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Trauma airway management is an inherently complicated and controversial topic and practice. Such procedures are often performed in unfamiliar settings under extreme duress and rife with less-than-optimal intubation conditions. Additional challenges such as inadequate preoxygenation or an inability to adequately assess the patient’s airway are often part of the puzzle that must be pieced together when it comes to the successful management of an airway during the treatment of traumatic injuries.
In this approximately 52-minute lecture entitled “Rapid-Sequence Induction in Patients with Trauma,” Catherine M. Kuza, MD, Assistant Professor of Anesthesiology, Division of Critical Care, Associate Director, Surgical Intensive Care Unit, and Director of Trauma Research, Keck School of Medicine of the University of Southern California, Los Angeles dives deeper into the use of Rapid-Sequence Induction (RSI) on patients who have suffered a traumatic injury. Dr. Kuza also compares and contrasts RSI with SSI, and takes a closer look at the options and considerations regarding induction agents and drugs.
This expert-level lecture is ideal for clinicians, nurses, and other healthcare professionals working within the anesthesiology ecosystem. As it provides an up-to-date, in-depth analysis of a vitally important topic and technique, it is also applicable to doctors, nurse practitioners, and professionals working in all aspects of healthcare today.
The primary goal of trauma airway management is always direct, to-the-point, and absolutely critical:
Secure the airway—with minimal intubation attempts.
“It’s important to secure the airway in a timely fashion to prevent hypoxia and hypocarbia,” explains Dr. Kuza. “This is particularly important in patients with traumatic brain injury.”
Multiple intubation attempts can and often do result in a higher risk for complications such as arrhythmias, hypoxemia, aspiration, airway trauma, dental trauma, laryngospasm, desaturation, and pneumothorax.
Unfortunately, there’s not a very extensive roadmap related to these intubation risks. Existing and up-to-date guidelines offer no recommendations on the use of specific induction agents or intubation techniques for patients experiencing trauma. Additionally, Dr. Kuza notes that there are only a few studies to consult on this delicate, yet-to-be-decisively understood issue.
“Currently, there’s no anesthesiology guidelines in the U.S. on preferred intubation techniques and induction medications,” says Dr. Kuza flatly.
Rapid-Sequence Intubation, or its common abbreviated acronym of RSI, involves the rapid administration of an induction medication—immediately followed by a quick-onset neuromuscular blocking drug. Ideally, the patient is preoxygenated—although apneic oxygenation with high flows of oxygen via nasal cannula can serve as a safe and acceptable alternative.
When it comes to successful RSI implementation and execution, it’s vital to immediately establish the patient’s airway—while also maintaining sufficient oxygenation. It’s optimal if the patient can be intubated within 30 seconds of paralysis.
“Ideally, you would want a more experienced provider performing the intubation,” says Dr. Kuza.
Dr. Kuza also cautions that it’s always best to avoid bag-mask ventilation unless it’s required to maintain oxygen saturation. She also notes that cricoid pressure remains in use by some providers, but is no longer recommended in working guidelines for trauma patients.
An alternative, contrasting approach to RSI is SSI—shorthand for Slow-Sequence Intubation. This trauma management technique involves the slow titration of induction agents, with ketamine acting as an ideal agent because it allows spontaneous respiration while achieving dissociative anesthesia.
The SSI approach is often opted for in anticipation of a difficult airway, intolerance to preoxygenation, or hemodynamic instability. It can also be selected to ensure unconsciousness before delivering a neuromuscular blocker or beginning a painful surgical intervention.
Dr. Kuza notes that the prolonged induction time associated with SSI is linked to an increased risk for aspiration. This technique may also be combined with physiologic optimization using aggressive preoxygenation, gastric decompression, and titration of vasopressors. Since there is no current data comparing RSIs to SSIs with respect to the effects of aspiration, hemodynamic instability, or awareness, the choice between the two techniques is left to the healthcare provider on the scene.
“There are very few studies that examine and compare induction agents used in trauma RSIs,” says Dr. Kuza. “Currently, there is no data that compares RSIs to slow-sequence intubations on the effects of aspiration, hemodynamic instability, or awareness. So we can’t say that one is better than the other.”
Ketamine is not without its own degree of controversy in the medical field. Dr. Kuza addresses this sensitive and fascinating issue in detail in her lecture.
When it comes to commonly used induction agents, ketamine, propofol, and etomidate lead the way today. Etomidate serves as the induction agent of choice for many Emergency Medicine and ER providers, due to its rapid onset and minimization of hemodynamic instability.
“The induction agents should create optimal conditions in a short amount of time and avoid secondary insult to injuries, while maintaining hemodynamic instability,” explains Dr. Kuza.
Much like with ketamine, there is some controversy surrounding etomidate—especially since some studies report an increased incidence of both acute respiratory distress syndrome and multiple organ dysfunction syndrome following the powerful drug’s infusion.
“Etomidate was once the drug of choice, and it still remains the drug of choice by many ED providers for its quick onset in hemodynamic instability,” says Dr. Kuza. “However, in the 1980s, ICUs that used prolonged etomidate infusions for sedation were associated with adrenal insufficiency and multi-organ dysfunction system. This has led to a debate. Should we decrease the use of etomidate in emergent RSIs? Some institutions have decreased its use.”
Dr. Kuza also explains that poor outcomes associated with the administration of etomidate may reflect more on particular patients with more severe injury—and less likelihood of favorable outcomes. She adds that the best overall outcomes were linked to the use of propofol.
Listen to Dr. Catherine Kuza explain the many challenges in trauma airway management. You can enjoy anytime, anywhere access to additional anesthesiology insights with our Best Lectures CME Collection for Anesthesiology and Anesthesiology CME/CE Platinum Membership.
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