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28
CHAP TER2 The injured patient
haemoptysis, and crepitus in the neck are highly suggestive of these
injuries. Carefully palpate the hyoid and larynx. Again, to assess the
front of the neck properly the hard collar will need to be unfastened
and the head suppor ted.
Loss of the air way is of ten due to a combination of factors (more com-
monly alcohol, head injury, bleeding, and being restrained supine). If
the patient is not breathing they require mechanical ventilation. This is
usually achieved by orotracheal intubation or with a surgical cricothy-
roidotomy. Nasotracheal intubation is usually contraindicated in midface
trauma or head injuries.
Airway risk factors in facialtrauma
• Inability to handle normal secretions
• Foreignbodies
• Altered level of consciousness (this may be secondary to alcohol,
drugs, or some medical conditions)
• Uncontrolled haemorrhage
• Surgical emphysema
• Adjacent soft tissue injuries/ gross swelling
• Burns
• Hyoid/ laryngeal/ trachealinjury
• Disrupted mid/ lower face anatomy
• Atightly tting collar when the patient has mandibular fr actures.
• Laying supine.
Remember that the unresponsive/ comatose patient may also require a den-
itive airway for protection in the event of vomiting. Remember also the risk
to the cervical spine . This must be presumed injured and stabilized using a
correctly tting collar, blocks, and tape. If these are not available, get an
assistant to stabilize the head manually.
Some dicult airway- related
problems infacialtrauma
Sudden vomiting insupine patients
Unexpected vomiting is a dicult problem in all immobilized patients
and poses an immediate threat to the air way. In all supine patients vom-
iting can occur at any time, often af ter the primar y sur vey has been
completed. Therefore, an experienced nurse escort and suction should be
with the patient at all times until they are allowed to sit up. Early warning
signs may include repeated attempts by the patient to try and get up.
Restrained supine patients should never be left unattended.
If vomiting occurs in the restrained supine patient, tilting the patient
head- down approximately 6– 12 inches and clearing the air way using
high- ow suction is the safest approach. In the head- down position,
vomitus preferentially ows into the oropharynx from the oesophagus
reducing the risk of causing obstruction around the laryngealinlet.
DIFFICULT AIRWAY-RELATED PROBLEMS
Have an agreed plan of action in the event of unexpected vomiting. When
it occurs, there is no time to debate the relative merits of log rolling/ sitting
up/ tilting the table head- down.
Is it safe forthe patient tositup?
See Figure 2.2. Acommon scenario seen in the emergenc y department
is the intoxicated, aggressive male with apparently isolated facial injuries following an assault or fall. The patient will often sit up with little
response to reason. In this situation an unstable cervical spine injur y is
rare. Allowing the patient to sit up may be the best initial option as it
reduces the risk of airway compromise from vomiting or unstable facial
fractures. If they will allow you to put a hard collar on them, do so. But
never forcibly restrain.
However, in the potentially multiply injured patients with facial inju-
ries a decision needs to be made quickly regarding the relative r isks of
keeping the patient supine (with potential airway obstruction) against the
risks of axially loading a potential spine, torso or pelvic injury, by allowing
29
Figure2 .2 Apatient with signicant , but isolated, facial in juries. In t his ca se,
allow ing th e patient to si t up ena bled self- p rotection of the airway. Had the
patie nt bee n placed supi ne, hi s air way would probably have obs tructed f rom th e
obvious bleeding, mobile midface, and facial swelling.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Ini tial Co nsiderat ions:High - vs. Low - En ergy Inj urie s and th e Impl icati ons of Co exis ting
Mult iple I njur ies’, 2014, Fig ure1.7, eds M. Perr y and S. Holm es, Copyri ght © 2014, S pringer Verlag L ondon. Wit h perm ission of Spr inger Natu re.
