As you approached the patient, you could see instantly that he had multi-system trauma. While darting across a busy interstate, the young man had been struck by a pickup truck, which was now parked farther up the roadway, its windshield and front bumper exhibiting the damage of a high-speed impact. The patient was unconscious, his limbs splayed. He had massive head and facial trauma and deformity to both legs. Each gasping exhalation produced a bloody froth. Your mind immediately inventoried the injuries and you set to work.
Critical Thinking Is a Must
The rapid assessment that takes place in trauma situations demands critical thinking on the part of the rescuer. Maximizing survivability in the trauma victim means you must act quickly and apply these critical thinking skills in rapid succession. Here are the steps you should take when treating the trauma patient1:
- Assessment – What is going on, what needs to be done, and what resources are available
- Analysis – Evaluating each of the above factors and cross-referencing them with your knowledge, defining steps that will provide the best care
- Construction of a Plan – Identifying the steps that will lead to the best patient care and reviewing them critically
- Action – Enacting the plan and putting it in motion
- Reassessment – Is your plan working, or does it need to be tweaked as conditions change?
- Changes Along the Way – Being flexible in the face of changing conditions, able to adjust your plan of action without worry of appearing indecisive
Utilizing critical thinking in your assessment and treatment of the trauma patient is the key to good decision-making. Don’t lock yourself into a plan. The patient’s condition may change, forcing you to adjust and refocus your plan of care. Stay vigilant.
Critical thinking skills must also be applied when suctioning the trauma patient. In patients with significant facial trauma, suctioning may be your only means of ensuring a patent airway. Blood, vomit, tissue, and teeth may result from facial or head trauma, impeding the airway and reducing your ability to maintain patency. Here are some important recommendations for suctioning the trauma patient:
- Patient Positioning – In suspected spinal trauma, you won’t have the luxury of repositioning the patient to enhance suctioning. The patient will be secured to a backboard, with a cervical collar in place, both of which can hamper clearing the airway. If necessary, tilt the backboard to let gravity assist in suctioning copious blood from the airway.
- Preoxygenate the Patient – Prolonged suctioning will produce hypoxemia, and in a trauma patient, whose circulation may be impeded by blunt or penetrating injuries, this is especially harmful. Preoxygenate using supplemental oxygen and limit suction time to avoid cardiac arrhythmias (tachycardia and bradycardia). The goal is to maintain an SpO2 at or above 95 percent.
- Use Good Technique – Guide your suction catheter with care. The patient may have loose teeth that can be forced down into the airway. Tracheal irritation can lead to vagal stimulation, which can result in bradycardia and hypotension. Use a rigid tip or evacuation tool to maximize effectiveness.
Suctioning the Endotracheal Tube
Once the patient is intubated, he or she may still require aggressive suctioning. Trauma to the chest may produce blood and froth, which must be cleared from the tube. Here are a few pointers:
- Prepare equipment while maintaining sterility.
- Use a soft, flexible suction catheter that is long enough to pass the tip of the artificial airway (20 to 22 inches).
- Preoxygenate your patient using 100 percent oxygen (Fi02 of 1.0).
- Insert the catheter without suction and then initiate suction as you withdraw the catheter.
- Reoxygenate the patient and ventilate for at least five assisted ventilations.
- Repeat as necessary, allowing adequate time to reoxygenate in between procedures.
Trauma patients present unique challenges, and suctioning these patients is a critical step in stabilization. So, employ critical thinking at each stage of the process, especially when suctioning the airway.
Prehospital Trauma Life Support, American College of Surgeons, Committee on Trauma, MOSBY JEMS, Elsevier.