SPECIAL MEDICAL REPORT : PREHOSPITAL TRAUMA CARE 2 PREHOSPITAL TRAUMA AIRWAY MANAGEMENT Prehospital trauma airway management is probably

y the biggest challenge faced by prehospital providers. These professionals must not only acquire but also maintain essential skills to adequately manage airway problems at the scene and during transport of trauma victims to trauma centers. Endotracheal intubation is the definitive method of airway management. However, to acquire such skill requires significant training and practice. Although the emergency technician-basic (EMT-B) curriculum contains an advanced airway module, the low frequency of these procedures makes it difficult for these professionals to maintain proficiency. In most systems, paramedics and flight nurses are the only professionals allowed to perform rapid sequence intubation (RSI). Therefore, there is a need to simpler ways to maintain a patent airway by emergency medical technicians, until the patient is delivered to a hospital. Several devices are now available and have been used by the pre-hospital personnel when endotracheal intubation is not practical or possible. These alternate methods include bag-valve-mask with oral or nasopharyngeal airway, the laryngeal mask, and the esophageal-tracheal double lumen tube, popularized as Combitube. In this part of discussion, the indications for airway management in the prehospital arena, the different modalities, devices and techniques, the recognition of a difficult airway, and associated pitfalls will be discussed. WHO NEEDS AN AIRWAY? Before we define who needs an airway in the prehospital arena, it is important to clarify that few studies to date shown efficacy of advanced airway management in trauma prior to arrival at a trauma center. The goal of airway management is to provide adequate oxygenation and ventilation as part of the overall resuscitation effort. Candidates include those with decreased or absent respiratory movements, signs of airway obstruction, and cardiopulmonary resuscitation (CPR) in progress. Severe traumatic brain injury (TBI) as an indication for prehospital intubation will be discussed later. In trauma, it has been shown that moribund patients would benefit from an airway, particularly those who are candidates for a resuscitative thoracotomy upon arrival at the hospital.

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PREHOSPITAL TRAUMA AIRWAY MANAGEMENT DIFFICULT AIRWAY The Mallampati classification has been used for many years by anesthesiologists during preoperative evaluation for the identification of a difficult airway and to predict difficult intubation (Figure 1). It compares tongue size with the oropharyngeal space, and its reliability has been questioned because it does not take into account other factors that may make intubation difficult or impossible in the prehospital setting. However, if the patient is still able to follow simple commands, direct visualization of the oropharynx by asking the patient to open the mouth will give additional and important information to the astute prehospital provider. Rich described the 6-D methods of airway management: disproportion; distortion; decreased thyromental distance; decreased interincisor gap; decreased range of motion in all or all of the jointsatlanto-occipital, temporomandibular, and cervical spine, always present in trauma; and dental overbite. Identifying a difficult airway prevents patient deterioration or death. Alternative devices and strategies should be used when the diagnosis of a difficult airway is made. These include the laryngeal mask airway (LMA), Combitube, or bag-valve-mask. WHICH STRATEGY SHOULD BE USED? The strategies described as follows are alternatives to conventional bag-valve-mask with either a nasopharyngeal or an oropharyngeal airway. Laryngeal Mask Airway The LMA is one alternative to endotracheal intubation (Figure 2). Its use is particularly important in patients with difficult airways (defined later) and in patients in unfriendly environments (rain, dark, prolonged extrication, etc.). it also can be used as a rescue strategy following a failed RSI. Additionally, it can be used to facilitate tube intubation, which is obtained by passing the endotracheal tube through the LMA. The insertion of the LMA is done blindly into the oropharynx, and it is usually tolerated without the need of neuromuscular blockade. The LMA lies in the hypopharynx in the supraglottic position. The successful placement of the LMA is independent of the Mallampati score, presence of a C-collar, or in-line immobilization of the neck. Spontaneous ventilation through the LMA is possible, and manual ventilation through the LMA is superior to bag-valve-mask ventilation, because the latter requires two hands to maintain a good seal. Studies comparing the success rates have shown that paramedics achieve higher levels of successful placement with the LMA compared to endotracheal intubation. The LMA may be particularly useful in patients with a difficult airway, since direct visualization of the cords is not required and neuromuscular blocking agents are not necessary. The advantages of the Please access www.medicalvillage.blogspot.com today