30
CHAP TER2 The injured patient
them to sit up. If the patient is combative despite adequate oxygenation,
correction of hypovolaemia, and adequate pain relief, then ear ly intubation and ventilation may be necessary to secure the airway and prevent
loading. This reinforces the concept of the mechanism of injur y in planning appropriate management for patients.
Beware the patient who keeps trying to sit up— they may be trying to clear
their airway.
Clearing thecervicalspine
This should t ake place as soon as possible due to the problems associated with prolonged spinal immobilization. Until then, the cervical spine
needs to be protected (manual stabilization or collar, blocks, and tape).
See E Chapter 4.
Assessment ofthe front ofthe neck
followingtrauma
This is often a forgotten site and requires careful examination. It should
be regarded as a watershed bet ween ‘Airway’ and ‘Breathing’ during the
primary survey, as life- threatening problems in both can manifest clinical
signs here. Assessment of the airway involves more than just looking into
the mouth and nose. Poiseuille’s law dictates that even a small change in
the diameter of a tube can result in a signicant change in ow through
it. Although strictly applicable to uid dynamics, this equation highlights
the potential for problems to arise when there is swelling within the
larynx and trachea. Although unusual, fractures of the lar ynx and hyoid
do occur and may lead to substantial glottic swelling. Motorc ycle helmet wearers, strangulation, and contac t spor ts injuries are important
clues from the history. Ahoarse voice, haemoptysis, and crepitus in the
neck are highly sug gestive of these injuries and should be actively sought
after. Carefully palpate the hyoid and lar ynx for signs of injury and look
for external swelling which may reect swelling internally. Useful clinical
signs to look for include:
• Tracheal deviation or separation
• Laryngeal tenderness or crepitus
• Hyoid tenderness
• Surgical emphysema
• Distended neckveins
• Openwounds
• Signicant swelling.
These may indicate the presence of signicant and potentially lifethreatening injuries.
AIRWAY PROBLEMS SEE N IN FACIALTRAU MA
Airway problems seen
infacialtrauma
Obstruction
This may be caused by dentures/ loose teeth or severe fractures of the
mandible or midface. The commonest causes are bleeding and/ or saliva,
notably when the patient is intoxicated or supine. Swelling is often an
aggravating factor. Saliva and blood should initially be cleared by suction.
If the bleeding is coming from an identiable controllable source it should
be stopped. However, it is usually generalized and from multiple sites.
Nasal packs may be necessary (remember the possibility of skull base
fractures). If bleeding continues, the air way should be protected with a
denitive airway.
Displaced tissues
Midface fractures may collapse in on themselves, impinging on the posterior phar yngeal wall and resulting in obstruction. Much of the ob struction
is due to the associated swelling in addition to loss of sof t palate support,
which progresses over several hours. Bilateral anterior (‘bucket handle’)
or comminuted mandibular fractures can similarly displace resulting in
loss of tongue support. The base of the tongue can then fall backwards
into the phar ynx. Swelling is again often associated. All these eects are
much more likely when patients are supine and there is alteration in their
conscious level. A denitive air way will therefore probably be required.
Seek senior help quickly.
Soft tissue swelling
This inevit ably occurs, especially with major injur ies, often necessitating prolonged intubation or an elective tracheostomy. However, major
swelling can also occur in the absence of any fracture, a s occasionally
seen in patients taking anticoagulants, or those with clotting abnormalities. Patients with cer vical spine fractures may develop posterior pharyngeal swelling contributing to an obstructed airway. Penetrating and
blunt (e.g. strangulation/ hanging) neck trauma may also be associated
with pharyngeal oedema and bleeding. It is important to appreciate that
swelling from whatever cause can take several hours to develop. Be wary and
regularly re - examine the patient. O f par ticular concern are those patients
who have suered facial bur ns. These are frequently associated with
inhalation injuries, which can lead to rapid swelling that is not apparent
on initial examination. Stridor is a particularly worrying sign and often
necessitates early intubation.
Direct trauma to the airway will probably require placement of a denitive
airway.
