The document provides a comprehensive overview of damage control resuscitation in trauma, emphasizing the critical importance of airway management and assessment techniques. It outlines the primary survey steps, the necessity of maintaining an intact airway, and various methods used in airway management such as the chin-lift and jaw-thrust maneuvers. Additionally, it details the roles of anesthesiologists in trauma care alongside the use of specific induction agents and adjuncts for endotracheal intubation.

1. DAMAGE CONTROL
RESUSCITATION IN TRAUMA
Moderator- Dr Pradeep Swami
Dr Narendra
Presented by- Dr Pramod
Dr Gauri
Dr Eliseba

3. “GOLDEN HOUR”

4. BASICS OF TRAUMA ASSESSMENT
Preparation
Triage
Primary survey (A B C D E)
Resuscitation
Secondary survey
Monitoring and evaluation
Secondary adjuncts
Transfer to definitive care

7. The earliest priorities in managing the injured patient are to
ensure an intact airway and recognize a compromised airway.

8. As Clinicians we can quickly assess A, B, C, and D in a
trauma patient (10-second assessment) by talking to
the patient. An appropriate response suggests
that ,there is:
• no major airway compromise( ability to speak
clearly)
• breathing is not severely compromised ( ability to
generate air movement to permit speech)
• the level of consciousness is not markedly
decreased (alert enough to describe what
happened)
• Failure to respond to these questions suggests
abnormalities in A, B, C, or D that warrant urgent
assessment and management.

9. ATLS : PRIMARY SURVEY
The primary survey encompasses the ABCDEs
of trauma care and identifies life-threatening
conditions by adhering to this sequence:
A Airway maintenance with restriction of
cervical spine motion
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability(assessment of neurologic status)
E Exposure/Environmental control

12. AIRWAY IN TRAUMA PATIENTS
• A patent airway and
adequate ventilation is of
primary importance because
hypoxia is the most
immediate threat to life.
• Inability to oxygenate the
patient will lead to
permanent brain injury and
death within 5 to 10 minutes.
• Trauma patients are at risk
for airway obstruction and
inadequate respiration for
the reasons listed!

13. Signs of airway obstruction:
Observe the patient-
• agitated (suggesting hypoxia) or
• obtunded(suggesting hypercarbia).
Listen for abnormal sounds-
• Noisy breathing means obstructed
breathing
• Snoring/ stridor- partial occlusion
of larynx or pharynx
• Dysphonia/ hoarsness- implies
functional layrngeal obstruction.
Evaluate Patient’s behaviour.
• Abusive and aggresive patient may
be infact hypoxic. Do not assume
intoxication.
Objective signs of inadequate
ventilation:
• Look for chest rise
Asymmetry suggest
pneumothorax or Flail chest.
• Listen for air entry B/L
Decreased/ absent breath
sounds- presence of thoracic
injury.
• Feel - deviated trachea,
broken ribs and injuries to
chest wall
• Use of pulse oximerty .
• Use of capnography.

14. PROTECTION OF THE CERVICAL SPINE
• All victims of blunt trauma be assumed to have an
unstable cervical spine until this condition is ruled out.
• direct laryngoscopy causes cervical motion, with the
potential to exacerbate spinal cord injury (SCI).
• Stabilization of the cervical spine should be done with a
rigid cervical collar in place( philadelphia collar).
• The presence of an “uncleared” cervical spine mandates
the use of manual in-line stabilization without
application of traction throughout any attempt at
intubation.

