Prise en charge pré-hospitalière du traumatisé crânien et ... · Plan • Approche en ......

Prise en charge pré-hospitalière du traumatisé crânien et médullaire.

Dr Jonathan PETIT,CHU UCL Namur - Site de Godinne - Soins intensifs, CMH Bra-sur-Lienne.

Méthode

• Exposé destiné à des professionnels de la santé expérimentés.

• Quelques rappels.

• Essentiellement des discussion thématique pour repenser notre pratique quotidienne.

• Mise en pratique explicative.

• Play and move!!!!!!

Plan

• Approche en sécurité !

• Énergie cinétique et traumatologie.

• Affirmations, généralités et réalités…

• Clinique et prise en charge du trauma crânien grave.

• Spécificité de la prise en charge du trauma médullaire. isolé.

• Orientation des blessés, Transmissions aux urgences.

Approche générale du travail en pré-hospitalier et de la traumatologie.

Approche et déplacement en sécurité !!

Risques routiers, mais également chimique, biologique, sécuritaire,…

Énergie cinétique et traumatologie

• En traumatologie, les lésions sont fonction de

• E = 1/2 Masse x vitesse²

• Le temps de la décélération.

• La direction des forces.

Affirmations, généralités et réalités…

Sur le trauma médullaire et/ou cérébral.

Trauma-crânien = trauma médullaire.

• trimodal age distribution,

• male-to-female ratio of 2:2,

• motor vehicle accidents as the primary spine trauma mechanism,

• 47.7% patients with severe polytrauma as graded using the Injury Severity Score (ISS),

• 17.3% with traumatic brain injury (TBI),

• the majority of patients with one spine injury level,

• 7% neurological deficit rate,

• 12.8% spine trauma operative rate,

• and 5.2% mortality rate.

Immobilisation spinale systématique ?

• Prehospital care personnel usually immobilize patients before their transport to th ED.

• Any patient with a suspected spine injury should be immobilized above and below the suspected injury site until a fracture is excluded by x-ray examination.


• It has been associated with a multitude of complications,

• including airway compromise,

• aspiration,

• increased intracranial pressure,

• cutaneous pressure ulcers,

• iatrogenic pain,

• combativeness of intoxicated patients and

• increased cost and time of extrication.


Intuber un traumatisé cérébral sur le terrain ?

Intubation : avec ou sans coller cervical?

AIRWAY/REVIEW ARTICLE

Manual In-Line Stabilization for Acute Airway Management ofSuspected Cervical Spine Injury: Historical

Review and Current Questions

Seth Manoach, MDLorenzo Paladino, MD

From the Department of Emergency Medicine, State University of New York-Downstate and KingsCounty Hospital Center, Brooklyn, NY.

Direct laryngoscopy with manual in-line stabilization is standard of care for acute trauma patients withsuspected cervical spine injury. Ethical and methodologic constraints preclude controlled trials ofmanual in-line stabilization, and recent work questions its effectiveness. We searched MEDLINE, IndexMedicus, Web of Knowledge, the Cochrane Database, and article reference lists. According to thissearch, we present an ancestral review tracing the origins of manual in-line stabilization and ananalysis of subsequent studies evaluating the risks and benefits of the procedure. All manual in-linestabilization data came from trials of uninjured patients, cadaveric models, and case series. Theprocedure was adopted because of reasonable inference from the benefits of stabilization duringgeneral care of spine-injured patients, weak empirical data, and expert opinion. More recent dataindicate that direct laryngoscopy and intubation are unlikely to cause clinically significant movementand that manual in-line stabilization may not immobilize injured segments. In addition, manual in-linestabilization degrades laryngoscopic view, which may cause hypoxia and worsen outcomes in traumaticbrain injury. Patients intubated in the emergency department with suspected cervical spine injury oftenhave traumatic brain injury, but the incidence of unstable cervical lesions in this group is low. Thelimited available evidence suggests that allowing some flexion or extension of the head is unlikely tocause secondary injury and may facilitate prompt intubation in difficult cases. Despite the presumedsafety and efficacy of direct laryngoscopy with manual in-line stabilization, alternative techniques thatdo not require direct visualization warrant investigation. Promising techniques include intubationthrough supraglottic airways, along with video laryngoscopes, optical stylets, and other imagingdevices. [Ann Emerg Med. 2007;50:236-245.]

