Pre-hospital intubation in traumatized...
Transcript of Pre-hospital intubation in traumatized...
O2 X Ratio = =
VO2
DO2
Reduce Oxygen Consumption
Rationale for emergency anaesthesia
SaO2 - SvO2
SaO2
Asphyxia
PaO2 100 mmHg (13 kPa)
5-10 mmHg (0,6-1,3 kPa)
in 5-8 min
Hypercapnia
PaCO2 6 mmHg (8 kPa)
per min
Essential in TBI management
Resuscitation 2008;76:333-340
cerebral
effects
systemic
effects
Cellular
O2 Del
pH mediated effects
Pulmonal
Barotrauma
Atelektasis
cardiovascular
CO drop
pH mediated effects
Cerebro-vascular
CO2 – vasoconstr.
Intrathoracic pressures
Indications for RSI and ETI in trauma
Airway loss
Respiratory failure
Shock state requiring organ support (?)
Traumatic cardio-respiratory arrest
GCS <=8 (TBI) or reduced conscious level (?)
Multi-system polytrauma
Immediate interventions needed
Mortality of awake shock patients
GCS 13-15
SBP <90
N=236
6% non PHEA
not intubated
25% PHEA
intubated
Acta Anaesth Scand 2018;62:504
GCS 13-15
AIS < 3 per body region
No blood transfusion needed
Intubated vs. Not-intubated
N= 600 per group (42.000 Traumaregister DGU)
Crit Care 2011;15:R207
Pre-hospital intubation – decrease in survival after TBI
Davis DP. J Trauma 2005;59:794
38 vs. 59.5% (-86.2%)
16.8 vs. 56.3%
Warner K. J Trauma 2007;62:1330-8
Lack of monitoring? Inappropriate management?
25% 16% 27% 36% Mortality
Davis DP. J Trauma 2010;69:294
Pre-hospital intubation seems to improve outcome
in more critically injured TBI patients
Iatrogenic hyper- and hypoventilation are associated
with adverse outcomes in ITN patients
Etomidate 0,3 mg/kg + Succinylcholin 1,5 mg/kg
Schock:
Etomidate 0,15 mg/kg + Succinylcholin 1,5 mg/kg
3-2-1:
Fentanyl 3 mcg/kg + Ketamin 2 mg/kg + Rocuronium 1 mg/kg
Schock 1-1-1:
Fentanyl 1 mcg/kg + Ketamin 1 mg/kg + Rocuronium 1 mg/kg
VENTILATION IN SHOCK
avoid hyperventilation & PEEP
Hypovolemia: IPPV CO
No or low PEEP in shock
Respiratory rate in shock
0
10
20
30
40
50
60
70
80
90
100
ITP syst BP
Pepe P,Crit Care Med 2004; 32:Supp S417
Pepe P. J Trauma 2003
Roppolo L, Yearbook Int Care and Emerg Med 2004
Webster JA. Can J Anaesth 2003
RR: 12 6 20 30 6 min
Authors conclusion
The efficacy of RSI has not been rigorously studied.
The skill level of the operator may be key in determining efficacy.
In non-traumatic cardiac arrest, it is unlikely that intubation carries
the same life saving benefit as early defib and bystander CPR
In trauma and pediatrics, the current evidence base provides no
imperative to extend the practice of RSI in urban systems.
Cochrane Database of Systematic Reviews 2008, Issue 2.