بنام خداوند جان وخرد

Airway Management in the Trauma Patient

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 Objectives of Airway Management & Ventilation

 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/Breathing

– 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 Airway obstruction

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 Inadequate Ventilation

1 liters/min. =24% 2 liters/min. = 28% 3 liters/min. = 32% 4 liters/min. = 36% 5 liters/min. = 40% 6 liters/min. = 44% 8 Nasal Cannula Flow Rates

 No reservoir  Can deliver up to 60% concentration  Rate 6 to 10 liters/min.  Not recommended for prehospital use 9 Simple Face Mask

April 2004Richard Lake10 Opening the airway

 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 Prophylaxis against Aspiration

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 Cervical Spine Injury

 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 Protection of the Cervical Spine

Modify for suspected spinal injury: 1. Tongue/jaw lift 2. Modified jaw thrust MANUAL TECHNIQUES

Jaw thrust technique may be needed if C-spine injury

 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 Indications for Endotracheal Intubation

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 mEq/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 of Anesthesia

Non-depolarizing  Vecuronium Minimal cardiovascular effect Long duration of action (may exceed 90 mins) Shorter onset than Pancuronium 0.1 mg/kg Induction Agents

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 ( mg/kg IV) 4 Pretreatment (optional) with sedative (midazolam) and/or opioid analgesic (fentanyl) 5 Induction agent (etomidate, 0.3 mg/kg IV, or ketamine, 2-3 mg/kg IV) plus succinylcholine ( 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) 8 Confirmation of correct endotracheal tube placement: bilateral auscultation plus end-tidal CO 2 confirmation Rapid-Sequence Induction

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®

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®

Combitube® Insertion

 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 COMBITUBE/ESSENTIALS

LMA

 Advanced airway  Useful alternative for “difficult intubation”  Easy to use  Sits on larynx - Protects lungs? LMA

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

Surgical Cricothyrotomy – Contraindications (relative) Age < 8 years (some say 10) evidence of fx larynx or cricoid cartilage evidence of tracheal transection Airway & Ventilation Methods: ALS

Jet Ventilation – Usually requires high-pressure equipment – Ventilate 1 sec then allow 3-5 sec pause – Hypercarbia likely – Temporary: mins – High risk for barotrauma Airway & Ventilation Methods

 Swelling and hematoma acute airway obstructin  Chemical or thermal injury laryngeal edema 47 Facial and Pharyngeal Trauma

 Intraoral hemorrhage  Pharyngeal erythema  Change in voice 48 Indication For Early Intubation

1. Maxillary and Mandibular Fx Mask ventilation difficult 2. Mandibular Fx endotracheal intubation easier 49

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 50

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

Full stomach Uncertain cervical spine Uncertain airway Blood Airway injury (larynx, cricoarytenoid cartilage) Skull base fracture Uncertain volume status Uncooperative/combative Hypoxemia Increased ICP Table Factors That May Be Relevant during Intubation of a Head-Injured Patient

 A single episode of hypoxemia ( < 60 mmHg) in sever TBI doubling of mortality  A single episode of hypotention (SBP < 90 mmHg) in sever TBI doubling of mortality  Hypotention + hypoxia threefold increase in mortality 53 TBI

 >60 mmHg  SBP > 90 mmHg  Fluid resuscitation euvolemic state  HCT >30 %  Paco2 :30-35 mmHg 54 Recommendation in TBI Patients

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