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CURRENTOPINION Airway and ventilator management in trauma

rokmannb, and Rolf Rossainta

and ventilation is of paramount importance in theculags

atiomraplicaira

t cants;ven

positive end-expiratory pressure must be the target.After early identification of patients with blunt chest trauma at risk for respiratory failure, noninvasiveventilatio

Keyworairway m

INTRODUCTION

Effectivemanagementin emergency and criting sufficient oxygenapreventing gastric, dtrauma patients. Enda standard proceduresive care medicine confor protecting the airwsettings, both pre anbased strategies areaccepted in internatioprehospital (e.g., prehand in-hospital (e.g., atreatment of trauma patients, in which Arepresents the airway and B subnostic and procedural tasks for bre

INDICMANASeverewith i

Department of Anaesthesiology, Emergency Department, UniversityHospital Aachen, RWTH Aachen University and cEmergency Medical

9 241 80 82304; e-mail: Rrossaint@ukaachen.de

www.c

REVIEWmultiple injuries are always associatedmpaired tissue oxygenation and the risk of

Curr Opin Crit Care 2014, 20:626631

DOI:10.1097/MCC.0000000000000160

o-criticalcare.com Volume 20 Number 6 December 2014hATIONS FOR AIRWAYGEMENT IN TRAUMA

Pauwefax: +4t Lippincott Williams &of Anesthesiology, University Hospital, RWTH Aachen University,lsstr. 30, D52074 Aachen, Germany. Tel: +49 241 80 88179;Correspondence to Professor Rolf Rossaint, MD, PhD, Departmentsumes all diag-athing [24].

Service, Fire Department, Aachen, Germanyn might be a treatment strategy, which should be evaluated in future research.

dsanagement, emergency management, intubation, prehospital, ventilation

of the airway is a central issueical care medicine for provid-tion and ventilation and forebris or blood aspiration inotracheal intubation (ETI) asin anesthesiology and inten-tinues to be the gold standarday in the emergencymedicined in-hospital [1]. Algorithm-well established and widelynal course strategies for theospital trauma life support)dvanced trauma life support)

overall damage to the affected human organism.Therefore, oxygen uptake is essential. In manypatients, adequate oxygenation can only be suffi-ciently provided via controlled or assisted mechan-ical ventilation using a secured airway. Followinginternational recommendations and guidelines,ETI represents the gold standard for this task[1,3,5]. In detail, there are widely accepted, specificrecommendations for the application of ETI andfurther ventilation in trauma patients for hypoxia(SpO2

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tension pnbrain iComa Scalout-of-studieswith T iparamesurvivaTBI ofthemodindicatdamageare as f

(1) hyp(2) im

rha(3) sev

Sca(4) sev(5) hem

rela

Antraumaresult owith anare not[5]. Hoanalysiwhereipatientatory inof emesuggestuse in t

well tolerated and effective, with success rates of98.7 and 96.6%, respectively [13,14]. A retrospectiveevaluation of overall 4317 patients (3571 prehospi-

s. 7asponaenTBou, inessr oatsorysiof-agisall, 1116 patients with TBI and 528 withorrrtedinstic

concludt, pia,emaliven tcuegit bst

tivreg

KEY POINTS

Adequate airway and ventilator management focus onprev

The rresperemadeter

Aftermedimoniinvoltidal

NIVsuffeoccufurth

Airway management in trauma Beckers et al.

1070-529ters and end-tidal carbon dioxide but alsol [7,8]. Patients with multiple trauma anden suffer from hypoxia in combination withynamic instability, and in these cases, ETI ised to prevent further secondary brain[9,10]. Indications of ETI in trauma patientsollows:

oxia (SpO2

Copyrigh d reproduction of this article is prohibited.

the other hand associated with the potential risk ofdelayed airway management procedures in criticalpatients [21].

Moditionshospitainfluenering [patients with airway management identified directinjury of thanatomy oflaryngospaairway mansituations fillofacial trapredictor ffacial bleedshould antThe summconside[24,25] (compilprehospitalries can besituations.)

