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InitialTraumaAssessmentTheAnaesthetist'sRole
IanZunderMDFRCPC,DepartmentofAnaesthesia
OttawaCivicHospital,UniversityofOttawa,Ottawa
Objectives

Followingthislecture,theparticipantshouldbeable:

1. Toadoptanorganizedapproachtoairwayofthetraumapatient
2. Tobeawareoftheoptionsavailabletoprovide/secureanairwayinthe
traumapatient

3. Tobeawareofthecontroversiesregardingvariousdrugs/techniquesused
CRITICALCARE

tosecuretheairwayinthetraumapatient

Introduction

Traumaistheleadingcauseofdeathinthefirstfourdecadesoflifewithin
modernindustrializedcountries.

Deathfromtraumahasatrimodaldistribution:

1. withinsecondstominutes,
2. minutestohours(GOLDENHOUR),
3. severaldaysorweeksaftertheinitialinjury.
Traumacutsacrosstheentirefieldofmedicine,requiringthephysiciantohave
abroadknowledgebaseoftreatmentprinciplesandanappreciationformultiple
varietiesofinjury.Anorganizedconsistentapproachtothetraumapatient
affordsanoptimaloutcome.
TheAdvancedTraumaLifeSupport(ATLS)CoursewasdevelopedinNebraska
andsoonadoptedbytheAmericanCollegeofSurgeonsin1979.Theprimary
focusofATLSisonthefirsthouroftraumamanagement,whenrapid
assessmentandresuscitationcanbecarriedouttoreducedeathswithinthe
GoldenHour.
Today,thiscourseistaughtthroughouttheworld.Involvementofanaesthesia
personnelintraumaresuscitationiscommonplacewhetheritbeinthesmall
countryhospitalorthebigcityTraumaCenter.Anaesthetistsnowtakean
activepartintheteachingofATLSskills,especiallywithregardstoairway
management.Coursecontentandrecommendationshavechangedoverthe
yearstoreflecttheinsightoftheanesthesiaproviders.
Thislecturewillfocusonourroleasanaesthetistsinthe"primarysurvey"as
definedbytheATLS.
Duringtheprimarysurvey,lifethreateningconditionsareidentifiedand
managementisbegunsimultaneously.

1. AAirwaymaintenancewithcervicalspinecontrol
2. BBreathingandventilation
3. CCirculationwithhemorrhagecontrol
4. DDisability:neurologicalstatus
5. EExposure:completelyundressthepatient
Asananaesthesiaprovider,ourskillswiththeAirway,Breathingandventilation
areoftencalledupon.Itisimportanttorememberthatitisimpossibleto
completelyisolateeachcomponentandthatinreality,thesemanagementgoals
areinterrelated.
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Airway/Breathing
Allpatientsshouldbetransported/treatedinitiallywithsupplemental
oxygen.
Aswell,immobilizationofthecervicalspineistheacceptedstandardofcareto
preventsecondaryneurologicinjury.Themosteffectivedeviceforthispurpose
isthehalovestalthoughittendstobeinappropriateintheemergencysetting.
Themostpracticalapparatusisacombinationofahardcollarandsandbagson
oppositesidesofthehead.Tapeisthenextendedfromonesideofthespine
boardovertheforeheadofthepatienttotheoppositesideoftheboard.This
providesnearcompletecessationofmovement.(1)Onitsown,ahardcollar
providesonlymoderateprotectionandasoftcollaroffersminimalbenefit.
Begintheassessmentbyestablishingverbalcontactwiththepatient.Clear
phonationbythepatientestablishesthattheairwayispatent.
Furtherinterventionwilldependon:

a. neurologicstability
b. adequacyofgasexchangeandthepotentialforairwaycompromise(i.e
Breathingandventilation)
ASSESS:NeurologicalStability
Adepressedlevelofconsciousnessisconsideredtobeintracranialpathology
untilprovenotherwise,althoughalteredmentationisoftenduetodrugs,
alcoholormedicalcauses.
Abriefneuroexamcanbedoneduringtheprimarysurvey:
AAlert
VrespondstoVerbalstimuli
PrespondstoPainfulstimuli
UUnresponsive
OnecanalsodeterminetheGlasgowComaScale(GCS).Itisgenerallyaccepted
thataGCS<8requiresdefiniteairwayinterventiontopreventaspiration
pneumonitis,toinsureadequateoxygendeliveryandtoavoidhypercarbia.Ifa
patientisrespondingonlytopainfulstimuliorisunresponsive/unconscious,the
GCSisorhasahighlikelihoodofbeinglessthan8.