16. • C-spine injury
• Significant maxillofacial or mandibular trauma
• Limited mouth opening.
• Obesity.
• Anatomical variations (e.g., receding chin,
overbite, and a short, muscular neck)
• Pediatric patients.
PREDICTING DIFFICULT AIRWAY
MANAGEMENT

20. Maintainance of airway patency
• Suction of secretions
• Chin lift/ jaw thrust
• Nasopharyngeal/ oropharyngeal
airway/supraglottic airway device/
Oxygen support
• NRBM with 100% oxygen
• Bag Valve Mask
Definitive Airway
• Endotracheal intubation
• Surgical cricothyroidectomy
• tracheostomy
AIRWAY MANAGEMENT

21. AIRWAY MAINTENANCE
TECHNIQUES
Chin-Lift Maneuver
• The chin-lift maneuver is
performed by placing the fingers of
one hand under the mandible and
then gently lifting it upward to
bring the chin anterior.
• With the thumb of the same hand,
lightly depress the lower lip to open
the mouth
• The thumb also may be placed
behind the lower incisors while
simultaneously lifting the chin
gently.
• Do not hyperextend the neck while
employing the chin-lift maneuver.

22. JAW-THRUST MANEUVER
To perform a jaw thrust maneuver,
grasp the angles of the mandibles with
a hand on each side and then displace
the mandible forward. When used
with the facemask of a bag-mask
device, this maneuver can result in a
good seal and adequate ventilation.
As in the chin-lift maneuver, be
careful not to extend the patient’s
neck.

23. • Nasopharyngeal
Airway
Do not attempt this
procedure in patients with
suspected cribriform plate
fracture.
• Oropharyngeal
Airway
can induce gagging,
vomiting, and aspiration;
therefore, use them with
caution in conscious
patients. Patients who
tolerate an oropharyngeal
airway are highly likely to
require intubation

24. • Supraglottic Airway Devices
laryngeal mask airway (LMA) and intubating laryngeal mask airway
(ILMA) have been shown to be effective in the treatment of patients
with difficult airways, particularly if attempts at endotracheal
intubation or bag-mask ventilation have failed.

25. BAG VALVE MASK
“A self inflating bag” is a hand
held device commonly used
to provide positive pressure
ventilation to patients who
require breathing
assistance.
NONREBREATHER
MASK
Utilized for patients with
physical trauma, chronic
airway limitations, smoke
inhalations, CO poisonings or
any patient who require high FI
O2 but do not require breathing
assistance

27. MANUAL INLINE STABILIZATION
MILS is performed by an assistant during airway management
to maintain neutral position and prevent inadvertant
movement of head and neck by either:
1. Standing in front of the intubator with hands placed on the
sides of patient’s head and forearms resting on the
patient’s chest. Traction must not be applied.(There is no
universal definition of neutral position)
2. This approach allows wider mouth opening and jaw
displacement.
MILS is replaced by cervical collar, lateral blocks or sandbags
and head and chin straps once the airway is secure.

28. The criteria for establishing a definitive airway are based
on clinical findings and include:
• A —Inability to maintain a patent airway by
other means, with impending or potential airway
compromise (e.g., following inhalation injury,
facial fractures, or retropharyngeal hematoma)
• B —Inability to maintain adequate oxygenation
by facemask oxygen supplementation, or the
presence of apnea.
• C —Obtundation or combativeness resulting
from cerebral hypoperfusion
• D —Obtundation indicating the presence of a
head injury and requiring assisted ventilation
(Glasgow Coma Scale [GCS] score of 8 or less),
sustained seizure activity, and the need to
protect the lower airway from aspiration of
blood or vomitus.

30. APPROACH TO INTUBATION
• Orotracheal intubation is the preferred route taken to protect
the airway.
• Nasotracheal intubation may be an alternative for
spontaneously breathing patients.
• If the patient has Facial, frontal sinus, basilar skull, and
cribriform plate fractures are relative contraindications to
nasotracheal intubation.
• Evidence of nasal fracture, raccoon eyes (bilateral
ecchymosis in the periorbital region), Battle’s sign
(postauricular ecchymosis), and possible cerebrospinal fluid
(CSF) leaks (rhinorrhea or otorrhea) are all signs of these
injuries. As with orotracheal intubation, take precautions to
restrict cervical spinal motion.

