Pr Olivier Langeron MD, PhD

Head of Multidisciplinary Intensive Care UnitHôpital de la Pitié-Salpêtrière

Université Pierre et Marie Curie –Paris VI

Airway and respiratory management in trauma patients

o Airway management :- Special issues in trauma patient- Basic airway management- Advanced airway management

o Respiratory management - Focus in chest trauma patient

Agenda

Trauma and cause of death

Airway and respiratory management are both mandatory

Sauaia A et al., J Trauma 1995

Difficult environmental situation, prehospital and emergency setting

Head or facial trauma with potential difficult airway access (oedema, hematoma or active bleeding)

Airway and Respiratory management in trauma : What are the issues ?

Scheduled surgery : IDS > 5 : 6%vs

Emergency : IDS > 5 : 16%

%

Mortality related to airway management

(Number of events)

ED 8 % (72%) of all events 11% (41%) of all deaths/BD

TOTAL 184

Airway complications and Causes

Difficult airway and difficult oxygenation

Basic Airway Management

Advanced Airway Management

Airway patencyCervical spine immobilization Mask Ventilation Use of oral or nasal canules Transtracheal O2 Intubation

IntubationLMAFastrachVideolaryngoscopeCricothyroidotomyTracheotomy

Basic airway management

o Chin lift and Jaw thrust, oral / nasopharyngeal airway devices

o Preoxygenation, SpO2 monitoring

o Pulmonary regurgitation prevention (Sellick)

o Limited tracheal intubation attempts (<3)

Benumof JL et al Anesthesiology. 1997

FRC

Basic rules

Manual In-Line Stabilization Manoeuvre

Adnet F et al Eur J Emerg Med. 1998

Difficult intubation depending of consciousness level

failed intubation increased significantly in plastic blade group :

17 vs. 3%; P < 0.01

Basic Airway Management

Advanced Airway Management

Airway patencyCervical spine immobilization Mask Ventilation Use of oral or nasal canules Transtracheal O2 Intubation

IntubationLMAFastrachVideolaryngoscopeCricothyroidotomyTracheotomy

Advanced Airway Management : Fastrach

Difficult environmental situation and emergency

Head or facial trauma with potential difficult airway access (oedema, hematoma or active bleeding)

Airway and Respiratory management in trauma : What are the issues ?

Makes tracheal intubation much more difficult !

A strategy should be implemented according oxygenation techniques

Airway control and clinical setting Initially

After surgery

Tension pneumothorax

The good question in case of an unstable respiratory and/or hemodynamic status

The good option : chest decompression

EMERGENCY DECISIONS

INITIAL ASSESSMENT

Imaging in chest trauma : what do we have ? what do we need ?

Bedside techniques

Computed tomography (CT) techniques

Diagnosis

Monitoring

Better understanding disease mechanism

Complementary techniques

Pneumothorax

Chest X-ray

Tension pneumothorax

Hemothorax

Estimated Volume (ml) = section x h

0 200 400 600 800 1000 1200

Volume drained (ml)

0200400600800

10001200

r2 = 0.722p < 0.001

Remerand F et al. Intensive Care Med 2010

Section

Multiplane ultrasound approach to quantify pleural effusion at the bedside

Chest spiral CT

Pulmonary contusion underestimated by chest X-ray better assessed by Computed Tomography

PEEP should be adjusted to lung morphology

Cqs 41 ml/cmH2O PaO2/FIO2 98 mmHg

Cqs 39 ml/cmH2O PaO2/FIO2 98 mmHg

High PEEP ≥ 15 cmH2O

to recruit the lung

Moderate PEEP ≤ 10 cmH2O

1000

00

250

500

750

10 20 30

Lung volume (ml)

ZEEP

P-V curve depends on :

- the mecanical properties of the lung remaining aerated at end-expiration

- the recruitment curve of nonaerated lung areas

Patients with a « focal » loss of aeration

interpretation of the P-V curve is much more complex

Airway pressure (cmH2O)

Lung overinflation occurs together with recruitment and cannot be detected from the global PV curve

Rouby et al., European Resp Journal, 22 (suppl 42) : 27s-36s , 2003

PULMONARY CONTUSION

Prone position

PEEP trial

Conclusiono Emergency makes airway management more difficult

o A strategy arising from guidelines and algorithms are always the first step to solve a difficult airway

(Maintenance of oxygenation +++)

o Initial chest X-ray/pulmonary echography are useful and respiratory setting is performed at best with CT-scan