8/24/2016 TRAUMA.

ORG:CriticalCare:InitialTraumaAssessment

InitialTraumaAssessmentTheAnaesthetist'sRole

IanZunderMDFRCPC,DepartmentofAnaesthesia
OttawaCivicHospital,UniversityofOttawa,Ottawa

Objectives
Followingthislecture,theparticipantshouldbeable:

1. Toadoptanorganizedapproachtoairwayofthetraumapatient
2. Tobeawareoftheoptionsavailabletoprovide/secureanairwayinthe
traumapatient
3. Tobeawareofthecontroversiesregardingvariousdrugs/techniquesused
tosecuretheairwayinthetraumapatient
CRITICALCARE
Introduction
Traumaistheleadingcauseofdeathinthefirstfourdecadesoflifewithin
modernindustrializedcountries.

Deathfromtraumahasatrimodaldistribution:

1. withinsecondstominutes,
2. minutestohours(GOLDENHOUR),
3. severaldaysorweeksaftertheinitialinjury.
Traumacutsacrosstheentirefieldofmedicine,requiringthephysiciantohave
abroadknowledgebaseoftreatmentprinciplesandanappreciationformultiple
varietiesofinjury.Anorganizedconsistentapproachtothetraumapatient
affordsanoptimaloutcome.

TheAdvancedTraumaLifeSupport(ATLS)CoursewasdevelopedinNebraska
andsoonadoptedbytheAmericanCollegeofSurgeonsin1979.Theprimary
focusofATLSisonthefirsthouroftraumamanagement,whenrapid
assessmentandresuscitationcanbecarriedouttoreducedeathswithinthe
GoldenHour.

Today,thiscourseistaughtthroughouttheworld.Involvementofanaesthesia
personnelintraumaresuscitationiscommonplacewhetheritbeinthesmall
countryhospitalorthebigcityTraumaCenter.Anaesthetistsnowtakean
activepartintheteachingofATLSskills,especiallywithregardstoairway
management.Coursecontentandrecommendationshavechangedoverthe
yearstoreflecttheinsightoftheanesthesiaproviders.

Thislecturewillfocusonourroleasanaesthetistsinthe"primarysurvey"as
definedbytheATLS.

Duringtheprimarysurvey,lifethreateningconditionsareidentifiedand
managementisbegunsimultaneously.

1. AAirwaymaintenancewithcervicalspinecontrol
2. BBreathingandventilation
3. CCirculationwithhemorrhagecontrol
4. DDisability:neurologicalstatus
5. EExposure:completelyundressthepatient
Asananaesthesiaprovider,ourskillswiththeAirway,Breathingandventilation
areoftencalledupon.Itisimportanttorememberthatitisimpossibleto
completelyisolateeachcomponentandthatinreality,thesemanagementgoals
areinterrelated.

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Airway/Breathing
Allpatientsshouldbetransported/treatedinitiallywithsupplemental
oxygen.

Aswell,immobilizationofthecervicalspineistheacceptedstandardofcareto
preventsecondaryneurologicinjury.Themosteffectivedeviceforthispurpose
isthehalovestalthoughittendstobeinappropriateintheemergencysetting.
Themostpracticalapparatusisacombinationofahardcollarandsandbagson
oppositesidesofthehead.Tapeisthenextendedfromonesideofthespine
boardovertheforeheadofthepatienttotheoppositesideoftheboard.This
providesnearcompletecessationofmovement.(1)Onitsown,ahardcollar
providesonlymoderateprotectionandasoftcollaroffersminimalbenefit.

Begintheassessmentbyestablishingverbalcontactwiththepatient.Clear
phonationbythepatientestablishesthattheairwayispatent.

Furtherinterventionwilldependon:

a. neurologicstability
b. adequacyofgasexchangeandthepotentialforairwaycompromise(i.e
Breathingandventilation)

ASSESS:NeurologicalStability
Adepressedlevelofconsciousnessisconsideredtobeintracranialpathology
untilprovenotherwise,althoughalteredmentationisoftenduetodrugs,
alcoholormedicalcauses.

