RESUSCITATION

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Resuscitation of the patient with major trauma Endotracheal intubation is a skill requiring considerable experience and is more difficult in trauma patients. Unless patients are completely obtunded with a Glasgow Coma Score (GCS) of 3, intubation can only be performed safely with the use of anaesthetic drugs and neuromuscular blocking drugs, together with cricoid pressure to prevent aspiration of gastric contents. Distorted anatomy, blood, and secretions, and the presence of a hard cervical collar all impair visualisation of the vocal cords. Removal of the collar and use of manual inline stabilisation will improve the view at laryngoscopy. Better visualisation of the vocal cords may be obtained by using the flexible tip of a McCoy laryngoscope, and cricoid pressure, directed backwards, upwards, and to the right (BURP manoeuvre), may also improve visualisation. A gum elastic bougie, with a tracheal tube “railroaded” over it, can be used to intubate the cords when they are not directly visible. Once the tracheal tube is inserted it is vital to confirm that it is in the correct position, particularly to exclude oesophageal intubation. Look and listen (with a stethoscope) for equal chest movement, and listen over the epigastrium to exclude air entry in the stomach, which occurs after oesophageal intubation. Capnography (measurement of expired carbon dioxide) is the best method of confirming tracheal placement, either using direct measurement of exhaled gases or watching for the change of colour of carbon dioxide sensitive paper. The laryngeal mask airway (LMA) and Combi-tube have both been advocated as alternative airways when endotracheal intubation fails or is not possible. The LMA is relatively easy to insert and does not require visualisation of the vocal cords for insertion. The cuff forms a loose seal over the laryngeal inlet but only provides limited protection of the trachea from aspiration. The Combi-tube is also inserted blind. It is a double lumen tube, the tip of which may either enter the trachea or, more usually, the oesophagus. Once inserted, the operator has to identify the position of the tube and ventilate the patient using the appropriate lumen. Neither of these devices should be used by operators unfamiliar with their insertion. Surgical airway A surgical approach is necessary if other means of securing a clear airway fail. Access is gained to the trachea through the cricothyroid membrane and overlying skin. Several techniques are used as described below. Needle cricothyroidotomy—a large (14G ) needle is inserted through the cricothyroid membrane in the midline. Spontaneous respiration is not possible through such a small lumen and high-pressure oxygen must be delivered down the cannula. A three-way tap or the side-port of a “Y” connector allows intermittent insufflation (one second on, four seconds off). This technique delivers adequate oxygen but fails to clear carbon dioxide and can only be used for periods not exceeding 30 minutes. Care must be taken to ensure that airway obstruction does not prevent insufflated air from escaping through the laryngeal inlet. Insertion of “minitrach” device—the “minitrach” has become popular as a device for obtaining a surgical airway. It is a short, 4.0 mm, uncuffed tube that is inserted through the cricothyroid membrane using a Seldinger technique. A guidewire is inserted through a hollow needle, the needle removed and the minitrach introduced over the guidewire. It is too small to allow spontaneous ventilation, but oxygen can be delivered as with a needle cricothyroidotomy or using a self-inflating ventilation bag. Removal of the hard collar and use of manual inline stabilisation will improve the view at laryngoscopy Indications for endotracheal intubation are: ● ● ● ● ● ● Apnoea Failure of basic airway manoeuvres to maintain an airway Failure to maintain adequate oxygenation via a face mask Protection of the airway from blood or vomit Head injury requiring ventilation Progressive airway swelling likely to cause obstruction—for example, upper airway burns. A gum elastic bougie can be used to intubate the cords when they are not directly visible 65
ABC of Resuscitation Surgical cricothyroidotomy—surgical cricothyroidotomy is the most difficult of the three procedures to perform but provides the best airway. A large, preferably transverse, incision is made in the cricothyroid membrane through both overlying the skin and the membrane itself. Tracheal dilators are then used to expand the incision and a cuffed tracheostomy tube (6.0-8.0 mm) is inserted into the trachea. An alternative technique entails insertion of a gum elastic bougie through the incision with a 6.0 mm cuffed endotracheal tube “railroaded” over it. Care must be taken not to advance the tube into the right main bronchus. Cervical spine An injury to the cervical spine occurs in about 5% of patients who suffer blunt trauma, whereas the incidence with penetrating trauma is less than 1%, provided that the neck is not directly involved. It is important to assume that all patients with major trauma have an unstable cervical spine injury until proven otherwise. Cervical spine stabilisation should be carried out at the same time as airway management. Most patients with suspected cervical spine injuries will be delivered by the ambulance crew on a spinal board with a hard collar, head blocks, and straps already in place. If not, manual inline stabilisation must be applied immediately, and a hard collar fitted, together with lateral support and tape. Some compromise may be necessary if the patient is uncooperative because attempts to fit a hard collar may cause excessive cervical spine movement. Hard collars must be fitted correctly; too short a collar will provide inadequate support, whereas too tall a collar may hyperextend the neck. The collar must be reasonably tight, otherwise the chin tends to slip below the chin support. Several different types of hard collar are available. One commonly used is the Stifneck extrication collar, which is sized by measuring the vertical distance from the top of the patient’s shoulders to the bottom of the chin with the head in a neutral position. Sizing posts on the collar are then adjusted to the same distance before the collar is fitted to the patient. Once the head is secured firmly in head blocks, consider loosening or removing the cervical collar because evidence shows that tight collars can cause an increase in intracranial pressure. Pressure sores are also a risk if the hard collar is left in place for several days. Patients should also be removed from the spinal board as soon as possible. Thyroid notch Cricothyroid membrane Anatomical location of the cricothyroid membrane Thyroid cartlidge Cricoid cartlidge Trachea Breathing Once the airway has been secured, attention must be turned to assessment of breathing and identification of any life-threatening conditions. The chest must be exposed and examined carefully. Assess the respiratory rate and effort and examine for symmetry of chest excursion. Look for any signs of injury, such as entry wounds of penetrating trauma or bruising from blunt trauma. Feel for surgical emphysema, which is often associated with rib fractures, a pneumothorax, flail segment, or upper airway disruption. Five main life-threatening thoracic conditions that must be identified and treated immediately are: ● ● ● ● ● Tension pneumothorax Haemothorax Flail chest Cardiac tamponade Open chest wound. Tension pneumothorax causes respiratory and circulatory collapse within minutes and is often exacerbated by positive pressure ventilation. Asymmetric chest wall excursion, Key dimensions of patient Sizing of the “Stifneck” collar Key dimensions of Stifneck If all the following criteria are met, cervical spine stabilisation is unnecessary: ● No neck pain ● No distracting injury ● No localised tenderness ● Patient alert and oriented ● No neurological signs or symptoms ● No loss of consciousness 66
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ABC OF RESUSCITATION Fifth edition
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ABC OF RESUSCITATION Fifth Edition
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Contents Contributors Introduction
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Introduction The modern era of resu
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