation, unless the Glasgow Coma Scale score indicates global unresponsiveness. Adjunctive use of lidocaine to blunt a potential rise in intracranial pressure remains controversial. Deterioration or desaturation of an intubated patient requires immediate re-evaluation of the airway. The mnemonic “Don't be a DOPE” may serve to remind the treating physician of common pitfalls of endotracheal intubation such as esophageal or right mainstem bronchial d islodgement, particularly when a patient is moved from the ambulance to the hospital stretcher, or from gurney to gantry, or vice versa, when undergoing computed tomography; o bstruction by blood, secretions, kinking, or biting; tension p neumothorax, either from exacerbation of an existing or unrecognized tension pneumothorax, or creation of a new tension pneumothorax from overly zealous assisted bag-valve-mask or -tube ventilation, or ventilator-induced baro- or volutrauma; or e quipment failure, most commonly the result of failure of oxygen supply, either from an empty tank or, in rare instances, inadequate delivery of wall oxygen. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9781416000877500271 Anesthetic Considerations for Pediatric NeurotraumaMonica S. Vavilala, Randall Chesnut, in Essentials of Neuroanesthesia and Neurointensive Care, 2008 Airway ManagementThe most important element during the primary survey phase is to establish an adequate airway. A lucid and hemodynamically stable child can be managed conservatively, but if the child has altered mental status, attempts should be made to establish the airway by suctioning the pharynx, performing chin-lift and jaw-thrust maneuvers, or inserting an oral airway. Children with a GCS score lower than 9 require tracheal intubation for airway protection and management of increased ICP. However, recent studies have not demonstrated any survival or functional advantage of prehospital tracheal intubation over prehospital bag-valve-mask ventilation in pediatric TBI. The most common approach to tracheal intubation remains direct laryngoscopy and oral intubation with cricoid pressure after induction of anesthesia, ventilation with 100% oxygen, and manual in-line stabilization without traction. Nasotracheal intubation is contraindicated in patients with basilar skull fractures. Fiberoptic bronchoscopy may not be available and often has poor resolution and suctioning capability. Moreover, it cannot be used in an agitated child. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9781416046530100305 NeurosurgeryAmanda L. Faulkner, Michael L. James, in Perioperative Medicine (Second Edition), 2022 Spinal Cord LesionsPriority is given to simultaneous airway assessment and management. Immobilization of the spine must be ensured until definitive radiographic studies are obtained. Listening for stridor caused by partial airway obstruction and feeling for air movement can determine adequacy of the airway. Patients who can speak without stridor or hoarseness usually have unobstructed airways. Some patients who demonstrate airway obstruction will respond to a jaw-thrust maneuver; however, during this process, spine manipulation must be avoided. Many patients with cervical cord lesions will require at least temporary endotracheal intubation. A significant proportion of spinal cord injured patients have associated head injuries and depressed levels of consciousness. Patients who are stuporous or unconscious are at increased risk of developing aspiration pneumonitis. In the patient with spinal cord injury, this risk is compounded by gastrointestinal paresis that develops soon after the injury.41 Patients with significant chance for regurgitation and aspiration require intubation or tracheotomy to protect their airway. Gastric atony should be suspected and managed with nasogastric tube suction until it resolves.42 View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B978032356724400037X Emergency Airway ManagementAnushirvan Minokadeh, William C. Wilson, in Cardiac Intensive Care (Second Edition), 2010 Oropharyngeal and Nasopharyngeal AirwaysWhen the tongue and other soft tissues are maintained in the normal forward position, the posterior pharyngeal wall remains nonobstructed, and the airway is generally open (Fig. 49-9, A). The most common cause of airway obstruction is falling back of the tongue and epiglottis in supine, unconscious patients (Fig. 49-9, B). This can be alleviated by the jaw thrust maneuver. Regardless of whether jaw thrust is successful, an oral or nasal airway as an adjunct to bag-mask ventilation can open up a closed airway. Both oral (Fig. 49-9, C) and nasal (Fig. 49-9, D) airways restore airway patency by separating the tongue from the posterior pharyngeal wall. A rigid oral airway may elicit a gag response from an awake patient, which may be followed by emesis. Soft nasal airways provoke less gag response than rigid oral airways. Soft nasal airways are commonly inserted in patients suffering from ventilatory failure, who are more awake and prone to gagging on the rigid oral airway. Coagulopathies and nasal or basilar skull fractures are relative contraindications to nasal airways. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9781416037736100497 AnesthesiaMichael L. Beckley, ... Chris Jo, in Clinical Review of Oral and Maxillofacial Surgery (Second Edition), 2014 • A (airway): The upper airway is rapidly evaluated and found to be clear of any obstruction. The patient's oropharynx is clear (secretions are suctioned with a tonsillar suction), and no inspiratory or expiratory noises are heard (stridor or gurgling noises may indicate upper airway obstruction). No tracheal tug is present. Chin tilt/jaw thrust maneuvers are applied. •B (breathing): There are no inspiratory efforts, and no chest wall or abdominal motion (apnea) is seen. Breath sounds are not heard with the precordial stethoscope (placed above the suprasternal notch), and the reservoir bag is motionless. The pulse oximetry (Spo2) reading has been steadily falling from 99% to 80%. (An Spo2 of 90% correlates with a Pao2 of 60 mm Hg; values below this correspond to the steep portion of the oxygen-hemoglobin dissociation curve.) •C (circulation): Blood pressure and heart rate are stable (bradycardia and hypotension resulting from an extended period of hypoxemia are ominous signs of impending circulatory collapse). The electrocardiogram shows normal sinus rhythm without any ST changes. (Leads II and V5 are most sensitive in detecting myocardial hypoxia.) View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323171267000030 Otorhinolaryngologic ProceduresRaafat S. Hannallah, ... Susan T. Verghese, in A Practice of Anesthesia for Infants and Children (Sixth Edition), 2019 Induction of AnesthesiaCompared with children undergoing adenotonsillectomy for chronic tonsillitis, children with OSAS experienced more respiratory complications during anesthetic induction including supraglottic obstruction and desaturation.46,101 The vulnerability of the upper airway musculature described for halothane in cats197 has subsequently been reported for most anesthetic agents in humans, resulting in a graded reduction in airway caliber with increasing anesthetic concentrations.198–202 As airway collapse occurs in the upper two-thirds of the pharyngeal airway201 during induction, airway obstruction may require a jaw thrust maneuver, insertion of an oral or nasopharyngeal airway, and/or the application of continuous positive airway pressure (CPAP). The application of CPAP acts as a pneumatic splint to increase the caliber of the pharyngeal airway (Fig. 33.10).203 Of equal importance, CPAP increases longitudinal tension on the pharyngeal airway, thereby decreasing the collapsibility of the upper airway (see Fig. 14.10), and increases lung volumes.204,205 Small increments in CPAP between 5 and 10 cm H2O increase the dimension of the pharyngeal airway dramatically (Fig. 33.11).206,207 In children with severe OSA, it is prudent to consider securing IV access before induction of anesthesia to expedite administration of an NMBD or IV agents should pharyngeal obstruction or laryngospasm occur. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323429740000331 SedationDavid Kessel MB BS MA MRCP FRCR, Iain Robertson MB ChB MRCP FRCR, in Interventional Radiology: A Survival Guide (Third Edition), 2011 MonitoringA named member of staff is responsible for monitoring each patient. They must be capable of recognizing and managing important changes in the sedated patient's condition. Many of the complications caused by sedation can be avoided if the patient is closely and responsively observed during the procedure and in the recovery period. The following parameters should be monitored: Pulse oximetry and respiratory rateAllows prompt recognition of hypoxia long before it is clinically obvious. Prompt action should be taken when the oxygen saturation falls below 95%. The patient should be encouraged to take some deep breaths and oxygen should be administered by mask or nasal cannulae. If this fails, try to establish an airway using the jaw thrust manoeuvre or a plastic airway. Seek assistance sooner rather than later. Give oxygen routinely to sedated patients; this saves an unseemly scuffle when the pulse oximeter alarm starts to ring. ECGThe ECG demonstrates heart rate and cardiac rhythms and detects signs of myocardial ischaemia. It is invaluable in the management of cardiac arrest and arrhythmia. It is not uncommon for you to hear a change in rate and rhythm before anyone else notices. N.B. Most cardiac events are late manifestations of hypoxia. Pulse and blood pressureThese are best monitored by an automatic device. Warn the patient that this is: •Uncomfortable •Normal practice and not a sign of impending problems. Most machines have alarms that can be set to respond to significant increases or falls in blood pressure. Record the pressure every 5 minutes and make additional recordings during procedures likely to affect the blood pressure. N.B. Tachycardia and hypertension are usually the response to pain but may also reflect hypercapnoea. Make sure that your staff notify you of any upward or downward trends in the record and warn them if you are going to do something likely to affect the values, e.g. give hyoscine butylbromide (Buscopan) or a vasodilator. |