31
32
CHAP TER2 The injured patient
Initial management oftheairway
Control of the airway can be lost ea sily and may be very dicult to
secure following facial tr auma and bur ns. Often early assistance from
an experienced anaesthetist is required and should be anticipated well
in advance of signs of impending obstruction. Occa sionally an immediate
surgical airway is required, notably when there is gross swelling in extensive facial injuries. Members of the trauma team should be competent in
performingthis.
All seriously injured patients should receive oxygen. The patient should be
given high- ow oxygen (15 L/ min) through a non- rebreathing mask, and
the oral cavity/ oropharynx carefully cleared with suction while further
assessment takes place. The following steps may help. They will probably require the hard collar to be loosened— ask someone to support
thehead.
Simple techniques tomaintain anair way
Chin lift and jawthrust
These are commonly used techniques to maint ain the air way but may
be dicult to carr y out in the presence of comminuted mandibular fractures. Both of these techniques have been shown to produce movement
of the cervical spine and should therefore be per formed with counter
support from an assist ant to the head to preventthis.
Reduction ofdisplaced facial fractures
This may involve gentle manipulation of the midface and its temporary
stabilization using bite blocks between the posterior teeth. Bridle wires
may be passed to temporarily st abilize mandibular fr actures.
High- volume suction
A wide- bore soft plastic sucker should be readily available to clear the
mouth, nose, and pharynx of blood and secretions, taking care not to
induce vomiting. Loss of the protective gag reex should prompt consideration of an oropharyngeal airway or intubation.
Adjuncts tosimple air way techniques
Oropharyngealairway
This is often poorly tolerated and can precipitate vomiting and laryngospasm. If not placed correc tly it can push the tongue posteriorly, causing
airway obstruction.
Nasopharyngealairway
This is better tolerated than an orophar yngeal air way but is associated
with epistaxis. Concerns exist about the potential for intracranial positioning in patients with midface/ anterior skull base fractures. In reality
the risks are ver y low, and in experienced hands nasopharyngeal tubes
can be safely passed in these patients.
ADVANCED AIRWAY TECHNIQUES
Advanced airway techniques
A denitive airway may be dened as a cued tube in the trachea. It may
be required if there is any doubt about the patient’s ability to protect
their own air way immediately or in the near future. In the emer gency
situation, it is important that the technique used is one with which the
clinician is most condent ; the trauma setting is not the time to at tempt
unfamiliar procedures.
Laryngeal maskairway
A laryngeal mask airway (LMA) can facilitate rescue ventilation when
mask ventilation and tracheal intubation are unexpectedly dicult.
However the airway is not formally protected and aspiration from vomiting can still occur. It is therefore not the r st choice of advanced airway.
A guide to initial airway management for the non- air way specialist
(i.e. mostofus)
• Give high- ow oxygen (15 L/ min) via a non- rebreathingmask .
• Get seniorhelp.
• Consider jaw thrust with counter support of thehead.
• Consider an orophar yngeal airway if the patient is unconscious and
obstructing (GCS score <8). Do not use a nasopharyngealtube.
• If the air way is patent but there is no spontaneous ventilation then
manually ventilate with a self- inating bag and mask. Call for urgent
anaesthetic assistance.
• If the patient is unconscious, you are on your own, and you cannot
ventilate with a face mask then insert a LMA. If the mask leaks, add
more air into the cu, up to a maximum of30mL.
• If experienced, consider orotr acheal intubation. Be careful,
however, not to extend thehead.
• If you are unable to intubate and cannot ventilate the patient, then
suction the mouth with a large- bore Yankauer sucker and perform
a surgical cricothyroidotomy.
