Anaesthesia For Trauma Patient

1. Anaesthesia For Trauma Patient Wan Ahmad Asyraf bin Wan Md Adnan 2nd May 2013 Moderator: Dr Lee PuiKuan

2. Contents • Case Example • Introduction • Problems Associated with Trauma • Initial Assessment • Primary and Secondary Survey • Anaesthetic Consideration & Management • Take Home Messages • References

3. Case Example • 17 years old boy • Alleged MVA (unknown mechanism of injury) • Was brought to A&E by ambulance • Upon arrival to A&E: • Vital signs: BP 130/78, HR 90, SpO2 93%, dscan 7.2 • Airway: patient was intubated for airway protection (poor conscious level), done with MILS • Given IV fentanyl, IV midzola and IV suxamethonium • Breathing: Equal chest movement, crepitations on right lung • Circulation: no external haemorrhage, 1st FAST negative • Pupils 3mm bilaterall equal, response to pain stimulus

4. Case Example • Further examinations: • Head: haematoma over occipital region (5cm x 6cm) with no active bleeding, no ENT bleeding • Chest: no external injuries, equal chest movement, crepitations on right side • Abdomen: soft, not distended • rpt FAST -> presence of minimal free fluid over rectovesical pouch, haematuria on CBD • Pelvis: no external wound • Spine: no obvious deformity

5. Case Example • Investigations • CXR: right lung contusion, no pneumothorax • Pelvic x-ray: no fracture • CT brain • Mix of EDH and SD at left temporo-parietal regions (thickness 12mm) • Right basal ganglia haemorrhage • CT cervical • No obvious fracture seen • CT abdomen • Traumatic liver injuries (at least Grade IV) with haemoperitoneum and active bleeders • Bibasal lung contusions with haemothorax

6. Case Example • Proceed with operation • Craniectomy + evacuation of blood clot • Exploratory laparotomy + liver packing • Classified as ASA IVE • Monitoring • NIBP + IABP • ECG • EtCO2 • IV access: triple lumen at right femoral, 14G x 2

7. Case Example • Intraoperatively: • Stable haemodynamically, started on noradrenaline infusion to achieve MAP of 80 • Difficulties to maintain oxygenation • Occasional desaturation to 86-90% • Higher settings requirement (PIP 22, PEEP 14, FiO2 100%) • SpO2 maintained mostly around 95% • EBL: 2L • Fluids: • 1 cycle of DIVC, 3 pints whole blood, 2 pints 0.9% saline, 2 pints venofundin • Postoperatively admitted to ICU for cerebral protection

8. Case Example • Patient was ventilated on bilevel mode initially in ICU • Able to wean down to SIMV after 1 day • Proceed with removal of pacing after 48 hours • Uneventful • At D4 of admission, developed signs of sepsis (unknown source) • Started on antibiotics, changed a few times after a few days • Recovered well afterward in terms of septic parameter • Extubated on D8 of admission, transferred out to general ward 2 days later • Patient stay for another 5 days in general ward before discharged home

9. Introduction • Trauma is the leading cause of death in young people worldwide, including Malaysia • Mainly involved in motor vehicle accidents

10. Introduction • Trimodal Death Distribution (50%, 30%, 20%) • 1st phase: major severe injuries • 2nd phase: treatable life threatening injuries • 3rd phase: infection, multiple organ failure • The concept of ‘golden hour’ • The importance of resuscitation from the arrival of patient to health care provider • Hence, the development of ATLS: framework for immediate management for trauma patient

11. Problems Associated with Trauma Patient • Multiple injuries (life threatening) • Compromised airway, breathing and circulation needing urgent/ongoing resuscitation • Limited time for preparation (dealing with life threatening situation) • Inadequate history or trauma circumstances in comatose / restless patient

12. Problems Associated with Trauma Patient • Risk of aspiration • Inadequate fasting time • Pregnancy • Pain • Potential difficult airway • Co-existing disease • Coagulopathy • Massive blood loss • On anticoagulant therapy • Dilutionalcoagulopathy

