Podcast
Questions and Answers
What is the primary concern for anesthesia providers when managing the airway of a trauma patient?
What is the primary concern for anesthesia providers when managing the airway of a trauma patient?
What is the purpose of cricoid pressure during laryngoscopy?
What is the purpose of cricoid pressure during laryngoscopy?
What percentage of trauma patients are estimated to have a cervical spine injury?
What percentage of trauma patients are estimated to have a cervical spine injury?
Why is cricoid pressure relatively contraindicated in patients with cervical spine injuries?
Why is cricoid pressure relatively contraindicated in patients with cervical spine injuries?
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What is the primary goal of in-line manual axial stabilization during airway management?
What is the primary goal of in-line manual axial stabilization during airway management?
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Why is it essential to assume that a trauma patient has a cervical spine injury?
Why is it essential to assume that a trauma patient has a cervical spine injury?
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What percentage of patients who have experienced a traumatic brain injury are estimated to have a cervical spine injury?
What percentage of patients who have experienced a traumatic brain injury are estimated to have a cervical spine injury?
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What is the primary benefit of using video laryngoscopy during airway management of a trauma patient?
What is the primary benefit of using video laryngoscopy during airway management of a trauma patient?
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What is the third most common respiratory-related event that leads to brain damage and death?
What is the third most common respiratory-related event that leads to brain damage and death?
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What is the primary goal of rapid sequence induction (RSI) in traumatic airway management?
What is the primary goal of rapid sequence induction (RSI) in traumatic airway management?
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Why is muscle relaxation associated with the highest overall rate of successful airway management?
Why is muscle relaxation associated with the highest overall rate of successful airway management?
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What is the preferred method for traumatic airway management?
What is the preferred method for traumatic airway management?
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What should be used during intubation of patients who have sustained a potential or actual cervical spine injury?
What should be used during intubation of patients who have sustained a potential or actual cervical spine injury?
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Why is it essential to have a contingency plan for difficult airway management?
Why is it essential to have a contingency plan for difficult airway management?
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What algorithm should be followed for emergency intubation of the trauma patient?
What algorithm should be followed for emergency intubation of the trauma patient?
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What is the major difference between a routine anesthetic induction and a rapid sequence induction (RSI)?
What is the major difference between a routine anesthetic induction and a rapid sequence induction (RSI)?
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What is the reason for avoiding deep placement of the ETT cuff?
What is the reason for avoiding deep placement of the ETT cuff?
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What is the primary effect of induction agents on blood pressure?
What is the primary effect of induction agents on blood pressure?
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Why should the dose of induction agents be reduced in trauma patients?
Why should the dose of induction agents be reduced in trauma patients?
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What is the principle behind apneic oxygenation?
What is the principle behind apneic oxygenation?
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What is the purpose of maintaining peak inspiratory pressures less than 20 cm/H2O during RSI?
What is the purpose of maintaining peak inspiratory pressures less than 20 cm/H2O during RSI?
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What is a potential exception to the use of induction agents in trauma patients?
What is a potential exception to the use of induction agents in trauma patients?
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What is the primary goal of apneic oxygenation during RSI?
What is the primary goal of apneic oxygenation during RSI?
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Why is cricoid pressure contraindicated in patients with tracheal and/or cricoid cartilage injury?
Why is cricoid pressure contraindicated in patients with tracheal and/or cricoid cartilage injury?
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What is the primary benefit of preoxygenation in Rapid Sequence Induction?
What is the primary benefit of preoxygenation in Rapid Sequence Induction?
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What is the recommended method for quantifying the adequacy of preoxygenation?
What is the recommended method for quantifying the adequacy of preoxygenation?
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What is the primary goal of cricoid pressure during Rapid Sequence Induction?
What is the primary goal of cricoid pressure during Rapid Sequence Induction?
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How long should cricoid pressure be maintained during Rapid Sequence Induction?
How long should cricoid pressure be maintained during Rapid Sequence Induction?
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What is the recommended flow rate for administering oxygen during preoxygenation?
What is the recommended flow rate for administering oxygen during preoxygenation?
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How many tidal volume breaths are estimated to provide an adequate degree of preoxygenation?
How many tidal volume breaths are estimated to provide an adequate degree of preoxygenation?
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What is the primary component of Rapid Sequence Induction that reduces the risk of gastric aspiration?
What is the primary component of Rapid Sequence Induction that reduces the risk of gastric aspiration?
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What is the primary purpose of apneic oxygenation during Rapid Sequence Induction?
What is the primary purpose of apneic oxygenation during Rapid Sequence Induction?
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What is the most important factor in achieving successful RSI?
