21: Optimizing Traumatic Ventilations

Prolonged Field Care is back with a new episode on a long awaited topic,  traumatic ventilation.  We were finally able to corner a real, live  anesthesiologist who was actually more than happy to sit down and talk  about ventilation after his years of experience working at the heads of  thousands of patients.  This episode starts right off with a difficult  scenario discussion that includes a hypovolemic patient with a GSW to  the pelvis, RR 35  As they work to get the patient stabilized, Dr. Kopp recommends an end  tidal CO2 Capnograph as the single best patient monitor for this  situation.  A SAVE2 vent is discussed along with the ARDSnet recommendations for a  lung protective vent strategy including the preferred tidal volume of  6-8ml/kg of ideal bodyweight based on patient height.  This is to reduce  barotrauma and over-ventilation that can lead to other problems.  This  begins with attempting to match the patients physiologic respiratory  rate to prevent acidosis by giving too few breaths.  The beginning Positive End Expiration Pressure (PEEP) recommendation  should start somewhere around 5 to keep alveoli open and recruited,  prior to increasing oxygen levels if available.  PIP or Peak Inspiratory Pressure or the maximum pressure of each breath  which has a default setting of 30 corresponding with the ARDSnet  protocol.  For an uninjured patient in the Operating Room, Dr. Kopp  would start at 20-22 and then titrate from there.  While we are working on an Airway Clinical Practice Guideline with the  Joint Trauma System and Army Institute of Surgical Research, this will  go along with our earlier posted PFC WG Airway recommendations (April,  14) until we can get a consensus on the CPG and get it published.   

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