0196-0644/$-see front matterCopyright © 2007 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2007.01.009

INTRODUCTION

Before the 1970s, emergency care providers did notconsistently immobilize the cervical spine, and the incidence ofsecondary injury was estimated to range from 10% to 25%.1

A review of 300 patients presenting to the Johns Hopkins andBaltimore City Hospitals between 1950 and 1972 noted that“180 were paralyzed and 120 were not.” No mention was madeof deterioration during transport, but 11 patients developeddeficits after reaching the hospital. Three of these patientsdeteriorated “while they were in the emergency room, and . . .seven others after neck immobilization was not provided.”2 Asemergency care systems developed in the 1960s and 1970s, thepractice of immobilization spread, and more patients presentedwith preserved neurologic function.1 These observations raisedconcerns that cervical movement during airway managementmay worsen spinal cord injury.3,4

During the 1980s and 1990s, direct laryngoscopy andorotracheal intubation with manual in-line stabilization becamestandard of care.5 The practice remains standard becausealternative techniques were reported to be more complex, to beless effective, or to have had problems that require furtherinvestigation.6-8 Like many established practices, spinalimmobilization has never been studied in controlled,randomized trials.9 It has been supported by less rigorousinvestigations, including studies in uninjured volunteers,10,11

newly dead patients with documented injuries,12 cadavericmodels,13,14 and case series.15-19 In addition, there is a 25-yearworldwide practice history of direct laryngoscopy andorotracheal intubation with manual in-line stabilization,20

and there are few, if any, credible reports of neurologicdeterioration.21

Despite this excellent safety record, questions have emergedabout the advisability of rigidly applying manual in-line

236 Annals of Emergency Medicine Volume 50, NO. 3 : September 2007

11. Hastings RH, Wood PR. Head extension and laryngeal view duringlaryngoscopy with cervical spine stabilization maneuvers.Anesthesiology. 1994;80:825-831.

12. Bivins HG, Ford S, Bezmalinovic Z, et al. The effect of axialtraction during orotracheal intubation of the trauma victim with anunstable cervical spine. Ann Emerg Med. 1988;17:25-29.

13. Donaldson WF 3rd, Towers JD, Doctor A, et al. A methodology toevaluate motion of the unstable spine during intubationtechniques. Spine. 1993;18:2020-2023.

14. Gerling MC, Davis DP, Hamilton RS, et al. Effects of cervicalspine immobilization technique and laryngoscope blade selectionon an unstable cervical spine in a cadaver model of intubation.Ann Emerg Med. 2000;36:293-300.

15. Holley J, Jorden R. Airway management in patients with unstablecervical spine fractures. Ann Emerg Med. 1989;18:1237-1239.

16. Rhee KJ, Green W, Holcroft JW, et al. Oral intubation in themultiply injured patient: the risk of exacerbating spinal corddamage. Ann Emerg Med. 1990;19:511-514.

17. Scannell G, Waxman K, Tominaga G, et al. Orotracheal intubationin trauma patients with cervical fractures. Arch Surg. 1993;128:903-905.

18. Shatney CH, Brunner RD, Nguyen TQ. The safety of orotrachealintubation in patients with unstable cervical spine fracture or highspinal cord injury. Am J Surg. 1995;170:676-679.

19. Patterson H. Emergency department intubation of trauma patientswith undiagnosed cervical spine injury. Emerg Med J. 2004;21:302-305.

20. Grande CM, Barton CR, Stene JK. Appropriate techniques forairway management of emergency patients with suspected spinalcord injury. Anesth Analg. 1988;67:714-715.

