Glen Bandiera, MD, MEd. FRCPC

Traumatic airway management

Objectives

1. Identify three reasons to choose RSIin trauma patients.

2. Identify the top three medications for sedation prior to RSI.

3. Describe the benefits and limitations of cricoid pressure

Case One

• Stab wound to the left chest

• BP 80/50, P 120, RR 26, JVP 8 cm

• Patient agitated

RSI –When

1.Progressive decline in GCS <8.

2.Anticipated deterioration in airway

3.Ventilatory compromise

4.Patient management

5.Therapeutic hyperventilation

6.Reduce patient workload

Reasons to delay – not urgent AND

1.Large air leak

2.Pneumothorax without decompression

3.Elective intubation/difficult airway

4.Evidence of pericardial effusion

Case One

• Stab wound to the left chest

• BP 110/70, P 110, RR 26, JVP flat

• FAST negative

• Patient agitated

• Nothing that reduces preload (including intubation)

• Ketamine if necessary, gentle sedation

Rapid Sequence Intubation

• The near- simultaneous administration of a potent sedative with a non-depolarizing neuromuscular blocking agent

• Preoxygenation with minimal ventilation

• Increase the success rate of intubation while minimizing rates of aspiration

Rapid Sequence Intubation

• Increases Success Rates (99% vs. 90%)

• Minimizes stimulation and effects on intracranial pressure

• Controls patient movement

LEMON Pnemonic

Malampatti Score

Cormack & Lehane

RSI

• Look for reasons NOT to use RSI

• There are LOTS

RSI – Who (Davis DP, Fakhry SM.)

1. Existing literature inconclusive different methodologies, variability in comparison groups

2. GCS alone to select TBI patients for RSI limited 3. Suboptimal technique and hyperventilation may

account for some of the mortality increase4. Proper training and experience with RSI appear

to affect performance 5. Success of a paramedic RSI program depends on

EMS and trauma system characteristics.

RSI – When

1.ASAP

2.Most qualified person

3.Before prolonged transport

4.Before moving to high risk area

Case Two

• Head On MVC

• BP 100/70, P 110, GCS 7, RR 18

• Obvious head injury, right pneumothorax

• Decision to intubate made

Etomidate

• Imidazole derivative

• Very hemodynamically stable

• 0.3 mg/kg

• Cerebroprotective

• 5-10 minutes

• Case reports of adrenal suppression with repeated and prolonged use

Etomidate

• Funny thing…– Myoclonus

– Up to 30%

– 30 – 120 seconds

• Answer: benzodiazepines or PARALYSIS

Ketamine

• Derivative of Phencyclidine

• Dissociative Anaesthetic

• 1-2 mg/kg IV (IM, IN)

• Cardiovascular stability

• BUT…

Ketamine – What about head injury??

• Ketamine increases Cerebral Blood flow, brain metabolism and intracranial pressure

• Emergence Reactions - Agitation– Benzodiazepines

Ketamine and Head Injury

• CPP = MAP - ICP

• Hypotension doubles mortality and morbidity from head injury

• Oxygenation is critically important

Recent Literature(Sehdev RS, Symmons DAD, Kindl K.)

• “In the modern acute management of head-injured patients, ketamine might be a suitable agent for induction of anaesthesia, particularly in those patients with potential cardiovascular instability.”

Ketamine and Head Injury (Himmelseher S, Durieux ME.)

• “ketamine does not increase intracranial pressure when used under conditions of controlled ventilation and coadministrationof a gamma-aminobutyric acid (GABA) receptor agonist”

Ketamine and Head Injury (Bourgoin A, Albanese J, et. al.)

• “ketaminewith midazolam is comparable with a combination of midazolam-sufentanilin maintaining ICP and CPP of severe head injury patients under controlled mechanical ventilation.”

Ketamine and Head Injury(Willman EV, Andolfatto G.)

• “Ketafol” – Equal parts ketamine and propofol in same syringe (0.75 mg/kg each)

• 96% effective,

• 2.6% transient hypoxia

• 2.6% emergence reaction

• 0% hypotension

Ketamine

• Funny thing – laryngospasm– 2-5 minutes

– Precludes intubation

• Answer: Forceful bagging or PARALYSIS

Cricoid Pressure

• Facilitate intubation

• Prevent regurgitation/aspiration

Surface Anatomy

Cricoid Pressure – effects on intubation

(McNelis, U. Syndercombe, A. Harper, I. Duggan, J.)

• Increase in ETT impingement with cricoidpressure

• Easily addressed with 90 degrees rotation

Cricoid Pressure (Shulman GB, Connelly NR)

• Bullard vs. fiberoptics– Bullard Faster, less failed attempts

– Cricoid Pressure affects fibreoptic intubation

Cricoid Pressure (Turgeon AF, Nicole PC.)

• CP applied by trained personnel does not increase the rate of failed intubation.

Cricoid Pressure (Butler J, Sen A.)

• “There is little evidence to support the widely held belief that the application ofcricoid pressure reduces the incidence of aspiration during a rapid sequenceintubation.”

Cricoid Pressure(Levitan, Richard M. Kinkle)

• “bimanual laryngoscopy improved the view compared to cricoid pressure, BURP, and no manipulation. Cricoid pressure and BURP frequently worsen laryngoscopy. These data suggest bimanual laryngoscopyshould be considered when teaching emergency airway management.”

Case Three

• Massive facial trauma, VSS

• Midface instability, mandible fracture

• Bleeding from mouth and nose

• Fibreoptic not helpful

• Direct visualization, retrograde, lighted stylet, bougie, SURGICAL AIRWAY

Failed Attempt, Able to Ventilate

• WHY?• Anatomy normal but difficult

– Fibreoptic, bougie, lighted stylet

• Anatomy Abnormal– Fibreoptic

• Fluid– Bougie, retrograde

• SURGICAL AIRWAY

QUESTIONS, COMMENTS, CRITICISMS, QUESTIONS, COMMENTS, CRITICISMS, CRITIQUES,CRITIQUES,