Anesthesia for Trauma Christopher DeSantis, MD Anesthesiology CA-3

1. Anesthesia for TraumaChristopher DeSantis, MDAnesthesiology CA-3 Boston University Medical Center October 12, 2006 Faculty Advisor: Dr. Lopes

2. Anesthesia for Trauma • Trauma is the leading cause of death between the ages of 1 and 45 • In the US preventable deaths decreased from 13% to 7% over the past decades because of more efficient systems of trauma care • Anesthesia Care • Airway and Resuscitation in Emergency Department • Operating Room Care • Management in Intensive Care Unit

3. Prioritizing Trauma Care • Do you know your ABC’s ?

4. Prioritizing Trauma Care • ABCDE • Airway • Vocal Response, Auscultation • Chin Lift, Bag-Valve-Mask, 100% O2, Intubation, Cricothyriodotomy, Tracheostomy • Breathing • Pulse Oximetry, Arterial Blood Gas, CXR • Mechanical Ventilation, Tube Thoracostomy

5. Prioritizing Trauma Care • Circulation • Vital Signs, Capillary Refill, Response to Fluid Bolus, CBC, Coagulation Studies, FAST, X-Ray • Adequate IV Access, Fluid Bolus, Pressure to Open Wounds, Thoracotomy, Transfusion, Surgery • Neurologic Disability • GCS, Motor/Sensory Exam, Head, Neck, and Spine CT, Cervical Spine Films • Support Oxygenation/Perfusion, ICP Monitoring

6. Prioritizing Trauma Care • Exposure and Secondary Survey • Laboratory Studies, ECG, Plain Films, CT scan, Detailed History and Physical Exam • Removal of all Cloths, Detailed Review of all Laboratory and Radiographic Findings

7. Airway/Breathing • Verification of adequate airway and acceptable respiratory mechanics is of primary importance • Hypoxia is the most immediate threat to life • Inability to oxygenate a patient will lead to permanent brain injury and death within 5 to 10 Minutes

8. Airway obstruction • Direct injury • Face, Mandible, or Neck • Hemorrhage • Pharynx, Sinuses, and Upper airway • Diminished Consciousness • Traumatic Brain injury, Intoxication, Analgesic medications • Aspiration • Gastric contents, Foreign body • Misapplication of Airway/Endotracheal Tube • Esophageal Intubation

9. Inadequate Ventilation • Diminished Respiratory Drive • Traumatic Brain injury, Shock, Intoxication, Hypothermia, Over Sedation • Direct Injury • Cervical Spine, Chest Wall, Pneumo/Hemothorax, Trachea, Bronchi, Pulmonary Contusion • Aspiration • Gastric contents, Foreign body • Bronchospasm • Smoke, Toxic Gas Inhalation

10. Indications for Endotracheal Intubation • Cardiac or Respiratory Arrest • Respiratory Insufficiency • Airway Protection • Deep Sedation or Analgesia • General Anesthesia • Transient Hyperventilation • Space Occupying Intracranial Lesion/Increased ICP • Delivery of 100% O2 • Carbon Monoxide Poisoning • Facilitation of Diagnostic Workup • Uncooperative or Intoxicated Patient

11. Prophylaxis against Aspiration • Trauma patients are always considered to have full stomach • Ingestion of food or liquids before injury • Swallowed blood from oral or nasal injury • Delayed gastric emptying • Administration of liquid contrast medium • Reasonable to administer nonparticulate antacid prior to induction • Cricoid pressure/Sellick Maneuver should be applied continuously during airway management • Rapid Sequence Induction • Avoidance of ventilation between administration of medication and intubation

12. Cervical Spine Injury • Trauma Patients • No Radiological Studies • Alert, Awake, and Oriented • No Neurological Deficits • No Distracting Pain • MRI Cervical Spine • Neck Pain • Cervical Tenderness to Palpation

13. Cervical Spine Injury • All Other Trauma Patients • Lateral radiograph of cervical spine • Anteropostererior spinous process C2-T1 • Open mouth odontoid view • Axial CT with reconstruction • Regions of questionable injury • Inadequate visualization

14. Protection of the Cervical Spine • All blunt trauma victims should be assumed to have an unstable cervical spine until proven otherwise • Direct laryngoscopy causes cervical motion and the potential to exacerbate spinal cord injury • An “uncleared” cervical spine mandates In-line Stabilization (Not Traction) • The front of the cervical collar may be removed for greater mouth opening and jaw displacement

