Prevention of hypoxemia requires a protected, unobstructed airway and adequate ventilation which takes priority over managing all other conditions.
- How do you know the airway is adequate? The patient is alert, oriented, and talking normally.
- Signs of airway compromise
- high index of suspicion, change in voice, sore throat, noisy breathing, tachypnea, dyspnea, agitation, abnormal breathing
- When to intervene?
- impending airway compromise (airway problem), need for ventilation (breathing problem), inability to protect the airway (disability problem)
- How do you manage the airway of a trauma patient?
- Supplemental oxygen, basic techniques (jaw thrust, chin lift), basic adjuncts (OPA, nasal trumpet – be careful in mid face trauma), definitive airway (cuffed tube in trachea below vocal cords, tube connected to some form of oxygen enriched ventilation, tube secured by tape, etc.), difficult airway adjuncts
- Difficult airway: be prepared for rapid sequence intubation vs awake fiberoptic intubation (maintaining cervical spine neutral) and the use of airway adjuncts like bougie, Combitube, intubating LMA, and other advanced techniques
After the “airway and breathing” aspect of the primary survey have been addressed, it’s time to move onto circulation. Shock is a generalized state of hypoperfusion characterized by:
- Inadequate O2 delivery
- Catecholamines and other responses
- Anaerobic metabolism
- Cellular dysfunction
- Cell death
Is the patient in shock? Look for tachycardia, hypotension, altered mentation, cold/warm extremities, decreased urine output
What is the cause of shock?
The majority of shock in trauma is hemorrhagic (a form of hypovolemic). Knowing this, consider the following:
- Physical exam
- CXR, pelvic XR, FAST (differentiates obstructive from hemorrhagic)
- Stop the bleeding – tourniquets, pressure, embolization, reduce pelvic volume (binder), hemostatic agents (reversing coagulopathy)
- Fluid resuscitation – two large bore (18G or better) PIVs or Cordis/introducer
- Balanced resuscitation
- Accepting lower than normal BP
- Packed red cells, FFP, platelets
- Not a substitute for definitive surgical control of bleeding
- What’s the patient’s response?
- Physical exam, vitals, labs, urine output, etc.
- Rapid responder, transient responder, nonresponder
- Hemorrhage Classes
- Class 1 – 750 cc (15%)
- Slight anxiety, normal BP, not tachycardia, UOP normal. Treat with crystalloid.
- Class 2 – 750 – 1500cc (15-30%)
- Normal BP but HR > 100 bpm (tachycardia), anxious, tachypnic, decreased pulse pressure. Still treat with crystalloid.
- Class 3 – 1500 – 2000cc (30-40%)
- Confused, anxious, decreased BP, HR > 120 bpm, decreased PP
- Class 4 – >2000 cc (>40%)
- Confused, lethargic, hypotension, HR > 140, RR > 35 bpm, urine output negligible
- Class 1 – 750 cc (15%)
- Special Considerations – patient factors in complications of shock
- Advanced age, athletes, pregnancy, medications, pacemaker
- Lethal triad of trauma: hypothermia, early coagulopathy, acidosis
- Preserved BP does not imply adequate cardiac output
- Misleading Hct/Hgb levels