Page 1598 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 117: Priorities in Multisystem Trauma 1117

identified. Therefore, assessment and resuscitation must proceed simul- are all very simple maneuvers that should be undertaken in the initial
taneously. The initial goal in managing the trauma patient is to provide care of the multiply injured patient. The patient who is fully conscious,
adequate oxygenation and perfusion. This goal is achieved by approach- vocalizing, and breathing adequately, and who is not in shock does not
ing assessment and treatment so that abnormalities in the injured patient require an artificial airway.
that affect oxygenation and perfusion take top priority. It is not essential The underlying principle of establishing an airway in the trauma
to establish a definitive diagnosis of the cause of the decreased perfusion victim is to institute the simplest technique that allows effective oxy-
or hypoxemia. For instance, airway obstruction may occur as a result genation and ventilation. Over 90% of patients do not require endo-
of a head injury, hypoperfusion from hemorrhagic shock or secretions tracheal intubation. Measures short of endotracheal intubation include
in the airway. In the initial resuscitative phase, airway compromise is the insertion of oropharyngeal or nasopharyngeal tubes, if these can
treated in the same fashion regardless of what specific injury leads to this be tolerated without stimulating gagging or vomiting. However, when
airway compromise. It is also of prime importance to recognize findings endotracheal intubation is necessary, it should be performed promptly
that suggest a need for emergent lifesaving surgical intervention so that and expeditiously. Prolonged unsuccessful attempts at endotracheal
appropriate personnel could be alerted as early as possible. intubation without oxygenation and ventilation should be avoided.
Mask ventilation with oxygen and an oropharyngeal airway should be
PRIORITIES performed intermittently to avoid hypoxia during prolonged attempts
at endotracheal intubation. All multiply injured patients should have
The order of priorities is a key feature for successful management of the oxygen administered by the most appropriate means as early as possible.
multiply injured patient and should adhere to the following sequence: A pulse oximeter should be attached to monitor O 2 saturation, which
should be maintained at 95% or greater. A definitive airway, defined as
1. Identification and correction of airway compromise and mainte- a cuffed tube securely placed in the trachea, is required if the patient is
nance of oxygenation and ventilation with cervical spine precaution. unable to maintain patency of the airway.
3. Identification and correction of other sources of inadequate tissue ■ SURGICAL AIRWAY
2. Identification and control of hemorrhage.

perfusion. In very rare circumstances, the patient’s airway may not be patent and
4. Identification and correction of neurologic abnormalities and it may be impossible to establish an airway nasally or orally. In such
prevention of secondary brain injury. situations, cricothyroidotomy is required. This procedure should only
5. Total exposure of the patient to allow complete assessment while be done when an airway cannot be established by other, nonsurgical
6
preventing hypothermia by minimizing the duration of this exposure. means. The landmarks for the cricothyroid membrane are indicated
in Figure 117-1. A cricothyroidotomy may be done using a large-bore
6. Temporary stabilization of fractures. needle (needle cricothyroidotomy) or scalpel (surgical cricothyroid-
7. Detailed systematic anatomic assessment and provision of otomy), the former method being preferable in children under 8 years of
definitive care. age because the cricoid cartilage is essential to the stability of the upper
airway of infants and young children. A 14-gauge needle and cannula
In the Advanced Trauma Life Support (ATLS) course for physicians, may be inserted through the cricothyroid membrane and combined with
5
steps 1 to 5 constitute the Primary Survey, during which immediately jet insufflation for temporary oxygenation and ventilation. To maximize
life-threatening abnormalities are identified by adhering to the sequence oxygenation and avoid hypercapnia, the needle cricothyroidotomy
ABCDE, where A stands for airway, B for breathing, C for circulation should be followed by tracheostomy in an operating room under ideal
and hemorrhage control, D for neurologic disability, and E for exposure. circumstances if a surgical airway is still required. The placement of
The basis for this order of priorities is the degree to which abnormali- the cricothyroidotomy needle allows approximately 30 to 45 minutes of
ties in the different systems threaten the life of the patient. Adherence to adequate oxygenation and ventilation without severe hypercapnia. The
this order allows assessment and resuscitation to occur simultaneously, surgical cricothyroidotomy is preferable and more effective in adults. A
because abnormalities will be identified in the order in which they are skin incision is made directly over the cricothyroid membrane, and after
likely to threaten the patient’s life. Although the patient with multiple the subcutaneous structures are reflected, the cricothyroid membrane
fractures requires treatment of these fractures, apart from hemorrhage
control associated with the fractures, such treatment should take lower
priority compared to treatment of abnormalities affecting the airway or
respiratory status.
Complete evaluation requires assessment of the entire front and
back of the patient, necessitating full exposure. Once this assessment is
completed, the patient should again be covered to minimize heat loss
and the risk of hypothermia.
■ AIRWAY, OXYGENATION, VENTILATION, AND CERVICAL

SPINE CONTROL
The most frequent cause of airway obstruction in the multiply injured Transverse incision
over cricothyroid
patient is loss of tone of the muscles supporting the tongue, either membrane Thyroid cartilage
because of hypoperfusion of the brain from hypovolemic shock or
because of central nervous system (CNS) injury. The simple maneu-
vers of chin lift and jaw thrust move the mandible forward. Because Cricoid cartilage
the tongue muscles are attached to the mandible, these actions move
the tongue anteriorly and open the upper airway. It is essential in the
trauma victim to inspect the oropharynx to ensure that there is no for-
eign material (including vomitus) in the pharynx that will occlude the
airway. Quick observation of the patient’s nares and mouth and listen-
ing for unobstructed passage of air through the upper airway, together
with inspection for the presence of foreign objects in the oropharynx, FIGURE 117-1. Landmarks for cricothyroidotomy.

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