Ain’t as good

1. Ain’t as good

2. Pet Peeves A pet peeve is a minor annoyance that an individual identifies as particularly annoying to themselves, to a greater degree than others may find it.

3. Attempting Ventilation Before Giving Succinylcholine • Decide before-hand if you can intubate • If you decide you will be able to intubate, don’t waste time attempting to ventilate • Just give the succinylcholine • Even if you can’t intubate, the patient will be easier to ventilate with succinylcholine than without it

4. Reflex Non-Thinking Inductions • Particularly in frail/elderly or trauma patients • Fent/hydromorphone/Prop/Succ/tube/2% Sevoflurane • Phenylephrine/Ephedrine • The three most common causes of hypotension • Too much anesthesia • Too much anesthesia • Too much anesthesia

5. Waiting For Return of Twitch Before Giving Vecuronium • AKA waiting for the patient to cough/move before giving vecuronium • We do this to avoid giving vecuronium to the rare, rare, exceedingly rare, patient with pseudocholinesterace deficiency • In whom the vecuronium will be terminated before the succinylcholine is terminated anyway • We should know when not to extubate a patient whether weak from succinylcholine or vecuronium

6. Papers and other garbage on the floor • Un-useful cord strewn under my feet • Un-useful pumps and other equipment hung on IV poles. • Tangled monitor cords

7. Basics (Practical Aspects) of Trauma AnesthesiaAugust 20, 2014D H Lambert No need to take notes. This lecture is published at http://dann2007.debunk-it.org

8. Lambert’s Trauma Blog http://trauma01.wordpress.com

9. Trauma Anesthesia • Things have changed (for the better) • This is a practical lecture on how to take care of trauma victims • It is not intended to help you answer board questions • My opinions are personal. Please do not share them, especially with other attendings

11. ARDS “Traumatic Wet Lung” “Congestive Atelectasis” “Da Nang Lung” • The result of way too much crystalloid

12. Damage Control Surgery • After the control of bleeding, we used to operate for hours and hours • Everyone (except some surgeons) hated doing trauma • We now control thebleeding, prevent contamination of the abdomen, pack and leave the abdomen open, and go to the ICU where we resuscitate with blood products and warm the patient • Goal is OR time less than 2 hours

13. I CHECK LISTS

17. Failure to do the Check List Everyone died. Pilot, co-pilot, flight attendant, 4 passengers.

18. Getting Organized In Chaos • Use a pre-trauma check list

20. Getting Organized In Chaos • Use an intraop-trauma check list

21. Additionally: • OGT or NGT Temperature probe

22. Whoa! Look at all of those wires! This patient is not going to be extubated. Get rid of the twitch monitor and two wires. If we are using the Belmont, get rid of the fluid warmer and another wire. Start simplifying this mess as soon as possible.

23. 2008 Trauma Care Overview • Trauma care overview

24. Civilians Learn from Soldiers War injuries are usually much worse than what we see in our ORs. The soldiers who care for war victims are researchers working in a laboratory. Their notebooks (how they do it), are our guidance.

25. The Military Approach to Trauma Military Approach to Trauma

26. Usually, We See, Good Pumps With a Leak in the Plumbing • Our job is to provide the pump with fluid while the leak is repaired • If you “catch up” and the pump has enough blood to pump, then the ABP should stabilize • If it does not then the patient is still bleeding • The surgeon may not be able to see it, but the patient is bleeding from somewhere

27. Keeping the Pump Full • Just one really big antecubital line • Don’t lose it transferring the patient to the OR table • The Rapid Infusion Catheter • The RIC (Rapid Infusion Catheter)

28. The RIC

29. The Enemy of GOOD • Is BETTER • If it ain’t broke, don’t fix it • If it ain’t broke, fix it until it is • A RIC catheter is nice, but I would rather have an 18 that is running poorly than a RIC that is not running at all

30. Factors Limiting Flow Through Tubes • Diameter (radius) of the tube(s) • Length of the tube(s) • Viscosity of the fluid being pumped • Driving pressure (Belmont > Level 1)

32. Keeping the Pump Full • The Level 1

33. Keeping the Pump Full • The Belmont Rapid Infuser (this hyperlink file requires Adobe Flash Player. Google Chrome has it). • Belmont Rapid Infuser • http://spinalist.debunk-it.org/FMS%20Instructional%20Video_01_1.mp4 • Some tips on the Belmont • Belmont Tips

34. Avoiding the “LETHAL TRIAD” • Hypothermia • Coagulopathy • Acidosis • Three goals: • The Lethal Triad • ACoTS (Acute Coagulopathy of Trauma Shock) • ACoTS

35. Massive Transfusion Protocol(MTP) • When the ER calls for blood, four units of PRBs are issued (NO FFP is sent). • This is not the MTP and it causes confusion. • Activate the MTP if the patient has active bleeding and hypotension. • BMC MTP • Give FFP first to maintain clotting factor levels and to treat ACoTS.

36. Avoiding the Lethal Triad Hypothermia  Belmont heats fluids  Temperature in room to 85-90 degrees  Active warming devices (Bair Hugger) Coagulopathy  Limit crystalloid  Give FFP, Plts, RBCs (to keep HGB >/= 7-10) Acidosis Iatrogenic acidosis Hyperchloremic Acidosis

38. Acidosis and ABG Interpretation • Simplify ABG analysis in trauma • ABG interpretation • Treat the acidosis • It is part of the lethal triad • It is contributing to the coagulopathy • Estimating the amps of NaHCO3 to give • Each amp of NaHCO3 contains 50 Meq • Amps = [0.3 X BE X Kg] /50

39. TBI (traumatic brain injury) • Subdural/subarachnoid/intracranial hemmorhage IS TBI. • The military approach • Military approach to severe head injury • Personal goals • Goals in TBI

40. The Damn A-Line • The Crash of Eastern Airlines Flight 401 • Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew's attention from the instruments and allowed the descent to go unnoticed. • The Captain, along with one of 2 flight crew members, two of 10 flight attendants and 97 of 163 passengers, died. There were 75 survivors. • The swamp saved many lives as mud blocked wounds sustained by survivors, preventing them from bleeding to death. • Eastern Airlines Flight 401 Crashes in the Everglades of Florida

41. Drawing a Blood Gas

42. Drawing a Blood Gas

43. Drawing a Blood Gas

44. Drawing a Blood Gas

45. Did you know? • There is no consensus on the “best” way to brush your teeth • As a result, we rely on “expert opinion” to make recommendations on how to do it • An expert is “someone from out of town with slides” • As a result we rely on so-called experts tell us how to do things in just about everything we do in anesthesia

46. “Despite all the techniques described by experts, there’s no evidence to suggest that any of them is more effective than a simple scrub,” said the lead author, John Wainwright, a dentist in Doncaster, England. “Expert opinionis worth something, but it’s low on the hierarchy of evidence.”

47. So, Now You Have My Opinion On How To Do Anesthesia in a Trauma • Since I have slides, but not “from out of town” • Makes me less than expert • Makes my opinions even lower on the list of hierarchical evidence • Take what I have said as nothing more than suggestions • The science they are based on is suspect

48. Trauma Anesthesia • After years of doing trauma, things have changed for the better • This was a “BASICS” lecture on how to take care of trauma victims • It wasn’t intended to help you answer board questions, although it might. • My opinions are personal. They are just between you and me.

49. As Much as Possible Keep Moving Fast • Age will slow you down • There are ways around that Zippy kinda zippy things!