(1) patient(a) blo(b) tra

res(c) inf

wa(d) sub(e) im(f)(g) inadequate depth of anesthesia;(h)(i)

(2) due(a)

(b)

(c)(d)(e)(f)

(g)

Tabwith aan ovethe airwthe Wo

an SocM

CaiIf possible, application of an adequate preox-ygenation with high FiO2 before any invasiveairwaymanagement [ETI or extraglottic airway(EGA)];Endotracheal tube as the gold standard, butonly if at least 100 documented ETIs occur inpatients under supervision and carried out 10ETIs/year;EGA as the primary access when the above-mentioned requirements cannot be fulfilledand if 10 applications are documented undersupervision and three EGAs/year were per-formed, or an alternative for difficult intuba-tion;UseofEGAwithdrainageandplacinga stomachtube or an intubating laryngeal mask airway;Use of video laryngoscopy is possible as analternative when there is sufficient internalclinical experience;Optimized mask ventilation (two-handed,double C-handle), optimal head positioning/ matching Guedel and with a high FiO2between two intubation attempts, particularlyin children;

Table 1. Identified risk factors associated with a difficultairway

ry

cal exam

d from [19&

Trauma

628 Volume 20 Number 6 December 2014t Lippincott Williams & Wilkins. Unauthorize

no neuromuscular blockade;usually no awake intubation features areavailable in the airways that are anticipatedto be difficult;

to situation and sitesimultaneous tasks or procedures to provide(e.g., chest compressions);environmental conditions (e.g., lighting,noise);restricted access to patient;limited equipment;differing teams;missing or not successfully communicatedstandards;lack of competent support on-site.

le 1 identifies general risk factors associateddifficult airway [26]. The following list givesrview of the recommendations for securingay in emergency medical settings (given byrking Group in Emergency Medicine of the

(3)

(4)

(5)

(6)

(7)

www.co-criticalcare.comnointubation. The corresponding catego-almost 1 : 1 transferred for in-hospital:

siteod, secretions or vomit;umatic or thermal damage of the upperpiratory tract;lammation or swelling of the upper air-ys;cutaneous emphysema;mobilization of the cervical spine;or limited preoxygenation;

GermCare

(1)

(2)

Adapteation of factors that can complicate

r ine head or neck with loss of the normalthe upper airway, pharyngeal tumor andsm as the main risk factors for difficultagement situations [12]. In fact, difficultor ETI are often obvious, such as max-uma, which is known as an independentor difficult airway management [22];ing or neck tumors, in which strategiesicipate possible complications [23,24].ary of possible aggravating factors toprehospital ETI is given as follows

Physireover, it has to be realized that the con-for patients who require ETI in the out-of-l emergency setting are challenging andced by several factors that are worth consid-3]. A 10-year evaluation of 6088 trauma

Historitical review of the indication for invasiverway management;edici

iety for Anesthesiology and Intensivene) [25].Reduced head/neck mobility

,26].Fixed or high larynx

Mouth opening

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(8) No application of cricoid pressure as prophy-laxes for aspiration;

(9) Continuous capnography after each airwaym

(10) Ctr

MEDIC

Airwayanesthethe airw[2729and effologistassociaRSI, thagent ayears,becausestudiestion. OincreasdromelengthpatientAdditioreporteincreaspital st

Forfentanypatientunstabagentscondititern of

Recsupporwithouparamesettingan RSIway mplicatio

Wiagent uuated 5nium v37 of tanalysedifferencholinebut the studcholineduration of

study including 1045 patients demonstrated moresuccessful RSI with fewer intubation attempts forsuccinylcholine compared with rocuronium [37],

rois

ER

ifagt sideo

rallopifice ta

batessp

o-gntitioairways. In an RCT using the direct laryngo-e) vinitaeverinntxi

TI

coenredentoThrevedemIt isu6]naatoguais effective for preventing hypocapnia andrcila

Airway management in trauma Beckers et al.