What is the most important factor in achieving successful RSI?
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What is the primary indicator of successful ETT placement?
What is the primary indicator of successful ETT placement?
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What should be done if the initial attempt at laryngoscopy is unsuccessful?
What should be done if the initial attempt at laryngoscopy is unsuccessful?
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What is the advantage of using video laryngoscopy over direct laryngoscopy?
What is the advantage of using video laryngoscopy over direct laryngoscopy?
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Why is supporting oxygenation throughout the intubation process crucial?
Why is supporting oxygenation throughout the intubation process crucial?
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What is essential for anesthetists to provide safe patient care?
What is essential for anesthetists to provide safe patient care?
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What is a possible complication in this patient's airway management due to his broken teeth and hematoma on his neck?
What is a possible complication in this patient's airway management due to his broken teeth and hematoma on his neck?
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Why is high-flow oxygen supplied to the patient via a nonrebreathing facemask, face tent, or blow-by oxygen?
Why is high-flow oxygen supplied to the patient via a nonrebreathing facemask, face tent, or blow-by oxygen?
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What is necessary before inducing anesthesia in this patient?
What is necessary before inducing anesthesia in this patient?
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Why is it essential to have a surgeon skilled in cricothyrotomy available during airway management?
Why is it essential to have a surgeon skilled in cricothyrotomy available during airway management?
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What position may be necessary for induction in this patient?
What position may be necessary for induction in this patient?
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What is necessary during airway management in this patient?
What is necessary during airway management in this patient?
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Why is the patient allowed to sit upright and suction his oral pharynx?
Why is the patient allowed to sit upright and suction his oral pharynx?
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What is critical to prepare for during airway management in this patient?
What is critical to prepare for during airway management in this patient?
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What is the primary reason for the patient's SpO2 remaining at 88% despite receiving a supraphysiologic concentration of inhaled oxygen?
What is the primary reason for the patient's SpO2 remaining at 88% despite receiving a supraphysiologic concentration of inhaled oxygen?
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What is the primary indicator of the patient's compensated hypovolemic shock?
What is the primary indicator of the patient's compensated hypovolemic shock?
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What is the primary role of the SNS response in the patient's hypoxia and hypovolemic shock?
What is the primary role of the SNS response in the patient's hypoxia and hypovolemic shock?
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What is the primary implication of the patient's blood coming out of their mouth?
What is the primary implication of the patient's blood coming out of their mouth?
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What is the primary reason for the patient's respiratory rate increasing?
What is the primary reason for the patient's respiratory rate increasing?
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What is the primary benefit of obtaining an arterial blood gas in this scenario?
What is the primary benefit of obtaining an arterial blood gas in this scenario?
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What is the primary implication of the patient's hematoma and edema on the right side of their neck?
What is the primary implication of the patient's hematoma and edema on the right side of their neck?
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What is the primary effect of the patient's hypovolemic shock on their blood pressure?
What is the primary effect of the patient's hypovolemic shock on their blood pressure?
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What is the preferred agent for facilitating intubation in patients without a specific contraindication?
What is the preferred agent for facilitating intubation in patients without a specific contraindication?
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What is the risk of administering succinylcholine to patients with neurologic deficits caused by spinal cord injuries?
What is the risk of administering succinylcholine to patients with neurologic deficits caused by spinal cord injuries?
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How long after a spinal cord injury does nicotinic cholinergic receptor upregulation occur?
How long after a spinal cord injury does nicotinic cholinergic receptor upregulation occur?
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What is the dose of rocuronium required for rapid sequence induction?
What is the dose of rocuronium required for rapid sequence induction?
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What is the timeframe for establishing adequate intubating conditions with high-dose rocuronium?
What is the timeframe for establishing adequate intubating conditions with high-dose rocuronium?
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What is the purpose of in-line manual axial stabilization with a cervical spine collar?
What is the purpose of in-line manual axial stabilization with a cervical spine collar?
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Who should be present during airway management if airway control is unsuccessful?
Who should be present during airway management if airway control is unsuccessful?
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What is the primary benefit of using succinylcholine for rapid sequence induction?
What is the primary benefit of using succinylcholine for rapid sequence induction?
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What is the primary implication of a prolonged period of apnea due to failed intubation?
What is the primary implication of a prolonged period of apnea due to failed intubation?
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What is the effect of increased PaCO2 on the oxyhemoglobin dissociation curve?
What is the effect of increased PaCO2 on the oxyhemoglobin dissociation curve?
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What is the primary mechanism by which the gum elastic bougie facilitates intubation?
What is the primary mechanism by which the gum elastic bougie facilitates intubation?
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What is the primary consequence of severe hypoxia in the trauma patient?
