trauma airway management

RSI in Trauma Airway Management : 

RSI in Trauma Airway Management 日期: 99 年8 月14日 (星期六) 11：20 – 12：20 Noon 地點:童綜合醫院梧棲院區20樓大講堂 主辦單位：台灣外傷醫學會 台中沙鹿 光田綜合醫院 沙鹿總院 大甲院區 通宵院區 急診部主任 兼外傷科、外傷小組 (Trauma Team) 主任 張立偉 2010外傷教育課程 (Ⅱ)【中部場次】

Airway Management 三大挑戰 : 

Airway Management 三大挑戰 小兒呼吸道: 沒有經驗 沒有裝備 沒有訓練 老人呼吸道 (AAALS:台灣老人急重症醫學會): Adult AALS Aged, 需要極為小心及aggressive 990711 外傷呼吸道

外傷呼吸道的挑戰 : 

外傷呼吸道的挑戰 MILS: Difficult Airway Blood 浴血 990712 Shock, Saturation or spine?

Saturation, shock or spine? : 

Saturation, shock or spine? MILS degrades DL view. 為了MILS 卻耽誤處理Airway 的黃金時間 一定要 MILS? Spine injury 比例是否真的如此高? Laryngoscopic View Cormack and Lehane Grade

Trauma Airway Management : 

Trauma Airway Management Initial Assessment & Management: The first priority is to establish and maintain a patent airway. Head injury with impaired consciousness and reduced pharyngeal tone is the commonest trauma-related cause of airway obstruction. Maxillofacial Injury Cervical spine injury

Trauma Airway Management : 

Trauma Airway Management 2003 Difficult Airway Algorithm Airway management: Most important initial element In trauma management！！ Trauma airway management deserves an organized approach to the general condition

Trauma Airway Management : 

Trauma Airway Management A specific protocol. A challenge. What is it important? What is the difference?

Mallampati Test : 

Mallampati Test Mallampati suggested a simple screening test which is widely used today. The patient sits in front of the anesthetist and opens the mouth wide. The`patient is assigned a grade according to the best view obtained. 外傷病人無法以此方法評估 Limited accuracy for predicting the difficult airway and thus are not useful screening tests. Lee A., Ngan Kee WD, Anesth Analg. 2006 Jun;102(6):1867-78

Mallampati Classification : 

Mallampati Classification Class I Class II Class III Class IV Not visible when tongue is protruded with patient in sitting position Difficult Airway: Mallampati class greater than II

60-SECOND EXAM “LEMON” : 

60-SECOND EXAM “LEMON” Look for external difficulty Evaluate using 3-3-2 rule Mallampati Rule (Class I & II) Obstruction Neck Mobility

Trauma with Shock : 

Trauma with Shock When cardiac output is adequate: Paco2 and end-tidal carbon dioxide (PETCO2) detection to confirm ETT position When cardiac output is inadequate: EDD 2003 ASA Algorithm

Slide 12: 

Stopping to come back another day is seldom an option with trauma.

Slide 13: 

An awake ETT technique should be chosen in a DA patient providing the patient is cooperative, stable, and spontaneously ventilating.

Awake Intubation : 

Awake Intubation An awake ETT technique should be chosen in a DA patient providing the patient is cooperative, stable, and spontaneously ventilating. An awake intubation technique is recommended for all trauma patients with a recognized difficult airway. Trauma + Difficult Airway = Challenge！

Slide 15: 

A surgical airway may be the first/best choice in certain conditions.

Slide 16: 

Once the patient is anesthetized or is rendered apneic or presents comatose and the trachea cannot be intubated, O2, enriched mask ventilation (MV) is attempted. If MV adequate, a number of intubation techniques may be employed.

Definitive Airway: Surgical Airway : 

Definitive Airway: Surgical Airway Indications: Inability to intubate the trachea is a clear indication for creating a surgical airway. Alternatives impossible Bleeding: severe oropharyngeal hemorrhage obstructs the airway Edema of glottis Fracture of larynx LAST RESORT!

Surgical AirwayNeedle Cricothyroidotomy : 

Surgical AirwayNeedle Cricothyroidotomy Insertion of a needle through the cricothyroid membrane or into the trachea: provide oxygen immediately until a definite airway can be placed. Needle cricothyroidotomy provides the simplest, fastest, and safest access

Surgical AirwaySurgical Cricothyroidotomy : 

Surgical AirwaySurgical Cricothyroidotomy Seldinger Technique Emergency Cricothyroidotomy Catheter-over-needle Wire-through-needle

Commercial Needle Cricothyroidotomy Devices : 

Commercial Needle Cricothyroidotomy Devices Pertrach

Slide 21: 

Quick Trach Pertrach Needle Cricothyrotomy Commercial Needle Cricothyrotomy Devices

Percutaneous Transtracheal Jet Ventilation (PTJV) during Difficult Airway Management : 

Percutaneous Transtracheal Jet Ventilation (PTJV) during Difficult Airway Management PTJV proved to be a life saving pr ocedure by providing adequate gas-exchange and ensuring the patency of the airway until a definitive procedure such as oral intubation with bronchoscopy followed by surgical tracheostomy was performed. Patient can be adequately oxygenated for only 30-45 minutes. CO2 slowly accumulates.

