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Blood transfusion with unmatched blood
0%
0/28
Focused Assessment with Sonography for Trauma (FAST) scan
29%
8/28
Orotracheal intubation
39%
11/28
Type and screen for matched blood transfusion
4%
1/28
Cricothyroidotomy
25%
7/28
Select Answer to see Preferred Response
The first priority in an unstable trauma patient is securing the airway. Naso- or oropharyngeal intubation is contraindicated in an individual who has undergone facial trauma resulting in significant blood in the oropharynx, who should be managed with a cricothyroidotomy. In practice, a well-run trauma response team may be accomplishing airway security, intravenous access, FAST scan, and blood product resuscitation simultaneously. However, it is important to recall that the hierarchy of trauma response indicates 1) Airway, 2) Breathing, and 3) Circulation. If trauma to the face precludes an oral airway, a cricothyroidotomy is the appropriate approach. Sagarin et al. determined the success rates of endotracheal intubation performed in emergency departments by emergency medicine residents in the US and Canada from 31 university-affiliated EDs. Emergency medicine residents performed 77% (5768/7498; 95% confidence interval [CI] 76% to 78%) of all initial intubation attempts in the US and Canada. The overall rate of cricothyroidotomy for all emergency resident intubations was 0.9% (50/5,757; 95% CI 0.6% to 1.1%). Salvino et al. reviewed 30 emergency cricothyroidotomies among 8320 admissions over a 36-month period at a level I trauma center and concluded that emergency cricothyroidotomy is a safe and rapid means of obtaining an airway when endotracheal intubation fails or is contraindicated. They noted that no major complications were identified. Minor complications included minimal subglottic stenosis (2), local wound infection (1), and nonthreatening hemorrhage (1). Fifteen patients were long-term survivors. Video V describes and identifies the surface markings and structures to be noted when performing a surgical cricothyroidotomy. Incorrect Answers: Answers 1 & 4: Blood transfusion should be initiated in a patient who is frankly bleeding and hypotensive, however this does not take priority over securing the airway. Unmatched, Type 0 negative blood is usually given in an emergent situation to a patient whose blood type is unknown. Answer 2: The FAST scan looking for intraabdominal trauma occurs after the primary survey. Answer 3: As discussed above, this patient requires a cricothyroidotomy as opposed to an oral airway.
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