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

Brown, Carlos V R; Inaba, Kenji; Shatz, David V.; Moore, Ernest E.; Ciesla, David J.; Sava, Jack; Alam, Hasan B.; Brasel, Karen J.; Vercruysse, Gary; Sperry, Jason L.; Rizzo, Anne G.; Martin, Matthew J.

doi:10.1136/tsaco-2020-000539

Cited by 14 publications

(7 citation statements)

References 49 publications

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“… Algorithm for adult airway management in patients with evidence of hemorrhagic shock . Adapted from Brown et al (30). This is an open-access article distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license.…”

Section: Rationale For Circulation First Resuscitation In Traumatical...mentioning

confidence: 99%

A Circulation-First Approach for Resuscitation of Trauma Patients With Hemorrhagic Shock

Chio

Piehl

Maio

et al. 2022

Shock

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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.

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Section: Rationale For Circulation First Resuscitation In Traumatical...mentioning

confidence: 99%

A Circulation-First Approach for Resuscitation of Trauma Patients With Hemorrhagic Shock

Chio

Piehl

Maio

et al. 2022

Shock

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Section: Discussionmentioning

confidence: 99%

“…Major trauma organizations, such as WTA, AAST, and EAST, provide guidelines discussing tracheostomy placement in a variety of settings; however, in respect to tracheostomy placement in COVID-19 seropositive patients, there is a lack of depth of discussion in the literature compared to other medical emergencies such as TBI. [35][36][37] Understanding procedures for airway maintenance in a critical respiratory disease such as COVID-19 is imperative due to shortages in ventilators and PPE and the potential for infected patients to overwhelm the hospital setting. Therefore, determining ways to decrease time to weaning from mechanical ventilation has both fiscal and humanitarian benefits.…”

mentioning

confidence: 99%

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

Barbera-Mirza

Chan

Newsome

et al. 2021

The American Surgeon™

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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.

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“…Pro-coagulant haemostatic dressings are in widespread use by military forces for penetrating trauma [16], with some marginally superior to others in preclinical models. Professional societies [17] have recognised that airway management in trauma requires a different protocol to generic anaesthetic airway management, as patients cannot usually be woken if the airway is unable to be secured (as in elective surgery), cardiovascular instability precludes the use of certain medications, and hypoxia at the time of induction is more common. Consequently, prioritising succinylcholine [18,19] over non-depolarising muscle relaxants unless contraindicated, removing the cervical collar (if one was applied) and providing manual in-line cervical stabilisation while attempting intubation, routinely using high-flow nasal oxygen and video laryngoscopy during intubation, and quickly excluding a pneumothorax after intubation using ultrasound are all useful recommendations.…”

Section: Clinical Interventions: Stop Bleeding Open and Protect The A...mentioning

confidence: 99%

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

Reade

2022

Crit Care

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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.

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

Cited by 14 publications

References 49 publications

A Circulation-First Approach for Resuscitation of Trauma Patients With Hemorrhagic Shock

A Circulation-First Approach for Resuscitation of Trauma Patients With Hemorrhagic Shock

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

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

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