What is the primary consequence of severe hypoxia in the trauma patient?
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What is the primary reason for the need to create a surgical airway in approximately 1% of situations?
What is the primary reason for the need to create a surgical airway in approximately 1% of situations?
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What is the primary effect of increased 2,3 DPG on the oxyhemoglobin dissociation curve?
What is the primary effect of increased 2,3 DPG on the oxyhemoglobin dissociation curve?
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What is the average rate of PaCO2 accumulation during apnea?
What is the average rate of PaCO2 accumulation during apnea?
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What is the primary role of the sympathetic nervous system (SNS) response in the patient's hypoxia and hypovolemic shock?
What is the primary role of the sympathetic nervous system (SNS) response in the patient's hypoxia and hypovolemic shock?
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What is the primary implication of a rightward shift of the oxyhemoglobin dissociation curve?
What is the primary implication of a rightward shift of the oxyhemoglobin dissociation curve?
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What is the primary consequence of anaerobic metabolism in the trauma patient?
What is the primary consequence of anaerobic metabolism in the trauma patient?
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Tension pneumothorax typically occurs shortly after the implementation of negative pressure ventilation.
Tension pneumothorax typically occurs shortly after the implementation of negative pressure ventilation.
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A tension pneumothorax allows gas to escape from the lung into the pleural cavity during exhalation.
A tension pneumothorax allows gas to escape from the lung into the pleural cavity during exhalation.
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The anesthetist should be aware of the signs associated with a tension pneumothorax and release the thoracic tension via surgical thoracotomy.
The anesthetist should be aware of the signs associated with a tension pneumothorax and release the thoracic tension via surgical thoracotomy.
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Needle decompression is accomplished by placing a 5- to 7-inch angiocatheter into the fifth intercostal space at the midaxillary line on the affected side of the chest.
Needle decompression is accomplished by placing a 5- to 7-inch angiocatheter into the fifth intercostal space at the midaxillary line on the affected side of the chest.
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If cardiac function does not immediately improve, the other side of the patient's chest should not be decompressed and the advanced cardiac life support protocol should not be initiated.
If cardiac function does not immediately improve, the other side of the patient's chest should not be decompressed and the advanced cardiac life support protocol should not be initiated.
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Once needle decompression occurs, the angiocatheter can be removed immediately and a chest tube does not need to be placed.
Once needle decompression occurs, the angiocatheter can be removed immediately and a chest tube does not need to be placed.
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A tension pneumothorax does not exert pressure on the mediastinum and does not impinge on the heart and major vasculature.
A tension pneumothorax does not exert pressure on the mediastinum and does not impinge on the heart and major vasculature.
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Release of the thoracic tension via chest tube thoracoscopy or needle decompression is not required to manage a tension pneumothorax.
Release of the thoracic tension via chest tube thoracoscopy or needle decompression is not required to manage a tension pneumothorax.
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Which of the following signs is associated with a tension pneumothorax?
Which of the following signs is associated with a tension pneumothorax?
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Which of the following is a contraindication for the use of succinylcholine?
Which of the following is a contraindication for the use of succinylcholine?
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A patient presents with a distended neck vein and hypotension. Which of the following is the most likely diagnosis?
A patient presents with a distended neck vein and hypotension. Which of the following is the most likely diagnosis?
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Which of the following is a cardiac manifestation of a tension pneumothorax?
Which of the following is a cardiac manifestation of a tension pneumothorax?
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A patient with a history of spinal cord injury is at risk for which of the following complications if given succinylcholine?
A patient with a history of spinal cord injury is at risk for which of the following complications if given succinylcholine?
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Study Notes
Emergency Airway Management for Trauma Patients
- Traumatic airway injury requires rapid assessment and emergency management in critically ill patients.
- Rapid sequence induction (RSI) is a vital and fundamental skill for anesthesia providers in airway management.
Endotracheal Intubation and Airway Management
- Endotracheal intubation is a mainstay of anesthesia practice.
- Difficult tracheal intubation is the third most common respiratory-related event that leads to brain damage and death.
- RSI is the preferred method for traumatic airway management.
Muscle Relaxants and Airway Management
- Muscle relaxation is associated with the highest overall rate of successful airway management.
- The use of muscle relaxants in RSI increases the risk of a "can't intubate/ can't ventilate" scenario.
Emergency Intubation for Trauma Patients
- Emergency intubation should adhere to the American Society of Anesthesiologists (ASA) difficult airway algorithm.
- Trauma patients are assumed to have delayed gastric emptying and are at increased risk for aspiration.
- Anesthesia providers must be skilled in utilizing airway adjuncts, including video laryngoscopy and cricothyroidotomy.
