EMCON 2014 Mumbai ppt

1. Airway Management in Acute
Trauma Setting
Dr.Venugopalan .P.P
DA,DNB,MNAMS,MEM [GWU]
Director, Emergency Medicine ,Aster-DM Healthcare Ltd
Deputy Director ,Academy
Founder and Executive Director – ANGELS[Active Network Group of Life Savers ]
PG Teacher Emergency Medicine , National board of Examination
Faculty –ATLS [American College of Surgeons ]
EMCON 2014 Mumbai

2. Lecture focus
• Why airway management
in Trauma ?
• How it is different ?
• What are the challenges?
• How to solve it?
EMCON 2014 Mumbai

3. Chapter Statement
ATLS [ACS]
Prevention of
hypoxemia
requires a
protected,
unobstructed
airway and
adequate
ventilation, which
take priority over
management of all
other conditions.
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4. Airway in Trauma
Priority -1
C-Spine
protection
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5. EMCON 2014 Mumbai

6. Definitive airway
Tube placed in the
trachea with the
cuff inflated below
the vocal cords,
Connected to
some form of
oxygen-enriched
assisted
ventilation,
Airway secured in
place
EMCON 2014 Mumbai

7. Airway Management
How do I manage the airway of a trauma patient?
● Supplemental oxygen
● Basic techniques
● Basic adjuncts
● Definitive airway
● Cuffed tube in the trachea
● Difficult airway adjuncts
● Unexpected difficult airway
● Predicted difficult airway
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8. Airway Decision Scheme
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9. Challenges
• Head Position to align
Intubation Axis
• C-Collar
• Decision to Intubate
• Decision to use drug
assisted intubation
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10. Challenges
• Alternate airway solutions
• Expertise to perform
surgical airway
• Maxillo Facial injuries
• Airway Burns
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11. Video
Laryngoscope
•Less neck
movement
•Blood in the
throat
•Oro-facial injuries
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12. Air manipulation without
obtunding reflexes • Laryngospasm
• Bronchospasm
• Tachycardia
• Hypertension
• Intracranial tension
• Intra ocular tension
• Vomiting
Deleterious
Airway
Breathing
Circulation
Disability
Extra
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13. Solutions • Lack confidence
• Surgeons mania
• Ketamine is safe
• Suxamethonium related
issues
• Rocuronium
• Reversal agent for
Rocuronium
Drug assisted
intubation
Awake intubation with
adequate airway block
Adequate
training is
essential
EMCON 2014 Mumbai

14. Venugopalan.P.P.INTEM
2010;:Nov;10-14
Ahammadabad, IND.
Ketamine in TBI ?
Effect of IV Ketamine on ICP/CPP/MAP in 8
ventilated TBI patients with ICP monitors in
place
# ICP reduced
# No alteration in CPP
# No alteration in MAP
Albanese J.Anesthesiology 1997;87;1328.

15. Venugopalan.P.P.INTEM
2010;:Nov;10-14
Ahammadabad, IND.
Ketamine in TBI ?
Ketamine produced a slight reduction in ICP
without increasing cerebral blood flow
velocity in patients undergoing
isoflurane/nitrous oxide anesthesia for
craniotomy
Mayberg et al Anesth Analg 1995;81:84-89

16. Venugopalan.P.P.INTEM
2010;:Nov;10-14
Ahammadabad, IND.
Ketamine in TBI ?
• Several authors have recently questioned the
historical dogma
• Potentially advantageous in hypotensive head
injury
• No data in ED RSI population
Himmelseher s. Anesth Analg 2005;101:524
Sehdev RS Emerg Med Austral 2006;18:37

17. Venugopalan.P.P.INTEM
2010;:Nov;10-14
Ahammadabad, IND.
RSI: Paralytic Agents
Rocuronium
At a dose of 1.0 mg/kg
• 95% of the patients ready in 60 seconds
• Success rate is comparable to
Succinylcholine
• Average duration of action 45 minutes
PerryJJ.Acad Emerg Med 2002;9:813.
Kirkegaard-Nielson H. Anesthesiology 1999; 19:131.

18. Succinylcholine & Rocuronium
• The Cochrane meta-analysis concluded
“Succinylcholine created superior intubation
conditions to Rocuronium when comparing
both excellent and clinically acceptable
intubating conditions.”
Perry J, Lee J, Sillberg VAH, et al. Rocuronium versus succinylcholine
for rapid sequence induction intubation. (database online). Cochrane
Database Syst Rev 2008;(2):CD002788.
Venugopalan.P.P.INTEM
2010;:Nov;10-14
Ahammadabad, IND.

19. Sugammadex (Bridion)
Venugopalan.P.P.INTEM
2010;:Nov;10-14
Ahammadabad, IND.
Rocuronium
Antagonist
New
New

20. Venugopalan.P.P.INTEM
2010;:Nov;10-14
Ahammadabad, IND.

21. No Yes
Venugopalan.P.P.INTEM
2010;:Nov;10-14
Ahammadabad, IND.
RSI- Paralytic Agents
Fundamental question
Is the patient at risk for an important Succinylcholine related
complication?
Succinylcholine 1.5mg/kg Rocuronium 1mg/kg

22. Regional Block for
intubation
•Vocal cord and
Vallecular spray
•Superior
laryngeal Nerve
block
•Trans Tracheal
injection to
block Recurrent
laryngeal nerve
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23. Vocal Cord spray

24. SLN block

25. Trans Tracheal anesthesia

26. Airway
can be
tricky
always
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27. www.drvenu.net
www.emergencymedicinemims.com
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28. EMCON 2014 Mumbai