13. Initial Assessment

14. Initial Assessment Primary Survey • Airway with cervical spine control • Breathing and ventilation • Circulation and haemorrhage control • Disability (neurological function) • Exposure

15. Initial Assessment: Primary Survey Airway with C-spine control • Aim: patent airway to maintain adequate oxygenation • Beware of airway obstruction features: • Respiratory distress, stridor, cyanosis • Oxygen therapy • Assess need for intubation • Upper airway obstruction • Severe lung contusion, with ventilatory compromise • Poor GCS • Airway protection (e.g. Bleeding intraorally) • Impending airway obstruction (e.g. Inhalational injury) • Manual in-line stabilisation (C-spine protection)

16. Initial Assessment: Primary Survey Airway with C-spine control • Establish responsiveness • Airway assessment: look, listen and feel • Airway opening and maintenance • Jaw thrust vs head tilt, chin lift • Suction airway adjunct (OPA, NPA) • Definitive: ETT, surgical airway • Maintenance of ventilation • Common problems encountered: • Tongue obstruction (fall back) • Secretion • Laryngospasm

17. Initial Assessment: Primary Survey Airway with C-spine control • Cervical spine assessment • 2 criteria available • National Emergency X-Radiography Utilisation Study (NEXUS) Low Risk Criteria • Canadian C-spine • CCS is superior than NEXUS criteria in terms of sensitivity and specificity * • Difficult in unconscious patient • Need of imaging: cervical x-ray, CT cervical, MRI • Who to clear? • Radiologist • Anaesthesiologist/Intensivist • Surgeon (Neurosurgery / Orthopaedic) *IG Stiell et al; The Canadian C-Spine Rule versus the NEXUS Low Risk Criteria in Patients with Trauma. N Engl J Med, 2003:349:2510-8

18. Initial Assessment: Primary Survey C-spine Assessment • NEXUS Low Risk Criteria • Canadian C-spine Rule

19. Initial Assessment: Primary Survey C-spine Assessment • High Risk Factor • Age >65 • Dangerous mechanism • Paraesthesias in Extremities NO • Low Risk Factor • (for safe assessment of ROM) • Simple rearend MVA • Sitting position in A&E • Ambulatory at any time • Delayed onset of neck pain • Absence of midline c-spine tenderness YES • ROM • Able to rotate 45 degree left and right

20. Initial Assessment: Primary Survey Breathing and Ventilation • Assess breathing efforts • Approach: look, listen, feel • Respiratory rate, breathing pattern, use of accessory muscles, flail chest • Chest spring, chest expansion • Reduced/absent breath sound

21. Initial Assessment: Primary Survey Breathing and Ventilation • Life threatening injuries: • Tension pneumothorax • Reduced chest movement, reduced breath sound • With respiratory distress, tachycardia, hypotension, tracheal deviation, distended neck veins • Mx: needle thoracocentesis, followed by chest tube • Open chest injury • Occlusive dressing, sealed on 3 sides • Massive haemothorax • Reduced chest movement, dull percussion note • With hypoxaemia and hypovolaemia • Mx: fluid resuscitation + chest drain

22. Initial Assessment: Primary Survey Circulation & Haemorrhage Control • Watch out for signs of shock • Cold peripheries, delayed capillary return, pallor, low pulse volume, tachycardia, hypotension • Secure external haemorrhage • Large bore IV cannulation + blood investigations • Rule out cardiac tamponade • Beck’s triad: hypotension, distended neck vein, muffled heart sound • 1st priority  stop bleeding & replace intravascular volume • Shock in trauma patient is hypovolaemic in nature, until proven otherwise

23. Initial Assessment: Primary Survey Circulation & Haemorrhage Control • Classification of hypovolaemic shock

24. Initial Assessment: Primary Survey Disability • Pupils for size and reaction to light • Rapid neurological assessment • Awake • Verbal response • Painful response • Unconscious

25. Initial Assessment: Primary Survey Exposure • Undress patient for through examination of other injuries • Prevent hypothermia • Increased oxygen requirement • Myocardial depression • Altered drug metabolism