Surgical AirwaySurgical Cricothyroidotomy : 

Surgical AirwaySurgical Cricothyroidotomy Cricoid cartilage The only circumferential support to the upper trachea. Not recommended for children under 12 years of age. (ATLS 7th 2004)

Slide 24: 

Open Cricothyroidotomy Incision: Vertical incision over membrane over membrane Pierce membrane in horizontal plane--Open and spread to insert 4.0 or 5.0 tube Secure tube in place and ventilate Secure tube in place and ventilate Surgical AirwaySurgical Cricothyroidotomy

Surgical Airway Surgical Cricothyroidotomy : 

Surgical Airway Surgical Cricothyroidotomy Surgical cricothyroidotomy is preferable to a tracheotomy for most patients requiring an emergency surgical airway (ATLS 7th 2004) Bleeding: less bleeding Easier Time: less time Percutaneous tracheotomy: an alternative to open tracheostomy. (ATLS 7th 2004) Not a safe procedure in the acute trauma situation (ATLS, 7th) Hyper-extension of neck Time-consuming

Surgical AirwayRetrograde Tracheal Intubation : 

Surgical AirwayRetrograde Tracheal Intubation One of the most threatening situations faced by EP is the inability to intubate the trachea when airway control or artificial ventilation is urgently required. Difficult intubation with loss of airway is a leading cause of death in anesthesia. An alternative technique is needed for cases in which FOI cannot be carried out or adequate equipments are not available.

Conventional Surgical Technique of Tracheostomy : 

Conventional Surgical Technique of Tracheostomy Operating room procedure (should not be performed as an emergency) Carried out under general anaesthesia Usually intubation prior to procedure

Airway Disaster: Tragedy in ICU : 

Airway Disaster: Tragedy in ICU Consult CS doctors: Prepare tracheostomy set. 準備氣切包 橫切, 打開 trachea 已經看到氣管內管 (ETT) 請站在病人上方的助手拔除 ETT Question? Conversion of OTI to Tracheostomy safely. 還少了什麼?

RSI : 

RSI RSI for endotracheal intubation in the trauma patient is risky. But in certain case the need for an airway justifies the risk of these drugs. First step in RSI: be prepared to perform a surgical airway if airway control is lost. RSI 第一步: 準備氣切包!!

New Era, Future : 

New Era, Future Difficult Airway algorithm Video Laryngoscope 引進 OLV 觀念

Trauma Difficult Airway Algorithm : 

Trauma Difficult Airway Algorithm Keypoints: Airway history for predicting DA Airway PE before anesthetic care & airway management whenever feasible Sniff position: contraindicated whenever C spine injury is suspected. Head & Neck: MILS throughout airway manipulation Oxygen deliver throughout trauma care Tight fitting mask before RSI Documentation of grading: Cormack & Lahane Caution against blind NT intubation Caution against blindly passing ETT through LMA (failure rate: 18-20%, & harmful) Consider awake intubation for trauma patients with known or anticipating DAs if they are cooperative, stable & spontaneously ventilating LMA for CNV-CNI & for conduit for ETI

Optic Stylet : 

Optic Stylet Intubating imaging stylets enable the practitioner to visualize airway throughout entire procedure Levitan Scope Clarus

Video Laryngoscope : 

Video Laryngoscope Use of Video Laryngoscopy in a Ground EMS System: Better for You, Better for Your Patients Marvin Wayne, MD, FACEP, FAAEM 2008 Sept 1

CTrach LMA : 

CTrach LMA 4th Generation

McGrath Video Laryngoscope : 

McGrath Video Laryngoscope

Trauma Airway Management : 

Trauma Airway Management 前線必備 外傷呼吸道處理 人員訓練 裝備 制度及流程 Do you have it? 缺一不可

Preparation First!! : 

Preparation First!! Prepare equipment ahead of time Check and recheck Gather all airway devices in one bag or area 百寶箱 Pre-oxygenate with 100% O2

A : 

A 如果說我看的比別人更遠，那是因為我站在巨人的肩膀上 If I have seen farther than others, it is because I was standing on the shoulders of giants －1676 Isaac Newton B C A B C

Start from the Scratch : 

Start from the Scratch ABC 永遠從 A 做起 Start from the beginning 從頭做起 從第一步做起 從基層做起 沒有 A, 就沒有 BCD 從最尖端 最難的做起 最困難 風險最高的先解決 其他的問題就少多了

Start from the Scratch : 

Start from the Scratch Starting line for a race: Dr. 別輸在起跑點 Pt. 別死在起跑點 大家努力的起始點

RSI 第一步: 準備 Surgical Airway : 

RSI 第一步: 準備 Surgical Airway 割包皮 4歲童枉死 書田診所麻醉師遭起訴 Rising ETCO2: undetected 麻醉界反應: 手術有大小 麻醉無大小 座右銘 以最高標準面對 呼吸道處理 氣管插管也無大小

AT&T : 

