Transcript Trauma Airway Management

Airway Management
in Trauma
Trauma Conference
UW Hospital and Clinics
Karen D. Serrano, MD
EM-2 Resident
September 3, 2009
Airway management in
trauma
Unique
Challenges
Airway assessment
Can the patient talk?
Quality of respirations?
Mental status?
Facial trauma with massive bleeding?
Neck hematoma compressing airway?
Oxygenating well?
Ventilating well?
Impending cardiovascular collapse?
Airway assessment
Indications for definitive airway
•Head injury with GCS < 9
•Midface instability or upper airway injury
•Hemodynamic instability
•Inadequate oxygenation/ventilation
•High aspiration risk
Who needs an airway?
56 yo M with blunt
trauma from MVA:
SBP 60s, HR 140,
RR of 30, O2 sats
88% on 100%
NRB.
Who needs an airway?
24 yo F in MVA. Facial
trauma with bleeding out
of nose and mouth
Who needs an airway?
44 yo M construction worker who fell off a
roof. Opens eyes to only to painful stimuli,
moans incoherently, withdraws from a painful
stimulus.
GCS?
GCS
Score
Eye opening
Verbal
Motor
1
Does not open
eyes
Makes no noise
Makes no
movements
2
Opens eyes to
painful stimuli
Makes unintelligible
sounds
Extensor response to
pain
3
Opens eyes to
loud voice
Utters inappropriate
words
Flexor response to
pain
4
Opens eyes
spontaneously
Confused, disoriented
Withdraws to
painful stimuli
Alert and oriented
Localizes painful
stimuli
5
6
Follows commands
Airway basics
1. Evaluate for difficult Airway
2. Relieve obstruction
3. Oral airway or nasal airway
4. Neck immobilization
Assume unstable c-spine injury
Difficult airway
Evaluate for Difficult Airway
Look externally
Evaluate the “3-3-2” Rule
Mallampati class
Obstruction
Neck mobility
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Difficult airway
Evaluate for Difficult Airway
Look externally
Evaluate the “3-3-2” Rule
Mallampati class
Obstruction
Neck mobility
Relieve obstruction
•
Head tilt/chin lift
•
Jaw thrust
•
Oral airway or
nasopharyngeal
airway
C-spine injury
Cervical spine injury in trauma
•
MVC 42%
•
Falls 27%
•
Violence 15%
•
Sports-related 7.4 %
Always assume an unstable cervical spine
injury
Page: Level 2 trauma. 20 yo male MVC
ejected from vehicle, can’t move arms
or legs. A cervical spine injury
suspected.
On arrival, the patient’s mental status
begins to deteriorate. Definitive
airway control is needed.
• Is direct laryngoscopy and
orotracheal intubation safe in the
patient with suspected cervical spine
injury?
C-spine injury
DL and orotracheal intubation with
manual in-line stabilization
•
Standard of care in trauma
since 1980s
•
Data from lower quality
studies in uninjured
volunteers, cadaver models,
and case series
•
Rare reports of neurologic
deterioration
Conflicting data
1993 Donaldson et al: Created an unstable posterior injury on
5 cadavers and used fluoroscopy to compare movement at
C5-C6 with various airway manuevers.
Results: DL intubation with inline stabilization reduced
subluxation and angulation at injury site compared to “crash” DL
and intubation without inline stabilization
Conclusion: manual inline stabilization limits neck motion
2000 Brimacombe et al: Used fluoroscopy to analyze spine
movement in 10 fresh cadavers with artificial unstable C2C4 injury using various airway manuevers.
Results: Subluxation occurred with all airway manuevers
except flexible fiberoptic intubation.
Conclusion: “….manual inline stabilization is generally
ineffective in preventing motion.”
Case series
Limited data in actual patients: only 9 case series
Manoach & Paladino 2007 Review of 5 case series in
which 120 patients with unstable injuries
underwent DL orotracheal intubation
• Results: no intubation-related complications
• Conclusion: probably safe
Laryngoscopic view
1993 Nolan and Wilson et al evaluated effect of
manual in-line stabilization on laryngoscopic
view
• 157 elective surgery patients who acted
as their own controls.
