- Approach to the Patient
Every trauma victim is considered to have both cervical spine and airway injury until proven otherwise. The standard ABC approach to the initial survey, followed by automatic C-spine x-rays, either identifies or rules out C-spine or airway problems.
The discussion in the section on general management of the trauma patient details the sequence of examination and stabilization of the airway and cervical spine.
In dealing with the trauma victim, airway management takes first priority. Assessment of the patients airway is the very first action taken on encountering the patient. Three questions should be answered:
1. IS THE PATIENT BREATHING?
2. IS THERE OBSTRUCTION?
3. IS THE AIRWAY AT RISK?
As you walk up to the trauma victim, ask How are you? Any answer at all indicates the patient is breathing and has a reasonably intact airway.
Before you touch the patient, insure that the C-spine is immobilized. An assistant can hold the head pending formal immobilization.
If the patient isnt breathing, open the airway by chin lift or jaw thrust. Insert an oropharyngeal airway. Begin artificial ventilations. DO NOT MOVE THE NECK while attempting to open or clear the airway!
You can secure the airway with endotracheal intubation if the neck, jaw, and mouth are sufficiently intact. The nasal route is preferred on conscious patients, and is the route of choice if C-spine injury is suspected.
Nasal intubation can only be accomplished if the patient is breathing. If the patient isnt breathing, use either oral intubation or establish a surgical airway.
Important: If the patient is not breathing, and C-spine injury is suspected, establish a surgical airway by cricothyrotomy.
Method of Securing Airway in C-Spine Injury:
With facial trauma Surgical Airway
Not breathing Surgical Airway
Breathing Nasotracheal Intubation
Ruled out by x-ray Oral Intubation Allowed
Indications for Surgical Airway
Failure to Intubate
Apneic with Suspected C-spine Injury
Facial Trauma with Suspected C-spine Injury
Severe Facial + Neck Trauma, altered anatomy
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Criteria for intubation
Intubation is necessary whenever the patient cannot maintain adequate ventilation on his own, or when he cannot protect his airway from secretions and foreign matter. Intubate when there is risk to the airway, such as an airway burn. The trachea should be intubated if the patient has, or likely will have, ongoing respiratory distress for example, the COPD patient with a pulmonary contusion.
Examples of inadequate respirations:
Respiratory arrest (such as narcotic overdose)
Respiratory failure (such as status asthmaticus)
Severe lung injury (such as pulmonary contusion)
Traumatic respiratory distress
Examples of protection:
Inadequate gag reflex (such as drug overdose)
Airway encroachment (such as burn or bleeding)
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The larynx may be fractured by contact with the steering wheel. The airway is at risk, as bleeding into the larynx, hematomas, or swelling may occur.
Clinical Findings: The Adams apple area may be puffy, distorted, or crepitant on palpation. Subcutaneous air may be palpable in the neck. The voice may be hoarse, or stridor may be present.
Diagnosis: The clinical findings are usually sufficient to diagnose injury to the larynx. Additional findings may be soft tissue air in the neck (but not in the chest) or deformity of the air column on lateral neck x-ray.
Treatment: In the multiply-injured patient, intubation should be performed on any patient suspected to have laryngeal injury. If the injury is isolated, and judged to be not severe, the patient may be observed (while prepared to intubate if signs of airway encroachment develop). Back to Top
Airway burns are most likely to occur in enclosed-space burn injuries. They are not as likely (but must be screened for) in flare-up burns, such as when gasoline in a carburetor flares into the face. Once swelling begins, it may progress so rapidly that intubation becomes extremely difficult.
Clinical Findings: Assume the airway is burned if there are burns within the mouth, nose or throat, or if the victim had significant time in an enclosed-space fire or explosion. Singed nasal hairs; red, tender oral membranes; or obvious intraoral or pharyngeal burns indicate likely airway burn.
Diagnosis: Based on history and clinical examination.
Treatment: If airway burn is suspected, intubate the patient nasally at the first opportunity. Back to Top
Severe Facial Fractures
Severe facial trauma often results in unstable tissues, which can occlude the airway. While lifting the jaw and inserting an oral or nasal airway may help temporarily, the airway will continue to be at risk due to bleeding, swelling, and hematoma formation. Patients with severe facial fractures will usually have a decreased level of consciousness due to intracranial injury. Neck fracture is also common in these patients.
Clinical Findings: Facial fractures sufficient to put the airway at risk will almost always be unstable. Palpate the jaw for crepitance and instability. Grasp the upper teeth between your thumb and knuckle of your index finger and test for maxillary instability. Bilateral eyelid swelling and a sunken facial appearance suggest a cranio-facial fracture.
Diagnosis: The diagnosis of risk to the airway is made based on the finding of significant fracturing and soft tissue injury. The airway is the critical issue the nature of the fracturing can be determined at leisure once the airway is safe.
Treatment: If trauma involves both the mandible and upper face, and the C-spine is still at risk, you are probably better off performing cricothyrotomy. If the C-spine is OK, oral intubation may be attempted first. Nasal intubation may cause complications such as entry into open fractures, and may restart bleeding into the airway.
Gastric tubes may be passed orally in the presence of facial trauma. If trauma is not too severe, a nasal airway can be inserted to guide a nasally-inserted NG tube downward the nasal airway prevents the NG from entering into tissue tears such as an open cribriform plate fracture. Back to Top
Cervical Spine Injury
The cervical spine is considered injured in all trauma victims until proven otherwise. In the multiply-injured or intoxicated patient, absence of pain or tenderness does NOT exclude cervical fracture.
Clinical Findings: The presence of a step-off deformity may indicate a fracture or dislocation. Complete spinal cord injury will result in a flaccid areflexia, flaccid sphincters, and diaphragmatic breathing. The patient may be able to flex, but not extend the arms. Painful stimulation may be felt only above the clavicle.
Neurogenic shock results from loss of sympathetic nerve stimulation of the blood vessels and heart. This is often described as a warm hypotension. Typically, both pulse rate and systolic pressure are around 80, with warm, pink extremities. However, hypotension in the injured patient should first be assumed due to hemorrhage. Only after fluid challenge, ruling out intraperitoneal hemorrhage, and measuring a normal CVP and normal urine output, should the hypotension be blamed on spinal cord injury.
Diagnosis: By cross-table cervical spine x-ray.
Treatment: Treatment of life-threatening injuries continues, with cautions to continue cervical protection. Gardner-Wells tongs may be applied in the emergency room for patients who are to undergo surgery. Obtain neurosurgical consultation. Placement of a CVP or Swan-Ganz catheter to monitor fluid resuscitation is advisable for those with spinal cord injury. Give immediate high-dose steroids. Back to Top
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All material referenced through this menu is excerpted from copyrighted works by Bruce Argyle, MD. You are welcome to use selected portions, as long as appropriate credit is given. The credit for the text referenced through this menu is:
Argyle, B., Trauma One! Computer Program Manual.
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