Western Trauma Association critical decisions in trauma: airway management in adult trauma patients

Resuscitation and Initial Management After Moderate-to-Severe Traumatic Brain Injury: Questions for the On-Call Shift

Traumatic brain injury (TBI) is a leading cause of disability and mortality globally, stemming from both primary mechanical injuries and subsequent secondary responses. Effective early management of moderate-to-severe TBI is essential to prevent secondary damage and improve patient outcomes. This review provides a comprehensive guide for the resuscitation and stabilization of TBI patients, combining clinical experience with current evidence-based guidelines. Key areas addressed in this study include the identification and classification of severe TBI, intubation strategies, and optimized resuscitation targets to maintain cerebral perfusion. The management of coagulopathy and special considerations for patients with concomitant hemorrhagic shock are discussed in depth, along with recommendations for neurosurgical interventions. This article further explores the role of multimodal neuromonitoring and targeted temperature management to mitigate secondary brain injury. Finally, it discusses end-of-life care in cases of devastating brain injury (DBI). This practical review integrates foundational and recent advances in TBI management to aid in reducing secondary injuries and enhancing long-term recovery, presenting a multidisciplinary approach to support acute care decisions in TBI patients.

Management of Respiratory Failure in Hemorrhagic Shock

Hemorrhagic shock results in acute respiratory failure due to respiratory muscle fatigue and inadequate pulmonary blood flow. Because positive pressure ventilation can reduce venous return and cardiac output, clinicians should use the minimum possible mean airway pressure during assisted or mechanical ventilation, particularly during episodes of severe hypovolemia. Hypoperfusion also worsens dead space fraction. Therefore, clinicians should monitor capnography during mechanical ventilation and recognize that hypercapnia may be treated with fluid resuscitation rather than increasing minute ventilation.

Trauma Bay Evaluation and Resuscitative Decision-Making

The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.

Airway Management in Trauma Patients

Airway assessment and management is the first priority in trauma care. The airway can be compromised by traumatic injuries or altered mentation. Airway assessment is conducted during the primary survey. Airway triage in trauma is determined by patient and environmental factors. Initial interventions include positioning maneuvers and suction to clear the airway with supplemental oxygen. Endotracheal intubation and surgical (or "front of neck") airways are considered definitive. Traumatic airway injuries are rare but have high mortality and morbidity if undetected.

Indications and Recommendations for Tracheostomy in Trauma Population With COVID-19 Infection: A Review of the Literature

This review explores the current body of evidence pertaining to tracheostomy placement in COVID-19 seropositive patients and summarizes the research by tracheostomy indications, timing, and procedure. Literature review was performed in accordance with the 2020 PRISMA guidelines and includes 12 papers discussing protocols for adult patients seropositive for COVID-19. The studies demonstrated high mortality rates after tracheostomy, especially in geriatric patients, and suggested a multifactorial determination of whether to perform a tracheostomy. There was inconclusive data regarding wait time between testing seropositive, tracheostomy, and weaning off of ventilation. COVID-19 generally reaches highest infectivity between days 9 and 10; furthermore, high early mortality rates seen in COVID-19 may confound mortality implicated by tracheostomy placement. Due to the aerosol-generating nature of tracheostomy placement, management and maintenance, techniques, equipment, and personnel should be carefully considered and altered for COVID-19 patients. With surgical tracheostomy, literature suggested decreased usage of electrocautery; with percutaneous tracheostomy, single-use bronchoscope should be used. The nonemergent exchange of tracheostomy should be done only after the patient tested negative for COVID-19. Placement of tracheostomy should only be considered in COVID-19 patients who are no longer transmissible, with rigorous attention to safety precautions. Understanding procedures for airway maintenance in a respiratory disease like COVID-19 is imperative, especially due to current shortages in ventilators and PPE. However, because of a lack of available data and its likelihood of change as more data emerges, we lack complete guidelines for tracheostomy placement in COVID-19 seropositive patients, and those existing will likely evolve with the disease.

