Monday, May 2, 2011

How To Manage Difficult Airway For Patient With Cerebral Disorder

Monday, May 02, 2011 Unknown No comments

ABSTRACT

The main problem is cerebral disorder and difficult airway. Cerebral disorder need airway clear.

Difficult airway, difficult to keep airway clear and to clear the airway.

Cerebral disorder associated with unconcious(upper airway problem), obstruction from base of tongue falling posteriorly, increase Intracranial Pressure(ICP), diminish cerebral autoregulation, highly sensitive to drugs(sedative, narcotic) and when head injury must be strictly considered to evaluate hypotension and increase Intracranial Pressure (ICP) produce reducing Cerebral Perfusion Pressure(CPP) result cerebral ischemia and neurologic damage.

Difficult airway usually related solely to tracheal intubation or problems with mask ventilation.

Intubation difficulty usually related to inability visualize the larynx or obstruction to passage of tracheal tube or combination of these.

Difficulty to visualize the glottis grade III can result severe difficulty to intubate and grade IV, complex methode may be required.

Principal management the airway are, keep the airway clear plus cervical stabilization, clear the airway, insertion of artificial airway and protection of the airway.

Smooth laryngoscopy and intubation approach, need relaxation of masseter muscle, abolish gag reflex, relax respiratory muscle/diaphragm to prevent bucking, coughing and depress the resulting sympato adrenal discharge to prevent increasing of blood pressure and ICP.

Clinical management for difficult airway depend on the availability skills and apparatus, the urgency of surgery and the type of surgery.

Commence with simple methode, sniffing position and Sellick Manouvre, appropriate laryngoscope and lighted, if necessary polioblade laryngoscope, gumelastic catheter stylet with flexie guide tip for grade II and III.

If fail, we use complex methode for example light wand, fibre optic laryngoscope, retrograde intubation, combitube, prosealed laryngeal mask airway(LMA) and in emergency situation use needle crycothyrotomi and transtracheal ventilation.

In massive cervical injury the trachea can be intubated directly through the injured area. Especially with head trauma must be assumed to have cervical spine is mandatory.

When associated with thorax injury with pneumothorax, don't intubate and control ventilation before having chestdrain without radiology confirmation.

Don't give muscle relaxant if ventilation mask difficult. In circulation support to correct hypotension, prevent over hydration and hypotonic solution.

Full stomach be careful, aspirate gastric content. Sellik manouvre and drugs to quick gastric emptying, increase lower oesophageal sphincter tone and decrease gastric secretion.

For very severe difficult intubation, awake intubation with local anestehesia is the safer approach.
Last but not least experts senior should be involved.

1. HOW TO MANAGE DIFFICULT AIRWAY FOR PATIENT WITH CEREBRAL DISORDER.

M A I N P R O B L E M

A. CEREBRAL DISORDER

B. DIFFICULT AIRWAY

CEREBRAL DISORDER NEED AIRWAY CLEAR

DIFFICULT AIRWAY, DIFFICULT :
- TO KEEP AIRWAY CLEAR - TO CLEAR THE AIRWAY

2. PATIENT CONSIDERATION

A.CEREBRAL DISORDER

1. UNCONCIOUS [UPPER AIRWAY PROBLEM] OBSTRUCTION FROM BASE OF TONGUE FALLING POSTERIOLY.

2. INTRACRANIAL PRESSURE [ICP] INCREASE

3. CEREBRAL AUTOREGULATION DIMINISH [CEREBRAL VASOPARALYSE]

4. HEAD INJURY

# ASSOCIATED WITH MULTIPLE INJURY
* CERVICAL SPINE --> STABILISATION
* MAXILOFACIAL
* AIRWAY
THORAX/ABDOMINAL/EXTRIMITY

# FULL STOMACH --> ASPIRATION

5. DRUGS : STRICTLY DOSE AND INDICATION

3. INTRACRANIAL PRESSURE INCREASE --> HERNIATION

CEREBRAL VOLUME INCREASED :

A. CEREBRAL BLOOD VOLUME(CBV) INCREASED

a. CEREBRAL BLOOD FLOW [CBF] INCREASE.

1. + CEREBRAL VASODILATION : HYPERCAPNIA
  + DRUGS : INHALATION AGENTS : HALOTHANE
                                                           INTRAVENOUS AGENT :
KETAMINE,
SUCCINYLCHOLINE

2. + HYPERTENSION

- LARYNGOSCOPY
- INTUBATION
- SUCTIONING
- PAIN
- ANXIOUS
- DRUGS

b. CEREBRAL VENOUS PRESSURE INCREASE :

- INTRATHORACAL/ABDOMINAL PRESSURE INCREASE
- COUGHING, STRAINING, BUCKING
- POSITION [HEAD DOWN, FLEXION]
- PEEP
- CVP JUGULAR/SUBCLAVIA

B. CEREBRAL SPINAL FLUID (CSF) INCREASE :

- PRODUCTION Up   } ETHRANE, HALOTHANE

- REABSORTION Down }
- OBSTRUCTION FLOW --> SHUNTING UP

CEREBRAL MASS INCREASE :

1. MASSIVE EDEMA : TRAUMA, OVERHYDRATION, HYPOTONIC SOLUTION HYPOXIA/ISCHEMIA
2. HEMATOMA INTRACEREBRAL
3. ABSCESS & TUMOR

To Be Continued