Abriefneuroexamcanbedoneduringtheprimarysurvey:

AAlert
VrespondstoVerbalstimuli
PrespondstoPainfulstimuli
UUnresponsive

OnecanalsodeterminetheGlasgowComaScale(GCS).Itisgenerallyaccepted
thataGCS<8requiresdefiniteairwayinterventiontopreventaspiration
pneumonitis,toinsureadequateoxygendeliveryandtoavoidhypercarbia.Ifa
patientisrespondingonlytopainfulstimuliorisunresponsive/unconscious,the
GCSisorhasahighlikelihoodofbeinglessthan8.

ASSESS:AdequacyofGasExchangePhysicalExamination

Airwaypatencydoesnotinsureadequateventilation.Look

Whatisthenatureoftheinjury?Maxillofacialtrauma/airwayburnshavethe
potentialforairwaycompromise.Isthereobviousairwayorchesttrauma
(suckingchestwounds,flailsegments)orcyanosis?

Istheretachypnea,useofaccessorymusclesofrespirationorevidenceof
trachealshift?

Listen

Stridorindicatesupperairwaycompromise.Hyperresonancetopercussion/lack
ofairentrysuggestspneumothoraxwhiledullnesstopercussion/lackofair
entrysuggestshemothorax.(Notethatthisisoftendifficulttodetermineinthe
settingofanoisyresuscitationroom)Bowelsoundsinthechestmaybe
indicativeofaruptureddiaphragm.

Feel

Placeahandoverthemouthandfeelforairexchange.Ifnecessary,inserta
fingerandsweeptoclearthemouthofanyforeignbodies(especiallydislodged
teeth)andtoevaluateforevidenceofmaxillofacialtrauma.

ASSESS:AdequacyofGasExchangeMonitoring/Laboratory

Pulseoximetrygivesimmediatefeedbackalthoughitisnecessarytobeawareof
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Pulseoximetrygivesimmediatefeedbackalthoughitisnecessarytobeawareof
itspitfalls(motion,peripheralvasoconstriction,carboxy/methaemoglobinemia).
Theonlyparametermeasuredbyoximetryishaemoglobinsaturation.

Arterialbloodgasesprovideamorecompletepictureofthepatientalthough
thereisadefinedwaitingperiod(institutiondependent).Resultsprovide
feedbackonoxygenation,ventilationandtissueperfusion.

Intervention
Cansurgicalinterventionsuchastubethoracostomyresolvetheproblem?If
not,basictoadvancedairwaymeasuresmustbeinitiated.

SecuringtheAirway
Ifadecisionismadetosecuretheairwaywithanendotrachealtube,several
questionsarise.

1)Howquicklymusttheairwaybesecured?

Airwayinterventioncanbeclassifiedasbeingimmediate,emergentorurgent.
(2)

Immediate

Ifapneaisevidentontheprimarysurvey,immediateendotrachealintubationis
warranted.

However,simplemechanicalmeansofopeningtheairwayandproviding
ventilationshouldnotbeoverlookedintherushtointubate.Aspreviously
noted,inspectthemouthforforeignbodies.Bloodandsecretionsshouldbe
suctioned.Breathingshouldbeassistedwithbagmaskventilationas
preparationsaremadetointubate.Considerationofpossiblespinalcordinjuries
ordirecttraumatictrachealinjuriesshouldnotpreventattemptsatlifesaving
translaryngealintubation.

Emergent

Patientswhoarehypoventilating,havesignificantheadinjury,orarecyanotic
requireemergencyinterventiontoestablishapatentairwayandeffective
ventilation.Occasionally,openingtheairwayandprovidingbagvalvemask
ventilationsufficientlyimprovesoxygenationtoallowuseofamoreelective
methodoftrachealintubation.Otherwise,thesepatientsshouldbetreatedas
above.

N.B.Inbothimmediateandemergentintubations,donothesitatetoproceedto
asurgicalairwayifinitialattemptsareunsuccessful.

Urgent

Patientswithburns,maxillofacialinjuryandcervicalhematomaswilllikely
requireasecureairwaytopreventupperairwayobstruction.Patientswithchest
wallandpulmonaryinjuriesareusuallyinitiallywellcompensatedbutmay
eventuallyrequiremechanicalventilation.Withthesepatients,thereisoften
timeforahistory,appropriatephysicalexamandcervicalradiographssuchthat
aplannedapproachtotheairwaymaybeundertaken.

