Trauma - Airway . Anesthetic management & consideration

Trauma airway

1. 11
Institute for International
Emergency Medicine and Health
Department of Emergency Medicine
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA
USA
Trauma AirwayTrauma Airway

2. 22
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
ObjectivesObjectives

Trauma Airway- recognize difficultyTrauma Airway- recognize difficulty
–C-spine immobilizationC-spine immobilization

ABCD’sABCD’s

Techniques for intubationTechniques for intubation
–OrotrachealOrotracheal
–NasotrachealNasotracheal
–RSIRSI

Surgical AirwaySurgical Airway

Facial/Neck InjuriesFacial/Neck Injuries

3. 33
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Trauma AirwayTrauma Airway

Primary SurveyPrimary Survey

ABCABC
–A always comes firstA always comes first

AAirwayirway

4. 44
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Open the AirwayOpen the Airway

5. 55
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
AirwayAirway

Is the airway clear?Is the airway clear?

Can patient maintain and protect their Can patient maintain and protect their
airway?airway?

What is the natural course of this What is the natural course of this
injury?injury?

Where does patient have to go and Where does patient have to go and
what procedures will patient what procedures will patient
undergo?undergo?

6. 66
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
BreathingBreathing

BreathingBreathing
–Supplemental oxygenSupplemental oxygen

Nasal cannulaNasal cannula

Face maskFace mask

Check Gag reflexCheck Gag reflex

7. 77
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
BreathingBreathing

Noninvasive Noninvasive
airway devicesairway devices
–Nasopharyngeal Nasopharyngeal
airwayairway
–Oropharyngeal Oropharyngeal
airwayairway
–Bag-valve maskBag-valve mask

8. 88
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Two Elements of Two Elements of
BreathingBreathing
OxygenationOxygenation
–Physical signsPhysical signs
–Pulse oxyimeterPulse oxyimeter
–Blood Gas (ABG)Blood Gas (ABG)
VentilationVentilation
–Physical signsPhysical signs
–FatigueFatigue
–Blood Gas (ABG)Blood Gas (ABG)

9. 99
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
BREATHINGBREATHING

Check adequacy of ventilation with Check adequacy of ventilation with
bilateral breath soundsbilateral breath sounds

InterventionsInterventions
–Needle thoracostomyNeedle thoracostomy
–Tube thoracostomyTube thoracostomy

10. 1010
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Indications for IntubationIndications for Intubation

Cardiac ArrestCardiac Arrest

ShockShock

Severe Head InjurySevere Head Injury

Airway burnAirway burn

Penetrating neck/face woundsPenetrating neck/face wounds

Flail ChestFlail Chest

Significant Pulmonary ContusionSignificant Pulmonary Contusion

11. 1111
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Head Trauma - SignsHead Trauma - Signs

Abnormal Glasgow coma scoreAbnormal Glasgow coma score

Asymmetric or abnormal pupilsAsymmetric or abnormal pupils

Otorrhea and rhinorrheaOtorrhea and rhinorrhea

Loss of skull integrityLoss of skull integrity

Battle’s signsBattle’s signs

Periorbital ecchymoses – raccoon eyesPeriorbital ecchymoses – raccoon eyes

PosturingPosturing

12. 1212
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
The Trauma AirwayThe Trauma Airway

Difficult by definitionDifficult by definition
–Blood and secretionsBlood and secretions
–Altered mental statusAltered mental status
–The combative patientThe combative patient

C-Collar makes alignment of axis’s C-Collar makes alignment of axis’s
impossibleimpossible

Have a plan “B” and “C”Have a plan “B” and “C”

13. 1313
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Advanced Airway Advanced Airway
TechniquesTechniques

Orotracheal intubationOrotracheal intubation

Rapid sequence intubationRapid sequence intubation

Nasotracheal IntubationNasotracheal Intubation

Surgical AirwaySurgical Airway

Other optionsOther options

14. 1414
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Cervical immobilization Cervical immobilization
impedes alignment of axesimpedes alignment of axes
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C
C
AA B
A
B
C
Trachea
Pharynx
Mouth

15. 1515
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Orotracheal IntubationOrotracheal Intubation

Method of choiceMethod of choice

Suspected cervical spine injuries Suspected cervical spine injuries
require in-line immobilizationrequire in-line immobilization

Contraindications – tracheal Contraindications – tracheal
disruptiondisruption

16. 1616
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Rapid Sequence Rapid Sequence
IntubationIntubation

Consider alternatives to paralysis if Consider alternatives to paralysis if
anticipate difficulty with bag-valve-mask anticipate difficulty with bag-valve-mask
ventilation and intubationventilation and intubation

Pretreatment: Pretreatment:
–oxygenateoxygenate
–consider lidocaine (1.5 mg/kg) in head injured consider lidocaine (1.5 mg/kg) in head injured
patientspatients
–Consider defasciculating dose of Consider defasciculating dose of
nondepolarizing agent (vecuronium or nondepolarizing agent (vecuronium or
pancuronium 0.01mg/kg)pancuronium 0.01mg/kg)
–Atropine (0.02mg/kg) in pediatrics (bradycardia)Atropine (0.02mg/kg) in pediatrics (bradycardia)

17. 1717
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Rapid Sequence Rapid Sequence
Intubation cont’dIntubation cont’d

Induction : fentanyl (3mcg/kg)or midazolam Induction : fentanyl (3mcg/kg)or midazolam
(0.1mg/kg) or etomidate (0.3mg/kg); (0.1mg/kg) or etomidate (0.3mg/kg);
etomidate is drug of choice for head traumaetomidate is drug of choice for head trauma