26. Goals for resuscitation for trauma patient before haemorrhage has been controlled

27. Initial Assessment Secondary Survey • Detailed examination (head-to-toe) after primary survey is completed and vital signs are relatively stable • Complete anatomical evaluation • Head • Chest • Abdomen • Pelvis • Spine • Extremities • History: AMPLE

28. Initial Assessment: Secondary Survey Head Injury • Assess conscious level according to GCS • Scalp: lacerations, haematoma, depressed skull fractures • Signs of basal skull fracture • Racoon eye, bruising over mastoid process, otorrhoea & rhinorrhoea • Presence of maxillofacial injury • Imaging: CT scan

29. Initial Assessment: Secondary Survey Chest Injury • Rule out lethal conditions • Pulmonary contusion • Hypoxaemia (reduced PaO2/FiO2 ratio) • CXR: patchy infiltrates • Cardiac contusion • Cardiac arrhythmia, ST changes on ECG • Tracheobronchial disruption • Hoarseness, SC emphysema, palpable fracture crepitus • Diaphragmatic rupture • Diminished breath sounds, chest and abdominal pain, respiratory distress • Eosophageal rupture • Aortic rupture

30. Initial Assessment: Secondary Survey Abdominal Injury • Examine for laceration, bruising, distension, tenderness • Imaging modalities • Ultrasound, CT scan

31. Initial Assessment: Secondary Survey Pelvic Fracture • Difficult to diagnose • Suspicious in patient who is pale and hypotensive with no obvious source of bleeding • Imaging modalities: pelvic x-ray

32. Initial Assessment: Secondary Survey Spinal Injury • Assume cervical injury until excluded • Quick neurological assessment of upper and lower limbs • Imaging: cervical x-rays • Log roll: examination of whole spinal length

33. Initial Assessment: Secondary Survey Extremities • Examine all limbs for any fractures or any damages towards nerve, tendon, blood vessel • Exclude compartment syndrome in closed fractures

34. Anaesthetic Considerations • Thorough preoperative evaluation and resuscitations • Blood samples including GXM • Type of anaesthesia • General anaesthesia • Regional anaesthesia • Peripheral nerve block

35. Anaesthetic Considerations General Anaesthesia • Identify potential airway problems • Rapid sequence induction with cricoid pressure • Minimise risk of aspiration • If anticipate difficult airway, may consider other modalities • Awake fibre optic • Inhalational induction • Surgical airway • MILS for cervical spine protection • Preoxygenation with 100% over 3-5 minutes • Choice of IV induction agent • Thiopentoneand propofol (head injury patient) • Ketamine (in hypotensive patient) • Etomidate

36. Anaesthetic Considerations General Anaesthesia • Muscle relaxant • Use suxamethonium unless contraindicated • Alternative: rocuronium • Maintenance • Avoid nitrous oxide in hypotension, hypovolaemic, hypoxia • Fluid resuscitation • Secure large bore IV line prior to starting operation • Blood products readily available when needed • Volume status must be continuously assessed throughout and after operation

37. Anaesthetic Considerations General Anaesthesia • Monitoring • ECG • NIBP or IABP in critical patient • SpO2 • End tidal CO2 • Temperature • Urine output • CVP • Consider intra-op investigation • E.g. ABG may help with resuscitation process

38. Anaesthetic Considerations General Anaesthesia • Reversal in usual manner at the end of surgery • Decision for extubation depends on the condition of patient • Consider ICU admission post operative • Severe head injury for cerebral protection • Severe chest injury • Polytrauma • Unstable haemodynamic status • Massive blood loss

39. Take Home Messages • Systematic patient assessment • Primary survey • Secondary survey • Rapid sequence intubation • Reduce risk of aspiration • Continuous haemodynamic assessment of patient intraoperatively

40. The End

41. References • C Y Lee; Manual of Anaesthesia. McGraw-Hill Education (2008). • G E Morgan, M S Mikhail, M J Murray; Clinical Anaesthesiology (4th Edition). Lange Medical Books (2006) • K G Allman, I H Wilson; Oxford Handbook of Anaesthesia (3rd Edition). Oxford Medical Publications (2012)