Airway Management & Trauma Assessment

Airway Management in Pre-hospital Care

• Ensure airway upkeep, external hemorrhage control, and shock management in the pre-hospital setting.
• Prioritize immobilization and quick transfer to the closest high-level care facility.
• Obtain incident and patient history to relay to the receiving hospital.
• Early notification of a trauma center is a must for optimal outcomes.
• Make preparations for patient upon arrival and assemble the trauma team.
• Mechanism of injury and patient history are vital for predicting potential needs for injuries and their degree of severity.
• Primary and secondary assessments offer a standard priority sequence for patients with multiple injuries.
• Repeat primary and secondary assessments for vigilance for deterioration and to identify any new treatments.
• Conduct follow-up tertiary surveys after 24+ hours for injuries not readily apparent.

Major Trauma Assessment

• Rapid injury diagnosis, resuscitation, stabilization, and prevention of secondary injuries are critical.
• Essential clinical skills and knowledge in trauma care is required by every emergency physician.
• Trauma care should be available to every fragile population, regardless of trauma center access.
• Specialized trauma centers have trauma-designated areas and multidisciplinary staff.
• The majority of emergency departments (EDs) also handle trauma patients alongside an array of other ailments.
• Pre-hospital providers' and emergency nurses' knowledge is similarly crucial in rural areas or more remote areas.

ED Trauma Patient Arrival

• Trauma patients' arrival times at EDs/trauma centers vary based on: location, EMS availability, reporting time, rescue duration, and factors including transport times and location.

Historical Context Of Trauma Systems

• 'Golden hour' concept emerged due to time's impact on trauma patient outcomes.
• Adams Cowley's research showed mortality and morbidity increase with delayed resuscitation/care.
• A one-hour delay increased mortality by 10%, while a 10-hour delay upped it to 75%
• The ‘golden hour' represents a critical window in which clinicians can save lives/limbs.
• The ‘golden hour’ may apply to urban areas, while the ‘silver day’ is more realistic for remote regions like parts of Australia and New Zealand.
• Balance effective pre-hospital care with timely patient retrieval to the highest-level facility.

Decreasing Mortality and Morbidity from Trauma

• Employ a coordinated strategy with EMS, ensuring advance notice to the receiving hospital, which expedites trauma team mobilization and setup.
• Follow 'do no further harm' principles, expedite care, and facility design within the ED.
• Facility design should include trauma bay and resuscitation area, team presence, and necessary drugs/equipment for complex injuries.
• ED requires architectural strengths and creative solutions for efficient personnel use.

Trauma Resuscitation Areas

• Facilitate rapid, efficient patient evaluation with sufficient lighting, space, and equipment.
• Help ID and manage life-threatening injuries.
• Facilitate seamless integration with paramedic staff.

Essential Guidelines In Trauma Centers

• Trauma guidelines help practitioners identify, prioritize, and treat trauma patients, should be accessible via portable electronic devices, posters, laminated cards, desktop icons, or online.

Resuscitation Equipment

• Intubation tools with assorted blades, handles, and tubes must be easy to access.
• Tracheostomy and cricothyroidotomy sets.
• Laryngeal masks in various sizes.

Resuscitation Equipment and Instruments

• Chest tube insertion kits with underwater-seal drains & chest tubes (28–32F).
• Rapid-sequence induction drugs.
• Laerdal bag & masks available in different sizes.
• Ventilator and oxygen equipment.

Resuscitation: Essential Circulation Tools

• A thoracotomy tray that includes rib spreaders, long-handled instruments, vascular clamps, pledgets, and cardiac sutures is key.
• Blood and fluid warmer preferably designed for high-volume use.
• Supplies designed for venous access, both peripheral, interosseous, and central.
• A defibrillator must be available together with pediatric and internal paddles.

Miscellaneous Resuscitation Equipment

• Includes resuscitation carts which should contain ACLS drugs.
• Transport monitors include ECG, NIBP, pulse oximetry, and end-tidal CO2.
• Requires dressings, suture supplies, and splinting material.
• Gastric tubes, urinary drainage system, and FAST ultrasound machine.
• Equipment like warming devices with convection blankets.