21. McLeod AD, Calder I. Spinal cord injury and direct laryngoscopy—the legend lives on. Br J Anaesth. 2000;84:705-709.

22. Sutcliffe AJ. Spinal cord injury and direct laryngoscopy—thelegend lives on [letter]. Br J Anaesth. 2000;85:665.

23. Lennarson PJ, Smith D, Todd MM, et al. Segmental cervical spinemotion during orotracheal intubation of the intact and injuredspine with and without external stabilization. J Neurosurg. 2000;92(2 suppl):201-206.

24. Nolan JP, Wilson ME. Orotracheal intubation in patients withpotential cervical spine injuries. An indication for the gum elasticbougie. Anaesthesia. 1993;48:630-633.

25. Heath KJ. The effect of laryngoscopy of different cervical spineimmobilisation techniques. Anaesthesia. 1994;49:843-845.

26. Chesnut RM, Marshall LF, Klauber MR, et al. The role ofsecondary brain injury in determining outcome from severe headinjury. J Trauma. 1993;34:216-222.

27. Brain Trauma Foundation Guidelines. Assessment: oxygenation andblood�pressure:�15-25.�Available�at:�http://www2.braintrauma.org/guidelines/downloads/btf_guidelines_prehospital.pdf?BrainTrauma_Session!61f7c04f1b7f6516cfce93221a153bee.Accessed�March�10,�2006.

28. Aprahamian C, Thompson BM, Finger WA, et al. Experimentalcervical spine injury model: evaluation of airway management andsplinting techniques. Ann Emerg Med. 1984;13:584-587.

29. Donaldson WF 3rd, Heil BV, Donaldson VP, et al. The effect ofairway maneuvers on the unstable C1-C2 segment. A cadaverstudy. Spine. 1997;22:1215-1218.

30. Brimacombe J, Keller C, Kunzel KH, et al. Cervical spine motionduring airway management: a cinefluoroscopic study of theposteriorly destabilized third cervical vertebrae in humancadavers. Anesth Analg. 2000;91:1274-1278.

31. Lennarson PJ, Smith DW, Sawin PD, et al. Cervical spinal motionduring intubation: efficacy of stabilization maneuvers in thesetting of complete segmental instability. J Neurosurg.2001;94(2 suppl):265-270.

32. Calder KK, Herbert M, Henderson SO. The mortality of untreatedpulmonary embolism in emergency department patients. AnnEmerg Med. 2005;45:302-310.

33. American College of Surgeons Committee on Trauma. AdvanceTrauma Life Support Manual. Chicago, IL: American College ofSurgeons; 1984:158.

34. Podolsky S, Baraff LJ, Simon RR, et al. Efficacy of cervical spineimmobilization methods. J Trauma. 1983;23:461-465.

35. Suderman VS, Crosby ET, Lui A. Elective oral tracheal intubationin cervical spine-injured adults. Can J Anaesth. 1991;38:785-789.

36. Meschino A, Devitt JH, Koch JP, et al. The safety of awaketracheal intubation in cervical spine injury. Can J Anaesth. 1992;39:114-117.

37. Criswell JC, Parr MJ, Nolan JP. Emergency airway management inpatients with cervical spine injuries. Anaesthesia. 1994;49:900-903.

38. Talucci RC, Shaikh KA, Schwab CW. Rapid sequence inductionwith oral endotracheal intubation in the multiply injured patient.Am Surg. 1988;54:185-187.

39. Regional Emergency Medical Services Council of New York City,Inc. Basic emergency technician protocols January 2006: 421—Head�and�spine�injuries.�Available�at:�http://www.nycremsco.org/images/articlesserver/04-BLS%20Protocols%20%20January%201%202006.pdf.�Accessed�March�10,�2006.

40. Kihara S, Yaguchi Y, Taguchi N, et al. The StyletScope is a betterintubation tool than a conventional stylet during simulatedcervical spine immobilization. Can J Anaesth. 2005;52:105-110.

41. Grossman MD, Reilly PM, Gillett T, et al. National survey of theincidence of cervical spine injury and approach to cervical spineclearance in U.S. trauma centers. J Trauma. 1999;47:684-690.

