Airway Management in Acute Trauma Setting Dr.Venugopalan .P.P DA,DNB,MNAMS,MEM [GWU] Director, Emergency Medicine ,Aster-DM Healthcare Ltd Deputy 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 ] EMCON 2014 Mumbai
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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 ]
EMCON 2014 Mumbai
Lecture focus • Why airway management
in Trauma ?• How it is different ?• What are the challenges?• How to solve it?
EMCON 2014 Mumbai
Chapter Statement ATLS [ACS]
Prevention of hypoxemia requires a protected,
unobstructed airway and adequate
ventilation, which take priority over
management of all other conditions.
EMCON 2014 Mumbai
Airway in Trauma
Priority -1
C-Spine protection
EMCON 2014 Mumbai
EMCON 2014 Mumbai
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
EMCON 2014 Mumbai
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
EMCON 2014 Mumbai
Vocal Cord spray
SLN block
Trans Tracheal anesthesia
Airway can be tricky always
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…
www.drvenu.netwww.emergencymedicinemims.com
EMCON 2014 Mumbai
EMCON 2014 Mumbai
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