The general approach to evaluation of an acute trauma victim has three sequential components: rapid overview, primary survey, and secondary survey (Fig. 52-1: Clinical sequence for initial management of a patient with major trauma).
- Airway Evaluation and Intervention. Airway evaluation involves the diagnosis of any trauma to the airway or surrounding tissues, recognition and anticipation of the respiratory consequences of these injuries, and prediction of the potential for exacerbation of these or other injuries by any contemplated airway management maneuvers.
- Airway Obstruction. Airway obstruction is a frequent cause of asphyxia and may result from posteriorly displaced or lacerated pharyngeal soft tissues; cervical or mediastinal hematoma; bleeding, secretions, or foreign bodies within the airway; and/or displaced bone or cartilage fragments.
- Maxillofacial, neck, and chest injuries, as well as cervicofacial burns, are the most common trauma-related causes of difficult tracheal intubation.
- Airway assessment should include a rapid examination of the anterior neck for feasibility of access to the cricothyroid membrane.
- Full Stomach. A full stomach is a background condition in acute trauma. (Urgency of securing the airway often does not permit adequate time for pharmacologic measures to reduce gastric volume and acidity.) After locating the cricothyroid membrane and denitrogenating the lungs, a rapid sequence induction may be used to permit securing the airway with direct laryngoscopy or, if necessary, with immediate cricothyroidotomy.
- Head, Open-Eye, and Contained Major Vessel Injuries
- These patients require deep anesthesia and profound muscle relaxation before airway manipulation (helps prevent hypertension, coughing, and bucking and thereby minimizes intracranial, intraocular, or intravascular pressure elevation, which can result in herniation of the brain, extrusion of eye contents, or dislodgment of a hemostatic clot from an injured vessel).
- The preferred anesthetic sequence in patients who are not hemodynamically compromised includes preoxygenation and opioid loading followed by relatively large doses of an intravenous (IV) anesthetic and muscle relaxant (prevent fasciculations produced by succinylcholine).