How should trauma patients be hyperoxygenated (supplemental oxygen therapy)?

From the Guidelines

Trauma patients should be hyperoxygenated with supplemental oxygen to maintain oxygen saturation (SpO2) above 94%, or above 88-92% in patients with chronic obstructive pulmonary disease, as recommended by the most recent guidelines 1. The initial oxygen therapy should be delivered via a non-rebreather mask at 15 liters per minute for severely injured patients, which provides approximately 85-90% inspired oxygen concentration. For less severe cases, nasal cannula at 2-6 liters per minute may be sufficient, as suggested by the BTS guideline for oxygen use in adults in healthcare and emergency settings 1. If the patient shows signs of respiratory failure despite these measures, escalation to high-flow nasal cannula (up to 60 L/min) or non-invasive positive pressure ventilation should be considered. For patients requiring intubation, pre-oxygenation with 100% oxygen for 3-5 minutes is recommended, followed by mechanical ventilation with an initial FiO2 of 100%, which can be titrated down based on arterial blood gas results, as stated in the european guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. Hyperoxygenation is crucial in trauma patients because tissue hypoxia worsens secondary injury, particularly in traumatic brain injury where maintaining cerebral oxygenation is vital. However, prolonged exposure to high oxygen concentrations (beyond 24-48 hours) should be avoided due to potential oxygen toxicity, which can cause alveolar damage and worsen lung injury, as highlighted by the BTS guideline for oxygen use in adults in healthcare and emergency settings 1. Some key points to consider when hyperoxygenating trauma patients include:

• Maintaining a target oxygen saturation range of 94-98% for most patients, or 88-92% for those with chronic obstructive pulmonary disease, as recommended by the BTS guideline for oxygen use in adults in healthcare and emergency settings 1.
• Avoiding excessive oxygen therapy, which can lead to hyperoxia and increased mortality, as suggested by the european guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.
• Continuously reassessing and weaning oxygen therapy as the patient stabilizes to prevent complications while ensuring adequate tissue oxygenation, as stated in the BTS guideline for oxygen use in adults in healthcare and emergency settings 1. It is essential to note that the management of trauma patients requires a multidisciplinary approach, and oxygen therapy should be tailored to the individual patient's needs, taking into account their underlying medical conditions, injury severity, and response to treatment, as recommended by the european guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.

From the Research

Hyperoxygenation in Trauma Patients

• The administration of supplemental oxygen to trauma patients is a common practice, but the evidence supporting its use is limited 2, 3, 4.
• A systematic review of the literature found that supplemental oxygen should be titrated to achieve an oxygen saturation (SpO2) of greater than 92% 2.
• However, another study found that the administration of supplemental oxygen was associated with a higher incidence of in-hospital mortality and acute respiratory distress syndrome (ARDS) in trauma patients, particularly those with an oxygen saturation greater than 97% 5.
• The initial use of supplementary oxygen for trauma patients is not well supported by evidence, and more research is needed to determine the optimal oxygenation strategy 4.

Oxygenation Targets

• The American Association for Respiratory Care (AARC) recommends aiming for an SpO2 range of 94-98% for most hospitalized patients, and 88-92% for those with chronic obstructive pulmonary disease (COPD) 6.
• However, the optimal oxygenation target for trauma patients is not well established, and more research is needed to determine the best approach 2, 5.

Administration of Supplemental Oxygen

• Supplemental oxygen can be administered via a variety of devices, including nasal cannulas, face masks, and ventilators 6.
• High-flow oxygen therapy may be beneficial in certain situations, such as avoiding escalation to noninvasive ventilation or re-intubation 6.
• Humidification of supplemental oxygen may be considered when flows greater than 4 L/min are used 6.

Clinical Practice Guidelines

• The AARC recommends following evidence-based practices to provide maximum benefit and avoid harm when administering supplemental oxygen to hospitalized adults 6.
• Clinicians should consider the individual patient's needs and circumstances when determining the optimal oxygenation strategy 2, 6.