42. Levitan RM. Myths and realities: the “difficult airway” andalternative airway devices in the emergency setting. Acad EmergMed. 2001;8:829-832.

43. Avidan MS, Harvey A, Chitkara N, et al. The intubating laryngealmask airway compared with direct laryngoscopy. Br J Anaesth.1999;83:615-617.

44. Martel M, Reardon RF, Cochrane J. Initial experience ofemergency physicians using the intubating laryngeal mask airway:a case series. Acad Emerg Med. 2001;8:815-822.

45. Brain AI, Verghese C, Addy EV, et al. The intubating laryngealmask. II: A preliminary clinical report of a new means ofintubating the trachea. Br J Anaesth. 1997;79:704-709.

46. Ferson DZ, Rosenblatt WH, Johansen MJ, et al. Use of theintubating LMA-Fastrach in 254 patients with difficult-to-manageairways. Anesthesiology. 2001;95:1175-1181.

47. Goldman AJ, Rosenblatt WH. The LMA CTrach in airwayresuscitation: six case reports. Anaesthesia. 2006;61:975-977.

48. Komatsu R, Nagata O, Kamata K, et al. Intubating laryngeal maskairway allows tracheal intubation when the cervical spine isimmobilized by a rigid collar. Br J Anaesth. 2004;93:655-659.

49. Liem EB, Bjoraker DG, Gravenstein D. New options for airwaymanagement: intubating fibreoptic stylets. Br J Anaesth. 2003;91:408-418.

50. Levitan RM. Design rationale and intended use of a short opticalstylet for routine fiberoptic augmentation of emergencylaryngoscopy. Am J Emerg Med. 2006;24:490-495.

51. Hastings RH, Kelley SD. Neurologic deterioration associated withairway management in a cervical spine-injured patient.Anesthesiology. 1993;78:580-583.

52. Piatt JH Jr. Detected and overlooked cervical spine injury incomatose victims of trauma: Report from the PennsylvaniaTrauma Outcomes Study. J Neurosurg Spine. 2005;19:210.

Manual In-Line Stabilization for Acute Airway Management Manoach & Paladino


Table 1. Studies of manual in-line stabilization and other immobilization techniques: early and supportive articles presented inthe order they appear in the text.

Reference Subjects Study Design Key Findings Comments

Podolsky et al, 198334 25 Volunteers Measured voluntary head movementwith mechanical immobilization

Combination of collar, tape,sandbags most effective

No airway maneuvers.No manual techniques.

Aprahamian et al,198428

Single fresh cadaver.Surgically createdC5–C6 disruption

Baseline radiograph in neutralposition compared to radiographduring airway maneuvers while“neck stabilized anteriorly withhand pressure”

Chin lift and jaw thrust: moresegmental movement thanDL-OTI.

Head tilt: minimal movementcomparable to placingnasal trumpet.

Collars ineffective

No MILS.Single cadaver.

Majernick et al,198610

16 Uninjured electivesurgery pts.

Phase 1: 8 pts neutral positionstraight versus curved blade.

Phase 2: 2 groups of 4 pts. Group1 Philadelphia collar, Group 2MILS. Each group 2 pts curvedblade, 2 pts straight blade.

Neutral radiographs compared toradiographs at vocal cordvisualization.

Phase 1: No difference inmovement straight vs.curved blades.

Phase 2: Philadelphia collarineffective. MILSsignificantly reduced AOextension and “movementthat occurred over thelordotic curve of the spinein general.”

First airway study tocompare MILS toanotherimmobilizationtechnique.

Immobilization groupssmall (4), divided 2straight and 2curved.

Movement in uninjuredspine may notpredict injuredsegment movement.

Bivins�et�al,�198812� 4�traumatic�arrestpts with unstablecervical spines.

Lateral radiographs: neutralposition, axial traction, and duringintubation with and without axialtraction. 15-kg caudal tractionapplied to shoulders forradiographs.

Traction with DL-OTIdecreased subluxation butincreased distraction by upto 14 mm.

MILS not evaluated.Caudal shouldertraction “may haveresulted in some ofthe abnormalities.”

