Anaesthesia considerations in penetrating trauma
2014; Elsevier BV; Volume: 113; Issue: 2 Linguagem: Inglês
10.1093/bja/aeu234
ISSN1471-6771
AutoresNadav Sheffy, R. V. Chemsian, Andreas Grabinsky,
Tópico(s)Trauma Management and Diagnosis
ResumoTrauma and penetrating injury, mostly in the form of assault and self-inflicted gunshot and stab wounds, is a major contributor to mortality and morbidity in the modern world, specifically among younger populations. While the prevalence of this form of injury is drastically lower in the UK and Europe in comparison with the USA, it is still common enough to necessitate practising anaesthetists to have a good understanding and working knowledge of the principles in treating victims with penetrating injury. This review article aims to cover basic principles of attending to penetrating trauma victims starting at the pre-hospital level and continuing into the emergency department (ED) and the operating theatre. We will highlight major issues with regard to airway control, severe bleeding treatment, and emergency scene and ED procedures. We also suggest a work flow for treating life-threatening penetrating injury and review the major controversies in this field. Our perspective is based on the experience and procedures used at the University of Washington’s Harborview Medical Center, the only level 1 trauma centre covering the states of Washington, Alaska, Montana, Idaho, and Wyoming in the USA. This region contains almost 11 000 000 persons over a surface area of more than 2 700 000 km2. Trauma and penetrating injury, mostly in the form of assault and self-inflicted gunshot and stab wounds, is a major contributor to mortality and morbidity in the modern world, specifically among younger populations. While the prevalence of this form of injury is drastically lower in the UK and Europe in comparison with the USA, it is still common enough to necessitate practising anaesthetists to have a good understanding and working knowledge of the principles in treating victims with penetrating injury. This review article aims to cover basic principles of attending to penetrating trauma victims starting at the pre-hospital level and continuing into the emergency department (ED) and the operating theatre. We will highlight major issues with regard to airway control, severe bleeding treatment, and emergency scene and ED procedures. We also suggest a work flow for treating life-threatening penetrating injury and review the major controversies in this field. Our perspective is based on the experience and procedures used at the University of Washington’s Harborview Medical Center, the only level 1 trauma centre covering the states of Washington, Alaska, Montana, Idaho, and Wyoming in the USA. This region contains almost 11 000 000 persons over a surface area of more than 2 700 000 km2. Editor’s key points•Bullets can travel a considerable distance through the body making the extent of injury from gunshot wounds (GSW) unpredictable.•GSW to the chest, abdomen, and pelvis can cause extensive injury with potential for rapid haemodynamic deterioration.•Penetrating neck injuries can progress rapidly to airway obstruction. •Bullets can travel a considerable distance through the body making the extent of injury from gunshot wounds (GSW) unpredictable.•GSW to the chest, abdomen, and pelvis can cause extensive injury with potential for rapid haemodynamic deterioration.•Penetrating neck injuries can progress rapidly to airway obstruction. The World Health Organization estimates that traumatic injuries from traffic accidents, drowning, poisoning, falls, burns, and violence kill more than five million people worldwide annually, with millions more suffering from the consequences of injuries. Eight of the 15 leading causes of death for people aged 15–29 yr are violence or injury-related. Trauma is the second-most common single cause of death and represents 8% of all deaths worldwide. A large proportion of people surviving their injuries incur temporary or permanent disabilities. Trauma puts not only a burden onto the individual and the individual’s family, but also creates a significant cost for society in the short- and long-term treatment of trauma victims, and also in the loss of productivity of these often young victims.1Peden M McGee K Sharma G The Injury Chart Book: A Graphical Overview of the Global Burden of Injuries. World Health Organization, Geneva2002Google Scholar Penetrating trauma is most commonly caused by assault or self-inflicted injuries with firearms or knives. Civilian penetrating injuries caused by gunshot wounds (GSW) and stab wounds are one of the leading causes of morbidity and mortality in the USA. In 2010, homicide and suicide, the majority of which were firearms-related, were among the leading five causes of death in the 10–44 age group in the USA. There were 16 259 homicides in the USA, and of those, 11 078 were committed with firearms, a rate of 3.62 per 100 000 for firearm-related homicides based on the 2000 census population. An additional 19 392 deaths were self-inflicted firearm injuries and 858 deaths were caused by either unintended or undetermined causes of firearm discharge. In 2010, a total of 2598 people died in the USA from stabbing or cutting-related incidents, and of those, 1799 were considered homicides. The same year 53 738 non-fatal assaults with firearms and 131 338 non-fatal assaults with cutting or piercing instruments were treated in hospitals.2Centers for Disease Control and PreventionInjury prevention and control: data and statistics. 