Cervical Spine Injuries
- Patients with blunt or penetrating neck and face injuries should be considered to have cervical spine instability.
- The incidence of cervical spine injury after trauma is approximately 3% to 6% of all trauma patients and approximately 10% for patients with traumatic brain injury.
- In-line manual axial stabilization is essential for immobilizing the neck during airway management.
- Cricoid pressure (Sellick maneuver) assists the anesthetist by displacing the larynx posteriorly and providing an improved view of the vocal cords.
- Cricoid pressure may be contraindicated in patients with cervical spine injuries due to the risk of spinal cord and vascular injury.
- Patients with actual or suspected cervical spine injuries should be intubated using in-line manual axial stabilization.
Rapid Sequence Induction (RSI)
- RSI is used to rapidly control a patient's airway while reducing the likelihood of gastric aspiration in patients with traumatic injuries.
- Indications for endotracheal intubation include inadequate oxygenation/ventilation, loss of airway reflexes, decreased level of consciousness, and the need to secure the airway for sedation during painful procedures.
Preoxygenation
- Preoxygenation is essential before inducing anesthesia for RSI.
- The goal is to increase the concentration of oxygen in the functional residual capacity, providing an increased period before hypoxemia ensues.
- Administration of 100% high-flow (10 to 15 L/min) oxygen via a nonrebreathing facemask or bag-valve facemask is required.
- Four to eight tidal volume breaths provide an adequate degree of preoxygenation.
- Quantifying the adequacy of preoxygenation by observing the ETO (end-tidal oxygen) is recommended.
Cricoid Pressure
- Cricoid pressure was first described by Sellick in 1961.
- The goal is to reduce the risk of pulmonary aspiration of gastric contents by compressing the esophagus against the cricoid cartilage and cervical vertebrae.
- Cricoid pressure is maintained throughout the RSI and is not released until endotracheal tube (ETT) placement has been confirmed to be bilaterally equal.
- Contraindications for cricoid pressure include patients with confirmed or suspected cervical spine injury, patients with tracheal and/or cricoid cartilage injury, and patients who are actively vomiting.
Induction Agents
- The anesthetic induction for RSI can be achieved using various agents.
- Initial dose selection should be cautious, as any induction agent can cause a dramatic decrease in blood pressure, especially in hypovolemic patients.
- The precise dose of induction agent is variable and highly individualized.
- Induction agents should be titrated to response, realizing that sympathetic nervous system (SNS) inhibition can have dramatic cardiovascular effects in patients with hypovolemic shock.
Apneic Oxygenation
- Apneic oxygenation is the concept of providing pulmonary ventilation using high-flow oxygen.
- The purpose is to reduce the risk of gastric distension and pulmonary aspiration from positive pressure ventilation while preventing hypoxemia.
- The principle is based on the Boyle law, where gas leaves the facemask, fills the lungs, and exchanges within the lungs based on the concentration gradient of gases in the alveoli.
- Clinical modifications to RSI include bag-valve-mask ventilation through cricoid pressure, which does not appear to increase the risk of aspiration.
Laryngoscopy for RSI
- There is no optimal laryngoscope blade or size for successful RSI; anesthetists should use the equipment they are most comfortable with.
- Confirmation of successful ETT placement includes:
- Presence of carbon dioxide
- Bilateral equal and clear breath sounds
- Absence of sounds over the stomach
- Chest rise and fall
Approach to Unsuccessful Laryngoscopy
- If the initial attempt is unsuccessful, a second attempt should incorporate a change in technique, including:
- Change of operator
- Change of laryngoscope blade
- Change in patient position
Video Laryngoscopy
- Video laryngoscopy provides superior visualization compared to direct laryngoscopy, especially in patients with cervical spine injury during intubation.
- Video laryngoscopy does not reduce cervical spine movement during intubation.
Airway Management
- Supporting oxygenation throughout the intubation process is crucial.
- Proficiency in airway management adjuncts is essential for safe patient care.