1070-5295 2ight Lippincott Williams & Wilkins. Unauthor014 Wolters Kluwer Health | Lippincott Williams & Wilkinsaction. In fact, another observational vent

wasy team finally concluded that succinyl-clinically superior because of its shorter

andhypeanagement procedure;ommunication of standards and corporateaining of emergency teams.

ATION

management for ETI as part of emergencysia should be performed as RSI to ensure thatay is secured as quickly and safely as possible]. This approach is described to be sufficientective in the hands of experienced anesthesi-s [12], whereas a nonstructured usage isted with increased patient mortality [3]. Fore application of a neuromuscular blockingnd a sedative agent is necessary. For manyetomidate was the first-line medicationof its hemodynamic stability, but several

have called the previous strategies into ques-ne retrospective study [30] showed an

ed risk for acute respiratory distress syn-with multiorgan failure and a prolongedof hospital stay and ventilator days fors treated with a single dose of etomidate.nally, a prospective and randomized triald a prolonged stay in the ICU and aned rate of ventilator days and length of hos-ay following etomidate use [31].the analgetic part of emergency anesthesia,l or sufentanil for hemodynamically stables and ketamine for hemodynamicallyle patients are commonly used; anestheticare often used depending on the differentons, such as the hemodynamic status, pat-injuries and experience of the user [32,33].ent literature follows this line of research andts the substitution of etomidate by ketaminet negatively influencing the hemodynamicters in both prehospital [34

&

] and in-hospitals [35]. Additionally, Ballow et al. [35] reportedmedication protocol for simplifying the air-anagement strategy to avoid potential com-ns.th respect to the neuromuscular blockingsed, a Cochrane database review [36] eval-8 studies concerning the question of rocuro-s. succinylcholine for RSI intubation, andhese studies were included in the updateds in2008.This analysis reportednosignificantce in intubation conditions when succinyl-was compared with 1.2mg/kg rocuronium,

but pify th

ALT

EvenmanmenconsmumsevedevespecthesmaskintusuccwithvideinvesolucultscopUSAwerehospHowlongandpatiehypo

VEN

Thesequcoveincid[42][44].to pardizplacary.can[45,4natioing pcapnadeqd reproduction of this article is prohibited.

apnia as well as hypoventilation and hyper-tion. Further, particularly for patients with

www.co-criticalcare.com 629or the GlideScope (Verathon Inc., Bothell,ideo laryngoscope, 623 in-hospital patientscluded; there was no difference in survival tol discharge in the observed patients [41

&

].er, use of GlideScope was associated withintubation times than direct laryngoscopythe subgroup of severe head injury traumas was associated with a greater incidence ofa (SaO280%) and mortality.

LATION AND MONITORING

mplication with the utmost fatal con-ce in airway management with ETI is undis-

esophageal intubation, which has ance rate reported to range from less than 117% [43], with mortality rates reaching 80%erefore, it is widely accepted that strategiesent esophageal intubation, such as a stand-check, verification of endotracheal tube

ent and ventilation monitoring, are necess-s evident that the inclusion of capnographyfficiently detect esophageal misplacement, so it is therefore also part of the inter-l guidelines and recommendations for treat-ients with cardiac arrest [1,47

&

]. Additionally,raphy is also the gold standard for ensuringte ventilation during mechanical ventilationspective randomized trials are needed to clar-topic.

NATIVE TECHNIQUES

ETI remains the gold standard for airwayement in trauma patients, alternative equip-hould be available and techniques must bered in a structured approach after a maxi-f three insufficient attempts [2729]. In fact,adjuncts and technical equipment have beened [38] for use if ETI is not possible, buttraining is required to efficiently handle

ools. A commonly used tool is the laryngealirway and its different variations, such as theing laryngeal mask airway, which has provenful after failed direct laryngoscopy in patientsredicted difficult airways [39,40]. Usinguided airway management technology, thison might represent a theoretically optimaln in cases of predicted or unpredicted diffi-

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TBI, excessive deviations in both directions shouldbe prevmortaliPaCO2is assoc