ASSESS:AdequacyofGasExchangePhysicalExamination
Airwaypatencydoesnotinsureadequateventilation.Look
Whatisthenatureoftheinjury?Maxillofacialtrauma/airwayburnshavethe
potentialforairwaycompromise.Isthereobviousairwayorchesttrauma
(suckingchestwounds,flailsegments)orcyanosis?
Istheretachypnea,useofaccessorymusclesofrespirationorevidenceof
trachealshift?
Listen
Stridorindicatesupperairwaycompromise.Hyperresonancetopercussion/lack
ofairentrysuggestspneumothoraxwhiledullnesstopercussion/lackofair
entrysuggestshemothorax.(Notethatthisisoftendifficulttodetermineinthe
settingofanoisyresuscitationroom)Bowelsoundsinthechestmaybe
indicativeofaruptureddiaphragm.
Feel
Placeahandoverthemouthandfeelforairexchange.Ifnecessary,inserta
fingerandsweeptoclearthemouthofanyforeignbodies(especiallydislodged
teeth)andtoevaluateforevidenceofmaxillofacialtrauma.
ASSESS:AdequacyofGasExchangeMonitoring/Laboratory

Pulseoximetrygivesimmediatefeedbackalthoughitisnecessarytobeawareof

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Pulseoximetrygivesimmediatefeedbackalthoughitisnecessarytobeawareof
itspitfalls(motion,peripheralvasoconstriction,carboxy/methaemoglobinemia).
Theonlyparametermeasuredbyoximetryishaemoglobinsaturation.
Arterialbloodgasesprovideamorecompletepictureofthepatientalthough
thereisadefinedwaitingperiod(institutiondependent).Resultsprovide
feedbackonoxygenation,ventilationandtissueperfusion.
Intervention
Cansurgicalinterventionsuchastubethoracostomyresolvetheproblem?If
not,basictoadvancedairwaymeasuresmustbeinitiated.
SecuringtheAirway
Ifadecisionismadetosecuretheairwaywithanendotrachealtube,several
questionsarise.

1)Howquicklymusttheairwaybesecured?
Airwayinterventioncanbeclassifiedasbeingimmediate,emergentorurgent.
(2)
Immediate
Ifapneaisevidentontheprimarysurvey,immediateendotrachealintubationis
warranted.
However,simplemechanicalmeansofopeningtheairwayandproviding
ventilationshouldnotbeoverlookedintherushtointubate.Aspreviously
noted,inspectthemouthforforeignbodies.Bloodandsecretionsshouldbe
suctioned.Breathingshouldbeassistedwithbagmaskventilationas
preparationsaremadetointubate.Considerationofpossiblespinalcordinjuries
ordirecttraumatictrachealinjuriesshouldnotpreventattemptsatlifesaving
translaryngealintubation.
Emergent
Patientswhoarehypoventilating,havesignificantheadinjury,orarecyanotic
requireemergencyinterventiontoestablishapatentairwayandeffective
ventilation.Occasionally,openingtheairwayandprovidingbagvalvemask
ventilationsufficientlyimprovesoxygenationtoallowuseofamoreelective
methodoftrachealintubation.Otherwise,thesepatientsshouldbetreatedas
above.
N.B.Inbothimmediateandemergentintubations,donothesitatetoproceedto
asurgicalairwayifinitialattemptsareunsuccessful.
Urgent
Patientswithburns,maxillofacialinjuryandcervicalhematomaswilllikely
requireasecureairwaytopreventupperairwayobstruction.Patientswithchest
wallandpulmonaryinjuriesareusuallyinitiallywellcompensatedbutmay
eventuallyrequiremechanicalventilation.Withthesepatients,thereisoften
timeforahistory,appropriatephysicalexamandcervicalradiographssuchthat
aplannedapproachtotheairwaymaybeundertaken.