2010http://www.cdc.gov/injury/wisqars/LeadingCauses.htmlGoogle Scholar In the UK, the number of homicides and firearm-related deaths and injuries is drastically lower. In 2011, there were 329 deaths from homicides, 31 caused by discharge of firearms and 114 deaths by assault with a sharp object.3UK National Statistics Publication HubInjury and poisoning mortality in England and Wales. 2011http://www.statistics.gov.uk/hub/release-calendar/index.html?newquery=*&uday=0&umonth=0&uyear=0&title=Injury+and+poisoning+mortality+in+England+and+Wales&pagetype=calendar-entry&lday=&lmonth=&lyear=Google Scholar This translates to a rate of 0.56 per 100 000 for firearm-related homicides based on the 2001 census population and a total homicide-related rate of 0.19 per 100 000. The crime statistics from the office for national statistics reported a total of 6001 assaults with firearms in which the weapon was discharged in 2230 instances, resulting in 42 deaths and 1244 injuries.4Office for National StatisticsStatistical Bulletin: Crime in England and Wales—Quarterly First Release. 2012http://www.ons.gov.uk/ons/dcp171778_273169.pdfGoogle Scholar A study by Davies and colleagues looking at the trends in civilian firearm injuries and deaths in England and Wales between 1998 and 2007 showed a mean incidence rate of 0.53% for firearm injuries among trauma patients reaching the hospital alive (487 patients). While the data set (The Trauma Audit and Research Network) only covers around 70% of trauma receiving hospitals in the UK and a large proportion of GSW fatalities die on scene, it is still clear that the ratios are much lower than those seen in the USA.5Davies MJ Wells C Squires PA Civilian firearm injury and death in England and Wales.Emerg Med J. 2012; 29: 10-14Crossref PubMed Scopus (21) Google Scholar Stab wounds are likewise significantly less common in the UK than in the USA but still remain a problem. In the years 2011–2, there were more than 12 326 cases of actual bodily harm and grievous bodily harm caused by sharp instruments.6Office for National StatisticsStatistical Bulletin: Crime in England and Wales, Year Ending June. 2013http://www.ons.gov.uk/ons/dcp171778_331209.pdfGoogle Scholar In a study by Crewdson and colleagues7Crewdson K Lockey D Weaver A Davies GE Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service.Injury. 2009; 40: 560-563Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar examining all penetrating injuries in London between 1991 and 2006, an annual increase of 23.2% was found in patients sustaining stabbing injuries and 11.0% for those sustaining GSW. In Europe, about 2% of all trauma-related fatalities are caused by homicide, which amounted to an annual average of 4704 deaths between 2008 and 2010. Of those, 34% were due to sharp objects and 17% are due to firearm discharge. With regard to self-inflicted injuries, 57 614 deaths (25%) of all trauma-related fatalities were caused by suicide. Of those, 7% were due to firearm discharge and only 2% due to sharp objects.8European Association for Injury Prevention and Safety Promotion (EuroSafe)Injuries in the European Union: Summary of Injury Statistics for the years 2008–2010. 2013Google Scholar The direct and indirect economic implications of trauma, specifically penetrating injuries which usually affect young people, are enormous. According to the US Center for Disease Control and Prevention (CDC), the direct medical costs for more than 12 000 patients dying of assault-related GSW in 2005 were more than US $60 million, while the cost for lost work and productivity was more than US $18 billion. For hospitalized patients injured as a result of an assault by firearm, direct medical costs were estimated at more than US $400 million. The cost of loss of work and productivity were estimated at US $2.27 billion and a combined lifetime cost of US $2.6 billion.9Centers for Disease Control and Prevention, Data and Statistics: Cost of Injury Reports, Available from http://wisqars.cdc.gov:8080/costT/ (accessed 4 November 2013).Google Scholar In the UK, the mean hospital costs for adults over 18 yr of age suffering penetrating injuries between 2000 and 2005 was £7983, ranging between 6035 in patients with injury severity score (ISS) 9–25 to more than 16 000 in patients with ISS>34.10Christensen MC Nielsen TG Ridley S Lecky FE Morris S Outcomes and costs of penetrating trauma injury in England and Wales.Injury. 