2)Whichrouteofintubationistobeemployed?(oralvs.
nasal)

PriortothemostrecentrevisionoftheATLScourse,averysimplisticapproach
totheairwaywastaken(seefig.1).Blindnasotrachealintubationwasheavily
relieduponalthoughmostanaesthetistsaremorecomfortablewithdirect
orotrachealintubation.

Blindnasotrachealintubationrequiresaspontaneouslybreathingunconscious
orcooperativeconsciouspatient.Thereisanunacceptablefailurerate(35%)
anditrequires3.7vs.1.3oralattempts.Nasalintubationsarecontraindicated
inthepatientwithbasalskullormidfacefracture.Theprocedurecan
precipitateepistaxiswhichmayinterferewithsubsequentalternativeattempts
atintubationifunsuccessful.Thereisahighincidenceofsinusitisifatubeisleft
inplacegreaterthan72hours.

Currentteachingrecognizestheintegralroleoftheanaesthesiaprovider.The
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Currentteachingrecognizestheintegralroleoftheanaesthesiaprovider.The
mostimportantdeterminantofwhethertoproceedwithorotrachealor
nasotrachealintubationistheexperienceofthephysician.Bothtechniquesare
safeandeffectiveifperformedproperly.(3)

3)Whatisthestatusofthecervicalspine?

N.B.Assumethecervicalspinetobeunstableuntilprovenotherwise.

Upto50%ofpatientssustainingcervicalspinetraumadevelopneurologic
abnormalitiesrangingfromnerverootcompressionandweaknesstoquadri
plegia,andinmanyinstances,death.Asmanyas10%ofpatientwithcervical
spinalcordinjuryareinitiallyneurologicallyintact,butdevelopdeficitsduring
thecourseofemergencycare.(4)

Theradiographicdictum"oneviewisnoview"isnowheremoreaptthaninthe
roentgenographicevaluationofacutespinalinjury.(i.e.asinglecrosstable
lateralisnotenough).Inthelateralview,onemustbeabletodemonstrateall
7cervicalvertebraeandpreferablyincludingT1asapproximately30%of
injuriesoccurattheC7T1level.

TheAPviewisassessedforverticalalignmentofthespinousandarticular
processandabnormalitiesinjointanddiscspaces.

Theopenmouthviewisusedtoassesstheintegrityoftheatlantooccipitaland
atlantoaxialjointsaswellastheodontoidprocess.

Obliqueviewsmaybeusedtodetailmoreclearlytheintervertebralforamenand
thevertebralarches.

Mostauthorsfeelthatatechnicallyadequate,normalthreeviewseriescanbe
usedtocleartheCspinewhenthereisappropriatecorrelationwiththeclinical
picture.

PleuridirectionalandCTscanningareusedtoruleoutinjurywhentheplain
radiographsaresuspiciousorequivocalorwhenthereisclinicalevidenceofa
cordinjurydespitenegativeradiographs.

Thelateralcervicalspinehasasensitivityofabout85%.Thisincreasesto92%
inathreeviewseriesandupto100%whenselectiveCTscanningisemployed.
(5)

RadiographicAnalysis

AnaesthetistsshouldbeskilledatbasicinterpretationoftheCspinefilms.
Secondaryspinalinjuryisoftenaresultofmisinterpretationoffilms.

WhenreadingaCspinefilm,concentrateon:

1. softtissue
2. vertebralalignment
1)Abnormalsofttissuecanprovidesignificantinformationwithregardstothe
localizationofCspinetrauma.Aprevertebralhematomaisusuallyassociated
withafractureandshoulddrawattentiontoahyperextensioninjury.Normally,
thedistancebetweentheposteriorpharyngealaircolumnandtheanterior
inferioraspectofC2islessthan7mm.andthedistancefromC6shouldbe22
mm.inadults(notvalidwhenNasogastric/Orotrachealtubesareinplace).

2)Normally,thecervicalspinehasalordoticcurve.Somecontendthattheloss
oflordosisissuggestiveofmusclespasmandCspineinjuryalthoughthisisnot
totallyreliable.Spinalmusclesdonotplayasignificantroleinneckstability.
Instead,itismainlydependentontheligamentousandbonycomplex.