Staff Education and Trauma Outcomes

• Skilled paramedics and nursing leaders, who understand and manage complex patient needs, is a necessity in environments needing fast decisions.
• Studies show patient outcomes improve given a good work environment, higher patient volume, high levels of clinical experience and education among nurses, and prior experience
• Pre-hospital and in-hospital trauma systems need trauma teams that are well-trained and organized.
• EDs need multidisciplinary teams with necessary skillset/knowledge in triage, surveys and adjuncts for trauma.
• Interchangeable roles best filled by most experienced clinicians when needed.
• Non-trauma centers sometimes depend on paramedics and their skills.

The Evolution of Trauma Education

• Trauma education incorporates online modules and human patient simulators, thus realism of simulation is increased and improved education outcomes.
• Standard trauma team training can improve team performance & communication.
• Literature reports on the various courses' impact on trauma patient outcomes after completion of the Advanced Trauma Life Support (ATLS) course.

Trauma Training Programs

• Variety of trauma training options exists for paramedics/nurses in Australia/New Zealand.
• Options include Trauma Nursing Program (TNP) and Trauma Nursing Core Course (TNCC)
• Advanced Trauma Care for Nurses (ACTN) and Australian Trauma Team Training are also available
• Courses such as Early Management of Severe Trauma (EMST) and American College of Surgeons Advanced Trauma Life Support (ATLS) exist
• Emergency Trauma Management Course and Emergency Management of Severe Burns (EMSB) options

Specialized Training

• Definitive Perioperative Nursing Trauma Care (DPNTC) is available.
• International Trauma Life Support (ITLS) courses also exist.
• There are also Pre-Hospital Trauma Course (PHTC) and Pre-Hospital Trauma Life Support (PHTLS) Programs
• Managing Obstetric Emergencies and Trauma Course (MOET) available
• Web-based scenarios, modules, podcasts, videos, trauma conference information & web resources are accessible.

Composition of a Trauma Team

• A specialized team of health professionals whose collective expertise aims to resuscitate trauma patients.
• Trauma teams include medical and nursing staff, but personnel can vary based on location/hospital resources
• Emergency clinicians may act as most-skilled staff members when needed, this will require them to possess a stronger skillset.

Defined Roles within Trauma Teams

• Procedures such as IV access should have members trained and assigned
• Anatomical area assessments should also be delegated
• Responsibilities have to be well-defined in trauma centers and small, rural EDs

Tasks for Specific Trauma Team Members

• Nurses and anesthesiologists manage airways
• Doctors, nurses, and paramedics assess patients and conduct FAST exams
• Doctors, nurses, and paramedics treat patients per expertise for specified procedures.

Supportive Staff

• Senior nurses can provide leadership by documenting and supporting nursing care.
• Emergency Department Assistants/orderlies help with clothing removal, warming, log rolls, transport, and cardiac massage.
• Radiographers perform X-rays within 5 minutes.

Surgical and Specialist Support

• Consultant general surgeons and intensivists provide rapid availability from within the hospital.
• Surgical registrars conduct secondary surveys, examine abdomens, and collaborate with surgical teams for decision-making.
• Medical & allied health personnel are notified for background support via a trauma paging system.
• Necessary trauma call page notifications: blood bank, biochemistry/haematology staff and operating theatre/bed management personnel.
• Specialists like neurosurgeons/orthopedic surgeons can help with patient supervision and management
• Those needing support during a particularly distressing resuscitation: social/pastoral care workers, and peer-support teams.

Maintenance of Care Through Trauma Guidelines

• Trauma guidelines define staff responsibilities and ensure quality patient care.

Early Identification Through Trauma Team Notification

• Promptly ID severely injured who need specialty resources.
• EMS plays a major role via pre-notification with essential patient status updates.
• Team members notified via overhead paging or other systems.
• A degree of over-triage is preferred to ensure capture of all severely injured patients.

Trauma Teams

• Trauma centers use 'trauma call-out' criteria to mobilize teams during major events.
• Trauma team activation traditionally relies on risk injuries and physiological criteria.
• Using injury mechanism to determine activation is ineffective as a measure of injury severity.

Trauma Team Criteria

• Recognize vital signs and injuries that require team activation, and prepare each hospital with individual criteria.
• Establish that major trauma is small compared to other presentations in smaller hospitals but the over-triage is an opportunity to improve trauma training.

Vital Sign Criteria

• Systolic blood pressure below 90 mmHg
• Pulse rate greater than 124 beats/minute
• Respiratory rate less than 12 or greater than 24 breaths/minute

Additional Diagnostic Factors

• Glasgow Coma Scale (GCS) score of 9 or less.
• Oxygen saturation level below 90%.
• Penetrating injuries of the head, neck, torso, or groin.
• Blunt injuries to one or more area - head, neck, torso, or groin.