2)Whichrouteofintubationistobeemployed?(oralvs.
nasal)
PriortothemostrecentrevisionoftheATLScourse,averysimplisticapproach
totheairwaywastaken(seefig.1).Blindnasotrachealintubationwasheavily
relieduponalthoughmostanaesthetistsaremorecomfortablewithdirect
orotrachealintubation.
Blindnasotrachealintubationrequiresaspontaneouslybreathingunconscious
orcooperativeconsciouspatient.Thereisanunacceptablefailurerate(35%)
anditrequires3.7vs.1.3oralattempts.Nasalintubationsarecontraindicated
inthepatientwithbasalskullormidfacefracture.Theprocedurecan
precipitateepistaxiswhichmayinterferewithsubsequentalternativeattempts
atintubationifunsuccessful.Thereisahighincidenceofsinusitisifatubeisleft
inplacegreaterthan72hours.
Currentteachingrecognizestheintegralroleoftheanaesthesiaprovider.The

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Currentteachingrecognizestheintegralroleoftheanaesthesiaprovider.The
mostimportantdeterminantofwhethertoproceedwithorotrachealor
nasotrachealintubationistheexperienceofthephysician.Bothtechniquesare
safeandeffectiveifperformedproperly.(3)

3)Whatisthestatusofthecervicalspine?
N.B.Assumethecervicalspinetobeunstableuntilprovenotherwise.
Upto50%ofpatientssustainingcervicalspinetraumadevelopneurologic
abnormalitiesrangingfromnerverootcompressionandweaknesstoquadri
plegia,andinmanyinstances,death.Asmanyas10%ofpatientwithcervical
spinalcordinjuryareinitiallyneurologicallyintact,butdevelopdeficitsduring
thecourseofemergencycare.(4)
Theradiographicdictum"oneviewisnoview"isnowheremoreaptthaninthe
roentgenographicevaluationofacutespinalinjury.(i.e.asinglecrosstable
lateralisnotenough).Inthelateralview,onemustbeabletodemonstrateall
7cervicalvertebraeandpreferablyincludingT1asapproximately30%of
injuriesoccurattheC7T1level.
TheAPviewisassessedforverticalalignmentofthespinousandarticular
processandabnormalitiesinjointanddiscspaces.
Theopenmouthviewisusedtoassesstheintegrityoftheatlantooccipitaland
atlantoaxialjointsaswellastheodontoidprocess.
Obliqueviewsmaybeusedtodetailmoreclearlytheintervertebralforamenand
thevertebralarches.
Mostauthorsfeelthatatechnicallyadequate,normalthreeviewseriescanbe
usedtocleartheCspinewhenthereisappropriatecorrelationwiththeclinical
picture.
PleuridirectionalandCTscanningareusedtoruleoutinjurywhentheplain
radiographsaresuspiciousorequivocalorwhenthereisclinicalevidenceofa
cordinjurydespitenegativeradiographs.
Thelateralcervicalspinehasasensitivityofabout85%.Thisincreasesto92%
inathreeviewseriesandupto100%whenselectiveCTscanningisemployed.
(5)
RadiographicAnalysis
AnaesthetistsshouldbeskilledatbasicinterpretationoftheCspinefilms.
Secondaryspinalinjuryisoftenaresultofmisinterpretationoffilms.
WhenreadingaCspinefilm,concentrateon:

1. softtissue
2. vertebralalignment
1)Abnormalsofttissuecanprovidesignificantinformationwithregardstothe
localizationofCspinetrauma.Aprevertebralhematomaisusuallyassociated
withafractureandshoulddrawattentiontoahyperextensioninjury.Normally,
thedistancebetweentheposteriorpharyngealaircolumnandtheanterior
inferioraspectofC2islessthan7mm.andthedistancefromC6shouldbe22
mm.inadults(notvalidwhenNasogastric/Orotrachealtubesareinplace).
2)Normally,thecervicalspinehasalordoticcurve.Somecontendthattheloss
oflordosisissuggestiveofmusclespasmandCspineinjuryalthoughthisisnot
totallyreliable.Spinalmusclesdonotplayasignificantroleinneckstability.
Instead,itismainlydependentontheligamentousandbonycomplex.
Fourlinescanbedrawntoassessalignment:
anteriormarginofthevertebralbodies
posteriormarginofthevertebralbodies
spinolaminarline
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spinousprocesses
Disruptionofanyoneofthesesmoothlinesaresuggestiveofinjury.
BiomechanicalstudiesbyWhiteandcoworkers6haveshownthatinstabilityof
thecervicalspineexistsif1)alltheanteriororposteriorelementsare
destroyed,2)thereisgreaterthan31/2mmhorizontaldisplacementofone
vertebralbodyontoanother,or3)thereisgreaterthan11degreesofkyphotic
hyperangulation.Additionalhelpfulfindingsincludewideningofthe
intervertebraldiskspace,prevertebralhematomaanddisplacementofthe
apophysealjoints.

