5.TraumaAirwayMGMT

8/9/2019 5.TraumaAirwayMGMT

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Initial Assessment of the

Trauma Patient

www.gims-org.com


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ATLS Guidelines

Systematic approach necessary to rapidly

identify injuries and stabilize the patient

This approach is divided into:

1. Primary Survey

2. Resuscitative Phase

3. Secondary Survey4. Definitive Care Phase


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ABCDE


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Airway Management in the

Trauma Patient


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Objectives of Airway Management

& Ventilation

Primary Objective:

Provide unobstructed passage for airmovement

Ensure optimal ventilation

Ensure optimal respiration


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Airway

Patency is primary

Obstruction in trauma patients

Tongue Swelling

Foreign Body

Blood and secretions


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Airway

Evaluation begins by asking the patient a

question such as 'How are you?

A response given in a normal voiceindicates that the airway is not inimmediate jeopardy; a breathless, hoarseresponse or no response at all indicates

that the airway may be compromised.


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Airway

Mechanical removal of debris, chin lift

and/or jaw thrust maneuver, are usefull inclearing the airway in less injured patients

If there is any question of an adequateairway, severe head injury, profoundshock, severe facial trauma, voice

changes, then definitive airway control isnecessary


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Airway & Ventilation Methods

Supplemental Oxygen

increased FiO2 increases available oxygen

objective is to maximize hemoglobinsaturation


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Airway Maneuvers

Chin lift

Jaw thrust

(Neck extension iscontraindicated)

Airway Devices

Oropharyngeal airway

Nasopharyngeal

airway BVM


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Assessment & Recognition of Airway &Ventilatory Compromise

Visual Assessment

Position

tripod

orthopnea Rise & Fall of chest

Paradoxical motion

Audible gasping,

stridor, or wheezes Obvious pulm edema

Visual Assessment

Skin color

Flaring of nares

Pursed lips Retractions

Accessory Muscle Use

Altered Mental Status

Inadequate Rate ordepth of ventilations


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Gastric Distention

Common when ventilating without intubation

pressure on diaphragm

resistance to BVM ventilation

avoid by increasing time of BVM ventilation


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Orotracheal Intubation- preferred in almostall situations Indications

present or impending respiratory failureapnea

unable to protect own airway (GCS


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Surgical Cricothyrotomy

Indications

absolute need for a definitive airway AND

unable to perform ETT due for structural or anatomicreasons, 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 effectiveventilation and respiration


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Airway & Ventilation Methods: ALS

Surgical Cricothyrotomy

Contraindications (relative)

Age < 8 years (some say 10)

evidence of fx larynx or cricoid cartilageevidence of tracheal transection


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Needle Cricothyrotomy & Transtracheal JetVentilation

Indications

Same as surgical cricothyrotomy along withContraindication for surgical cricothyrotomy

Contraindications

caution with tracheal transection


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Airway & Ventilation Methods:

Jet Ventilation

Usually requires high-pressure equipment

Ventilate 1 sec thenallow 3-5 sec pause

Hypercarbia likely

Temporary: 20-30

mins High risk for

barotrauma


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Pharmacologic Assisted Intubation (RSI)

Sedation

Used for

induction

anxious or agitated patient

Contraindications

hypersensitivity

hypotension (e.g. hypovolemia 2to trauma)


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Neuromuscular Blockade

Induces temporary skeletal muscle paralysis

Indications

When Intubation is required in a patient who

is awake,

has a gag reflex, or

is agitated or combative


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Neuromuscular Blockade

Contraindications

Most are specific to the medication

inability to ventilate patient once paralysis is induced

Advantages

reduces risk of laryngospasm


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Disadvantages & Potential Complications

Does not provide sedation or amnesia

Provider unable to intubate or ventilate after NMB

Aspiration during procedure

Difficult to detect motor seizure activity

Side effects and adverse effects of specific meds


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Tension Pneumothorax


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Recognizing Life ThreateningEmergenies

Aka, When to pee in your

pants in the trauma bay


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Tension Pneumothorax

Signs and Symptomssevere respiratory distress or absent lung sounds (unilateral usually) resistance to manual ventilationCardiovascular collapse (shock)

asymmetric chest expansion

anxiety, restlessness or cyanosis (late)

JVD or tracheal deviation (late)


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Great Vessel Injury


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Aortic Transection

Signs:

- widened mediastinum, 1st rib fx, apical capping,left hemothorax, tracheal deviation to right

- widening from bridging veins and arteries, notaorta itself

- need aortic evaluation in pts with significant

mechanism (deceleration injuries), usually tearsat ligamentum

- 90% of patients die at the scene


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Cardiac Tamponade


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Cardiac Tamponade

Becks triad:

- hypotenstion, jugular venous distention,and muffled heart sounds

- causes decreased diastolic ventricular

filling and resultant hypotension

- echocardiogram shows impaired diastolicfilling of right atrium initially (1st sign)


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Traumatic Brain Injury

Epidural Hematoma SA Hemorrhage


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TBI:

High index of suscpicion in any patient

with history of or identifiable evidence ofaltered level of consciousness

Best determined by GCS (a decrease ofeven 1-2 points is indicative of significantchange in neurological status)

Pupillary function

Lateralizing signs


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Solid Organ Injury

Splenic Laceration Liver Laceration


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Solid Organ Injury

25% of all trauma victims require an

abdominal exploration

Blunt trauma caused by MVCs, MCCs,falls, assaults, and auto vs. pedestriansremains the most frequent mechanism ofinjury

High index of suspicion in those patientswith c/o abdominal pain, and/or objectivefindings on exam (seatbelt sign)


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Hemorrhage

Pelvic fracture


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