15. Protection of the Cervical Spine • Emergency Awake Fiberoptic Intubation • Requires less manipulation of the neck • Generally very difficult • Airway Secretions • Hemorrhage • Rapid Desaturation • Lack of Patient cooperation

16. Induction of Anesthesia • Propofol/Thiopental • Vasodilator, Negative Inotropic effect • May Potentate hypotension/Cardiac Arrest • Etomidate • Increased cardiovascular stability • Ketamine • Direct myocardial depressant • Catecholamine release • Hypertension/Tachycardia • Midazolam • Reduced Awareness • Hypotension • Scopolamine (Tertiary Amine) • Inhibits memory formation • Muscle relaxants alone • Recall of Intubation/Recall of Emergency procedures

17. Neuromuscular Blocking Drugs • Succinylcholine • Fastest onset <1 min • Shortest Duration5-10 min • Potassium increase 0.5-1.0mEq/L • Potassium increase >5mEq/L • After 24 hours • Safe in acute airway management • Burn Victims • Muscle Pathology • Direct Trauma • Denervation • Immobilization • Increase intraocular pressure • Caution in patients with ocular trauma • Increase ICP • Controversial in head trauma

19. Circulation • Hemorrhage is the next most pressing concern • Ongoing blood loss will be fatal in minutes to hours • Shock is presumed to be a consequence of hemorrhage until proven otherwise

20. Symptoms of Shock • What are the symptoms of shock ?

21. Symptoms of Shock • Pallor • Diaphoresis • Agitation or Obtundation • Hypotension • Tachycardia • Prolonged Capillary Refill • Diminished Urine Output • Narrow Pulse Pressure

22. Early Resuscitation • Maintain SBP at 80-100 mm Hg • Maintain Hematicrit at 25-30% • Maintain PT/PTT in normal range • Maintain Platelet count > 50,000 • Maintain Normal serum ionized calcium • Maintain core temperature > 35°C • Prevent increase in serum lactate • Prevent Acidosis

23. Intravenous Access • Order of Desirability • Large-bore (16g or greater) antecubital vein • Other large-bore peripheral veins • Subclavian vein • Femoral vein • Internal jugular vein (Requires removal of cervical collar and neck manipulation) • Intraosseous (Tibia or distal end of femur)

24. Fluid Infusion System • Active fluid administration up to 1500 ml/min • Compatible with crystalloid, colloid, RBC, plasma, washed/salvaged blood (Not platelets) • Reservoir allows for mixing of products • Controlled temperature (38°-40°C) • Able to pump through multiple IV lines • Fail safe detection system to prevent infusion of air • Accurate recording of volume administered • Portable to travel with patients between units

25. Risks of Aggressive Volume Replacement • Increased blood pressure • Decreased blood viscosity • Decreased hematocrit • Decreased Clotting factors • Greater transfusion requirements • Electrolyte imbalance • Direct immune suppression • Premature reperfusion

26. Glasgow Coma Score • What is the Glasgow Coma Score ?

27. Glasgow Coma Score • Eye Opening Response Motor Response • 4=Spontaneous 6=Follows Commands • 3=To Speech 5=Localizes to Pain • 2=To Pain 4=Withdraws from Pain • 1=None 3=Abnormal Flexion (Decorticate Posturing) • Verbal Response 2=Abnormal Extension • 5=Oriented to Name (Decerebrate Posturing) • 4=Confused 1-None • 3=Inappropriate Speech • 2=Incomprehensible Sounds • 1=None

28. Traumatic Brain Injury • Anesthetic Management • Avoidance of Hypoxemia • Intubation • Airway protection • Controlled Hyperventilation • Uncooperative/Combative Patient • GCS < 8 • Control Hemodynamics • Avoid Hypotension • Fluid Administration • Vasopressors • Arterial Line

29. Traumatic Brain Injury • Management of Cerebral Circulation • Hyperventilation • PaCO2 at 35 mmHg • PaCO2 at 30 mmHg for episodes of elevated ICP • Mannitol • 0.5-1g/kg • Barbiturate

30. Traumatic Brain Injury • Temperature • Avoid Severe Hypothermia • Do not warm aggressively • Hyperthermia increases CMRO2 • Position Therapy • Elevation of Patients Head • Facilitate venous drainage • Lower ICP • Improved Ventilation/Perfusion

31. The End