PREHOSPITAL TRAUMA AIRWAY MANAGEMENT LMA over the Combitube (described next) include lower risk of malpositioning, no risk of esophageal intubation, and less trauma to the oropharynx. A major disadvantage of the LMA is that it does patients with intact airway reflexes. Another limitation of MA is related to the difficulty in generating high airway pressures, which may lead to ineffective ventilation. Combitube The Combitube consists of a device with two lumens. One of the lumens has an open distal end similar to an endotracheal tube, whereas the other lumen has a closed distal end, with several holes proximal to its balloon cuff. A second balloon of higher volume is located more proximally to the sides of the holes, and it is used to secure the tube in position. The Combitube is inserted blindly and allows ventilation through either lumen. Following blind insertion, the distal tip is usually located in the esophagus. After inflating the oropharyngeal balloon, the esophageal cuff is inflated. Attempts to ventilate through the pharyngeal lumen will determine whether the distal tip is in the esophagus or trachea. If there is no change in the colorimetric, end-distal carbon dioxide detector, or if breath sounds are absent, then the distal tip is in the trachea, and the patient should be ventilated through the tracheal lumen (Figure 3 and 4). The Combitube is a useful alternative to endotracheal intubation when an airway is not obtained after multiple attempts, when the airway is considered by a difficult one, when direct visualization of the vocal cords by laryngoscopy is not possible at the scene, or when prehospital providers are not trained to perform orotracheal intubation. The great majority of patients brought to trauma centers after insertion of a Combitube will be ventilating and oxygenating well, and there is no need for immediate removal of the Combitube and the orotracheal intubation. The Combitube, is also useful in patients with significant maxillofacial trauma and cervical spine injuries. Because the esophageal cuff is immediately inflated after tube insertion, the Combitube offers protection against aspiration of gastric contents. The Combitube is contraindicated in patients with intact gag reflex, or when upper airway obstruction is suspected. The Combitube is not available in pediatric sizes. Potential complications include injury to the pharynx and esophagus, and failure to recognize the exact location of the distal end and attempting to oxygenate and ventilate through the wrong lumen.

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PREHOSPITAL TRAUMA AIRWAY MANAGEMENT

Orotracheal Intubation Endotracheal intubation (ETI) is the gold standard of airway management. In the prehospital setting, endotracheal intubation without the use of sedatives or neuromuscular blockade is only achievable in obtunded patients. Because few systems allow paramedics to use RSI, and based on the fact that obtunded patients carry a poor prognosis, endotracheal intubation in those situation may cause more harm than good. Without ideal conditions, endotracheal intubation may be accompanied by an increased number of complications, including hypoxemia, esophageal intubation, and intubation of the mainstem bronchus, with subsequent complete lung collapse, injury to the oropharynx, regurgitation, exacerbation of a potential spinal cord injury, circulatory compromise, increased intracranial pressure, and delay in transport to a trauma center, just to name a few. Inability to recognize difficult airway may make intubation impossible and if preceded by RSI may lead to devastating complications and eventually death. Common pitfalls of endotracheal intubation will be discussed. Confirmation of the Orotracheal Tube Placement Several factors contribute to endotracheal tube malpositioning and include poor lighting, limited access to the patient, insufficient suctioning, difficult airway, intraoral bleeding, vomiting, facial trauma, and airway swelling. The gold standard for confirmation of adequate placement of an endotracheal tube is the direct visualization of the tube passing through the vocal cords. This is obviously not always possible considering less than ideal conditions at the scene. Auscultation of breath sounds also may be difficult at the scene, particularly in a noisy and chaotic environment.

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PREHOSPITAL TRAUMA AIRWAY MANAGEMENT The colorimetric, end-tidal carbon dioxide detector has been used be prehospital personnel to confirm endotracheal tube placement. In the presence of high levels of carbon dioxide, the device changes color from purple to yellow. The device has been deemed reliable; however, it lacks sensitivity in the setting of cardiopulmonary arrest due to the lack of pulmonary blood flow limiting carbon dioxide delivery. Therefore, approximately 15% of patients properly intubated in that setting would have their endotracheal tubes removed based on the lack of color change in the device. The opposite is also true, and a color change may be observed in patients who have ingested large volumes of carbonated liquids (beer, sodas, etc.), when the tube is in the esophagus or when the stomach has been insufflated with expired gas during bag-valve-mask-ventilation. Another way to determine proper placement of endotracheal tubes is the syringe aspiration technique. If the tube is properly placed in the trachea, the provider should not feel any resistance when attempting to aspirate air from the endotracheal tube (ETT) with a 60-cc syringe. If the tube is in esophagus, upon negative pressure generated by the syringe, the wall of the esophagus collapses and resistance is felt by the provider. CONTROVERSIES IN PREHOSPITAL INTUBATION Prehospital Intubation in Trauma Brain Injury While an aggressive approach to airway management including ETI is standard-of-care for patients with severe TBI, it is notable that there is little evidence to support this approach. In fact, several recent studies have demonstrated an increase in mortality associated with prehospital intubation. It is not clear whether this represents a selection bias or a true detrimental effect of invasive airway management on outcome. The purported benefits of early intubation include reversal of hypoxia and airway protection from aspiration. However, the morbidity and mortality associated with these secondary insults may not be preventable or reversible with invasive airway management 10-15 minutes after the initial injury. In addition, there has been a recent increase in awareness of the adverse effects of positive-pressure ventilation on outcome, especially with hyperventilation and hypocapnia. This makes patient selection for an early intubation extremely important so as to maximize the benefit of the procedure. The use of the Glasgow Coma Scale (GCS) score alone to select patients to undergo prehospital intubation has several limitations. An early GCS score appears to have only moderate specificity in identifying severe TBI. In addition, the relationship between GCS score and aspiration is indirect at best. Aspiration events may occur prior to arrival of EMS personnel or with manipulation of laryngeal structures during intubation. Furthermore, hypoxemia may be reversible with noninvasive airway maneuvers, and oxygen saturation (SpO2) values with supplemental oxygen may be an important factor in considering prehospital intubation. While no study has clearly undergo early intubation, neural network analysis using data from our trauma registry suggests that the most critically injured patients, as defined by GCS score and the presence of hypotension, benefit from the procedure. In addition, intubation does provide additional benefit regard to the reversal of hypoxemia in some patients.

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