Fourlinescanbedrawntoassessalignment:

anteriormarginofthevertebralbodies
posteriormarginofthevertebralbodies
spinolaminarline

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spinousprocesses

Disruptionofanyoneofthesesmoothlinesaresuggestiveofinjury.

BiomechanicalstudiesbyWhiteandcoworkers6haveshownthatinstabilityof
thecervicalspineexistsif1)alltheanteriororposteriorelementsare
destroyed,2)thereisgreaterthan31/2mmhorizontaldisplacementofone
vertebralbodyontoanother,or3)thereisgreaterthan11degreesofkyphotic
hyperangulation.Additionalhelpfulfindingsincludewideningofthe
intervertebraldiskspace,prevertebralhematomaanddisplacementofthe
apophysealjoints.

4)HowdoairwaymanagementtechniquesaffectCspine
movement?

BasicAirwayManeuvers

Inastudywhereallligamentsinacadavericmodelweretransectedbetween
C56leavingonlythemusclesintact,variousairwaymanagementtechniques
wereappliedwithandwithoutcollarsusedtosplinttheunstablespine.Achin
lift/jawthrustproducedsignificant(>5mm.)increaseindiscspacedespitethe
presenceofeitherahard/softcollar.Likewise,oralendotrachealintubation
(curvedorstraightblade)produceda34mmincreaseindiscspace.In
contrast,oral/nasalairwayinsertionwasresponsiblefor2mmposterior
subluxation(i.eminimalchange).(7)

AdvancedAirwayManeuvers

Inanotherstudy,agroupofhealthy,anaesthetizedandparalyzedvolunteers
scheduledforelectivesurgerywereinvestigatedforcervicalspinemovement
duringintubation.Significantmovementwasnotedduringroutineintubation
regardlessofbladechoice(Macintoshvs.Miller).ThepresenceofaPhiladelphia
collarwasinconsequential.However,therewasasignificantdecreaseincervical
spinemovement(notcompleteelimination)duringorotrachealintubationwhen
thepatientwasplacedonashortspineboardandanassistantapplied"inline
immobilization".(8)

CricoidPressure

Cricoidpressureisconsideredthestandardofcareinthetraumapatient.
Sellick'smaneuverincreasestheconvexityofthecervicalspine,stretchesthe
esophagustaut,andthusimprovesitsfixationbytheposterioraspectofthe
cricoidcartilage.

Apotentialconcernexistsregardingtheapplicationofcricoidpressureagainsta
potentiallyunstableCspine,especiallyattheC57level.Someauthorsstate
thatinstabilityatthislevelisacontraindicationtocricoidpressure.However,
thisappearstobemoreofatheoreticalthanpracticalconcern.Inmany
situations,thestatusoftheCspineisnotclearlydefinedwhenairway
managementisinitiated.Aswell,informationfromlargevolumetraumacenters
wherecricoidpressureisroutinelyapplieddoesnotrevealanincreased
incidenceofsecondaryneurologicinjury.

Contraindicationstotheapplicationofcricoidpressureare:

1. Suspectedairwayinjury(especiallyinjuriesatthecricotrachealjunction).
2. Foreignbodyatthelevelofthecricoid(eitherwithintheesophagusor
thetrachea).
3. Activevomiting.
4. Awakeintubationorlightlysedatedpatient.
5)Ifthespineisunstable,shouldtheairwaybesecuredwith
thepatientawakeorasleep?

Theoptimalmodeofintubationiscontroversial.Aspartoftheearlyefforts
aimedatreducingsecondaryneurologicinjury,ahypothesiswasgeneratedthat
theairwayofpatientswithunstablecervicalspinescouldnotbesafelymanaged
byoralintubation.Althoughneverproven,itwasassumedthatmovement
associatedwithoralintubationand"inlineimmobilization"wouldleadto
secondaryneurologicinjury.(9)Sudermanetal(10)showednodifferencein
newneurologicdeficitsinastudycomparingawakevs.anaesthetizedoral/nasal
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newneurologicdeficitsinastudycomparingawakevs.anaesthetizedoral/nasal
intubationsinatenyearreviewof150patients.Rosen(11)haslabeledthis
unsubstantiatedhypothesisasa"therapeuticlegendofemergencymedicine".
Therearenumerousstudiesshowingthatinductionofanaesthesiaandoral
intubationinneckinjuredpatientsresultsinoutcomessimilartothosepatients
undergoingawakeintubation.