No statistical analysis.

Hastings and Wood,199411

31 Uninjured electivesurgery pts class1 airways.

Angle finder: measured headextension at arytenoid view andbest view. All pts 2 consecutiveDLs. 14 pts DL with and withoutMILS. 10 pts DL with and withoutaxial traction. 7 pts 2 DLs toassess reliability of angle finder.

MILS reduced head extensionfor arytenoid and best viewby 6 and 10 degrees,respectively.

Traction nonsignificantlyincreased extensionangles.

Head extension maynot predictmovement of injuredspine.30

Two pts in MILS group,2 pts in tractiongroup excluded:views degraded bystabilization (seetext).

Donaldson et al,199313

5 Fresh cadavers,surgicallydestabilized C5–C6

Videofluoroscopy frame grabs takenin neutral before lesion andpostlesion at maximumangulation translation anddistraction.

“Crash”/“forced” DL-OTIwithout MILS: moresegmental movement than“direct” DL-OTI with MILS.Chin lift/jaw thrust: asmuch movement as DL-OTIwith MILS.

Nasal intubation lessmovement that DL-OTI.

No definition of“forced,” “crash”oral intubation. ? Ifdifferent than“direct” intubation.

Several imagestechnicallyinadequate;precluded statisticalanalysis.Videofluoroscopy issignificantinnovation.

Gerling�et�al,�200014 14 Fresh frozencadavers.Complete C5–C6instability created.

Crossover: collar vs MILS, Miller vsMacintosh vs McCoy blades. Alltechniques and blades used oneach cadaver. Videofluoroscopy.Segmental motion and view gradecompared.

MILS superior to collar forreducing AP displacementand for view grade.

Miller superior to Mac orMcCoy for APdisplacement.

No note of whetherforce during DLcontrolled.

No DL-OTI withoutstabilization.

AO, Atlanto-occipital; DL, direct laryngoscopy; DL-OTI, direct laryngoscopy and orotracheal intubation; pts, patients; MILS, manual in-line stabilization; AP, anterio-posterior.

Manoach & Paladino Manual In-Line Stabilization for Acute Airway Management

Volume 50, NO. 3 : September 2007 Annals of Emergency Medicine 239

volunteers. Using manual in-line stabilization to model thedifficult airway, Kihara et al40 compared direct laryngoscopy

Table 2. Studies that do not support manual in-line stabilization presented in the order they appear in the text.

Reference Subjects Study Design Key Findings Comments

Donaldson�et�al,�199729 6 Fresh cadavers. Type IIodontoid fx created.

Chin lift, jaw thrust, “oralintubation,” “gentleoral intubation,” nasalintubation donepre- and postinjurywith MILS.Videofluoroscopy.Emphasis on space forcord.

Jaw thrust causes greaterdecrease in space forcord than DL or nasalintubation.

Oral and nasal intubationcaused similardecrease in space forcord.

As with previous Donaldsonstudy, “oral intubation”and “gentle oralintubation” not clearlydefined.

Sawin�et�al,�19966� 10�Uninjured�electivesurgery patients withclass 1 or 2 airways.

Trauma DL techniquewithout stabilization:DL limited to viewneeded to pass tube.

Spinal movementassessed bycinefluoroscopy framegrabs at variousstages of DL-OTI.

Extension occurred atevery level and at allstages of DL-OTI.

Most cervical motion atAO and C1–2. Verylittle motion caudal toC2.

Lennarson studies thatfollow include Sawin asauthor and use sameimaging and DL-OTI stagemethodology.

Lennarson�et�al,�200023 16 Fresh cadavers. C4–5posterior and facetligaments cut.

Cinefluoroscopy framegrabs and DL-OTItechnique as perSawin et al.6

16 Cadavers axialtraction vs nostabilization.

11/16 also MILS vs nostabilization.

All techniques performedpre- and postinjury

“Neither traction norMILS significantlyreduced the motionproduced by DL-OTI atthe destabilizedsegment.”

“Little motion occurs atC4–5 during DL-OTI ineither intact orposteriorly injuredstates.”