33
Tracheal intubation
Orotracheal intubation with in- line cervical immobilization is usually the
technique of choice in the majority of cases. Acued tube in the trachea
provides a denitive, protected airway. However, placement can be challenging in patient s with facial trauma. Diculties can result in aspiration,
hypoxaemia, hypercarbia, and hypertension, all of which may signicantly worsen any coexisting cerebral injury. In the absence of midface or
craniofacial fractures, alternative techniques include breoptic- assisted
oro- and nasotracheal intubation. These specialized techniques have
been shown to be associated with less manipulation of the injured cervical spine. However, they require extensive training. The use of breoptic
assistance is usually limited as the view is often obscured byblood.
34
CHAP TER2 The injured patient
Surgicalair way
This is required when it is not possible to secure the air way by any other
means within a safe period oftime.
Needle cricothyroidotomy
This is rarely required as it is better to place a surgical cricothyroidotomy directly. However, in some circumstances it allows you to ‘buy time’
(approximately 30 minutes) while preparing for a surgical cr icothyroidot omy. ATLS® recommendations are that oxygen is delivered at a rate of
15 L/ min via a Y- connector. Carbon dioxide removal is inadequate with
this technique
Surgical cricothyroidotomy
This is widely recognized as the preferred choice of emergency air way
control when endotracheal intubation is not possible. The main advantage of this technique over a needle cricothyroidotomy is that a larger,
cued airway can be placed, facilitating positive pressure ventilation and
reliable expiration with removal of carbon dioxide. The key factor in performing a needle or surgical cricothyroidotomy is identication of the
cricothyroid membrane. This should be possible, provided the anterior
neck is not too oedematous.
Tracheostomy
This is considered inappropriate in the emergency setting as it is timeconsuming, technically more dicult to per form, and requires a previously secured air way during the procedure. Only those surgeons with
extensive experience of performing tracheostomy (under local anaesthesia) should undertake this. For the rest of us, perform a surgical
cricothyroidotomy.
Percutaneous tracheostomy
This should only be performed by experienced practitioners familiar
with the technique. It cannot be under taken if the neck has not been
cleared (the neck needs to be extended).
Primary survey:breathing
All patients must be given 100% ox ygen.
Look for signs that the patient is having problems in breathing (i.e.
using accessory muscles of respiration, tachypnoea, stridor, or wheeze).
This rapid assessment of breathing in the tr auma patient should include
the following:
• St and at the top or foot of the bed and look at the chest. You are
more likely to see asymmetrical movement of the chest than standing
beside the patient.
• Talk to the patient.
• Assess respiratory rate (should be less than 20 breaths/ min).
PRIMARY SURVE Y:BREATHI NG
• Pulse oximetry— this is a non- invasive method of continuously
measuring the ox ygen saturation of arterial blood. An oxygen
satur ation of 95% or greater by pulse oximetry is good evidence of
adequate peripheral arterial oxygenation. Changes in oxygenation
can occur rapidly and cannot be detected clinically. For this reason
the patient should have continuous pulse oximetry.
• Check the position of tr achea. Is the trachea deviated? If so, consider
a possible tension pneumothorax.
• Auscultation of chest— is there equal and good air entr y bilaterally
throughout both lung elds? If not, look for one of the underlying
common causes following trauma listed in the following ‘Conditions
aecting ventilation’ section and manage accordingly.
• Comatose patients (head injury/ drugs/ alcohol) may be
hypoventilating. At tach a pulse oximeter and get some bloodga ses.
Conditions aecting ventilation
If you are a member of the ‘ATLS® Fan Club’ you will remember life threatening problems in the chest (mostly ‘B’ problems):
• Airway:foreign bodies in the chest— emergency bronchoscopy/
aspiration/ inhalation injury.
• Tension pneumothorax:needle decompression and for mal
chestdrain.
• Large (massive) haemothora x:volume replacement and chestdrain.
• Sucking chest wound (open pneumothorax):three- sided dressing
initially then chestdr ain.
• Flail chest:analgesia, monitoring, and ventilatory support.
• Cardiac tamponade:drainage, analgesia, monitoring, and ventilatory
support.