Optimumcaredoesnotnecessarilymeanthesamecare.Differentcentresmay
choosedifferentapproachesaslongastheessentialelementsarepreserved.(9)

6)Whichdrugsaremostappropriateinthetraumasetting?

Securingtheairwaycanbeperformedwithorwithoutpharmacologic
assistance.

Patientswithmaxillofacialtrauma,evidenceofairwayobstruction/injuryor
otherobjectiveevidencewhichmaysuggestadifficultlaryngealvisualization
shouldhavetheirairwaysecuredwhileawake.Considertheuseoflocal
anaesthetictopicalizationwith/withouttheadditionofsedativemedication
(e.g.fentanyl/midazolam).

Forthepatientwithanticipatednormalanatomy,arapidsequenceintubationis
anappropriatechoice.Ifpossible,thepatientispreoxygenatedfor35minutes
oraskedtotakeseveralvitalcapacitybreaths.

Precurarization(whenconsideringtheuseofsuccinylcholine)

Cons

1. Largerdosesofsuccinylcholinearerequiredandonsetmaybedelayed.
2. Durationofactionmaybeincreasedandretardthereturnto
spontaneousbreathingifventilation/intubationisunsuccessful.
3. Aprecurarizationdosemayleadtoaspirationofgastric/pharyngeal
contents.

Pros

1. dTCattenuatestheincreaseinintragastricand?intracranialpressure.
SupplementalDrugs

Inhemodynamicallystabletraumapatients,rapidsequenceinductionislikelyto
produceanexaggeratedhemodynamicresponsethatmaybeassociatedwith:

1. Increasedmyocardialoxygenconsumption(detrimentaltothepatient
withischemicheartdisease)
2. Elevationofintracranialpressure(detrimentaltothepatientwithhead
injury)
3. Elevationofintraocularpressure(detrimentaltothepatientwithopen
eyeinjury)

Theuseoftitrateddosesofnarcotics,shortactingblockers(e.g.esmolol)
andlidocaine,whetheraloneorincombinationcanbebeneficialin
attenuatingtheresponsetolaryngoscopy/intubation.

InductionAgents

Alargevarietyofintravenousinductionagentsareavailablefortherapid
sequenceinductionofanaesthesia.Withthepossibleexceptionofketamine,
thesedrugsareallcardiovasculardepressantsandshouldbeadministeredin
reduced(2550%ofnormal)doses.Inseverelyhemodynamicallycompromised
patients,theseagentsshouldbeomittedentirely.Themostcommondruggiven
attraumacentresthroughouttheworldforthepurposeofintubationissodium
thiopental.AlthoughnotavailableinCanada,etomidatehasgainedpopularity
becauseofitssupposedhemodynamicstabilityineuvolemicpatientsatusual
inductiondoses.

MuscleRelaxants
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MuscleRelaxants

Itistheopinionofthisauthorthatsuccinylcholineisstillthedrugofchoicefor
intubationofthetraumapatient.Atthetimeofwriting,noneofthenon
depolarizerscanmatchsuccinylcholineineitheritsspeedofonsetoroffset.

Succinylcholine:

1. Doescauseanincreaseinintragastricpressurebutalsocausesa
simultaneousincreaseinloweresophagealsphincter
2. tonewhichwillpreventaspiration.
3. Probablydoesnotcauseanelevationinintracranialpressure.(12)
4. Maycauseanincreaseinintraocularpressurealthoughthiscanbe
attenuatedbyanondepolarizingprimer.
5. DoescauseanincreaseinK+althoughthisisnotanissueinthepatient
withnewonsetparalysisfromtraumawhorequiresairwayintervention
intheresuscitationroom.Itisapotentialprobleminthepatientwith
massivecrushinjury.
6. Rarelycausescardiacdysrhythmiasinadultpatientsandpretreatment
withatropinewillattenuatepediatricbradydysrhythmias

Contraindicationstosuccinylcholineinclude:

1. thepatientwithmalignanthyperthermia
2. ongoingneuromuscularpathology
3. underlyinghyperkalemiaregardlessofetiology
NondepolarizingMuscleRelaxants:

Theuseofthesedrugsavoidsthepotentialcomplicationsfromsuccinylcholine.
However,largedosesoftheseagentsarerequiredtoproduceanacceptable
onsettime.Thisgreatlyincreasesthedurationofactionofthedrug.