4)HowdoairwaymanagementtechniquesaffectCspine
movement?
BasicAirwayManeuvers
Inastudywhereallligamentsinacadavericmodelweretransectedbetween
C56leavingonlythemusclesintact,variousairwaymanagementtechniques
wereappliedwithandwithoutcollarsusedtosplinttheunstablespine.Achin
lift/jawthrustproducedsignificant(>5mm.)increaseindiscspacedespitethe
presenceofeitherahard/softcollar.Likewise,oralendotrachealintubation
(curvedorstraightblade)produceda34mmincreaseindiscspace.In
contrast,oral/nasalairwayinsertionwasresponsiblefor2mmposterior
subluxation(i.eminimalchange).(7)
AdvancedAirwayManeuvers
Inanotherstudy,agroupofhealthy,anaesthetizedandparalyzedvolunteers
scheduledforelectivesurgerywereinvestigatedforcervicalspinemovement
duringintubation.Significantmovementwasnotedduringroutineintubation
regardlessofbladechoice(Macintoshvs.Miller).ThepresenceofaPhiladelphia
collarwasinconsequential.However,therewasasignificantdecreaseincervical
spinemovement(notcompleteelimination)duringorotrachealintubationwhen
thepatientwasplacedonashortspineboardandanassistantapplied"inline
immobilization".(8)
CricoidPressure
Cricoidpressureisconsideredthestandardofcareinthetraumapatient.
Sellick'smaneuverincreasestheconvexityofthecervicalspine,stretchesthe
esophagustaut,andthusimprovesitsfixationbytheposterioraspectofthe
cricoidcartilage.
Apotentialconcernexistsregardingtheapplicationofcricoidpressureagainsta
potentiallyunstableCspine,especiallyattheC57level.Someauthorsstate
thatinstabilityatthislevelisacontraindicationtocricoidpressure.However,
thisappearstobemoreofatheoreticalthanpracticalconcern.Inmany
situations,thestatusoftheCspineisnotclearlydefinedwhenairway
managementisinitiated.Aswell,informationfromlargevolumetraumacenters
wherecricoidpressureisroutinelyapplieddoesnotrevealanincreased
incidenceofsecondaryneurologicinjury.
Contraindicationstotheapplicationofcricoidpressureare:

1. Suspectedairwayinjury(especiallyinjuriesatthecricotrachealjunction).
2. Foreignbodyatthelevelofthecricoid(eitherwithintheesophagusor
thetrachea).

3. Activevomiting.
4. Awakeintubationorlightlysedatedpatient.
5)Ifthespineisunstable,shouldtheairwaybesecuredwith
thepatientawakeorasleep?
Theoptimalmodeofintubationiscontroversial.Aspartoftheearlyefforts
aimedatreducingsecondaryneurologicinjury,ahypothesiswasgeneratedthat
theairwayofpatientswithunstablecervicalspinescouldnotbesafelymanaged
byoralintubation.Althoughneverproven,itwasassumedthatmovement
associatedwithoralintubationand"inlineimmobilization"wouldleadto
secondaryneurologicinjury.(9)Sudermanetal(10)showednodifferencein
newneurologicdeficitsinastudycomparingawakevs.anaesthetizedoral/nasal
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newneurologicdeficitsinastudycomparingawakevs.anaesthetizedoral/nasal
intubationsinatenyearreviewof150patients.Rosen(11)haslabeledthis
unsubstantiatedhypothesisasa"therapeuticlegendofemergencymedicine".
Therearenumerousstudiesshowingthatinductionofanaesthesiaandoral
intubationinneckinjuredpatientsresultsinoutcomessimilartothosepatients
undergoingawakeintubation.
Optimumcaredoesnotnecessarilymeanthesamecare.Differentcentresmay
choosedifferentapproachesaslongastheessentialelementsarepreserved.(9)

