NCEPOD: Trauma - Who Cares? - London Health Programmes

CHAPTER 6 - Airway and breathingIntroductionAdequate oxygenation of the tissues is critical to survivalafter trauma, and the maintenance of adequate levels ofoxygen in the blood stream is a paramount objective in themanagement of severe trauma. Tissue hypoxia may occuras a result of multiple injuries, haemorrhage or depressedrespiration and it may occur acutely or insidiously. A leading,but rapidly reversible, life-threatening cause of insuffi cientoxygenation is obstruction of the airway. Therefore, thereversal of an obstructed airway is regarded as fundamentalin any approach to managing the severely injured patient.Airway management is therefore one of the key componentsof emergency care. The primary objective is to recognisean obstructed or potentially obstructed airway, to clearthe obstruction and keep the airway patent. No medicalemergency, short of complete cardiopulmonary arrest,is more immediately life-threatening than the loss of anadequate airway. Failure to manage airway patency andventilation adequately has been identifi ed as a major causeof preventable death in trauma 1-4 .Many studies highlight the preventable mortality andmorbidity that occur following major trauma 5, 6 . Airwayproblems and hypovolaemia are very often the causes.The advanced trauma life support (ATLS) system of traumacare stresses the importance of recognition of airway andventilation problems. The value of early senior experiencedanaesthetic involvement cannot be over-stated. Theanaesthetist should be a key member of the resuscitationtrauma team, and not simply called when serious problemshave already developed.ResultsAirway and ventilation in hospitalTable 49 shows the airway status on arrival at the emergencydepartment and the 72 hour mortality for each group ofpatients. As can be seen, 85/676 (12.6%) of patients arriveat hospital with either a partially or completely obstructedairway and these groups had a much higher mortality ratealthough from this dataset, causality cannot be assumed.Table 49. Airway status on arrival at hospitalAlive Deceased Total % MortalityClear 526 65 591 11.0Noisy 27 13 40 32.5Blocked 28 17 45 37.8Subtotal 581 95 676Not97 22 119 18.5recordedTotal 678 117 795The provision of an adequate airway by intubation of thetrachea is often required to facilitate the management of theseverely injured patient. Table 50 shows that 74 patientswere intubated before arrival at hospital, 11 patients hadattempted but failed intubation and 362 patients wereintubated after arrival at hospital. Table 50 also showsmortality rates at 72 hours after injury. It can be seen that thegroup that was intubated prehospital had a higher mortalitythan the group intubated in hospital. This is in line withprevious literature 7 although a causal relationship cannot bedetermined from this dataset.62