Airway management in acute trauma setting emcon14 upload version

Airway Management in Acute Trauma Setting

Dr.Venugopalan .P.PDA,DNB,MNAMS,MEM [GWU]

Director, Emergency Medicine ,Aster-DM Healthcare LtdDeputy Director ,Academy

Founder and Executive Director – ANGELS[Active Network Group of Life Savers ]PG Teacher Emergency Medicine , National board of Examination

Faculty –ATLS [American College of Surgeons ]

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Lecture focus • Why airway management

in Trauma ?• How it is different ?• What are the challenges?• How to solve it?

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Chapter Statement ATLS [ACS]

Prevention of hypoxemia requires a protected,

unobstructed airway and adequate

ventilation, which take priority over

management of all other conditions.

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Airway in Trauma

Priority -1

C-Spine protection

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Definitive airway

Tube placed in the trachea with the cuff inflated below the vocal cords, Connected to some form of oxygen-enriched assisted ventilation, Airway secured in place

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How do I manage the airway of a trauma patient?● Supplemental oxygen● Basic techniques● Basic adjuncts● Definitive airway

● Cuffed tube in the trachea

● Difficult airway adjuncts● Unexpected difficult airway● Predicted difficult airway

Airway Management

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Airway Decision Scheme

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Challenges • Head Position to align

Intubation Axis • C-Collar • Decision to Intubate • Decision to use drug

assisted intubation

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Challenges • Alternate airway solutions• Expertise to perform

surgical airway • Maxillo Facial injuries • Airway Burns

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Video Laryngoscope

•Less neck movement •Blood in the throat •Oro-facial injuries

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Air manipulation without obtunding reflexes • Laryngospasm

• Bronchospasm• Tachycardia• Hypertension • Intracranial tension • Intra ocular tension• Vomiting

Deleterious

Airway Breathing Circulation Disability Extra

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Solutions • Lack confidence • Surgeons mania • Ketamine is safe • Suxamethonium related

issues• Rocuronium • Reversal agent for

Rocuronium

Drug assisted intubation Awake intubation with adequate airway block

Adequate training is essential

Concerns EMCON 2014 Mumbai

Venugopalan.P.P.INTEM 2010;:Nov;10-14 Ahammadabad, IND.

Ketamine in TBI ?

Effect of IV Ketamine on ICP/CPP/MAP in 8 ventilated TBI patients with ICP monitors in place

# ICP reduced # No alteration in CPP # No alteration in MAP

Albanese J.Anesthesiology 1997;87;1328.

Venugopalan.P.P.INTEM 2010;:Nov;10-14 Ahammadabad, IND.

Ketamine in TBI ?

Ketamine produced a slight reduction in ICP without increasing cerebral blood flow velocity in patients undergoing isoflurane/nitrous oxide anesthesia for craniotomy

Mayberg et al Anesth Analg 1995;81:84-89

Venugopalan.P.P.INTEM 2010;:Nov;10-14 Ahammadabad, IND.

Ketamine in TBI ?

• Several authors have recently questioned the historical dogma

• Potentially advantageous in hypotensive head injury

• No data in ED RSI population

Himmelseher s. Anesth Analg 2005;101:524

Sehdev RS Emerg Med Austral 2006;18:37

Venugopalan.P.P.INTEM 2010;:Nov;10-14 Ahammadabad, IND.

RSI: Paralytic Agents

At a dose of 1.0 mg/kg• 95% of the patients ready in 60 seconds• Success rate is comparable to

Succinylcholine • Average duration of action 45 minutes

Rocuronium

PerryJJ.Acad Emerg Med 2002;9:813.

Kirkegaard-Nielson H. Anesthesiology 1999; 19:131.

Venugopalan.P.P.INTEM 2010;:Nov;10-14 Ahammadabad, IND.

Succinylcholine & Rocuronium

• The Cochrane meta-analysis concluded “Succinylcholine created superior intubation conditions to Rocuronium when comparing both excellent and clinically acceptable intubating conditions.”

Perry J, Lee J, Sillberg VAH, et al. Rocuronium versus succinylcholine for rapid sequence induction intubation. (database online). Cochrane Database Syst Rev 2008;(2):CD002788.

Venugopalan.P.P.INTEM 2010;:Nov;10-14 Ahammadabad, IND.

Sugammadex (Bridion)

Rocuronium Antagonist

New

New

Venugopalan.P.P.INTEM 2010;:Nov;10-14 Ahammadabad, IND.

Venugopalan.P.P.INTEM 2010;:Nov;10-14 Ahammadabad, IND.

RSI- Paralytic AgentsFundamental question

Is the patient at risk for an important Succinylcholine relatedcomplication?

Succinylcholine 1.5mg/kg Rocuronium 1mg/kg

No Yes

Regional Block for intubation

•Vocal cord and Vallecular spray•Superior laryngeal Nerve block •Trans Tracheal injection to block Recurrent laryngeal nerve

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Vocal Cord spray

SLN block

Trans Tracheal anesthesia

Airway can be tricky always

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…

www.drvenu.netwww.emergencymedicinemims.com

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EMCON 2014 Mumbai