6)Whichdrugsaremostappropriateinthetraumasetting?
Securingtheairwaycanbeperformedwithorwithoutpharmacologic
assistance.
Patientswithmaxillofacialtrauma,evidenceofairwayobstruction/injuryor
otherobjectiveevidencewhichmaysuggestadifficultlaryngealvisualization
shouldhavetheirairwaysecuredwhileawake.Considertheuseoflocal
anaesthetictopicalizationwith/withouttheadditionofsedativemedication
(e.g.fentanyl/midazolam).
Forthepatientwithanticipatednormalanatomy,arapidsequenceintubationis
anappropriatechoice.Ifpossible,thepatientispreoxygenatedfor35minutes
oraskedtotakeseveralvitalcapacitybreaths.
Precurarization(whenconsideringtheuseofsuccinylcholine)
Cons

1. Largerdosesofsuccinylcholinearerequiredandonsetmaybedelayed.
2. Durationofactionmaybeincreasedandretardthereturnto
spontaneousbreathingifventilation/intubationisunsuccessful.

3. Aprecurarizationdosemayleadtoaspirationofgastric/pharyngeal
contents.
Pros

1. dTCattenuatestheincreaseinintragastricand?intracranialpressure.
SupplementalDrugs
Inhemodynamicallystabletraumapatients,rapidsequenceinductionislikelyto
produceanexaggeratedhemodynamicresponsethatmaybeassociatedwith:

1. Increasedmyocardialoxygenconsumption(detrimentaltothepatient
withischemicheartdisease)

2. Elevationofintracranialpressure(detrimentaltothepatientwithhead
injury)

3. Elevationofintraocularpressure(detrimentaltothepatientwithopen
eyeinjury)
Theuseoftitrateddosesofnarcotics,shortactingblockers(e.g.esmolol)
andlidocaine,whetheraloneorincombinationcanbebeneficialin
attenuatingtheresponsetolaryngoscopy/intubation.
InductionAgents
Alargevarietyofintravenousinductionagentsareavailablefortherapid
sequenceinductionofanaesthesia.Withthepossibleexceptionofketamine,
thesedrugsareallcardiovasculardepressantsandshouldbeadministeredin
reduced(2550%ofnormal)doses.Inseverelyhemodynamicallycompromised
patients,theseagentsshouldbeomittedentirely.Themostcommondruggiven
attraumacentresthroughouttheworldforthepurposeofintubationissodium
thiopental.AlthoughnotavailableinCanada,etomidatehasgainedpopularity
becauseofitssupposedhemodynamicstabilityineuvolemicpatientsatusual
inductiondoses.
MuscleRelaxants

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MuscleRelaxants
Itistheopinionofthisauthorthatsuccinylcholineisstillthedrugofchoicefor
intubationofthetraumapatient.Atthetimeofwriting,noneofthenon
depolarizerscanmatchsuccinylcholineineitheritsspeedofonsetoroffset.
Succinylcholine:

1. Doescauseanincreaseinintragastricpressurebutalsocausesa
simultaneousincreaseinloweresophagealsphincter

2. tonewhichwillpreventaspiration.
3. Probablydoesnotcauseanelevationinintracranialpressure.(12)
4. Maycauseanincreaseinintraocularpressurealthoughthiscanbe
attenuatedbyanondepolarizingprimer.

5. DoescauseanincreaseinK+althoughthisisnotanissueinthepatient
withnewonsetparalysisfromtraumawhorequiresairwayintervention
intheresuscitationroom.Itisapotentialprobleminthepatientwith
massivecrushinjury.