2008; 39: 1013-1025Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Penetrating traumatic injury, and trauma in general, is a burden to society with respect to the loss of life and the direct and indirect costs caused by these injuries, especially in the USA and to a lesser degree in the UK and Europe. ‘The Golden Hour’ concept, coined by R. Adams Cowley, founder of the Maryland Institute of Emergency Medical Services is used regularly to characterize the importance of the time interval between incident and arrival at tertiary care centres. Cowley identified the importance of time from injury to arrival at the appropriate facility supplying definitive care as a key concept in the management of trauma patients.11National Association of Emergency Medical TechniciansPHTLS: Basic & Advanced Prehospital Trauma Life Support. 6th Edn. Mosby, St Louis, MO2007Google Scholar During that first crucial hour after injury, many patients are being treated by emergency medical services (EMS) providers or in the emergency department (ED). Civilian pre-hospital management varies with regard to staffing capabilities, times for evacuation, and distance to nearest trauma centres. Regardless of the set-up, a crucial component is preparation. A pre-laid programme with policies for field treatment (or not to treat in the field), proper staff to be dispatched, evacuation routes, and decision schemes for transporting patients to the nearest hospitals vs nearest trauma centres must be in place. For those patients with life-threatening injuries, rapid evacuation and transport to definitive care is a key component. While there has been a lack of mortality benefits shown for shorter pre-hospitals transport times for trauma patients as a whole, for a subset of patients, especially patients with penetrating injuries and those showing haemodynamic instability in the field, there is an advantage for shorter transport times12Swaroop M Straus DC Agubuzu O Esposito TJ Schermer CR Crandall ML Pre-hospital transport times and survival for hypotensive patients with penetrating thoracic trauma.J Emerg Trauma Shock. 2013; 6: 16-20Crossref PubMed Scopus (74) Google Scholar 13McCoy CE Menchine M Sampson S Anderson C Kahn C Emergency medical services out-of-hospital scene and transport times and their association with mortality in trauma patients presenting to an urban Level 1 trauma center.Ann Emerg Med. 2013; 61: 167-174Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar and an increased mortality for prolonged on scene times.14Funder KS Petersen JA Steinmetz J On-scene time and outcome after penetrating trauma: an observational study.Emerg Med J. 2011; 28: 797-801Crossref PubMed Scopus (48) Google Scholar Where distances are great, as in parts of the USA, helicopter-based EMS systems provide a potentially lifesaving resource to expedite inter-hospital patient transport from a non-trauma centre to a trauma centre.15Stephen HT Controversy in prehospital care: air medical response.Emerg Med Pract. 2005; 7: 1-26Google Scholar, 16Galvagno Jr, SM Thomas S Stephens C et al.Helicopter emergency medical services for adults with major trauma.Cochrane Database Syst Rev. 2013; 3: CD009928Google Scholar, 17Andruszkow H Lefering R Frink M et al.Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients.Crit Care. 2013; (Advance Access published on June 21)doi:10.1186/cc12796PubMed Google Scholar A ‘Guideline for field triage of injured patients’ published by the CDC has been in use in the USA since 1986. This guideline (last updated in 2011) aims to use an evidence-based medicine approach and provide criteria for transport destination. Physiological data, such as the Glasgow coma scale (GCS), systolic arterial pressure (SAP) and heart rate, anatomic injury data, and mechanism of injury, are used to help identify the need for treatment in a trauma centre. The guideline recommends the transport of any penetrating injury involving the torso, head, or neck to a trauma centre.18Centers for Disease Control and Prevention, Guidelines for Field Triage of Injured Patients, Available from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm (accessed 4 November 2013).Google Scholar Controversy exists concerning the effect on morbidity and mortality of advanced treatment done in the field, specifically airway management and fluid therapy. The success rates for successful field intubation by paramedic systems are well researched and range from 69% to 98%.19Cobas MA De la Peña MA Manning R Candiotti K Varon AJ Prehospital intubations and mortality: a level 1 trauma center perspective.Anesth Analg. 