31. PERSONELLE
Three providers are required to
• ventilate the patient and
manage the airway,
• Administer medications, and
• provide manual in-line
stabilization (if indicated).
• fourth provider may be needed
to provide cricoid pressure if
deemed appropriate

32. A trauma patient should always be treated as having a full
stomach and at risk for aspiration of gastric contents during
induction of anesthesia.
Reasons include:
• ingestion of food or liquids before the injury,
• swallowed blood from oral or nasal injuries,
• delayed gastric emptying associated with the stress of trauma,
and
• administration of liquid contrast medium for abdominal CT
scanning.

34. SELLICKS MANEUVRE
Has been recommended to be applied continuously during emergency
airway management from the time the patient loses protective airway
reflexes until ETT placement and cuff inflation are confirmed.
• It should be explained to the patient.
• Cricoid pressure must be exerted by an assistant.
• Before induction the cricoid is palpated and lightly held between the
thumb and second finger.
• As induction begins pressure is exerted on cricoid cartilage mainly by
the index finger.
• Cricoid pressure presses cricoid against the cervical vertebrae (C6)
and so it compresses lumen of pharynx.
• Pressure applied should be backward and in midline.
• Recommended : 10 N before induction and 30 N after induction.

35. BURP MANEUVRE
• B- backward
• U- upward
• R- right-lateral
• P- posterior

36. INDUCTION AGENTS
• ETOMIDATE
Most commonly used agent for induction due to its hemodynamic stability
profile.
Dose: 0.2-0.3 mg/Kg.
Disadvantages- transient adrenocortical supression and myoclonic jerks.
This is prevented by use of rapidly acting neuromuscular blocking agents.
• KETAMINE
Used in hypotensive trauma patients.
It increases sympathetic tone and catecholamine release. It preserves
cerebral perfusion by maintainance of Mean Arterial blood pressure in
Hemodynamically unstable patients.
Dose: 0.5-2 mg/Kg.
• PROPOFOL
Although propofol is the mainstay of induction in the OR, its use in trauma
patients is problematic because of its vasodilatory and negative ionotropic
effects.

37. NEUROMUSCULAR BLOCKING
AGENTS.
SUCCINYLCHOLINE
It is the NMB of choice with fastest onset i.e, less than 1
minute and shortest duration of action i.e, 5-10 minutes.
Dose: 0.3-1.1 mg/Kg.
Hyperkalemia is not seen in the first 24 hours after injury
hence and be used in trauma patients.
ROCURONIUM
DOSE 0.9-1.2 mg/Kg
Advantage- with the availability of SUGGAMADEX- rapid
onset selective binding agent for rocuronium, RSI and
intubation with Rocuronium followed by reversal with
Suggamadex allow more rapid return of spontaneous
return of ventilation than with succinylcholine.

38. ADJUNCTS TO ENDOTRACHEAL INTUBATION

41. NEEDLE CRICOTHYROTOMY
• Assemble and prepare equipment
• Position the patient supine, with the neck in a neutral position
• Clean the patient’s neck in a sterile fashion using antiseptic swabs
• Anesthetize the area locally, if time allows
• Locate the cricothyroid membrane anteriorly between the thyroid and the
cricoid cartilage
• Stabilize the trachea with the thumb and forefinger of one hand
• Using the other hand, puncture the skin in the midline with the 14-16G iv
cannula attached to a 10cc syringe over the cricothyroid membrane; direct
it at a 45° angle caudally while applying negative pressure to the syringe
• Maintain needle aspiration as the needle is inserted through the lower half
of the cricothyroid membrane; aspiration of air signifies entry into the
tracheal lumen
• Remove the syringe and needle while advancing the cannula
• The cannula is then attached to oxygen at 15L/min.

45. ROLE OF ANAESTHESIOLOGIST IN
TRAUMA CARE
At all levels of trauma care, anesthesiologists are uniquely
juxtaposed with the multidisciplinary trauma team.
• direct patient care through definitive airway management.
• preparing the operating room (OR).
• allocating resources for resuscitation.
• advanced resuscitation
• intensivists and pain management experts.