• Compared laryngoscopic view with
optimal positioning to laryngoscopic
view when inline manual stabilization
utilized
Laryngoscopic view
Results
Method
Grade 1
Grade 2
Grade 3
Optimal
positioning
129
26
2
Manual in-line
stabilization
75
48
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Conclusion: DL with manual inline
stabilization worsens laryngoscopic view.
Conclusions?
DL and orotracheal intubation with manual inline stabilization
• Likely does not worsen c-spine injury
• Probably worsens laryngoscopic view
“Any beneficial effects of using manual in-line stabilization with direct
laryngoscopy and orotracheal intubation must be balanced
against the potential for the practice to contribute to clinically
apparent and subtle hypoxic impairment in brain function.”
Manoach & Paladino. “Manual in-line stabilization for acute airway management of suspected cervical
spine injury: Historical review and current questions. Annals of Emergency Medicine. 2007;50:236-245.
A failed airway is a bad outcome!
Risk-benefit analysis
Direct laryngoscopy with orotracheal
intubation and manual in-line stabilization
Risk of
exacerbating
cervical spine
injury
Risk of anoxic
brain injury
from failed
intubation
Alternative airways
What are the options for
securing an airway in trauma
patients?
Glidescope
Videolaryngoscopy
Pros:
• Minimizes neck
movement
• Good at visualizing glottis
when neck unable to be
moved or mouth unable to
be opened wide
Cons:
• Difficult to pass tube
• Availability
Fiberoptic intubation
Fiberoptic
Pros:
• Good visualization
• Minimal neck motion
Cons:
• Availability
• Operator dependent
• Relatively slow
Rescue airways: LMA
Supraglottic airway
Pros:
Easy to put in
Cons:
Not a definitive
airway
Aspiration risk
? Neck movement
Intubating LMA
King LT
King laryngeal
tube
• Supraglottic airway
• Easy to use
• May be more difficult
to change to ET tube
Nasotracheal intubation
More common in pre-RSI days
• Pros:
•
• Can be done in awake patient
Cons:
• Contraindicated with facial
trauma and basilar skull fracture
• Operator dependent
• Complications:
bleeding
incorrect tube placement
Cricothyrotomy
• Surgical airway
– Incision through cricothyroid
membrane
– Indicated when oral or
nasotracheal intuation fails and
when BVM ineffective
– “can’t oxygenate, can’t
ventilate.”
Case report
46 yo M with ankylosing
spondylitis was assaulted after
leaving a bar. Reportedly
someone pushed him forward as
he was walking, causing
hyperextension of his neck. He
collapsed and became unable to
move his extremities but did not
lose consciousness. He was
immobilized with a c-collar and
backboard and transported to a
nearby hospital. CT head was
negative, but lateral c-spine
films showed bilateral jumped
facets at C4-C5.
Case report
The patient was alert and oriented
but unable to move his
extremities and had no sensation
below the clavicles. He
exhibited paradoxic abdominal
movements with respirations.
When the patient’s mental status
deteriorated, he required
emergent intubation.
How would you
intubate him?
Case report
Challenges to
securing airway:
• Limited mouth opening
• Rigid cervical spine
• Known cervical spine
injury
• Small hospital with limited
resources
Case report
How would you intubate him?
A. Direct laryngoscopy with manual in-line stabilization
B. Videolaryngoscopy (i.e. Glidescope)
C. Supraglottic airway (LMA or King LT)
D. Nasotracheal intubation
E. Grab a scalpel and do a cricothyrotomy
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Videolaryngoscope-assisted
nasotracheal intubation
• Posterior nasopharynx anesthetized
with benzocaine
• Glidescope inserted into
oropharynx
• 6-0 ET tube passed through left
nare until visualized with
Glidescope
• Intubation timed with respirations
and ET tube passed easily through
vocal cords and without neck
motion
• Transported emergently for
posterior spinal fusion
Summary
1. Airway management in
trauma has significant
challenges
2. Don’t forget airway basics
3. DL with manual in-line
stabilization
• probably safe
• may reduce success of
intubation
4. Be familiar with rescue
airways