, giving clues to understanding the mechanism of injury and, from that,such as cardiac, respiratory, and metabolic diseases may also alter the usual physiological response to injury.
Atlantoaxial dislocation.Lateral view of the cervical spine done as a cross-table lateralshows a marked increase in the distance between the anterior surfaceof the dens and the posterior surface of the C1 tubercle (blue arrow) that measured 14 mm (black line),well in excess of the 3 mm maximum in adults. The imaginary line connecting the spinolaminarwhite lines (white line) shows that the body of C1 (red arrow) is displaced anteriorly relative to the remainderof the spine. The patient died shortly after this study was obtained.Intubating the patient who has undergone acute trauma and whose cervical spinal status is uncertain. A hypnotic and a relaxant have been administered. One assistant maintains in-line axial stabilization with the occiput held firmly to the backboard; a second assistant applies cricoid pressure. The posterior portion of the cervical collar remains in place. (From Stene186 )
Preventing hyperextention or hyperflexion of neck.as excessive movement,can turn a cervical spinal injury without neronal damage into neuronal deficiet,or even paralysis.Adjustable rigid cervical collarThe anterior window allows for it to be used in tracheostomized patients as well
Cervical spine and airway in trauma
Primary survey and Resuscitation
of trauma patient
Trauma is the leading cause of death from birth to age 44 years.
It is third only to cancer and atherosclerosis in all age groups.
Worldwide ,approx. 50 million people are severely or moderately disabled as a result of
trauma and more than 180 million disability adjusted life years are lost each year.
The burden of trauma constitutes 12% of world’s total disease load. It is estimated that global
financial cost of trauma exceeds U.S. $500 billion annually.
Trauma is one of the few disease categories in which mortality is increasing.
More than 20 % of trauma patients come from RTAs. Others from sports related injuries,
interpersonal violence , occupational injuries, and falls.
The ideal hospital is level –I trauma centre where all medical specialties ,with full back up
infrastructure ,are on site 24 hours a day.
TRAUMA CARE CONTINUUM
Arrival of emergency
AIMS OF TRAUMA CARE
INITIAL ASSESSMENT OF PATIENT
PRIMARY SURVERY AND RESUSCITATION
AIMS OF TRAUMA CARE
•Identification of major trauma patient at scene of incident
•Immediate intervention to allow safe transport
•Rapid transfer to appropriate trauma centre for surgical management
and critical care
•Coordinated specialist recontruction
•Targeted comprehensive rehabilitation
•Need to identify and deliver to a place of definitive care safely and quickly
•Ambulance services vehicles are outfitted with essential equipments
necessary to provide immediate resuscitation
•Ambulance control room-102
•Emergency & management disaster services-108
•Road accident emergency services on national highway-1073
•Railway accident emergency sevices-1072
Trained paramedics – Assess the victims
- Providing basic life support
- Communicate with planned receiving hospital
regarding no.of patients and time of arrival
Triage is sorting of patients based on their need for treatment and the available resources
to provide the treatment .
It can be field triage, done by paramedics at the accident scene, who decide what level of
care is required and therefore to which hospital the patient needs to be transferred.
It may also be done at receiving hospital –which patients need immediate ,life saving
intervention, which can wait, and which are ,in fact, beyond saving.
Term used when the number of patients
and severity of their injuries do not exceed
the ability of the facility to provide care .
Patients with life threatening problems
and those who have sustained multiple
system injuries are treated first.
Term used to describe the situation in
which no. of patients and the severity of
injuries exceed the capability of the
facility and staff. Those who have greatest
chances of survival with the least
expenditure of time, supplies ,
equipments, and personnel are managed
Best environment for resuscitation is a safe ,warm ,dry, well lit,fully
staffed and eqipped area with complete backup resourses.
Role of Maxillofacial surgeon
The involvement of maxillofacial
surgeon in trauma teams has
significant benefits in terms of training
and in the early identification and
optimal management of craniofacial
trauma. As a member of trauma team
he/she must be skilled in TLST and
capable of dealing with both specialty
specific problems and other life
Expertise concerning midface injuries
and any potential threat to eyesight
from trauma and heamorrhage is
A formally constituted trauma team ,ideally comprising specialist anesthetic, surgical, and
orthopedic component in addition to emergency Deptt. Staff.
All members should have appropriate training ,such as the ALTS course, which has
become the gold standard and common language of trauma management.
•Immunization against tetanus , hep b
•Start the clock
•Transferring patient from strecter to trolly
Preparation at receiving hospital
Always speak to the pre-hospital team
Initial assessment of patient
Deaths from trauma follow a trimodel distribution.
The first peak,contituting 40-50% of trauma
deaths,occur immediately or within minutes of
accident at the scene.cause-laceration of
brain,brainstem,high spinal cord,heart,aorta,or
other large vessels.due to severity of injuries very
few of these patient survive. cannot be saved no
matter what intervention or skill level is available
immediately around them
To prevent:safer roads,speed restriction,air bags,
and speedy arrival of paramedics..
Second peak:-30% of trauma deaths.who arrive
alive to hospital but succumb to injuries over next
minutes or hours is period referred to as golden
hour..die largely from hypoxia and hypovolemic
shock as a chest injuries,abdominal
trauma,orthopedic ,intracranial heamatomas.
