Questions related to topics like these appear in Article 999’s Road to Disaster card game, which is available to purchase here.
Tag: Trauma
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Revise the Signs and Symptoms of Pelvic Fractures
Quizzes based on topics like these are included in Article 999’s Road to Disaster card game, which is available to purchase here. Profits from the game go to search and rescue charities and the organisations supporting them.
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Road to Disaster – The Game – Now Available to Purchase
Road to Disaster is a quiz based tile-laying game. It’s designed for anyone interested in the medical side of disaster response. Profit from these games goes to real search and rescue/international response teams and the organisations that support them. Do your bit for charity while updating your trauma and remote first aid knowledge.
The evidence supporting the cards are the culmination of over a year of research by Article 999. The cards are fully referenced, using the QR code provided.
To purchase, please head to article999.co.uk/shop
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Article Summary: Maxillofacial Trauma Patient
An summary of a Krausz et al (2009) article discussing the importance of effective airway management in the maxillofacial trauma patient and the complexities that such an injury presents. Only points relevant to UK paramedics have been included. For more details, please read the original article. Any additions made by Article 999 are in square brackets [].
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[restab title=”Full Summary and Reference” active=”active”]The Key Points
- Remember to follow ATLS protocol [and/or your local guidance and JRCALC guidelines]
- Use cervical spine control along with effective airway management
- ‘The most common critical care errors are related to airway and respiratory management. Gruen et al studied 25 trauma mortality patients […] [and] found that failure to intubate, secure or protect the airway was […] responsible for 16% of inpatient deaths’ [and that was in a trauma centre, albeit in 1996-2004!] (Gruen et al, 2006)
Hutchinson et al (1990) (in Krausz et al, 2009) found 6 potential ways maxillofacial trauma might prevent effective airway management.
These, from the top of the head downwards, can be summarised as:
Head and soft tissue trauma
– These risk ‘delayed airway compromise’Nasal bleeding/open wounds causing obstruction
Mandible fractures
– Leading to the tongue to drop back, blocking the oropharnyx
– Leading to blockage of the nasopharnygeal airwayMouth obstructions
– From loose items & bodily fluidsTracheal trauma
– Leading to swelling and displacement of essential airway structures behind them.C-spine injury
– Leading to the need for “in-line stablization”. This can cause a reduced view during intubation
– The act of intubating might increase neck movements, potentially worsening this injuryStomach
– [All patients ambulance personnel intubate in the prehospital environment might realistically have a full stomach]
– Note the risk of regurgitation
– Consider cricoid pressure – but also consider that this might ‘worsen the larnygeal view’
– Other tips noted in this section are not relevant to UK paramedics. Please read the full article for more informationThese cause:
– Difficulties fitting a mask
– Less ‘efficient air transferring from the mask to the lungs’
– A ‘difficulty in visualizing the vocal cords’ when intubating due to fluids & obstructions
Final points
- Consider all of the above and ‘avoid future complications’. Then address other injuries.
- Emergency intubation is fraught with risks
- Consider your expertise and experience. Ensure the trauma patient can access ‘the most experienced personnel’ where possible. This would reduce one of the risks.
- Ensure prompt treatment
- Consider the patient’s GCS, breathing level & risk to aid your decision making about transport
- Check the ‘extent, the composition and the anatomy of the injury’. Is it possible to ventilate with a mask?
- ‘Is there a limitation in mouth opening? Is that limitation the result of pain’ only? [In a prehospital environment, this may be difficult to ascertain]
- An LMA may ‘not be suitable for managing trauma patients. However, it could enable ventilating the patient until definitive airway is achieved’
References
Gruen, R.L. et al. 2006. Patterns of Errors Contributing to Trauma Mortality: Lessons Learned from 2594 Deaths, Annals of Surgery, 244 (3): 371-380, Available Online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856538/Krausz, A. et al. 2009. Maxillofacial trauma patient: coping with the difficult airway, World Journal of Emergency Surgery, 4: 21, Available Online: https://wjes.biomedcentral.com/articles/10.1186/1749-7922-4-21
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[restab title=”Article 999 Super Summary”]Remember to follow ATLS protocol [and your local guidelines], use cervical spine control and focus on airway management.
Head and soft tissue trauma, nasal bleeding or open wounds, mandible fractures, mouth obstructions, tracheal trauma, c-spine injury and the patient’s stomach contents can all make airway management more challenging (Hutchinson et al, 1990 in Krausz et al, 2009).
Top tips?
- Consider cricoid pressure but bear in mind it may actually worsen your view during intubation.
- Ensure rapid transport and treatment of the patient and consider your own expertise.
- What level of experience do you really need to deal with this patient, who has it, and where are they?
- The patient’s GCS, breathing level and risk should all support this decision.
- You can use an LMA, but it’s a time-stop measure [Article 999 interpretation; see full summary].
- Consider the ‘extent’ of the patient’s injuries and how they are going to make it difficult to use a mask and intubate if required.
(Krausz et al, 2009)
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