Airway management of patients with life threatening haemorrhage: principles of safe and effective care
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Airway care of the patient with life threatening haemorrhage presents many challenges during damage control resuscitation. The essential requirements are to maintain oxygenation at all stages of care and when necessary deliver general anaesthesia to facilitate invasive haemorrhage control procedures. In the remote, pre-hospital setting, providers must be able to assess the airway and intervene with a range of strategies to prevent hypoxaemia. These interventions may vary from basic airway opening manoeuvres to advanced techniques such as drug-assisted rapid sequence intubation. The initial delivery of these skills in remote settings will be the responsibility of whichever medical provider is present, and so their training, equipment and decision-making skills must reflect the challenges they will face. Rapid sequence intubation skills may not be widely available in remote environments and so providers must be equipped with alternative airway management strategies including cricothyrotomy and use of extraglottic airway devices. When invasive haemorrhage control procedures are required for patients with life threatening haemorrhage, rapid sequence intubation will need to be performed. This procedure carries significant risk in the presence of haemorrhagic shock. Providers must be aware of the hypotensive effects of induction agents and the adverse impact of positive pressure ventilation upon cardiac output in the presence of life threatening haemorrhage. The risks of intubation should be minimised with appropriate blood production administration and ventilation techniques as part of a coordinated damage control resuscitation strategy.