2009; 109: 489-493Crossref PubMed Scopus (137) Google Scholar, 20Colwell CB Cusick JM Hawkes AP et al.Denver Metro Airway Study GroupA prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.Prehosp Emerg Care. 2009; 13: 304-310Crossref PubMed Scopus (9) Google Scholar, 21Warner KJ Sharar SR Copass MK Bulger EM Prehospital management of the difficult airway: a prospective cohort study.J Emerg Med. 2009; 36: 257-265Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar However, even physician-staffed systems have a wide range of intubation success rates, ranging from 90% in systems with emergency medicine-certified physicians from different medical specialities to 100% when the emergency medicine-certified physicians were experienced anaesthetists.22Timmermann A Russo SG Eich C et al.The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.Anesth Analg. 2007; 104: 619-623Crossref PubMed Scopus (259) Google Scholar, 23Timmermann A Eich C Russo SG et al.Prehospital airway management: a prospective evaluation of anesthesia trained emergency physicians.Resuscitation. 2006; 70: 179-185Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar, 24Helm M Hossfeld B Schafer S Hoitz J Lampl L Factors influencing emergency intubation in the pre-hospital setting. A multicenter study in German Helicopter Emergency Medical Service.Br J Anaesth. 2006; 96: 67-71Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar When analysing these studies, it becomes clear that the success rate of intubation, and ultimately the effect on mortality, depends primarily on the specific amount of airway training and expertise of the provider rather than their professional field.25Davis DP Koprowicz KM Newgard CD et al.The relationship between out-of-hospital airway management and outcome among trauma patients with Glasgow Coma Scale Scores of 8 or less.Prehosp Emerg Care. 2011; 15: 184-192Crossref PubMed Scopus (45) Google Scholar A multitude of retrospective studies and a recent animal model for exsanguination conveyed no mortality benefits for field intubation in comparison with bag mask ventilation and in some cases even increased mortality attributed to prolonged scene time, oesophageal intubation, positive pressure ventilation, and more.26Stockinger ZT McSwain Jr, NE Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation.J Trauma. 2004; 56: 531-536Crossref PubMed Scopus (127) Google Scholar, 27Taghavi S Jayarajan SN Khoche S et al.Examining prehospital intubation for penetrating trauma in a swine hemorrhagic shock model.J Trauma Acute Care Surg. 2013; 74: 1246-1251Crossref PubMed Scopus (14) Google Scholar, 28Shafi S Gentilello L Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank.J Trauma. 2005; 59: 1140-1145Crossref PubMed Scopus (67) Google Scholar, 29Eckstein M Chan L Schneir A Palmer R Effect of prehospital advanced life support on outcomes of major trauma patients.J Trauma. 2000; 48: 643-648Crossref PubMed Scopus (194) Google Scholar However, none of these studies has properly controlled for experience of the paramedics in successfully performing tracheal intubation. At this point, there are not enough data to recommend against tracheal intubation in the field and it seems that proper airway management by a trained and experienced provider improves patient outcome. In the UK, a very low percentage of trauma patients are intubated in the pre-hospital setting according to a 2007 report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).30Trauma: who cares?, 2007, National Confidential Enquiry into Patient Outcome and Death, Available from http://www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf (accessed 4 November 2013).Google Scholar The report cited about 10% of all trauma patient airway management examined by experts to be inadequate and recommended that any pre-hospital trauma patient intubation ‘… needs to be in the context of a physician-based pre-hospital care system’. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) in its 2009 guidelines for pre-hospital anaesthesia reaffirms the statement that ‘… it should only be performed by appropriately trained and competent practitioners…’.31AAGBI Safety Guidelines—Prehospital Anaesthesia, 2009, The Association of Anaesthetists of Great Britain and Ireland, February. Available from http://www.aagbi.org/sites/default/files/prehospital_glossy09.pdf (accessed 4 November 2013).Google Scholar We disagree with the earlier statement about physician-based systems because of the more than 99% success rate for pre-hospital intubation in the Seattle and King county area paramedic-based pre-hospital system (MEDIC 1).32Prekker ME Kwok H Shin J Carlbom D Grabinsky A Rea TD The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation.Crit Care Med. 2014; (Advance Access published on February 28)doi:10.1097/CCM.0000000000000213PubMed Google Scholar However, we agree that it is crucial to ensure proper training, experience, and continuing education