Pre-hospital intubation in traumatized...

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Transcript of Pre-hospital intubation in traumatized...

Pre-hospital intubation in traumatized patients

advantages and limits

W. Voelckel

No conflict

of interest

O2 Del = [(HbxSaO2x1,39) + (paO2x0,003) ] x CO

CaO2

Shock = cellular hypoxemia

O2 Del = [(HbxSaO2x1,39) + (paO2x0,003) ] x CO

CaO2

Optimize Oxygen Delivery

O2 X Ratio = =

VO2

DO2

Reduce Oxygen Consumption

Rationale for emergency anaesthesia

SaO2 - SvO2

SaO2

Treat lung trauma

Vietnam 1960-75

Da Nang Lung - ARDS

Correct hypoxia

Improve safety

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

Indication

RSI and Intubation

Post RSI Management

Traumatized airway vs. Intubation in trauma

On-scene intubation

In trauma patients

West Midlands

CARE Team

PHEA Standard

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

BJA 2015;114:657-62

> 50% !

269 / 472

BJA 2015;114:657-62

BJA 2015;114:657-62

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

(Almost) all outcome parameters

significantly worser

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

Effect in TBI patients

Bossers POLS online 2015

EMS (181) HEMS (85)

Airway secured 16% 95%

Hypoxia 10% 2%

Hypotension 4% 5%

Helm M BJA 2006;1:67

Fluids

Anatomy

Exposure

1,5 L

MAP > 30%

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

SBP MAP

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.

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