A CIRCULATION-FIRST APPROACH FOR RESUSCITATION OF TRAUMA PATIENTS WITH HEMORRHAGIC SHOCK

ABSTRACT

The original guidelines of cardiopulmonary resuscitation focused on the establishment of an airway and rescue breathing before restoration of circulation through cardiopulmonary resuscitation. As a result, the airway-breathing-circulation approach became the central guiding principle of resuscitation. Despite new guidelines by the American Heart Association for a circulation-first approach, Advanced Trauma Life Support guidelines continue to advocate for the airway-breathing-circulation sequence. Although definitive airway management is often necessary for severely injured patients, endotracheal intubation (ETI) before resuscitation in patients with hemorrhagic shock may worsen hypotension and precipitate cardiac arrest. In severely injured patients, a paradigm shift should be considered, which prioritizes restoration of circulation before ETI and positive pressure ventilation while maintaining a focus on basic airway assessment and noninvasive airway interventions. For this patient population, the most reasonable current strategy may be to target a simultaneous resuscitation approach, with immediate efforts to control hemorrhage and provide basic airway interventions while prioritizing volume resuscitation with blood products and deferring ETI until adequate systemic perfusion has been attained. We believe that a circulation-first sequence will improve both survival and neurologic outcomes for a traumatically injured patient and will continue to advocate this approach, as additional clinical evidence is generated to inform how to best tailor circulation-first resuscitation for varied injury patterns and patient populations.

Perspective: the top 11 priorities to improve trauma outcomes, from system to patient level

BACKGROUND

The Haemorrhage, Airway, Breathing, Circulation, Disability, Exposure/Environmental control approach to individual patient management in trauma is well established and embedded in numerous training courses worldwide. Further improvements in trauma outcomes are likely to result from a combination of system-level interventions in prevention and quality improvement, and from a sophisticated approach to clinical innovation.

TOP ELEVEN TRAUMA PRIORITIES

Based on a narrative review of remaining preventable mortality and morbidity in trauma, the top eleven priorities for those working throughout the spectrum of trauma care, from policy-makers to clinicians, should be: (1) investment in effective trauma prevention (likely to be the most cost-effective intervention); (2) prioritisation of resources, quality improvement and innovation in prehospital care (where the most preventable mortality remains); (3) building a high-performance trauma team; (4) applying evidence-based clinical interventions that stop bleeding, open & protect the airway, and optimise breathing most effectively; (5) maintaining enough circulating blood volume and ensuring adequate cardiac function; (6) recognising the role of the intensive care unit in modern damage control surgery; (7) prioritising good intensive care unit intercurrent care, especially prophylaxis for thromboembolic disease; (8) conducting a thorough tertiary survey, noting that on average the intensive care unit is where approximately 15% of injuries are detected; (9) facilitating early extubation; (10) investing in formal quantitative and qualitative quality assurance and improvement; and (11) improving clinical trial design.

CONCLUSION

Dramatic reductions in population trauma mortality and injury case fatality rate over recent decades have demonstrated the value of a comprehensive approach to trauma quality and process improvement. Continued attention to these principles, targeting areas with highest remaining preventable mortality while also prioritising functional outcomes, should remain the focus of both clinician and policy-makers.

Auditing the status of prioritization of nursing actions in the trauma emergency department

INTRODUCTION

Patient assessment is considered as one of the key actions of nurses to provide professional services. Prioritizing the care needs based on the assessment could save patients' lives. Nurses should be able to prioritize patients' care needs and then, based on this prioritization, plan for patient life-threatening situations one after the other. The aim of this study was to audit the status of prioritization of nursing care for trauma patients in the trauma emergency department of Kowsar Hospital in Sanandaj.