of the pre-hospital personnel. While this may allow practitioners other than the experienced anaesthesia provider to manage airways in the field, it does require oversight and training by anaesthetists to provide a higher degree of expertise in airway management. The controlled environment of the operating theatre (OT) can be used to facilitate training of pre-hospital providers in airway management and expose them to an adequate number of procedures to gain critical experience. Placement of i.v. lines and fluid resuscitation is a standard part of pre-hospital advanced life support (ALS). However, there are uncertainties whether the extended on-scene time to secure i.v. access and to initiate fluid therapy are beneficial. Two recent large prospective studies showed completely differing outcomes regarding i.v. placement and pre-hospital fluid therapy effect on mortality. In one study done with more than 700 000 trauma patients, an increased mortality was found for penetrating trauma patients when receiving an i.v. line in the field [odds ratio 1.25, 95% confidence interval (CI) 1.08–1.45].33Haut ER Kalish BT Cotton BA et al.Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis.Ann Surg. 2011; 253: 371-377Crossref PubMed Scopus (126) Google Scholar In another study including more than 1000 trauma patients in 10 level 1 trauma centres across the USA, pre-hospital fluid administration was associated with reduced mortality (hazards ratio 0.84, 95% CI 0.72–0.98).34Hampton DA Fabricant LJ Differding J et al.PROMMTT Study GroupPrehospital intravenous fluid is associated with increased survival in trauma patients.J Trauma Acute Care Surg. 2013; 75: S9-15Crossref PubMed Scopus (60) Google Scholar Pre-hospital providers at the scene may have a better chance of securing i.v. access before substantial haemorrhage makes subsequent attempts at i.v. placement more challenging due to hypovolaemia and severe vasoconstriction. In 2013, Engels and colleagues found obtaining pre-hospital i.v. access was associated with longer EMS on-scene and pre-hospital times; 16.1 vs 11.4 min and 18.9 vs 16.5 min, respectively. Obtaining i.v. access in patients arriving to the ED without pre-hospital i.v. required 20.5 min for peripheral and 21.7 min for central line access.35Engels PT Passos E Beckett AN Doyle JD Tien HC IV access in bleeding trauma patients: a performance review.Injury. 2014; 45: 77-82Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar The concept of ‘hypotensive resuscitation’ for patients with uncontrolled haemorrhage is based on the theory that overzealous fluid resuscitation, apart from further hindering the coagulation system, can potentially increase bleeding by interrupting delicate blood clots formed by the increased arterial pressure. Several studies have shown improved survival rates for trauma patients (general and penetrating injury) treated with a lower SAP goal before reaching the OT (90 and 70 mm Hg, respectively).36Bickell WH Wall Jr, MJ Pepe PE et al.Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.N Engl J Med. 1994; 331: 1105-1109Crossref PubMed Scopus (1705) Google Scholar 37Dutton RP Mackenzie CF Scalea TM Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality.J Trauma. 2002; 52: 1141-1146Crossref PubMed Scopus (429) Google Scholar Modern civilian and military protocols for resuscitation of trauma patients call for the use of physiological data such as consciousness level for patients with shock and the absence or presence of radial pulse to decide upon fluid therapy, rather than the targeting of set SAP goals. Our approach to the current conflicting evidence is to recommend securing i.v. access while en route to the hospital without delaying transport time, avoiding over-resuscitation of patients and using physiological goals for resuscitation instead of set arterial pressure goals until conclusive evidence shows otherwise. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines for pre-hospital fluid therapy in trauma patients published in 2004 underline the lack of solid evidence supporting pre-hospital fluid therapy, and recommend limiting this therapy to patients without a palpable radial pulse or central pulse for patients with penetrating torso injuries. Furthermore, it states that transport time should not be prolonged and any vascular access be instituted en route.38Pre-hospital initiation of fluid replacement therapy in trauma, 2004, National Institute for Clinical Excellence, January. Available from http://www.nice.org.uk/nicemedia/live/11526/32820/32820.pdf (accessed 4 November 2013).Google Scholar There is a lack of evidence showing mortality advantages in using pre-hospital ALS vs basic life support in urban trauma victims with some evidence suggesting higher mortality with the use of ALS,39Isenberg DL Bissell R Does advanced life support provide benefits to patients?: A literature