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Prehospital Trauma Care 2

Prehospital Trauma Care 2

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Published by: seigelystic on Sep 27, 2012
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11/29/2012

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PREHOSPITAL TRAUMA AIRWAY MANAGEMENT
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Please access www.medicalvillage.blogspot.com today
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 Prehospital trauma airway management is probably the biggest challenge faced by prehospitalproviders. These professionals must not only acquire but also maintain essential skills to adequatelymanage airway problems at the scene and during transport of trauma victims to trauma centers.Endotracheal intubation is the definitive method of airway management. However, to acquire suchskill requires significant training and practice. Although the emergency technician-basic (EMT-B)curriculum contains an advanced airway module, the low frequency of these procedures makes itdifficult for these professionals to maintain proficiency. In most systems, paramedics and flightnurses are the only professionals allowed to perform rapid sequence intubation (RSI). Therefore,there is a need to simpler ways to maintain a patent airway by emergency medical technicians, untilthe patient is delivered to a hospital. Several devices are now available and have been used by thepre-hospital personnel when endotracheal intubation is not practical or possible. These alternatemethods include bag-valve-mask with oral or nasopharyngeal airway, the laryngeal mask, and theesophageal-tracheal double lumen tube, popularized as Combitube.In this part of discussion, the indications for airway management in the prehospital arena, thedifferent modalities, devices and techniques, the recognition of a difficult airway, and associatedpitfalls will be discussed.WHO NEEDS AN AIRWAY?Before we define who needs an airway in the prehospital arena, it is important to clarify that fewstudies to date shown efficacy of advanced airway management in trauma prior to arrival at atrauma center.The goal of airway management is to provide adequate oxygenation and ventilation as part of theoverall resuscitation effort. Candidates include those with decreased or absent respiratorymovements, signs of airway obstruction, and cardiopulmonary resuscitation (CPR) in progress.Severe traumatic brain injury (TBI) as an indication for prehospital intubation will be discussed later.In trauma, it has been shown that moribund patients would benefit from an airway, particularlythose who are candidates for a resuscitative thoracotomy upon arrival at the hospital.
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SPECIAL MEDICAL REPORT : PREHOSPITAL TRAUMA CARE 2
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PREHOSPITAL TRAUMA AIRWAY MANAGEMENT
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Please access www.medicalvillage.blogspot.com today

 DIFFICULT AIRWAYThe Mallampati classification has beenused for many years byanesthesiologists during preoperativeevaluation for the identification of adifficult airway and to predict difficultintubation (Figure 1). It comparestongue size with the oropharyngealspace, and its reliability has beenquestioned because it does not takeinto account other factors that maymake intubation difficult or impossiblein the prehospital setting. However, if the patient is still able to follow simplecommands, direct visualization of the oropharynx by asking the patient to open the mouth will giveadditional and important information to the astute prehospital provider. Rich described the 6-Dmethods of airway management: disproportion; distortion; decreased thyromental distance;decreased interincisor gap; decreased range of motion in all or all of the joints
atlanto-occipital,temporomandibular, and cervical spine, always present in trauma; and dental overbite.Identifying a difficult airway prevents patient deterioration or death. Alternative devices andstrategies should be used when the diagnosis of a difficult airway is made. These include thelaryngeal mask airway (LMA), Combitube, or bag-valve-mask.WHICH STRATEGY SHOULD BE USED?The strategies described as follows are alternatives to conventional bag-valve-mask with either anasopharyngeal or an oropharyngeal airway.Laryngeal Mask AirwayThe LMA is one alternative to endotracheal intubation (Figure 2). Its use is particularly important inpatient
s with difficult airways (defined later) and in patients in “unfriendly” environments (rain,
dark, prolonged extrication, etc.). it also can be used as a rescue strategy following a failed RSI.Additionally, it can be used to facilitate tube intubation, which is obtained by passing theendotracheal tube through the LMA.The insertion of the LMA is done blindly into the oropharynx, and it is usually tolerated without theneed of neuromuscular blockade. The LMA lies in the hypopharynx in the supraglottic position. Thesuccessful placement of the LMA is independent of the Mallampati score, presence of a C-collar, orin-line immobilization of the neck. Spontaneous ventilation through the LMA is possible, and manualventilation through the LMA is superior to bag-valve-mask ventilation, because the latter requirestwo hands to maintain a good seal. Studies comparing the success rates have shown that paramedicsachieve higher levels of successful placement with the LMA compared to endotracheal intubation.The LMA may be particularly useful in patients with a difficult airway, since direct visualization of thecords is not required and neuromuscular blocking agents are not necessary. The advantages of the
 
PREHOSPITAL TRAUMA AIRWAY MANAGEMENT

Please access www.medicalvillage.blogspot.com today

 LMA over the Combitube (described next) include lower risk of malpositioning, no risk of esophagealintubation, and less trauma to the oropharynx. A major disadvantage of the LMA is that it doespatients with intact airway reflexes. Another limitation of MA is related to the difficulty in generatinghigh airway pressures, which may lead to ineffective ventilation.CombitubeThe Combitube consists of a device with two lumens. One of the lumens has an open distal endsimilar to an endotracheal tube, whereas the other lumen has a closed distal end, with several holesproximal to its balloon cuff. A second balloon of higher volume is located more proximally to thesides of the holes, and it is used to secure the tube in position. The Combitube is inserted blindly andallows ventilation through either lumen. Following blind insertion, the distal tip is usually located inthe esophagus. After inflating the oropharyngeal balloon, the esophageal cuff is inflated. Attemptsto ventilate through the pharyngeal lumen will determine whether the distal tip is in the esophagusor trachea. If there is no change in the colorimetric, end-distal carbon dioxide detector, or if breathsounds are absent, then the distal tip is in the trachea, and the patient should be ventilated throughthe tracheal lumen (Figure 3 and 4).The Combitube is a useful alternative to endotracheal intubation when an airway is not obtainedafter multiple attempts, when the airway is considered by a difficult one, when direct visualization of the vocal cords by laryngoscopy is not possible at the scene, or when prehospital providers are nottrained to perform orotracheal intubation. The great majority of patients brought to trauma centersafter insertion of a Combitube will be ventilating and oxygenating well, and there is no need forimmediate removal of the Combitube and the orotracheal intubation. The Combitube, is also usefulin patients with significant maxillofacial trauma and cervical spine injuries. Because the esophagealcuff is immediately inflated after tube insertion, the Combitube offers protection against aspirationof gastric contents.The Combitube is contraindicated in patients with intact gag reflex, or when upper airwayobstruction is suspected. The Combitube is not available in pediatric sizes. Potential complicationsinclude injury to the pharynx and esophagus, and failure to recognize the exact location of the distalend and attempting to oxygenate and ventilate through the wrong lumen.

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