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BATLS Chapter 4 Airway

Draft Manual for Role 1 BATLS - LT held copy

Gareth Sheppard

on 26 February 2016

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Transcript of BATLS Chapter 4 Airway

Chapter 4


Learning Objectives

On completing this chapter you will appreciate:

The anatomy of the airway
Consequences of airway compromise
Recognition and assessment of airway compromise
Treatment of airway compromise

The airway consists of an upper and a lower part and the main function is the transfer of oxygen to the lungs and carbon dioxide out of the body.
Airway Obstruction
Airway Obstruction

Disruption to the airway can impair oxygen transit to the lungs, this in turn will lead to hypoxia of the tissue and if not corrected, cellular death.

Brain cells are extremely sensitive to oxygen deprivation and can begin to die within five minutes after oxygen the supply has been cut off. When hypoxia lasts for longer periods of time, it can cause coma, seizures, and even brain death.

Anything that prevents the flow of air is causing an airway obstruction. It is like blocking a tube.
Inhalation Injury

Special considerations are required for an airway burn as it is not always obvious in the early stages but needs to be observed as it is difficult to treat once the swelling occurs.

These injuries can affect all body systems.
Structure of the Airway
Special consideration should be given to the paediatric airway. See Chapter 13.
Assessment will allow you to ascertain whether there is airway obstruction and if it is partial or complete.
A lack of oxygen delivered to the lungs and therefore to the rest of the body and the brain will make the patient drowsy and they will eventually become unconscious.

When a patient’s level of consciousness decreases it may reach a point when the patient is unable to maintain their own airway. This may occur at GCS 8 (or P on the AVPU scale). The soft tissues of the airway such as the tongue and soft palate can become floppy and obstruct the airway. This is what happens when you snore at night. It is like a foreign body blocking the tube.
Airway Problems

If a patient has an airway problem and experiencing difficulty in breathing they may get distressed and panic. A choking patient may cough causing their face to redden, this will turn to a pale colour as they become hypoxic and eventually blue, most pronounced around the lips and mouth (cyanosed).
Airway Assessment

Airway assessment involves:

History - Was it sudden / traumatic / medical?

Looking - At the patient as a whole (Alert, Distressed etc).

Visual inspection of the airway - Swelling to soft tissues, obstruction from blood, soot around the mouth/nose etc.

Listening to the noises of breathing.
Illustration of Cyanosis
Airway obstruction as the floppy tongue occludes the passage of air
Symptoms of Partial Airway Obstruction

Rocking motion of the chest not in sync with respiratory effort
Harsh, high-pitched sound upon inspiration (stridor)

Symptoms of Complete Airway Obstruction

Lack of any air movement perceived by feeling with the hand over the mouth or placing the ear over the mouth
Lack of breath sounds while listening with stethoscope to lung fields
Exaggerated movement of the sternum and rib cage
Rocking motion of the chest not in sync with respiratory effort
Simple Airway Manouevres
Airway Treatment in the Semi Permissive or Permissive Environment

The GCOs (JSP 999) provide a universal airway algorithm - Section 3 - 3b. Review via link below.


Consider your skill set and available equipment to manage the airway problem you are faced with at the time.
Airway Swelling

Airway swelling occurs progressively for many hours following inhalation injury and may not be evident when the casualty is first seen. It is important to anticipate those at risk of developing airway obstruction.
C spine

The cervical spine is considered with the airway.

When there is a high risk of cervical spine injury, IF POSSIBLE try to maintain cervical spine control—even during a rapid evacuation. This is a judgement call.

You are aiming to maintain the cervical spine in alignment with the rest of the spine

GCOs give further guidance on C spine immobilisation: Section 3 - 4a. Review via link below.

Airway Treatment in a Non Permissive environment

In a patient with a reduced level of consciousness place them in a ¾ prone position.

This will optimise their airway until movement to a permissive environment is achievable.
Removing Debris from Airway

Remove any debris by:

1. Postural draining – sit the patient forward or roll onto their side

2. Use suction –
Airway burn

Airway burn is caused by inhalation of hot gases (flame, smoke and steam).
The injury is normally confined to the upper airway and leads to oedema with the risk of obstruction. The swelling develops over several hours and is maximal between
6 and 24 hours.

Steam is more likely to cause injury below the cords than smoke or flame.

Lung injury occurs if the products of combustion are inhaled into the lower airway where they dissolve into the fluid lining the bronchial tree and alveoli. This leads to a chemical lung injury and varying degree of respiratory failure often delayed by hours or even days.
System Toxicity

Systemic toxicity occurs from absorption of inhaled products of combustion. This is the most common cause of death due to fires in enclosed spaces. The most important agents are carbon monoxide and cyanides.
Recognising possible inhalation injury

The presence of any of the following indicates the possibility of an inhalation injury:
A history of exposure to fire or smoke in an enclosed space
Exposure to blast as a mechanism of burn
Collapse, confusion or restlessness following burn injury
Hoarseness or any change in voice
Harsh cough
Flame or steam burns to the face
Singed nasal hairs
Soot in saliva or sputum
An inflamed and/or blistered oropharynx/tongue

A high index of suspicion is the key to diagnosing inhalation injury
The Non Permissive Environment
Semi Permissive
Permissive Environment
Casualty being placed in the supported recovery position

When there is a high risk of cervical spine injury, IF POSSIBLE try to maintain cervical spine control
Suction Easy Device

Fig 4.2:
Jaw thrust applied as a simple airway opening manoeuvre
1. Jaw thrust - preferred option if suspicious of c-spine injury.
Head tilt chin lift applied as a simple airway opening manoeuvre
2. Head tilt chin lift
Surgical airway - JSP 999.
Oropharyngeal Airway Insertion - JSP 999
Nasopharyngeal Airway Insertion - JSP 999
Figure 4.14:
Immobilisation - JSP 999.
C spine

The NEXUS guidelines are a set of guidelines aimed at medical officers and are difficult to apply in a Battlefield setting. If the history is suspicious of a c spine injury treat the patient accordingly.

If you have no assistance at the scene and you must leave an unconscious patient with potential spinal injury to attend to other casualties, roll the casualty into the supported recovery position while controlling the head. This position will help to maintain the airway with the neck in-line.

The C spine should be immobilised with a collar and head blocks. The correct sizing of the collar is essential.
Sizing and application of a collar

The collar should be applied direct to the skin, the ears should be free from obstruction and the neck fully inspected before the collar is applied. Padding to lacerations beneath the collar may assist with comfort as is removing hair buns / pony tails. Do not cut these off.

When securing a patient to a rigid stretcher the body must be secured prior to the head.
Log Roll

The log roll enables you to safely move a patient with a supected spinal injury.

CGOs cover the log roll at Section 3 - 4b. Review via link below.

Insertion of simple airway adjuncts

Procedures for the insertion of airway adjuncts (Oropharyngeal (OPA) and Nasopharyngeal (NPA) are shown in CGOs at Section 3 - 3c. Review via link below.

Surgical Airway

The process for the insertion of a surgical airway is shown in CGOs at Section 3 - 3g. Review via link below.

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