review.Prehosp Disaster Med. 2005; 20: 265-270Crossref PubMed Scopus (35) Google Scholar 40Stiell IG Nesbitt LP Pickett W et al.OPALS Study GroupThe OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity.Can Med Assoc J. 2008; 178: 1141-1152Crossref PubMed Scopus (200) Google Scholar whether these findings are the result of longer on-scene or transport times to perform advanced procedures is unknown. This caveat might also not hold true for trauma in rural areas where transport times are much longer and haemodynamic changes are more significant by the time the patient arrives to the hospital. There are clearly more questions than answers with regard to scientific evidence for the utility of pre-hospital treatment, especially in urban setting where trauma centres are generally in close proximity. In the Harborview system, the ED’s role in the penetrating trauma patient is primarily as a triage station and initial treatment area. Patients can arrive haemodynamically stable, unstable, or without signs of life. Depending on the patient’s haemodynamic stability, further treatment, diagnostic tests, or immediate transport to the OT are indicated. Upon arrival to the hospital, urgent securing of airway is indicated in unstable patients or those destined to the OT not already intubated. In the severely injured patient, loss of airway or breathing is the most immediate threat to life alongside massive haemorrhage. Thus, airway stabilization with adequate pulmonary mechanics remains the first priority of resuscitation.41American College of SurgeonsATLS Manual. 9th Edn. American College of Surgeons, Chicago, USA2012Google Scholar Airway management is tailored to the type of injury, the nature and degree of airway compromise, and the patient’s haemodynamic and oxygenation status. An immediate assessment of the patient’s airway in the context of injuries, overall condition, and potential for deterioration help determine if and when to proceed in securing the airway. Indications for intervening to secure the airway include: respiratory failure, apnoea, reduced level of consciousness (GCS≤8), rapid change of mental status, airway injury or impending airway compromise, high risk for aspiration, or ‘trauma to the box’, which includes all penetrating injuries to the abdomen or chest cavity. Since patients with penetrating injuries can rapidly decompensate, our institution asserts a low threshold for securing a definitive airway in a time-sensitive fashion. Control of the airway and sedation can facilitate prompt resuscitative measures, thorough diagnostic injury workup, and, if warranted, emergent surgical intervention. If injuries are deemed non-threatening after complete workup, early tracheal extubation is a priority upon meeting the appropriate criteria. With ballistic injuries, we consider ‘trauma to the box’ to include GSW with entrance wounds from the neck to the pelvis, especially when the bullet trajectory is not obvious. In the absence of an exit wound, bullets can travel a considerable distance within the body and bullets entering the abdomen can potentially cause injuries to the chest or neck. Bullets entering through the upper arm can also be found in the chest cavity. Thus, injury related to GSW is unpredictable and many trauma surgeons will proceed urgently to diagnostic laparotomy or thoracotomy. In the context of traumatic brain injury, early airway intervention is critical in order to avoid secondary injuries caused by hypoxia and hypercarbia. Penetrating facial or neck injuries require early attention as those can rapidly progress into complete airway obstruction, secondary to evolving oedema and anatomical distortion. As more time elapses from initial injury, increasing oedema, subcutaneous emphysema, blood, vomitus, and secretions further complicate securing the airway. The ASA algorithm for management of difficult airways is a useful starting point for the trauma anaesthesiologist, whether in the ED or the OT.42Ferson D Chi TL Developments in general airway management.Thorac Surg Clin. 2005; 15: 39-53Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar However, as the algorithm suggests, reawakening a patient after difficulty in securing the airway is usually not an option; tracheal intubation must be achieved using conventional or surgical means. A surgical airway may be the first or the best option in certain conditions.43Wilson WC Trauma: airway management, ASA difficult airway algorithm modified for trauma—and five common trauma intubation scenarios.ASA Newsletter. 2005; 69: 9-18Google Scholar In general, rapid-sequence induction accompanied after pre-oxygenation with cricoid pressure and in-line cervical stabilization, followed by direct laryngoscopy (DL), is the safest and most effective approach.44Shearer VE Giesecke AH Airway management for patien
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