Third peak:who succumb days or even weeks after
traumatic incident because of MOF,sepsis.RD.
The immediate assessment and early management of trauma patent is
comprehensively covered by ATLS course . ATLS focuses on the second peak, because
apprehensive and timely intervention in the resuscitation room will both save lives and
minimize morbidity, thereby also reducing the third peak in the subsequent definitive
care period lasting days or weeks.
Primary survey and resuscitation
In the resuscitation room a rapid primary survey is carried out.
care must follow the safest pathway, diagnosing and simultaneously treating life
threatening injuries in the order in which they would otherwise kill the patient.
As each most pressing killer injury is treated, more resuscitation time is created to deal
with the next most pressing problem.
Each patient should be assessed
in the same way and appropriate
tasks should be performed
automatically and simultaneously
by the team..
To facilitate this ,the primary
survey of patient follow a strict
sequential “ABCDE” protocol
•Airway with cervical Spine Control
•Breathing and Ventilation
•Circulation and Hemorrhage Control
•Disability- (Neurological status )
•Exposure + environment — completely
undress the patient, but prevent hypothermia
To these, another point may be added:
•Frequent Reassessment must be made
It is essential to ensure that prehospital personnel provide a comprehensive account of
the accident scene.
• patient details
• important information such as the time of the accident, other factors such as fires,
explosions, hazardous chemicals, and injuries sustained by other victims.
•Photographs taken at the scene also provide vital informa-tion* what injuries might be
anticipated (index of suspicion).13
Maxillofacial injuries are addressed at this stage only if they have an impact on the
airway, breathing, or circulation. Comprehensive assessment and definitive
management of maxillofacial injuries occur later, away from the resuscitation room
•Priorities for care of the pediatric patient are the same as for adults,
• Priorities for care of the pregnant woman are similar to those for nonpregnant patients. Pregnancy should be identified
early by palpation of the abdomen for a gravid uterus and by laboratory testing for human chorionic gonadotropin (HCG).
Early fetal assessment is important for maternal and fetal survival.
In the elderly, comorbidities* are more common, and, together with the aging process, they reduce the patient's functional
reserve and ability to respond to injury.
The chronic use of medications
The narrow therapeutic window frequently leads to overresuscitation or underresuscitation in the elderly, and early
invasive monitoring is valuable.
High index of suspicion for cervical spine injury :
•if the patient has maxillofacial injuries or multisystem trauma,
•if the level of consciousness is altered,
• if there is a history of a high-speed impact.
Approximately 15% of patients with supraclavicular injuries also
and 5% of head-injured patients have some form of associated
Therefore, great care should be taken to prevent exces-sive
movement of the cervical spine during assessment and
management of a patient's airway.
A: AIRWAY AND CERVICAL SPINE CONTROL
Traumatic atlantoaxial subluxation /dislocation
(Atlantoaxial instability is defined by an increase in
the predentate space of greater then 3 mm in adults
and 5 mm in children) usually results from a motor
vehicle collision in which an unrestrained occupant’s
head strikes the windshield or dashboard .
Predictable Patterns of Intracranial and Cervical Spine Injury in Craniomaxillofacial Trauma: Analysis of 4,786 Patients. 2008 .AAPS.Annual Meeting Abstracts
Assume cervical spine injury and maintain the
spine in neutral (by using backboards,
bindings,and purpose build head
immobolizers) until proven otherwise clinically
Use of soft semirigid collars –discourage!
During intubation it is
acceptable to remove the hard
collar to aid jaw movement so
long as someone performs
‘manual in line immobilisation’
of the head and neck ,achieved
simply and quickly by placing
one hand on either side of the
patient's head and holding the
head in a neutral position, taking
care not to cover the ears.
Assurance of an airway is the first step in all
emergency medicine protocols
The First Step
•Oxygen is essential to life!
Physically disrupted airway is obviously a major challenge
An assessment must immediately be made as
to whether the patient can maintain and
protect his or her own airway. The most
sophisticated of tecniques in treating facial
trauma can be meaningless if attention is not
first directed to airway.
Much information can be gained very quickly by asking the patient a simple question such as
"How are you?" or "What happened?“
If the patient gives an appropriate and. coherent response,
it suggests that the airway (A) is clear, that-breathing and ventilation (B) are sufficiently
effective to deliver enough oxygen into the circulation (C), which is functional sufficiently to
transport the oxygen to the brain (D) which in turn is functioning sufficiently to allow the
patient to comprehend and respond. However, there is a significant caveat: Although the
patient's ABCD factors may be functioning sat-isfactorily at the time of questioning, they
may not be shortly, so that frequent re-examination is essential.