Unclear why no MILS in 5/16 cadavers.

First truly comparativestudy of MILS, traction,and no stabilization inunstable injury model.

Lennarson�et�al,�200131 10 Fresh cadavers.Complete C4–5transection.

Each cadaver intubatedwithout stabilization,with MILS, and with7–10 lbs tractionadministered byGardner-Wells tongs.

DL-OTI andcinefluoroscopy as perSawin et al

Compared to unstabilizedDL-OTI:

DL-OTI with MILSsignificantly increasessubluxation (approx 1mm) Axial tractionincreases distraction(approx 5–9 mm)

Most relevant study ofMILS because ofcarefully controlled DL-OTI, validated fluoroscopytechnique, and relevantcomparison groups.

Brimacombe et al,200030

10 Fresh cadavers C3posteriorly destabilizedby ligament incisionand direct blow.

Cinefluoroscopyperformed pre- andpostinjury duringairway maneuvers withand without MILS andwith maximumextension and flexion.

Maximum angulation andsubluxation measured.

Subluxation “for all airwaymanagementtechniques was similarto maximum extensionand some were similarto maximum flexion,suggesting that MILS isgenerally ineffective inpreventing motion.”

MILS technique seemed toinclude an element ofmanual axial traction,which may limitrelevance.

Table 3. Laryngoscopic views with and without manualin-line stabilization in 157 patients (reproduced from Nolanand�Wilson24).

Method Grade 1 Grade 2 Grade 3

Optimal positioning 129 26 2MILS 75 48 34

Table 4. Mouth opening and laryngoscopic view in 50 patientswith optimal positioning, tape-collar-sandbags, and manualin-line�stabilization�(from�Heath25).

Method

MouthOpening,

mm Grade 1 Grade 2 Grade 3 Grade 4

Optimal positioning 53 46 4 0 0MILS 38 12 27 11 0Collar-tape-sandbags 19 2 16 25 7

Manoach & Paladino Manual In-Line Stabilization for Acute Airway Management

Volume 50, NO. 3 : September 2007 Annals of Emergency Medicine 241

• The available literature suggests that direct laryngoscopy and orotracheal intubation is unlikely to cause dangerous cervical spine movement and that manual in-line stabilization does not limit the movement that does occur.

• Manual in-line stabilization worsens laryngoscopic view

• Traction is not an acceptable alternative, because it is ineffective for stabilization and causes significant distraction.

• Approaches that should be investigated include intubating supraglottic airways and other imaging devices, including video laryngoscopes and optical stylets.

• Although a recent Cochrane review of spinal immobilization made no clinical recommendations because of the limited available data.

• Data supporting the rigid application of manual in-line stabilization are weak and contradictory.

AIRWAY/REVIEW ARTICLE

Manual In-Line Stabilization for Acute Airway Management ofSuspected Cervical Spine Injury: Historical

Review and Current Questions

Seth Manoach, MDLorenzo Paladino, MD

From the Department of Emergency Medicine, State University of New York-Downstate and KingsCounty Hospital Center, Brooklyn, NY.

Direct laryngoscopy with manual in-line stabilization is standard of care for acute trauma patients withsuspected cervical spine injury. Ethical and methodologic constraints preclude controlled trials ofmanual in-line stabilization, and recent work questions its effectiveness. We searched MEDLINE, IndexMedicus, Web of Knowledge, the Cochrane Database, and article reference lists. According to thissearch, we present an ancestral review tracing the origins of manual in-line stabilization and ananalysis of subsequent studies evaluating the risks and benefits of the procedure. All manual in-linestabilization data came from trials of uninjured patients, cadaveric models, and case series. Theprocedure was adopted because of reasonable inference from the benefits of stabilization duringgeneral care of spine-injured patients, weak empirical data, and expert opinion. More recent dataindicate that direct laryngoscopy and intubation are unlikely to cause clinically significant movementand that manual in-line stabilization may not immobilize injured segments. In addition, manual in-linestabilization degrades laryngoscopic view, which may cause hypoxia and worsen outcomes in traumaticbrain injury. Patients intubated in the emergency department with suspected cervical spine injury oftenhave traumatic brain injury, but the incidence of unstable cervical lesions in this group is low. Thelimited available evidence suggests that allowing some flexion or extension of the head is unlikely tocause secondary injury and may facilitate prompt intubation in difficult cases. Despite the presumedsafety and efficacy of direct laryngoscopy with manual in-line stabilization, alternative techniques thatdo not require direct visualization warrant investigation. Promising techniques include intubationthrough supraglottic airways, along with video laryngoscopes, optical stylets, and other imagingdevices. [Ann Emerg Med. 2007;50:236-245.]