In the context of maxillofacial injuries, breathing problems may occur
following aspiration of teeth, vomit, dentures, and other foreign bodies.
If teeth or dentures have been lost and the whereabouts unk nown, a CXR and
soft tissue view of the neck should be taken to exclude their presence in the
pharynx or lower airway (Figure2.3).
Unfor tunately, acrylic, from which ‘plastic’ dentures are made, is not
very obvious on a radiogr aph and a careful search is necessary. All foreign bodies need to be removed.
35
36
CHAP TER2 The injured patient
Figure2 .3 Co ntrary to popular belief, a CXR alone does not excl ude loose
or fore ign bodies in the airway. Asoft tissue vi ew of the neck is o fte n requ ired
(or look closely at the C- spine views).
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Ini tial Co nsiderat ions:High - vs. Low - En ergy Inj urie s and th e Impl icati ons of Co exis ting
Mult iple I njur ies’, 2014, Fig ure1.27b, eds M . Perry and S . Holmes, Co pyright © 2014, S pringer Verlag L ondon. Wit h perm ission of Spr inger.
Initial management ofbreathing
problems
Breathing problems can occur following aspiration of vomit, teeth, dentures, and other foreign mater ials. If teeth or dentures have not been
accounted for then a CXR and a soft tissue view of the neck is mandatory
to exclude their presence in the pharynx or lungs. Unfortunately, fractured acrylic dentures may not be readily identiable on plain radiography. CT may be required.
Summary ofbreathing management
• High- ow ox ygen (15 L/ min) through a non - rebreathing mask should
be given to all patients initially.
• Rapid clinical examination and consider the six common dierentials
that can have an adverse eect on breathing. Treat accordingly.
PRIMARY SURVEY:CIRCULATION
• Call for anaesthetic help early. Tachypnoea and using accessory
muscles of respiration can lead to patient exhaustion very quickly. If
spontaneous ventilation is inadequate it will need to be supported
as soon a s possible. Intubation and ventilation is indicated in the
following situations:
•
Apnoea
•
Inability to maintain an air way by othermeans
•
Protection of the lower airway from aspiration/ vomit
•
Risk of losing the airway from swelling
•
Inability to maintain adequate ventilation by othermeans.
Primary survey:circulation
Hypovolaemic shock secondary to haemorrhage is responsible for up to
40% of the mortality following trauma. Following high- velocity or penetrating trauma, patients can quickly lose signicant amounts of blood
into several anatomical sites. Life- threatening blood loss from the face
can also occur, but is uncommon.
The commonest cause of preventable death following trauma is hypovolae-
mia. Therefore any patient that is cold to touch and has a rapid pulse is in
hypovolaemic shock until proven otherwise.
The important initial observationsare:
• Pulse
• Skincolour
• Level of consciousness.
These are a good guide to the presence of shock. The earliest sign of
blood loss is tachycardia. Caution should be taken particularly with the
elderly, children, and athletes. These patients do not respond to blood
loss in the same manner as other patients. Anormal pulse rate is no guarantee that the patient is not actively bleeding.
Hypotension is a relatively late sign in hypovolaemic shock. If a tension pneu -
mothorax has been excluded, all hypotensive trauma patients should be considered to be in severe hypovolaemic shock unless proven otherwise (ATLS®).
37
Key points inthe management ofbloodloss
• Identify source of bleeding (internally or externally):
•
Identication may involve log rolling the patientearly.
•
The main areas of bleeding are external wounds, chest,
abdomen, retroperitoneum, pelvis, and long- bone fractures.
• Rapid assessment is the key to success. CT is increasingly being
used in the over all evaluation of stable patients. Additionally:
•
CXR— identify pneumo/ haemothoraces, mediastinal widening.
•
Echocardiography— rapidly diagnose a pericardial eusion.
•
FAST scan— useful to identif y free uid in abdomen and visualize
solid organs (spleen, liver, and kidneys).
•
Pelvic X- ray— fractured pelvis.