Obpatientlarge t[53,54]body wventila

A rexaminventilatraumanine stRCTs,observathere mthese pone RCcationinitiati(12 vs.the ouplayed)

CONC

A strapproaplicatioor procfore, adways mmonitostandardate, carole offor ou

and idet ienedan ilation should befulftt cmad to be the subject of research in the future.

no

.

fli

vieors

ERDof

ighlspeout

akines fatioeric

anua

Table 2. Outcomes associated with noninvasive ventilation

Study (dSeverity of Need for intubation Nosocomial

in

Hernand(RCT)

8

Gunduz 9

BolligerEeden

1

Data are rNIV, noninaThe rate o excAdapted fr

Trauma

630ented because the data support a trend toty reduction [4851]; a particularly lowupon arrival in the emergency departmentiated with fatal outcomes [52].servational studies suggest that even ins with normal lung function, the use of aidal volume could result in lung injury; thus, a tidal volume of 6ml/kg predictedeight or even less is part of the protectivetion recommendations.ecently published systematic review [55

&&

]ed the safety and efficacy of noninvasivetion (NIV) in patients with blunt chest. These authors stated that although onlyudies were included in their analysis (threetwo retrospective cohort studies and fourtional studies without a control group),ight be a role for the early use of NIV in

atients. This finding is based on the data fromT, which suggested that the early identifi-of at-risk patients with the consequenton of NIV resulted in lower intubation rates40%) [56]. Table 2 [55

&&

,5658] summarizestcomes (only the analyzed RCTs are dis-associated with NIV.

agenV

injurtionhelp

AblunNIVhas h

Ack

None

Con

Theauth

REFREAPapersbeen h& of&& of

1. Delincit

2. AmMesign) hypoxemia due to failure of NIV

ez et al. (2010) [56] PaO2/FiO2 200for >8 h

12% in NIV vs. 40% inhigh-flow oxygengroup

et al. (2005) [57] (RCT) PaO2/FiO2 300 17%aand Van(1990) [58] (RCT)

PaO2/FiO2 150

eported as rates (%) for all variables.vasive ventilation; RCT, randomized controlled trial.f intubation was not reported in the journal text, and patients requiring ETI wereom [55

&&].t Lippincott Williams & Wilkins. Unauthorized

LUSION

ategic and algorithm-based systematicch to airway management can prevent com-ns that arise due to inadequate oxygenationedural difficulties in trauma patients; there-vanced equipment for handling difficult air-ust be available. Additionally, standardizedring, including capnography and the use ofdized medication protocols without etomi-n reduce further complications. Overall, theETI in patients with severe TBI and strategiest-of-hospital management remain unclear,

3. Paal Pand in

4. WolfltraumaSuppo

5. Dunhaintuba

6. Badjatment(Supp

7. Bernaambul2002;

8. KlemesequeAnaes

9. Jeremafter s2003;

www.co-criticalcare.comwledgements

cts of interest

ws expressed in this review are those of theand do not reflect any official policy or position.

ENCES AND RECOMMENDEDINGparticular interest, published within the annual period of review, haveighted as:cial intereststanding interest

CD, Nolan JP, Soar J, et al. European Resuscitation Council Guide-or Resuscitation 2010 Section 4. Adult advanced life support. Resus-n 2010; 81:13051352.an College of Surgeons Committee on Trauma ATLS. Student Course.l 8th ed. Chicago: American College of Surgeons; 2008..er the early identification of patients withhest trauma at risk for respiratory failure,ight be a treatment strategy, even if thisd preventing hyperventntifying the ideal neuromuscular blockings a subject for future research.tilation can affect the outcome of severelypatients; therefore, ensuring normoventila-

fection Pneumothorax Mortality

% in NIV vs. 12%in high-flowoxygen group

24% in NIVvs. 12% inhigh-flowoxygen group

4% in NIV vs. 4% inhigh-flow oxygengroup

% 9%

3.8% 5.5% 0

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maticthesio

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view12;rsonAFy 2appuba03;attstien13;

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suC