6. Rarelycausescardiacdysrhythmiasinadultpatientsandpretreatment
withatropinewillattenuatepediatricbradydysrhythmias
.
Contraindicationstosuccinylcholineinclude:

1. thepatientwithmalignanthyperthermia
2. ongoingneuromuscularpathology
3. underlyinghyperkalemiaregardlessofetiology
NondepolarizingMuscleRelaxants:
Theuseofthesedrugsavoidsthepotentialcomplicationsfromsuccinylcholine.
However,largedosesoftheseagentsarerequiredtoproduceanacceptable
onsettime.Thisgreatlyincreasesthedurationofactionofthedrug.
Thedrugofchoiceatthepresenttimeisvecuroniumwhichisgiveninadoseof
0.15.0.25mg/kg.Ithasnocardiovasculareffects.Althoughmivacuriumhasa
shortdurationofaction,ithasalongonsettime.Increasingtheinductiondose
wouldspeedonsetattheexpenseofunacceptablehistaminereleaseand
hypotension.RocuroniumwillprobablybecometheNDMRofchoiceonce
availableinCanadaasithasanevenshorteronsettimethanvecuronium.

Whatdoyoudowhentheairwaycannotbesecuredwith
traditionaltechniques?
Thefollowingisalistofalternativetechniquestosecuretheairway:
GumRubberBougie
Whenthisdeviceisplacedinthetrachea,onecansensethe"bumps"ofthe
trachealringsincontrasttothesmoothsensationoftheesophagus.The
endotrachealtubeisthenfedoverthebougie.
LightedStylet
AgoodtechniqueforthepatientwithpotentialCspineinjuryastheneckis
maintainedintheneutralposition.However,mostofthecommerciallyavailable
styletsrequirelowlightlevelsandconcomitantresuscitationmaybeslowed.
Newermodelsclaimsuperiorbrightnesssuchthatdimmingtheroomlightsmay
nolongerberequired.
FiberopticBronchoscope
Thistechniquerequiresconsiderableexpertiseaswellasacooperativepatient.
Itisbesttousethelargestscopepossibleasairwaybleedingand/orsecretions
maylimitsuccess.
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Tip:attachoxygensourcetosuctionportsoastobothoxygenatethepatient
andclearsecretions.
RetrogradeorTranslaryngealRoute
Thisisprobablytherouteofchoiceinthesettingofmaxillofacialtrauma.
Varioustechniqueshavebeendescribed.(13,14)Thecommondenominatoris
thepassageofaneedle/wiresystemthroughthecricothyroidmembraneup
intotheoropharynxwithsubsequentantegradethreadingofanendotracheal
tubeoverthewireintothetrachea.
CricothyroidPuncture
Allanaesthesiaprovidersshouldbefamiliarwiththisskill.Equipmenttoperform
thisprocedureshouldbeimmediatelyavailable.Personnelshouldbereadily
availabletoproceedtoaformalcricothyroidotomyortracheostomy.
LaryngealMask
Thelaryngealmaskisusedforthe"cannotintubate,cannotventilate"scenario.
Itisrelativelyeasytoinsertalthoughalearningcurvedoesexist.Itcanbe
placedblindlyorwiththeaidofalaryngoscope.Rememberthattheairwayis
notsecurewithalaryngealmask.Itisastopgapmeasureonly.
Combitube
TheCombitubeisafieldairwaydevicewhichisinsertedblindlyintothe
esophagusandallowsforindirectventilationviaadoublelumendesign.Itisthe
opinionoftheauthorthatthisisthetubeofchoiceforthe"cannotintubate,
cannotventilate"scenario.Nolearningcurveexistsanditissuperiortothe
laryngealmaskforairwayprotection.

References
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64
2.GrandeC.TextbookofTraumaAnesthesiaandCriticalCare.MosbyYearBook1993
3.AdvancedTraumaLifeSupportCourseforPhysicians.TheAmericanCollegeof
Surgeons1993
4.RogersWA.Fracturesanddislocationsofthecervicalspine:Anendresultstudy.J.
BoneSurg195739A:34176
5.RossS.E.etal.ClearingtheCervicalSpine:InitialRadiologicEvaluation.J.Trauma
27:910551060
6.WhiteAA.etal.Biomechanicalanalysisofclinicalstabilityinthecervicalspine.Clin
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injuredadults.CanJAnaesth199138:67859
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12.KovarikWD,etalSuccinylcholineDoesNotChangeIntracranialPressure,Cerebral
BloodFlowVelocity,orTheElectroencephalograminPatientswithNeurologicInjury.
AnesthAnalg199478:46973
13.BarriotP,RiouB.Retrogradetechniquefortrachealintubationintraumapatients.Crit
CareMed16:771214
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