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Trauma Anaesthesia

Trauma Anaesthesia. Dr James Peerless December 2013. Approaching Trauma. Airway + c-spine control Breathing Circulation Disability Exposure Multidisciplinary approach. Session Learning Points. Shock Damage Control Resuscitation GSTT Major Haemorrhage Protocols. Shock. Shock.

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Trauma Anaesthesia

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  1. Trauma Anaesthesia Dr James Peerless December 2013

  2. Approaching Trauma • Airway + c-spine control • Breathing • Circulation • Disability • Exposure • Multidisciplinary approach

  3. Session Learning Points • Shock • Damage Control Resuscitation • GSTT Major Haemorrhage Protocols

  4. Shock

  5. Shock • “Tissue and organ perfusion is not sufficient to meet metabolic demand” • Haemorrhagic • Non-haemorrhagic • Neurogenic • Anaphylactic • Cardiogenic • Septic

  6. Recognition of Shock • Recognition and initialisation of treatment important • Haemostasis and fluid replacement • Beware occult haemorrhage • “on the floor and four more” • Long bones • Retroperitoneum • Chest • Pelvis

  7. Fluid Resuscitation • Fluid resuscitation delivery determined by Hagen-Poiseuille • ΔP – level 1 infuser • r/l – large bore, short cannula • η – warm blood to reduce viscosity

  8. Which Cannula?

  9. Fluid Resuscitation • Level One Infuser • Combined heat and pressured fluid delivery system • Max. flow 1400mL min-1 • Cell Salvage

  10. Damage Control Resuscitation

  11. Concept of Damage Control Resuscitation • Previously accepted concepts of trauma resuscitation challenged during Iraq and Afghanistan Wars • Mortality amongst injured US servicemen: • First Gulf War (1990-1) – 24% • Afghanistan and Iraq – 10% • Transferable concepts in civilian practice

  12. The Lethal Triad

  13. The Lethal Triad • Acidosis • Hypoperfusion  reduced DaO2  switch to anaerobic metabolism • Lactate production • Metabolic acidosis AVOID HYPOTHERMIA ACIDOSIS COAGULOPATHY

  14. The Lethal Triad AVOID HYPOTHERMIA ACIDOSIS COAGULOPATHY • Hypothermia • Core temperature <35°C is independent predictor of mortality • Exposure • Administration of cold IV fluids • Heat production limited by anaerobic metabolism

  15. The Lethal Triad AVOID HYPOTHERMIA ACIDOSIS COAGULOPATHY • Acute Coagulopathy • Coagulopathy on arrival at hospital associated with a four-fold increase in mortality • Procoagulant losses secondary to bleeding and consumption • Dysfunction secondary to hypothermia and acidosis • More complex mechanisms triggered by hypoperfusion and tissue injury

  16. Management Strategies

  17. Permissive Hypotension • Strategy of restricting fluid administration until haemorrhage becomes controlled • Accept a period of suboptimal end-organ hypoperfusion • SBP < 90, palpable radial pulse • Caveat to this: • Head injuries – maintenance of cerebral perfusion pressure highly important.

  18. Haemostatic Resuscitation • Treatment of coagulopathy perhaps the most important corner of the triad • Treatment strategies: • Fresh frozen plasma • Platelets • Recombinant Factor VIIa • Cryoprecipitate • Tranexamic acid • Calcium

  19. Blood Products • Packed Red Cells • No. infective complications and MOF increases with age of stored blood • Shelf-life PRCs 6 weeks; risk significantly increased after 2 weeks if being transfused >6 units of blood • FFP • Current military practice to give as 1:1 ratio (packs) • Attenuates the acute coagulopathy • One trial: mortality reduced by 46% when compared with 1:8 ratio (Borgman et al., 2007)

  20. Blood Products • Platelets • Also 1:1 ratio, as this approximates whole blood • In the civilian setting, this is perhaps impractical • 1:5 is advocated in patients requiring massive transfusion • Cryoprecipitate • Fibrinogen, Factor VIII, Factor XIII, vW Factor • Aim to maintain Fibrinogen > 1.5 g.L-1

  21. Other Therapies • Recombinant Factor VIIa • Factor VII a crucial initial component of the coagulation cascade • Also important as an enhancer of localised haemostasis • Calcium • Important cofactor in most of the coagulation cascade • Citrate present as an anticoagulant in blood products • Chelates Ca2+ and exacerbates systemic hypocalcaemia • Maintain ionised Ca2+ >0.9 mmol.L-1

  22. CRASH-2 & Tranexamic Acid • Tranexamic Acid • Synthetic antifibrinolytic: blocks binding sites on plasminogen • Hyperfibrinolysis a feature of acute trauma coagulopathy • Antifibrinolytics therefore have a role to play in trauma • TXA known to reduce bleeding in patients in elective surgical patients • Reduction of blood transfusion by one-third • This large multi-centre study (RCT) showed that risk of death was significantly reduced in bleeding trauma patients • Most benefit found when given within 1h of injury (CRASH-2 trial collaborators, 2010)

  23. Hypothermia • Easier to prevent than to correct • Limit exposure • Warm all blood products • Use forced air blankets

  24. Damage Control Surgery • Surgical strategy aimed at: • Controlling haemorrhage • Limiting contamination • Restoring normal physiology as soon as possible • Restoring anatomical integrity is not the primary aim, e.g.: • Bowel injuries are identified and brought out, not internally anastomosed • Temporary clamping, packing of bleeding areas • Planned return to theatre after stabilisation

  25. GSTT Haemorrhage Protocols

  26. GSTT Transfusion Protocols • Two pathways for obtaining urgent blood products • Code red • Crash blood

  27. GSTT Transfusion Protocols

  28. Summary • Uncontrolled bleeding needs to be identified and acted upon – surgical control, not aggressive resuscitation • Early treatment with blood products • Prevent hypothermia with forced air blankets and fluid warmers

  29. The End

  30. Reference • Jansen JO, Thomas R, Loudon MA et al. Damage control resuscitation for patients with major trauma. British Medical Journal 2009;3381436-40 • Borgman MA, Spinella PC, Perkins JG et al. The ratio of blood products transfused affects mortality in patients receiving massive trasfusions at a combat support hospital. J Trauma 2007;63:805-13 • American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Student Course Manual, Eighth Edition, 2008. • http://tww-wafr/WAFR-FAD/Applications/ClinicalGuidance/User/Details.aspx?id=2888 (accessed 12.12.13)

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