Key Injury Indicators

• Evidence of spinal cord injuries
• Injuries that threaten limb integrity - including potential amputations
• Burn injuries exceeding 20%, and suspected respiratory tract involvement
• Major bone fractures or dislocations.

Injury Mechanisms: Critical Indicators

• Ejection from vehicle.
• Impact from a motor vehicle or cyclist exceeding 30 kilometers per hour.
• Falls from heights of 3+ meters.
• Being struck on the head when there is falling object from higher than 3 meters.

Additional Risk Factors

• Explosions or high-speed collisions with motor vehicles happening up to 60 kilometers per hour.
• Pedestrian accidents.
• Prolonged extrication of greater than 30 minutes.

Special Population Considerations

• Pregnancy of greater than 20 weeks with instances such as rupturing of membranes per vagina, bleeding or a fetal heart rate less than 100 beats/minute, be they pregnant females.
• Advanced age greater than 55.
• Significant underlying medical conditions
• Tiered response systems aid in separating patients with increased mortality likelihood from others
• Prevent under-triage to avoid clinical deterioration and secondary complications.

Triage and Trauma Team Activations

• All hospitals should have unique activation criteria so trauma
• Senior clinicians best assess activation based on injury assessments, but note subtle, unseen injuries

Trauma Triage

• Maintain constant monitoring of patients meeting trauma call criteria.
• Prioritize a working space for resuscitation.
• Mobilize the team for specific details and responsibilities while prioritizing clinical requirements.

Pre-hospital Communication

• Communicate with EMS regarding patient care
• Elicit information re mechanism or injuries.

Primary Survey

• Patients receive continuous assessment through primary and secondary surveys from injury to admission.
• Life-threatening ailments addressed right away.
• Focus on airway maintenance, hemorrhage control, and quick transportation.
• Triage is based on physiology, injury, and injury's mechanism.

Prioritization is Key

• Priorities include airway maintenance with C-spine control, breathing and ventilation, circulation with hemorrhage control, disability via neurological status, exposure and temperature control.
• High-risk airway patients include the unconscious, with altered consciousness, head injuries, blood loss, or drug-affected.
• Loss of airway may be lethal within 4 minutes.

Airway and Circulation

• Assess the best way to manage airways when speaking with the patient
• Look closely while examining the patient for foreign bodies, burns, fractures.
• Signs of obstruction, are identified by checking the patients pallor or by cyanosis, as well as late.
• Be alert for sounds like snoring and stridor.
• Palpate the position of the trachea and diminish air movement.

Spinal Immobilization

• It's crucial to stabilize the cervical spine, avoid hyperflexion and rotation and neutral positioning according to established recommendations
• Clinicians must understand spine vulnerability and prevent cord injuries.

Patients who do not want to lay flat

• Be aware of maxillofacial trauma and allow trauma patient to sit up to manage secretions and airways.

Steps to Breathing/Ventilation Assessment

• Be aware that good respiration is all about appropriate lung, chest division and diaphragm functioning
• Check the chest, patient colors and breathing.

Respiratory Mechanics

• Listen and check for absent and unequal breath and air sounds.
• Check for signs of any subcutaneous elements, as well as trachea location

Emergency intubation

• Consider intubation while addressing placement by visually checking and confirming proper chest expansion, followed by lung checks and end-tidal CO2 exams.

Chest Injury

• An easy was to retain info is A-J: Airway transection or tear, Bronchial tear or rupture, Cord Spinal injury, Diaphragmatic rupture, Esophageal injury, Flail chest or rib fracture, Gas, Hemothorax, Infarction, and Jugular venous distension.

Chest Problems

• Treat tension pneumothorax, as well as open pneumothorax by placing oxygen and chest tubes.
• Tamponade can be identified via distended back veins.

Hemorrhage and Controlling it

• Identify symptoms of hemorrhage along with mental status, pulse and coloring.
• Key signs are changes in consciousness, poor perfusion, skin pallor, thready pulses, and bleeding; also determine if the shock is a result of some factor instead of hemorrhage.
• A trauma team is comprised of medical professionals with special experience, such as a surgical registrar.

Pericardial Tamponade

• Its signs are similar to that of a tension pneumothorax.

Neurogenic Shock

• Can result if there are spine or chord injuries
• It's important to look for certain items, such as pulse, breathing and amount of fluids.