Trauma Airway Management: Myths & Pearls

Transcription

1 Trauma Airway Management: Myths & Pearls Past Present and Future G Kovacs MD MHPE FRCPC Professor, Department of Emergency Medicine & Anesthesiology Dalhousie University Halifax, NS

2 Speaker Disclosure I do not have an affiliation (financial or otherwise) with any commercial organization that may have a direct or indirect connection to the content of my presentation.

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4 Nuts and Bolts

5 Expect the unexpected V 2

6 Expect the unexpected

7 Plan ATLS and the airway Decisions C-spine Drugs Devices

8 Trauma Airway past, present and future

9 Who s Job is it? Who owns the airway.. Anesthesiology? The TTL does: - EM, GP, CC, Surgeon, - Others: EMS, RT Knowledge and Skill Experience Availablity

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11 Airway Decision Scheme

12 The Decision: Prioritization of Resuscitation?

13 Reprioritization of Resuscitation

14 Decisions

15 Intubation acuity

16 Duncan R, Thakore S. J Emerg Med. 2009

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18 Caution Protect the cervical spine during airway management!

19 All hands on neck

20 Airway and C-spine Is it much a do about nothing?

21 Deficit ectate after injury juy Prehospital phase Extrication ti Immobilization In ED Assessment Airway management

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23 Deterioration after tube Case reports Related to difficulty/# of attempts Unrestricted spine movement

24 Manoach S, Paladino L. Ann Emerg Med. 2007

25 Intubation and C-spine pearls

26 Airway Decision Scheme

27 Airway Decision Scheme

28 What is our goal? Is this a failed airway?

29 Redefining success Sample case of RSI with successful placement of ETT In head injured patient Davis et al, A Follow up Analysis of Factors Associated with Head Injury Mortality After Paramedic Rapid Sequence Intubation. J Trauma. 2005;59: Is this a successful airway?

30 The point is... The goal in airway management is OXYGENATION and VENTILATION...by any means: BMV, EGD, ETT (most definitive is a cuffed ETT)

31 Airway Decision Scheme

32 Airway Decision Scheme

33 Definitions and Drugs Rapid Sequence Induction (OR) Intubated to provide anesthesia Rapid Sequence Intubation (ED) Anesthetized/paralyzed to facilitate intubation

34 Definitions and Drugs 100 To Sux or Not to Sux 90 Propofol alone vs Propofol with Sux Optimal conditions: 30 30% vs 98% 50 P 40 P+S P P+S Naguib M. Anesthesiology 2003

35 Airway Drugs Success & Safety

36 What s new what s old? Warner K et al. J Trauma Filannysky Y, Miller P. CJEM. 2010

37 Case: single shot.22

38 In conclusion RSI is the preferred method of p intubation for patients presenting with PNI.

39 Is it? Penetrating neck injury is only a marker for airway injury Is RSI safe with a penetrating neck injury? Is RSI safe with a penetrating ti airway injury? IF using an RSI: Don t mask vent No blind device use Get it on 1st attempt t

40 Airway Decision Scheme

41 Airway Decision Scheme

42 Where do you press? Pushing on the thyroid cartilage usually helps the view With ELM/BURP most patients improved one full laryngoscopic grade. Benumof JL et.al. J. Clinical Anesthesia 1996 Pushing on the cricoid id cartilage may worsen the view With Cricoid pressure (not ELM/BURP) worsens DL view in 30% of cases Levitan R et al. Ann Emerg Med. 2006

43 Airway Decision Scheme

44 Device confusion turned out to be a difficult intubation. ti After desaturation and dbradycardia di we switched to a lightwand which h was successful. Fixation error

45 Device Confusion

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47 I can t get the tube You see this 89, 88, 86, 84

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49 Can I Bag em? YES NO

50 Can I Bag em? YES You have time NO You have NO time

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52 Have time devices

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54 No time devices

55 Airway Decision Scheme

56 Airway Decision Scheme

57 Surgical airway when, why, what & where Cricothyroidotomy vs Tracheostomy Open, 4-step, Qicktrach, Minitrach Melker, etc

58 Surgical airway when, why, what & where MacIntyre et al. Three-step emergency cricoyhyroidotomy. Mil Med 2007

59 Surgical airway

60 The future

61 Good judgment may come from experience but experience comes from bad judgment....mark Twain

62 Expect the Unexpected