Airway management options include:
Basic airway manouvers: chin lift+ jaw thrust
Oropharyngeal or nasopharyngeal airway- but caution with bleeding
Surgical airway ie Cricothyroid/Tracheostomy
Basic Airway Maneuvers
Supplemental oxygen delivered through a well-fittpH rpgpr-voir (rebreathing) mask, at a rate ot 15 L/min to achieve
maximum oxygenation of the tissues, should be given to every trauma patient.
the patient fails to respond to questioning, formal airway assessment must be immediately instigated. As always,
ini-cal assessment should follow the protocol, "Look, Listen, and Feel.“
ook to see if the patient is agitated or obtunded. Agitation suggests hypoxia, and obtundation suggests hypercarbia.
yanosis indicates hypoxemia and can be seen in the lips arid nailbeds. Look for the pattern of breathing and use of
ccessory muscles of ventilation.
ook for facial burns; singed eyebrows, facial hair, or nasal "vibrissae; and soot around the lips, in the mouth, or in
he sputum (indicating burn injury, inhalational burns, and possibly impending airway obstruction).
isten for abnormal sounds. Noisy breathing is obstructed breathing. Snoring, gurgling, and crowing noises (stridor)
may be associated with partial obstruction of the pharynx or larynx. Hoarseness implies functional laryngeal
bstruction. The abusive or belligerent patient may hypoxic and should not be presumed to be intoxicated.
eel: for the location of the trachea and determine whether it is in the midline. The mouth should be opened and any
oreign objects (e.g., fractured teeth, fillings, dentures) should be removed. The mouth is examined, and any fluid is
ucked out. The nature and volume of the fluid (secretions, blood) and evidence of pooling in the oropharynx indicate
oss of airway control by the patient.
In an unconscious patient who is lying supine the tongue may fall back and obstruct the airway;
a simple chin lift or jaw thrust maneuver can be used to correct the-tongue position and open the
A jaw thrust is performed by grasping the angles of the mandible with one hand on each side and
displacing the mandible forward. If the patient is breathing spontaneously, high-flow oxygen via the
facemask and resevoir bag will provide good oxygenation and ventilation. If the patient is not
breathing, a facemask with a bag-valve device (Ambubag) connected to the oxygen supply and
compressed by an assistant will work until formal management of the airway is achieved.
A chin lift should be performed without hyper extending the patient's neck. The mandible is gently lifted
upward using the fingers of one hand placed under the chin. The thumb of the same hand lightly
depresses the lower lip to open the mouth
The oropharyngeal airway must not he used in a conscions patient, became it may induce coughing. gagging vomiting,
and aspiration. During its insertion, care must be taken not to push the tongue backward and thereby block rather than
clear the airway. Those patients with a gag reflex can maintain their own airway. The use of oropharyngeal (Guedel) airways in these patients can precipitate vomiting,
neck movement, and a rise in intracranial pressure; therefore, a nasopharyngeal airway is preferred, provided there is no evidence to suggest a fracture of the base of the skull.
If the patient vomits, the patient’s head should not be moved to one side unless cervical spine injury has been excluded If
the patient is secured on a spinal board, the whole board can be turned. In the absence of a spinal board, the whole
gurney should be tipped so that the head is down and the vomit sucked away with a rigid sucking device.
In a conscious patient, a well-lubricated nasopharyngeal airway is inserted in the nostril that appears to be unobstructed
and passed gently into the posterior oropharynx. If obstruction is encountered during introduction of the airway, the
procedure is stopped and then retried on the other side.
The laryngeal mask airway (LMA) has an established role in routine surgery to provide a protected airway and also in
patients with difficult airways, particularly if orotracheal intubation has failed or bag-mask ventilation is not maintain-ing
sufficient oxygenation. However, it is not a definitive airway because there is no cuffed tube in the trachea. Also, some
training is required to use it, and it can be displaced relatively easily. If a patient presents with an LMA already in place,
conversion to a definitive airway must be planned.
A multilumen esophageal airway is a form of LMA that has two tubes, enabling occlusion of the esophagus to reduce the
risk of aspiration. However, it does not have a cuffed tube in the trachea and therefore does not constitute a definitive
Advanced Airway Maneuvers: Definitive Airway
A definitive airway is defined as an inflated cuffed tube in the Trachea.
types: the orotracheal tube, the nasotracheal tube, and the surgical airway (crico-thyroidotomy or tracheostomy).
A definitive airway should be considered if any of the following is present:
•Inability to maintain a patent airway by other means
•The need to protect the lower airway from blood or vomit
•Potential compromise of the airway (e.g., after burn injury, other inhalational injury, facial fractures, retropharyngeal
hematoma, or sustained seizure activity)
•A closed-head injury requiring assisted ventilation (Glasgow Coma Scale [GCS] score of 8 or less).
•Inability to maintain adequate oxygenation by facemask oxygen supplementation
Orotracheal intubation with cervical in-line immo-bilization is recommended, rather than blind nasotracheal intubation,
especially if a base-of-skull fracture is suspected. If this proves to be difficult, a surgical airway is then considered.
The most important determinant of whether to proceed with orotracheal or nasotracheal intubation is the experience of the
doctor. Nasotracheal intubation should not be attempted in an apneic patient nor undertaken if a fracture of the base of the
skull is suspected.
The route of choice for securing the airway depends on several factors(cervical injury)
Laryngoscope and orotracheal intubation are generally considered to be safe procedures and can be accomplished with
minimal changes in the position of the neck when performed by a competent operator with ILI.