Download Trauma patients are always considered to have full stomach

‫بنام خداوند جان وخرد‬
Airway Management
in the Trauma Patient
Objectives of Airway Management &
Ventilation
Primary Objective:
 Provide unobstructed passage for air movement
 Ensure optimal ventilation
 Ensure optimal respiration
Objectives of Airway Management &
Ventilation
Why is this so important in the trauma patient?
– Prevention of Secondary Injury
• Shock & Anaerobic Metabolism
• Spinal Cord Injury
• Brain Injury
Airway/Breathing
 Verification of adequate airway and acceptable
respiratory mechanics is of primary importance
 Hypoxia is the most immediate threat to life
 Inability to oxygenate a patient will lead to permanent
brain injury and death within 5 to 10 Minutes
Airway obstruction
– Direct injury
• Face, Mandible, or Neck
– Hemorrhage
• Pharynx, Sinuses, and Upper airway
– Diminished Consciousness
• Traumatic Brain injury, Intoxication, Analgesic medications
– Aspiration
• Gastric contents, Foreign body
– Misapplication of Airway/Endotracheal Tube
• Esophageal Intubation
Inadequate Ventilation
Diminished Respiratory Drive
– Traumatic Brain injury, Shock, Intoxication, Hypothermia,
Over Sedation
Direct Injury
– Cervical Spine, Chest Wall, Pneumo/Hemothorax,
Trachea, Bronchi, Pulmonary Contusion
Aspiration
– Gastric contents, Foreign body
Bronchospasm
– Smoke, Toxic Gas Inhalation
Nasal Cannula Flow Rates
1 liters/min. =24%
2 liters/min. = 28%
3 liters/min. = 32%
4 liters/min. = 36%
5 liters/min. = 40%
6 liters/min. = 44%
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Simple Face Mask
 No reservoir
 Can deliver up to 60% concentration
 Rate 6 to 10 liters/min.
 Not recommended for prehospital use
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Opening the airway
April 2004
Richard Lake
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Prophylaxis against Aspiration
 Trauma patients are always considered to have full stomach




Ingestion of food or liquids before injury
Swallowed blood from oral or nasal injury
Delayed gastric emptying
Administration of liquid contrast medium
 Reasonable to administer nonparticulate antacid prior to
induction
 Cricoid pressure/Sellick Maneuver should be applied
continuously during airway management
 Rapid Sequence Induction
 Avoidance of ventilation between administration of medication and
intubation
Cervical Spine Injury
Trauma Patients
– No Radiological Studies
• Alert, Awake, and Oriented
• No Neurological Deficits
• No Distracting Pain
– MRI Cervical Spine
• Neck Pain
• Cervical Tenderness to Palpation
Cervical Spine Injury
All Other Trauma Patients
– Lateral radiograph of cervical spine
– Anteropostererior spinous process C2-T1
– Open mouth odontoid view
– Axial CT with reconstruction
• Regions of questionable injury
• Inadequate visualization
Protection of the Cervical Spine
 All blunt trauma victims should be assumed to have an
unstable cervical spine until proven otherwise
 Direct laryngoscopy causes cervical motion and the potential
to exacerbate spinal cord injury
 An “uncleared” cervical spine mandates In-line Stabilization
(Not Traction)
 The front of the cervical collar may be removed for greater
mouth opening and jaw displacement
Protection of the Cervical Spine
Emergency Awake Fiberoptic Intubation
– Requires less manipulation of the neck
– Generally very difficult
• Airway Secretions
• Hemorrhage
• Rapid Desaturation
• Lack of Patient cooperation
MANUAL TECHNIQUES
Modify for suspected spinal injury:
1. Tongue/jaw lift
2. Modified jaw thrust
Jaw thrust technique may be needed if
C-spine injury
Indications for Endotracheal Intubation