0196-0644/$-see front matterCopyright © 2007 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2007.01.009

INTRODUCTION

Before the 1970s, emergency care providers did notconsistently immobilize the cervical spine, and the incidence ofsecondary injury was estimated to range from 10% to 25%.1

A review of 300 patients presenting to the Johns Hopkins andBaltimore City Hospitals between 1950 and 1972 noted that“180 were paralyzed and 120 were not.” No mention was madeof deterioration during transport, but 11 patients developeddeficits after reaching the hospital. Three of these patientsdeteriorated “while they were in the emergency room, and . . .seven others after neck immobilization was not provided.”2 Asemergency care systems developed in the 1960s and 1970s, thepractice of immobilization spread, and more patients presentedwith preserved neurologic function.1 These observations raisedconcerns that cervical movement during airway managementmay worsen spinal cord injury.3,4

During the 1980s and 1990s, direct laryngoscopy andorotracheal intubation with manual in-line stabilization becamestandard of care.5 The practice remains standard becausealternative techniques were reported to be more complex, to beless effective, or to have had problems that require furtherinvestigation.6-8 Like many established practices, spinalimmobilization has never been studied in controlled,randomized trials.9 It has been supported by less rigorousinvestigations, including studies in uninjured volunteers,10,11

newly dead patients with documented injuries,12 cadavericmodels,13,14 and case series.15-19 In addition, there is a 25-yearworldwide practice history of direct laryngoscopy andorotracheal intubation with manual in-line stabilization,20

and there are few, if any, credible reports of neurologicdeterioration.21

Despite this excellent safety record, questions have emergedabout the advisability of rigidly applying manual in-line


Ventilation

Management cardio-pulmonaire?

• Severely injured patients demonstrate marked reductions in

• expected vital capacity and inspiratory capacity

• and may experience relative hypoxemia and can exacerbate spinal cord ischemia after acute injury.

• Although a prospective controlled assessment of the effects of hypotension on acute human SCI has not been performed,

• Laboratory evidence suggests that

• Hypotension contributes to secondary injury after acute SCI by further reducing spinal cord blood flow and perfusion

Management cardio-pulmonaire?

Perfusion

Thérapeutique osmotique : Quand ?

• Mydriase aréactive, anisocorie et/ou aggravation neurologique non attribuable à une cause systémique.

Échographie mesure de la gaine du nerf optique à 3 mm en arrière de la rétine.

>6 mm administration de th osmotique.

Thérapeutique osmotique : Quoi et combien ?

• A dose équi-osmotique (environ 250 mosmoles), le mannitol et le sérum salé hypertonique (SSH) ont une efficacité comparable.

• Effets secondaires qu’il est nécessaire de considérer avant leur utilisation :

• le Mannitol induit une diurèse osmotique et nécessite une compensation volémique lors de son utilisation

• et le SSH expose à l’hypernatrémie et l’hyperchlorémie.


• Mannitol :

• 1g/kg,

• solution 20% = 2ml/kg

• NaCl :

• 2 ml/kg de SSH à 7,5 % chez l'adulte

• (20%, 0.1ml/kg)

• 3-5ml/kg de NaCL 3% en pédiatrie


Prise en charge pré-hospitalière du traumatisé crânien et ... · Plan • Approche en ......

Documents

Transcript of Prise en charge pré-hospitalière du traumatisé crânien et ... · Plan • Approche en ......