METHODS

This study was a quasi-experimental study (pre- and post-training) conducted using simple random sampling during the February to June 2021, in the emergency department of Kowsar Hospital in Sanandaj. The data collection tool was a standardized checklist for prioritizing nursing care, which contained a total of 53 items. At the beginning of the study, 64 nurses (32 in the experimental group and 32 in the control group) entered the study and the experimental group was evaluated based on a standardized prioritization checklist. Then, the data were collected and after statistical analysis, based on the obtained results and examining the weaknesses, the intervention group nurses participated in an educational course for one month. The checklist assessment was performed again and the results were compared with the results of the first assessment (before the intervention).

RESULTS

The number of items requiring training in the experimental group before the intervention was 258 cases which decreased to 53 cases after training and this decrease was statistically significant (p < 0.05). However, in the control group, the number of measures requiring training in the first stage was 220 cases, which in the second stage of assessment fell to 213, but this decrease was not statistically significant (p > 0.05).

CONCLUSION

By auditing the status of nursing care prioritization in the trauma emergency department and providing training related to focusing on the identified weaknesses, nurses' skills to prioritize patients' care needs as well as the quality of nursing care delivery increased.

Indications for prehospital intubation among severely injured children and the prevalence of significant traumatic brain injury among those intubated due to impaired level of consciousness

BACKGROUND

Prehospital endotracheal intubation (PEI) of head injured children with impaired level of consciousness (LOC) aims to minimize secondary brain injury. However, PEI is controversial in otherwise stable children. We aimed to investigate the indications for PEI among pediatric trauma patients and the prevalence of clinically significant traumatic brain injury (csTBI) among those intubated solely due to impaired consciousness.

METHODS

This is a multicenter retrospective cohort study of children who underwent PEI in northern Israel between January 2014 and December 2020 by six EMS agencies and were transported to two trauma centers in the area. We extracted data from EMS records and trauma registries.

RESULTS

PEI was attempted in 179/986 (18.2%) patients and was successful in 92.2% of cases. Common indications for PEI were hypoxemia not corrected by supplemental oxygen (n = 30), traumatic cardiac arrest (n = 16), and facial injury compromising the airway (n = 13). 112 patients (62.6%) were intubated solely due to impaired or deteriorating LOC. Among these patients, 68 (62.4%) suffered csTBI. The prevalence of csTBI among those with field Glasgow Coma Scale (GCS) of 3, 4-8, and > 8 was 81.4%, 55.8%, and 28.6%, respectively (p < 0.001). Among children ≤ 10 years old intubated due to impaired LOC, 50% had csTBI.

CONCLUSION

Impaired LOC is a major indication for PEI. However, a significant proportion of these patients do not suffer csTBI. Older age and lower pre-intubation GCS are associated with more accurate field classification. Our data indicate that further investigation and better characterization of patients who may benefit from PEI is necessary.

Head & Neck Hemorrhage: Technical tools and tricks

Background

The purpose of the present work is to provide a fresh, simple, and accessible document for all surgeons who treat traumatic hemorrhage from the head and neck.

Methods

This article arose from the work of a consortium of experienced trauma surgeons who collaborated to produce a first-of-its-kind surgical course for multifocal hemorrhage control. The "Bloody Simple Hemorrhage control masterclass course" has been offered at national and international venues since 2019 and has been both well received by participants and well regarded in academic trauma surgical circles. This paper—and the series of articles which accompany it—was meant to be a literature companion to or extension of the Bloody Simple course, a way to distill and digest the hemorrhage control strategies espoused therein but in the form of a journal article.

Results

The result of this work is a succinct and experience-based set of principles for conquering life-threatening, traumatic bleeding from a variety of sources in the head and neck.

Conclusion

This article translates experience and evidence into a simple and digestible format that will provide a sound approach for any surgeon facing traumatic hemorrhage from the head and neck.

Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document

Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness

OBJECTIVE

Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason.

METHODS

Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma.

RESULTS

In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively.

CONCLUSION

Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.