Airway Management Considerations for Trauma Patient
- Patient exhibits signs of significant respiratory distress: respiratory rate 32 breaths/min, audible stridor, oxygen saturation 88%, and oxygen delivered by non-rebreathing oxygen facemask
- Respiratory compensation: increased minute ventilation to compensate for hypoxia
- despite supraphysiologic concentration of inhaled oxygen, oxygen saturation remains low, indicating arterial hypoxemia
Physiologic Response to Hypoxia and Hypovolemic Shock
- Physiologic compensatory response to hypoxia and hypovolemic shock: increased cardiac output and systemic vascular resistance to increase blood pressure and systemic perfusion
- However, patient's blood pressure remains low, suggesting moderate to severe hypovolemic shock
Airway Complications
- Intraoral or pharyngeal laceration suspected due to blood coming out of mouth, which will complicate direct laryngoscopy by obscuring anesthetist's vision and distorting airway anatomy
- Pulmonary contusion and active bleeding may require lung isolation using double-lumen ETT or bronchial blocker
Acute Airway Management
- Safest and most efficient method: rapid sequence intubation (RSI) with in-line manual axial stabilization
- Patient should be allowed to sit upright and suction oral pharynx as tolerated to facilitate fluid movement from airway by gravity
- High-flow oxygen should be supplied via non-rebreathing facemask, face tent, or blow-by oxygen to optimize pulmonary reserve prior to induction
- Preparation for immediate surgical airway intervention is warranted
Succinylcholine vs Rocuronium for Intubation
- Succinylcholine (1.5 mg/kg) provides the most rapid onset of muscle relaxation for intubation and is the preferred agent without specific contraindications.
- Contraindications for succinylcholine include life-threatening hyperkalemia in patients with neurologic deficits caused by spinal cord injuries, especially after 24-48 hours post-injury.
- High-dose rocuronium (1.2 mg/kg) can also be used for RSI, with adequate intubating conditions within 1 minute.
Management Strategy for Failed Direct Laryngoscopy
- The anesthetist must have alternative plans for airway management in case of failed intubation.
- The ASA difficult airway algorithm helps organize a plan, but alternative strategies may be required for trauma patients.
- The gum elastic bougie can facilitate nearly blind passage of the ETT.
- Prolonged apnea may require bag-valve-mask ventilation with cricoid pressure, and in rare cases, creation of a surgical airway.
Physiologic Implications of Prolonged Apnea
- Failure to secure a patent airway rapidly results in physiologic decompensation in trauma patients.
- Apnea and hypoventilation cause pathologic responses, including increases in PaCO2 and decreases in PaO2, exacerbated by increased metabolic demands in trauma patients.
- Decreased PaO2, increased PaCO2, and decreased pH stimulate an increase in sympathetic nervous system (SNS) outflow, leading to cardiac excitation and vasoconstriction.
- Hypercarbia, hypoxemia, and increased 2,3 DPG cause a rightward shift of the oxyhemoglobin dissociation curve, leading to decreased affinity between oxygen and hemoglobin.
- The rate of PaCO2 accumulation during apnea is predictable, with an average increase of 6 mm Hg in the first minute and 3-4 mm Hg for each additional minute.
Tension Pneumothorax
- Occurs when air becomes trapped in the thorax due to a defect or rupture in lung tissue
- Gas escapes from the lung into the pleural cavity during inspiration, but is trapped in the thoracic cage due to a one-way flap valve
- Increasing pressure in the thoracic cavity impinges on the heart and major vasculature, reducing cardiac filling and output
Signs and Management of Tension Pneumothorax
- Typically occurs shortly after implementing positive pressure ventilation
- Anesthetist should be aware of associated signs and release thoracic tension via chest tube thoracoscopy or needle decompression
- Needle decompression involves placing a 2- to 3-inch angiocatheter into the second intercostal space at the midclavicular line on the affected side of the chest
- If cardiac function does not improve, decompress the other side of the chest and initiate advanced cardiac life support protocol
- After needle decompression, the angiocatheter must remain in place until a chest tube is placed to prevent reaccumulation of air
Signs of Tension Pneumothorax
- Hypoxemia and hypercarbia are pulmonary manifestations of tension pneumothorax
- Increased peak inspiratory pressures and decreased pulmonary compliance are also signs of tension pneumothorax
- Absence of breath sound on the affected side and tracheal deviation in the opposite direction of the pneumothorax are key pulmonary manifestations
- Hypotension, tachycardia, and mediastinal shift in the opposite direction of the pneumothorax are cardiac manifestations of tension pneumothorax
- Distended neck veins are another sign of tension pneumothorax
Contraindications for Succinylcholine
- Malignant hyperthermia is a contraindication for the use of succinylcholine
- Hyperkalemia, spinal cord injury (except for acute airway management within 24 hours of trauma), and crush injury are contraindications
- Stroke, Guillain-Barré syndrome, and burn injury (>24 hours) are also contraindications
- Muscular dystrophy, motor neuron disease, and mitochondrial myopathies are contraindications
- Hyperkalemic periodic paralysis and pseudocholinesterase deficiency are contraindications for the use of succinylcholine
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Description
Learn about the rapid assessment and emergency management of traumatic airway injuries in critically ill patients, including rapid sequence induction and endotracheal intubation.
