IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS
Cervical Spine Immobilization
Any patient with blunt force injury to the head should be suspected of having cervical spine injury until proven otherwise. Penetrating injuries to the torso and extremities not associated with blunt force are rarely associated with cervical spine injury. Cervical spine injury is associated with 5% of all blunt force injuries to the head; the greater the force, the greater the incidence of associated injury. Immobilization of the cervical spine during transport of a patient with potential injuries must include an appropriately sized and fitted cervical collar. Immobilize the cervical spine during evaluation by manual stabilization and logrolling the patient. Do not apply traction to the cervical spine.
Hypoxia is associated with increased morbidity and mortality in trauma patients. In patients with traumatic brain injury hypoxia is an independent risk factor for mortality with a 50% higher incidence that in those without hypoxia. Hypoxia must be avoided or corrected immediately. All patients with traumatic head injury should receive 100% oxygen by high-flow nonrebreathing mask as initial therapy. Keep the airway clear by suctioning of blood and secretions as needed. Remove foreign bodies, avulsed teeth, and dental appliances. Loss of gag reflex, inability to adequately clear secretions, or Glasgow Coma Scale (GCS) score of 8 or less are all indications to secure the airway with an endotracheal tube. Use clinical judgment to determine if a patient needs to be intubated in other situations, with priority on maintaining the airway during resuscitation, evaluation, and transport. Ventilate apneic or hypoventilating patients with an Ambu bag and 100% oxygen until intubation can be accomplished. Overventilation is also dangerous to the head-injured patient as hypocarbia will lead to cerebral vasospasm and worsen outcome. Avoid using a bag to provide positive-pressure ventilation to an actively breathing patient because this induces gastric distention.
Perform intubation while maintaining manual in-line cervical immobilization without applying traction. Rapid sequence induction intubation should be strongly considered for all patients. Once sedatives and paralytics have taken effect, remove the cervical collar and maintain manual stabilization. After intubation, secure the endotracheal tube and replace the cervical collar.
Orotracheal intubation is preferred because of the technical difficulty of nasotracheal intubation as well as the complications of bleeding, elevated intracranial pressure (ICP), and possible passage of the endotracheal tube through a fractured cribriform plate into the cranium. If orotracheal intubation is not successful, intubate the patient using videolaryngoscopy, fiberoptic-guided intubation, or cricothyroidotomy depending on the equipment available immediately, the clinical status of the patient and the procedures with which the physician is most skilled. In addition, consider a temporizing device, such as a laryngeal mask airway, in the patient who is difficult to intubate. After intubation, confirm endotracheal tube position by auscultation over the lung fields and epigastrium. Additional devices, such as color capnometers and aspiration devices may be used to confirm ...