AT&T 95年3月外科醫學會與外傷醫學會: 急診與外傷前輩 台北榮總李建賢副院長: 急診最容易出問題的兩大問題: Abdominal Pain & Trauma 再加上 Airway- 張立偉 急診三大問題 張立偉所長期關注的問題 A: Abdominal Pain T: Trauma T: Trachea

困難插管案例的啟示 : 

困難插管案例的啟示 950816 Wed. 八十一年我們處理永和麥當勞爆炸事件 憑的是經驗 及 運氣 以前處理呼吸道大概只有 ?成把握 現在可以提高到?成 以前可謂 初生之犢 沒見過老虎

頓悟 : 

頓悟 961016 麻醉部主任 comment during Airway Course (第一屆軍陣外傷訓練) Better late than never.

Basic, Advanced Airway Course : 

Basic, Advanced Airway Course 950422 國軍戰傷呼吸道處理訓練課程 951013 外傷醫學會教育委員會 陳石池主任委員決定籌辦 Secure Trauma Airway Training 預定960819 (Sunday), 0820 (Monday) 開辦 Basic Airway Management Advanced Airway Management Difficult Airway Management 9609 完成四梯次 ART 實習 三軍總醫院呼吸道救火隊籌辦中 999 小組二十四小時作業 困難插管隊 (ART)

Suggestions for Airway Management : 

Suggestions for Airway Management 短期 強化九九小組呼吸道處理能力 強化Trauma Team 呼吸道處理能力 Difficult Airway Cart 困難插管車籌設: 960326 急加會通過 Difficult Airway Algorithm 推廣 ASA Difficult Airway Algorithm 2003: 將接受麻醉的外科病人: 於 960819, 0820 Airway Course 中將介紹 Airway Management emergency, trauma, and critical care 中期 全院的 Airway Management surveillance NEAR (National Emergency Airway Registry) 比照長庚醫院住院醫師升等需通過 AALS I - IV 選派有志於急診及重症的大夫參加困難插管隊 ART 招募中 (Airway Rescue Team)! 長期 配合 OSCE重點發展 呼吸道處理 訓練中心

從天而降的外傷病人 : 

從天而降的外傷病人 無預定 無預約 無法選擇 及 拒絕 任何時間都會來 沒有插管前訪視的機會 A 只是第一步 接下來還有許多步驟 但永遠是從A 開始 唯一解決的方法: 永遠以最高標準面對 Airway Management Trauma Surgeon: 最需要具備 ART 的大夫!!

醫療偏遠地區最需要的急診訓練 : 

醫療偏遠地區最需要的急診訓練 馬祖日報: 2009-09-07  連江縣衛生局呼吸道處置訓練課程　醫護人員充電 衛生局昨特別舉辦「呼吸道處置訓練課程」，局長劉增應及院長謝春福也難得與一線醫護人員一起充電，學習呼吸道處置的最新知識及技術。 三軍總醫院急診醫學部主治醫師陳穎信、成功大學附設醫院一般外科主治醫師羅崇杰、恩主公醫院外科部主任劉曉東三位專業醫師來馬主講 FAST member 推廣呼吸道處理教育訓練: 他們都是長期擔任急診工作，還身兼高級心臟救命術指導員、高級外傷救命術指導員及外傷醫學會教育委員會主任委員、理事等職務，實務經驗相當豐富。

What have we learnt? : 

What have we learnt? 法界的醫學常識與專業 媒體的醫學常識與專業 Autopsy: 肺內無血? Underestimated trauma airway risk. Missed upper airway obstruction: EP, OS, Anesthesiologist? 沒有任何專業醫師可以獨力處理呼吸道 加強Surgical Airway 能力

呼吸道處理訓練 2010 (5th year) : 

呼吸道處理訓練 2010 (5th year) 整合國內現有呼吸道處理訓練 比照 ACLS 聯合甄審委員會 成立 呼吸道處理訓練 聯合委員會 (Airway 訓練聯委會) 日後成立呼吸道處理學會 & 困難氣管插管學會 (DAS)

DAS : 

DAS airway management S­ociety of the United Kingdom. This medical Society was for­med i­n 1995 and aims to improve management of the patient's airway by anaesthetists and critical care personnel.

(Airway 訓練聯委會) : 

(Airway 訓練聯委會)

如何落實訓練 如何培養 ART : 

如何落實訓練 如何培養 ART 市立醫院訓練反應: fancy 的訓練 永遠不會用到 且沒有裝備 醫學中心主治醫師: 沒有工具 無法練習 工欲善其事 必先利其器 呼吸道處理為個人裝備 急診 外傷 重症醫師 必要的訓練 就當做出國進修 到訓練中心進修三個月 50 萬裝備 Vs 890萬 (damage pay) 5萬 Vs 800萬 只賠償 只辦人 不做教育訓練的結果

工欲善其事 必先利其器 : 

工欲善其事 必先利其器 呼吸道訓練目前的問題 束之高閣的昂貴裝備 為了裝備檢查 財產保管 無人會用 沒有地方學

Slide 55: 

希望各位有所收穫 Thanks for your attention