Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

Abstract

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

Pro/con debate: Is etomidate safe in hemodynamically unstable critically ill patients?

“…Its use by infusion in trauma patients has been associated with an increase in mortality [16,17] and has led to recommendations not to use etomidate in trauma patients [18]. There are alternative induction agents with similar cardiovascular stability providing the same intubating conditions, such as ketamine [2,3,19].…”

Challenges in the Use of Video Laryngoscopes

“…The authors conclude that ketamine should be preferred in patients with sepsis. Etomidate is currently not recommended for use in trauma patients since it was associated with a higher risk of acute respiratory distress syndrome, multiorgan failure and prolonged ICU stay 23 . In a prospective study of 247 consecutive patients over a two-year period, the use of the C-MAC ® with Macintosh shaped blade improved visualization of the glottis during airway management in the ICU 24 .…”

“…Training and education in (difficult) airway management is essential to improve patient safety in the ICU [20][21][22][23][24] .…”

General intensive care for patients with traumatic brain injury: An update

“…[1314] Here, it is also important to recognize the artifacts and failure of pulse oximetry to detect episodes of desaturation, especially in conditions with severe hypotension, cold extremities and movement of extremities; thereby mandates regular arterial blood gas (ABG) sampling. However, there is no consensus over frequency of sampling in TBI patients.…”