The trauma airway and the trauma anaesthetic. Dr Steve Rowe, Sheffield. [1B02, 2A01, 2A08, 2F01]
- Which patients need prehospital interventions? Depends on who picks them up – big difference between HEMS-like teams and paramedic teams.
- Intubation by paramedics without NMB associated with very low survival rates. High rate of failure intubation by paramedics, but high rate of success with trained teams [http://bja.oxfordjournals.org/content/113/2/220.full]
- High incidence of aspiration in trauma patients, but outcome not effected.
- Meta-analysis impossible because of differing endpoints used in studies.
- Maximise success: NODESAT (nasal oxygenation during efforts securing a tube) [http://www.sciencedirect.com/science/article/pii/S0196064411016672]. V. cheap intervention and may buy you time. Reduction in desaturation (Sydney HEMS study- http://www.sciencedirect.com/science/article/pii/S0196064414015121)
- Ketamine (as part of 3:2:1) maximises success and minimises hypotension [http://www.ccforum.com/content/19/1/134/abstract]. Not contraindicated in TBI.
- Lower threshold for tracheal intubation in patients with TBI with the advent of MTCs but on compelling evidence for prehospital intubation [http://bja.oxfordjournals.org/content/early/2009/07/31/bja.aep202.abstract]
- KEEP SBP > 90 mmHg in TBI.
- But..which vasopressor should you use? Unclear (http://www.biomedcentral.com/content/pdf/2110-5820-3-13.pdf).
- VITRIS study results awaited (vasopressin vs. placebo) [https://clinicaltrials.gov/ct2/show/NCT00379522]
- Checklists are of value: in Sheffield use RSI checklist.
- How to write checklists? Read the Civil Aviation Authority Guidance [http://www.caa.co.uk/application.aspx?catid=33&pagetype=65&appid=11&mode=detail&id=158]
- PPPPPP: local simulation is of great value; the more realistic the better.