Cardiac or Respiratory Arrest
Respiratory Insufficiency
Airway Protection
Deep Sedation or Analgesia
 General Anesthesia
 Transient Hyperventilation
 Space Occupying Intracranial Lesion/Increased ICP
 Delivery of 100% O2
 Carbon Monoxide Poisoning
 Facilitation of Diagnostic Workup
 Uncooperative or Intoxicated Patient
Induction of Anesthesia
Propofol/Thiopental
– Vasodilator, Negative Inotropic effect
– May Potentate hypotension/Cardiac Arrest
Etomidate
– Increased cardiovascular stability
Ketamine
– Direct myocardial depressant
– Catecholamine release
– Hypertension/Tachycardia
Midazolam
– Reduced Awareness
– Hypotension
Scopolamine (Tertiary Amine)
– Inhibits memory formation
Muscle relaxants alone
– Recall of Intubation/Recall of Emergency procedures
Induction of Anesthesia
Succinylcholine
–
–
–
–
Fastest onset <1 min
Shortest Duration5-10 min
Potassium increase 0.5-1.0mEq/L
Potassium increase >5mEq/L
• After 24 hours
• Safe in acute airway management
• Burn Victims
• Muscle Pathology
– Direct Trauma
– Denervation
– Immobilization
– Increase intraocular pressure
• Caution in patients with ocular trauma
– Increase ICP
• Controversial in head trauma
Induction Agents
Non-depolarizing
 Vecuronium
Minimal cardiovascular effect
Long duration of action (may exceed 90 mins)
Shorter onset than Pancuronium
0.1 mg/kg
Rapid-Sequence Induction
1
Preparation of necessary equipment (suction, oxygen, laryngoscopes,
endotracheal tube, Ambu bag plus masks, stylet)
2 Preoxygenation with 100% oxygen (at least 3 minutes)
3
Pretreatment (optional) with small defasciculation dose of a nondepolarizing
neuromuscular blocking agent, such as vecuronium (0.01-0.015 mg/kg IV)
4
Pretreatment (optional) with sedative (midazolam) and/or opioid analgesic
(fentanyl)
Induction agent (etomidate, 0.3 mg/kg IV, or ketamine, 2-3 mg/kg IV) plus
5
succinylcholine (1.0-1.5 mg/kg IV)
6
Cricoid pressure (Sellick's maneuver), plus manual in-line stabilization for trauma
patients
7 Direct laryngoscopy with oral intubation (use of stylet is recommended)
Confirmation of correct endotracheal tube placement: bilateral auscultation plus
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end-tidal CO2 confirmation
Department of Anesthesiology
Uniformed Services University of the Health Sciences
ETT
Ped and Adult Normal Trachea
And This (after failed ETT attempt)
And This:
They Tend to look like This:
Combitube®
Combitube®
Advantages:
Protect airway from aspiration
Easy to use
AHA: alternative to ETT for CPR
Disadvantages:
Trauma to soft tissues
Combitube®
 Head neutral or slightly flexed
 Hold tongue and jaw between thumb & forefinger and lift
 Gently insert Combitube® in a curved back and downward
movement until black markers aligned with teeth
 Inflate (proximal) pharyngeal balloon
 Inflate (distal) tracheal balloon
 Confirm which one of #1 or #2 tube is in lungs by using
bag ventilator
Combitube® Insertion
COMBITUBE/ESSENTIALS
 Use only in patients who are unresponsive and
without protective gag reflex
 Do not use in any patient with injury to the
esophagus and children below 15
 Pay attention to placement
 Insert gently and without force
 Remove once patient regains consciousness
LMA
LMA
 Advanced airway
 Useful alternative for “difficult intubation”
 Easy to use
 Sits on larynx - Protects lungs?
Airway & Ventilation Methods
Surgical Cricothyrotomy
– Indications
• absolute need for a definitive airway AND
– unable to perform ETT due for structural or anatomic
reasons, AND
– risk of not intubating is > than surgical airway risk
• OR
• absolute need for a definitive airway AND
– unable to clear an upper airway obstruction, AND
– multiple unsuccessful attempts at ETT, AND
– other methods of ventilation do not allow for effective
ventilation and respiration
Airway & Ventilation Methods: ALS
Surgical Cricothyrotomy
– Contraindications (relative)
• Age < 8 years (some say 10)
• evidence of fx larynx or cricoid cartilage
• evidence of tracheal transection
Airway & Ventilation Methods
Jet Ventilation
– Usually requires high-pressure
equipment
– Ventilate 1 sec then allow 3-5
sec pause
– Hypercarbia likely
– Temporary: 20-30 mins
– High risk for barotrauma
Facial and Pharyngeal Trauma
 Swelling and hematoma
 Chemical or thermal injury
acute airway obstructin
laryngeal edema
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Indication For Early Intubation
 Intraoral hemorrhage
 Pharyngeal erythema
 Change in voice
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1. Maxillary and Mandibular Fx
Mask ventilation
difficult
2. Mandibular Fx
endotracheal intubation
easier
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3. Bilateral Mandibular Fx, and pharyngeal hemorrhage
 Upper airway obstruction
 Intubation
easier
4. Injury to the Jaw and Zygomatic Arch
 Trismus
 Assessment of airway anatomy
difficult
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A patient arriving at the ED in the sitting
or prone position because of airway
compromise is best left in that position
until the moment of anesthetic induction
and intubation
Table 63-11 -- Factors That May Be Relevant during
Intubation of a Head-Injured Patient
Full stomach
Uncertain cervical spine
Uncertain airway
Blood
Airway injury (larynx, cricoarytenoid cartilage)
Skull base fracture
Uncertain volume status
Uncooperative/combative
Hypoxemia
Increased ICP
TBI
 A single episode of hypoxemia (
in sever TBI
< 60 mmHg)
doubling of mortality
 A single episode of hypotention (SBP < 90 mmHg)
in sever TBI
doubling of mortality
 Hypotention + hypoxia
threefold increase in
mortality
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Recommendation in TBI Patients

>60 mmHg
 SBP > 90 mmHg
 Fluid resuscitation
euvolemic state
 HCT >30 %

Paco2
:30-35 mmHg
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