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$la||$re|$ce|A QuizPlus DEMO File    |||$ca
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This file is a sample from a medical teaching disk by Bruce 
Argyle, MD.  Titled "Emergency Airway Management", the disk covers 
airway anatomy, Basic Life Support airway techniques, advanced 
surgical airway techniques, and resuscitation equipment.

This disk is available only through the "QuizShare" program, to 
registered QuizPlus owners.  The cost is $10, as with all
QuizShare disks.
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||$la|$re|$ce|Airway Obstruction in Facial Trauma|$ca|
     The initial "Airway - Breathing - Circulation" assessment of 
the trauma victim may reveal the presence of upper airway 
obstruction.
|     This blockage of the upper airway is often due to fractures 
of the facial bones, particularly the mandible (jaw).  With no 
bone support, the tongue and other tissues fall back into the 
airway.  Midface fracture-dislocations can directly encroach on 
the airway by driving the maxilla and attached structures down 
onto the pharynx.
|     Swelling or hemorrhage within the tissues may also cause 
occlusion of the airway due to compression.  Secretions and 
bleeding into the airway may also block the passage of air.
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$QUIZ|d
|     An intoxicated 21-year old male hit a freeway pillar, and was 
ejected through the windshield of the car.  He appears aggitated, 
and is making "snoring" sounds as he breathes.  There is swelling 
and discoloration of the upper neck and face.  The jaw "crunches" 
when touched.  The face has a flattened, "dished" appearance.  He 
is blowing blood droplets out with respirations.

     Which of the following factors is definitely NOT contributing to 
his airway obstruction?

     A.  Jaw fractures with unstable soft tissues
     B.  Soft tissue swelling in the neck and pharynx
     C.  Blood clots and hemorrhage in the mouth and pharynx
     D.  Upper cervical spinal cord injury
     E.  Direct impaction of midface bones downward
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|     The "snoring" sound coming from this man's airway is due to 
mechanical airway obstruction.  It may be due to swelling or a 
hematoma within damaged tissues, soft-tissue collapse due to a 
fractured mandible, blood and clots within the airway, or 
mechanical compression due to the midface fracture.
|     Swelling and discoloration = possible pressure on airway from 
enlarged soft tissues.
     "Crunching" jaw = loss of soft tissue support, tongue falling 
into airway.
     Flattened "dish" face = mid-face fracture with downward 
displacement.
     Blood droplets = bleeding into airway.
|     There is, however, nothing to suggest an upper cervical cord 
injury.  This would likely cause apnea due to loss of nerve 
control of the muscles of respiration.
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$QUIZ|a||
     Our 21-year old drunken driver arrives strapped face-up on a 
backboard, with the obvious signs of airway obstruction as 
described.  The first treatment step in this patient would be:

     A.  Pull the jaw forward and suction the pharynx
     B.  Obtain a cross-table C-spine X-ray
     C.  Nasotracheal intubation
     D.  Oral intubation with suction and in-line cervical
         traction
     E.  Emergency tracheostomy
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||     The first measures instituted are those which can be done the 
most quickly with the least threat to the patient.
|     Pulling the jaw forward by grasping the chin may relieve 
mechanical blockage of the airway caused by the tongue.  You may 
need to put your fingers or thumb (depending on which side of the 
patient you're standing on) over the bottom teeth for traction.
|     Once the jaw is forward a stiff large suction catheter is 
inserted to suck out blood, secretions, and vomit.
|     Not only is orotracheal or nasotracheal intubation difficult 
in patients with facial or neck injuries, it risks paralyzing a 
patient if he should have a broken neck.
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$QUIZ|c||
     There is a little improvement in airflow in your injured 
patient after you pull the chin forward and suction.  His color 
improves a little.
||     Whether there is improvement or not, however, you are only 
buying time for:
|     A. a cross-table C-spine X-ray
     B. administration of 100% oxygen by mask
     C. a surgical airway
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|$la|$re|$ce|The Surgical Airway   |$ca|
     In any patient with severe facial injuries, you cannot risk 
further compression of the airway.  A surgical airway must be 
established.
     You should not attempt oral or nasal endotracheal intubation 
in these patients.  Proceed directly to cricothyroid membrane 
puncture or cricothyrotomy.
     In the trauma patient, cricothyroid puncture is done if 
there will be a delay in performing a cricothyrotomy, or if the 
patient is under 12 years old.  With pre-packed kits and a skilled 
operator, cricothyrotomy can be performed as quickly as a 
puncture.
     Tracheostomy has no place in the emergency management of 
airway obstruction.  This is a difficult procedure with a 
liability for severe bleeding and damage to important structures.
     We will now discuss technique for surgical airway access.
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$TPIC|cricothy
|$re|$la|$ce|Cricothyrotomy  |$ca|
     Quickly prep the cricothyroid membrane area and assemble your 
supplies.  Find the notch about one finger's width below the 
prominence of the thyroid cartilage (Adam's apple).  Alternatively 
feel up the trachea until you encounter the ring of the cricoid, 
then come up over the ring into the notch.
|$re|$sk
     (Refer to the diagrams by clicking on "Picture" periodically 
as you review the instructions.)
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     You may use a prepared cricothyrotomy kit, or just a scalpel 
and endotracheal tube.  The key to success is NOT the equipment, 
but the reliable location of landmarks and firm stabilization of 
the thyroid cartilage (so that it doesn't slip around).
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$TPIC|cricothy
||     Stand on the side of the patient so your non-dominant hand is 
closest to the top of the patient's head.  When the equipment is 
ready and within reach, stabilize the patient's thyroid cartilage 
by grasping it firmly with the hand closest to the patient's head.
$re|$sk
|     (Refer to the illustration by clicking on "Picture" as 
often as needed.)
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     Cut deep through the cricothyroid membrane.  Don't be timid.  
You should insert the scalpel almost to the hub.  If using an 
endotracheal tube rather than a trocar-cannula set, make the 
incision at least 1.5 centimeters wide.
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$TPIC|cricothy
     If using a trocar-cannula, insert it now.  First insert 
deeply, then rotate to turn the cannula down the trachea.  Remove 
the trochar.
|     If using an endotracheal tube (usually a smaller one, such as 
a #6), turn the scalpel over.  Insert the blunt end of the scalpel 
into the incision, then rotate it 90 degrees so it opens the 
tissues and serves as a guide to endotracheal tube passage.
$re|$sk
|     (Refer to the illustration by clicking on "Picture" as 
often as needed.)
|$ca
     Remember to continue stabilizing the thyroid cartilage with 
your non-dominant hand.  If you let go, the tissues will slide and 
you may not be able to get the ET tube into the trachea.
|     Now insert the endotracheal tube through the incision, 
angling it towards the feet.  Begin ventilating the patient.
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$QUIZ|d|
     Needle cricothyroid puncture is preferred over cricothyrotomy 
in children because their cricoid cartilage is easily injured 
during cricothyrotomy.
|     As you recall from the anatomy lesson, the cricoid cartilage 
provides the only complete circumferential support of the airway.
|     Because the cricoid cartilage can be damaged, cricothyrotomy
should NOT be performed on children below the age of: 

     A. 6
     B. 8
     C. 10
     D. 12
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||
$ou|$re|$ce|*** END OF SAMPLE FILE ***
$ca|
     This concludes the sample of Dr. Argyle's Emergency Airway 
Management QuizShare disk.  This disk can be obtained for $10 from 
Mad Scientist Software.

     Dr. Argyle is an emergency physician practicing in Utah.  He
is the author of six disks of ACLS training software, patient
discharge instruction printing software, a child safety videotape,
and a first-aid slide program.  At this time, he is past-president
of his hospital medical staff, and is president of the Utah Chapter
of the American College of Emergency Physicians.
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