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2011, vol. 33, br. 1-2, str. 141-145
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Disajni put i trauma
The airway and trauma
aUniverzitet u Nišu, Medicinski fakultet + Klinički centar Niš, Centar za anesteziologiju i reanimaciju bVojnomedicinska akademija, Klinika za anesteziologiju i intenzivnu terapiju, Beograd cKlinički centar Vojvodine, Klinika za anesteziju i intenzivnu terapiju, Novi Sad dKlinički centar Niš, Centar za anesteziologiju i reanimaciju
e-adresa: jankovic.radmilo@gmail.com
Sažetak
Obezbeđivanje i održavanje prohodnosti disajnog puta spadaju u osnovne postupke neophodne za efikasno zbrinjavanje politraumatizovanih pacijenata. Neuspeh u obezbeđivanju disajnog puta može značajno povećati morbiditet i mortalitet traumatizovanih pacijenata. Endotrahealna intubacija se obično smatra 'zlatnim standardnom' za obezbeđivanje disajnog puta u traumi. Ali, poznavanje drugih, alternativnih procedura takođe je od suštinskog značaja za svakog lekara koji učestvuje u urgentnom zbrinjavanju. Prehospitalno obezbeđivanje disajnog puta kod pacijenata u traumi predstavlja izazov te svaku intubaciju koja se izvodi kod politraumatizovanih pacijenata treba smatrati potencijalno otežanom. Povrede grudnog koša mogu otežati ventilaciju i oksigenaciju politraumatizovanog pacijenta. Svakog ozbiljno povređenog pacijenta u traumi treba tretirati kao da ima povredu vratne kičme sve dok se ne dokaže da takve povrede nema. Zato je ovim pacijentima neophodna manuelna stabilizacija, kako bi se sprečilo pokretanje vratne kičme tokom intubacije ali se time otežava vizuelizacija glasnica. Ventilacija na masku pomoću samoširećeg balona, bez sumnje može spasiti život traumatizovanog pacijenta ali njeno izvođenje iziskuje dobro poznavanje veštine i određeni nivo uvežbanosti. Nedostaci primene ventilacije na masku u traumi su: naduvavanje želuca, curenje vazduha ali i nemogućnost da se disajni put zaštiti od aspiracije gastričnog sadržaja ili krvi. U hitnim slučajevima ne postoje kontraindikacije za izvođenje endotrahealne intubacije. Najnovije preporuke ukazuju da se primenom rapid sequence intubation protokola skraćuje vreme i povećava efikasnost intubacije, te da sukcinilhoilin ostaje relaksant izbora. Supraglotisna sredstva takođe mogu imati ulogu u prehospitalnom obezbeđenju disajnog puta. I na kraju, kapnografija se preporučuje kao vid obaveznog monitoringa kada je u pitanju prehospitalno zbrinjavanje disajnog puta.
Abstract
Securing and monitoring the airway are among the key requirements of appropriate trauma management. Failures to secure the airways may considerably increase the morbidity and mortality of trauma patients. Endotracheal intubation is often called the 'gold standard' for airway management in a pre-hospital environment but knowledge and availability of alternative procedures is also crucial for every emergency physician. The trauma patient poses several unique challenges with respect to airway management and thus all intubations performed in the injured patient should be considered at least potentially difficult. Chest injury impairs ventilation and oxygenation. All severely injured blunt trauma patients have cervical spine injury until proven otherwise and require manual inline stabilization to prevent cervical spine movement during intubation. However, true benefit of this procedure remains controversial considering spine immobilization may prevent successful intubation. Ventilation with a self- inflating bag and non-return valve attached to a mask can, and undoubtedly does, save lives of trauma patients but requires considerably level of skill and practice. Disadvantages of using bag-mask-valve ventilation in trauma patients include gastric inflation, air leak and failure to protect the airway from aspiration of gastric contents or blood. There are no contraindications for ETI in an emergency and recent recommendations emphasis rapid sequence intubation protocol is more likely to result in successful intubation and succinylcholine is still the paralytic drug of choice. Also, supraglottic airway devices may also have a role in airway management for resuscitation as first responder devices or as rescue devices. Finally, capnography should be mandatory in connection with pre-hospital advanced airway management.
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