Thedrugofchoiceatthepresenttimeisvecuroniumwhichisgiveninadoseof
0.15.0.25mg/kg.Ithasnocardiovasculareffects.Althoughmivacuriumhasa
shortdurationofaction,ithasalongonsettime.Increasingtheinductiondose
wouldspeedonsetattheexpenseofunacceptablehistaminereleaseand
hypotension.RocuroniumwillprobablybecometheNDMRofchoiceonce
availableinCanadaasithasanevenshorteronsettimethanvecuronium.

Whatdoyoudowhentheairwaycannotbesecuredwith
traditionaltechniques?

Thefollowingisalistofalternativetechniquestosecuretheairway:

GumRubberBougie

Whenthisdeviceisplacedinthetrachea,onecansensethe"bumps"ofthe
trachealringsincontrasttothesmoothsensationoftheesophagus.The
endotrachealtubeisthenfedoverthebougie.

LightedStylet

AgoodtechniqueforthepatientwithpotentialCspineinjuryastheneckis
maintainedintheneutralposition.However,mostofthecommerciallyavailable
styletsrequirelowlightlevelsandconcomitantresuscitationmaybeslowed.
Newermodelsclaimsuperiorbrightnesssuchthatdimmingtheroomlightsmay
nolongerberequired.

FiberopticBronchoscope

Thistechniquerequiresconsiderableexpertiseaswellasacooperativepatient.
Itisbesttousethelargestscopepossibleasairwaybleedingand/orsecretions
maylimitsuccess.
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Tip:attachoxygensourcetosuctionportsoastobothoxygenatethepatient
andclearsecretions.

RetrogradeorTranslaryngealRoute

Thisisprobablytherouteofchoiceinthesettingofmaxillofacialtrauma.
Varioustechniqueshavebeendescribed.(13,14)Thecommondenominatoris
thepassageofaneedle/wiresystemthroughthecricothyroidmembraneup
intotheoropharynxwithsubsequentantegradethreadingofanendotracheal
tubeoverthewireintothetrachea.

CricothyroidPuncture

Allanaesthesiaprovidersshouldbefamiliarwiththisskill.Equipmenttoperform
thisprocedureshouldbeimmediatelyavailable.Personnelshouldbereadily
availabletoproceedtoaformalcricothyroidotomyortracheostomy.

LaryngealMask

Thelaryngealmaskisusedforthe"cannotintubate,cannotventilate"scenario.
Itisrelativelyeasytoinsertalthoughalearningcurvedoesexist.Itcanbe
placedblindlyorwiththeaidofalaryngoscope.Rememberthattheairwayis
notsecurewithalaryngealmask.Itisastopgapmeasureonly.

Combitube

TheCombitubeisafieldairwaydevicewhichisinsertedblindlyintothe
esophagusandallowsforindirectventilationviaadoublelumendesign.Itisthe
opinionoftheauthorthatthisisthetubeofchoiceforthe"cannotintubate,
cannotventilate"scenario.Nolearningcurveexistsanditissuperiortothe
laryngealmaskforairwayprotection.

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5.RossS.E.etal.ClearingtheCervicalSpine:InitialRadiologicEvaluation.J.Trauma
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8.MajernickTGetal.CervicalSpineMovementDuringOrotrachealIntubation.Ann
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BloodFlowVelocity,orTheElectroencephalograminPatientswithNeurologicInjury.
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13.BarriotP,RiouB.Retrogradetechniquefortrachealintubationintraumapatients.Crit
CareMed16:771214

14.KingHK.etal.Tranlaryngealguidedintubationfordifficultintubation.CritCareMed
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