This week I go through a major ED trauma resuscitation from start to finish. The patient has head, chest, pelvis, and extremity injuries with hypotension. I stress what you should be thinking as each new piece of data comes in, and what your rols should be as team leader, or supervisor/coach. I will also expand on some of the points on the website. Thanks, JY

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Review of definition, recognition, and treatment of shock. I go over some of the rationale for resuscitation from the military, and the usefulness of measuring lactic acid when triaging injured patient. Thanks for listening. JY.

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For my lecture on airways, and surgical airways. Go back to airway podcast for more information.

JY

Airway

• Tactical thinking
  • Can the air get into the trachea?
  • Can the air in the trachea get into the lungs?
  • Do the lungs work?
  • Can the air get in?
    • Open the airway
    • Use an adjunct to open the airway
      • Oral, nasal, fingers if necessary
• Obstructions
  • Suction
  • Get large objects out, but be careful not to push them farther in (dont blindly sweep)
  • Hold large tissue defects open to allow air passage
  • Remember the tongue is the most likely item to obstruct
• Bask mask technique
  • Remember do not push the mask down on the face causing the tongue to obstruct
  • Try not to blow vomit into the airway, if you hear noisy respirations you need to suction, or might need to get a definitive airway
  • Can the air get from the trachea into the lungs?
    • Problems
      • Large obstructions
        • Mucus plugs, blood, teeth
    • Transections of trachea
      • Huge neck
      • SQ emphysema
      • When ventilating neck looks like its expanding with each breath
      • Air comes back out of mouth with each ventilation
    • Perforation of trachea with airway device
      • Mass in neck
      • Symptoms of tracheal transection
      • Must get airway, less important to treat perforation
        • If you can maneuver tube past perforation, do that, and we’ll worry about perforation later.
        • Do whatever you need to do to get airway, most things can be fixed
        • Do the lungs work?
          • Massive aspiration
            • Unable to get sats up despite good airway (color change, see tube pass through cords)
              • Very important – in hyperurgent situation, if all data looks like tube is in, do not pull it out until you have ruled out other things. You may not get that airway back.
• Pneumothorax
  • Dart chest, or chest tube
  • Remember need to keep path open or with positive pressure pneumo will reaccumulate quickly
• Hemothorax
  • Not much can be done pre-hospital
  • Hemothorax should not cause tension situation
    • Other lung should function normally
    • Darting will not help
    • Only chest tube will help
    • Airway
      • Should be prepared for surgical airway at every intubation
        • I have seen normal intubations turn into catastrophes that requires surgical intervention – you can not predict when it will happen…
• At the least, someone should have their hand on a
  • Knife
  • Tube
  • Tracheal hook
    • (or crich kit)
• When the sats are dropping, you do not want to be tearing apart bags, or sending people back to the unit to get equipment
• Better idea – if you have time, get the airway in the back of the unit
  • Lighting
  • Better bed height
  • Better suction
  • Can run if you need to

In my opinion, you should try to do EVERYTHING in the back of the ambulance (you are one step closer to the hospital if things go south)

• Crich (you dont do traches in the field)
  • Make sure you find the cricothyroid membrane
    • It is VERY easy to think you are in the right place when you are not
    • In some patients it is higher that it looks, in some lower
    • Procedure
      • Find thyroid cartilage FIRST (gull winged cartilage)
      • Move down until you feel first tracheal ring (will usually be prominent)
      • then slide finger up and in to space between first tracheal ring and thyroid cartilage
      • In some people, this space may be small, but it can be widened.
    • Tube
      • If you dont have a tracheostomy tube, use an ETT
      • The ETT should be one entire size smaller than you would use endotracheally
        • In the average adult, I will use a 6.0 ETT for a crich
          • It is better to get a smaller tube in than be unable to get a bigger tube in
            • You can usually vent through anything down to a 4-4.5 tube in an adult, and even then you will probably do fine with pO2, the pCO2 may rise but who cares, its short term.
            • I recommend an NG tube as a guidewire if you are not using a crich kit
              • You need to know which NG tube you need and it should be readily available, or taped to the ETT or trache
              • It is OK to have one too small (a 12F will usually work)
    • Technique
      • Find the spot
      • Make a vertical cut at LEAST one inch deep (make darn sure you are into the trachea)
      • Make a MUCH bigger skin incision than the diameter of the tube (at least a half inch wider on each side)
      • DO NOT MAKE HORIZONTAL CUTS
        • You can make your vertical and then turn your knife 90 degrees and stab but do not cut laterally (anterior jugular veins are in variable positions)
        • If you can see into the trachea or you can put the tip of your finger into the trachea, then gently place the tube in with a 45 degree angle heading to the feet
        • If you can see in, or air is not blowing out with bagging, you will need a guidewire, or you will need to widen the hole. To do this you will likely need to cut a tracheal ring
        • Dont push the tube in too far
          • Very easy to do
          • Push it till you cant see the balloon, blow the balloon up (if you then see the balloon, deflate and push at least 2 inches farther in, the inflate and gently retract. Once you get the balloon seated, no one EVER lets go of the tube (best) or you use suture (our method) or you securely tie it in (usually does not work)
          • Best to secure it with trache tie (tube holder will NOT work), and continue to keep your hand on it until a respiratory therapist at the hospital takes it out of your hand.
• Pitfalls
  • Tube can go north
    • Air will come out of mouth
    • Tube can go to sides or through trachea
      • See signs on tracheal disruption or perforation
    • If you think tube is in wrong place, make certain its in the right place (if you need to shove your pinky into trachea, to make sure path is clear, than do it)
      • Check end tidal
      • Listen to lungs and stomach
    • Right main stems are VERY EASY with crichs

Discussion of respiratory insufficiency and failure, treatment, and some information on ventilator management. The podcast is available at Clinical Brain Training on iTunes.
Thanks for listening.
JY

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In this podcast, I try to tackle the issue of leading clinicians to safer and more effective care. I give no answers, but my take on the process from my experience in quality and patient safety. Whether you are a leader or are objecting to being led, I think you will get something out of it.
Music from Tom Jolly and I from the album “On Call” from our old group Nightbreeze.
Thanks
JY

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Here is the Clinical Brain Training podcast on airway, when to control it, how to control it, and what to do if it gets away from you. Enjoy.
Also the song “Leigh” that I wrote for my youngest daughter book-ending it.
JY

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Here is the second part of the lecture I podcasted last week. Sorry that it gets choppy toward the end, I was trying to edit out my “ummms” and ya knows” and kind of overdid it.
Also another tune from Tom Jolly and I.
Thanks for listening.
JY

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