Paralysis: succinylcholine (1-2mg/kg): fast Paralysis: succinylcholine (1-2mg/kg): fast
onset and offset – note contraindicationsonset and offset – note contraindications

Cricoid PressureCricoid Pressure

Confirm placement: ETT seen between Confirm placement: ETT seen between
cords, auscultation, O2 sat, ET CO2 cords, auscultation, O2 sat, ET CO2
detectors, fogging of the tube is unreliabledetectors, fogging of the tube is unreliable

18. 1818
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Nasotracheal IntubationNasotracheal Intubation

Higher complication and failure rateHigher complication and failure rate

ContraindicationsContraindications
–Respiratory arrest Respiratory arrest
–Maxillofacial injuryMaxillofacial injury
–Basilar skull fractureBasilar skull fracture
–coagulopathycoagulopathy

19. 1919
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
The Difficult AirwayThe Difficult Airway

National Emergency Airway Registry (NEAR)National Emergency Airway Registry (NEAR)
–31 centers US, Canada, Singapore31 centers US, Canada, Singapore
–>9000 ED intubations>9000 ED intubations
–99% intubated by three attempts99% intubated by three attempts
–> 4 attempts means airway can’t be > 4 attempts means airway can’t be
intubatedintubated
–1% failure rate1% failure rate

1% got a surgical airway1% got a surgical airway

20. 2020
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
The Difficult AirwayThe Difficult Airway

Normal airways can’t be intubatedNormal airways can’t be intubated

Literature states the 0.1% or Literature states the 0.1% or
1:10,000 patients can’t be intubated 1:10,000 patients can’t be intubated
even after being cleared pre-even after being cleared pre-
operativelyoperatively

Emergency Medicine data shows it’s Emergency Medicine data shows it’s
more difficult in traumamore difficult in trauma

21. 2121
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
The Difficult AirwayThe Difficult Airway
Have a system to identify the difficult Have a system to identify the difficult
airwayairway

22. 2222
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Characteristics of Difficult Characteristics of Difficult
airwayairway

Neck or lower face injuryNeck or lower face injury

Obese habitus/short neckObese habitus/short neck

Small Jaw- distance from chin to Small Jaw- distance from chin to
hyoid under 3 fingerbreathshyoid under 3 fingerbreaths

Limited cervical movementLimited cervical movement

Mouth opens less than 3cm wideMouth opens less than 3cm wide

Large tongueLarge tongue

23. 2323
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
The Failed AirwayThe Failed Airway

Plan “B” is adjunctPlan “B” is adjunct

Plan “C” is surgical airwayPlan “C” is surgical airway

24. 2424
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Plan “B”Plan “B”

FiberopticFiberoptic

RetrogradeRetrograde

Digital Digital

Laryngeal mask airway (LMA)Laryngeal mask airway (LMA)

25. 2525
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
LMALMA

26. 2626
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Plan “C”Plan “C”

27. 2727
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Surgical AirwaySurgical Airway

Indications: unfeasible or failed Indications: unfeasible or failed
intubationintubation

CricothryoidotomyCricothryoidotomy

TracheotomyTracheotomy

28. 2828
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Jet Insufflation for Jet Insufflation for
CricothyroidotomyCricothyroidotomy

29. 2929
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Facial Trauma – SignsFacial Trauma – Signs

HemorrhageHemorrhage

Endophthalmos, Endophthalmos,
exophthalmosexophthalmos

EcchymosesEcchymoses

Dysconjugate gazeDysconjugate gaze

DeformityDeformity

Asymmetry Asymmetry

InstabilityInstability

MalocclusionMalocclusion

Step offsStep offs

CrepitusCrepitus

Septal hematomaSeptal hematoma

30. 3030
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Special considerationsSpecial considerations

LeFort FracturesLeFort Fractures
–I: Maxilla nasal fossaI: Maxilla nasal fossa
–II: maxilla, nasal bones, medial aspects II: maxilla, nasal bones, medial aspects
of orbitsof orbits
–Maxilla, zygoma, nasal bones, Maxilla, zygoma, nasal bones,
ethmoids, vomer, lesser bones of the ethmoids, vomer, lesser bones of the
cranial basecranial base

31. 3131
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
LeFort FracturesLeFort Fractures

32. 3232
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Management of facial Management of facial
traumatrauma

CT scanCT scan

Panoramic view of mandiblePanoramic view of mandible

May delay repair (antibiotics)May delay repair (antibiotics)

33. 3333
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Traumatic AsphyxiaTraumatic Asphyxia

Deep violet color of the head and neckDeep violet color of the head and neck

Bilateral subconjunctival hemorrhagesBilateral subconjunctival hemorrhages

Facial edemaFacial edema

Condition benign and self limitedCondition benign and self limited

Associated intrathoracic injuryAssociated intrathoracic injury

1/3 lose consciousness1/3 lose consciousness

34. 3434
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
SUMMARY SUMMARY

Airway problems common in trauma Airway problems common in trauma
patientspatients

Head, facial and C-spine injuries Head, facial and C-spine injuries
main challengesmain challenges

Definitive airway needed but often Definitive airway needed but often
difficultdifficult

35. 3535
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
Summary contd…Summary contd…

Remember A, B,:Remember A, B,:
–A- airwayA- airway
–B- Breathing – Chest trauma.B- Breathing – Chest trauma.

Plan A- IntubationPlan A- Intubation

Plan B – Surgical Airway.Plan B – Surgical Airway.

36. 3636
©Institute for International Emergency Medicine and Health
Brigham and Women’s Hospital
Harvard Medical School
2001
??