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Advances in Trauma Anesthesia. Charles E. Smith, MD Professor, Case Western Reserve University Director, Cardiothoracic and Trauma Anesthesia MetroHealth Medical Center Cleveland, Ohio May 2009. Objectives. Approach to injured pt: airway, c-spine clearance

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advances in trauma anesthesia
Advances in Trauma Anesthesia

Charles E. Smith, MD

Professor, Case Western Reserve University

Director, Cardiothoracic and Trauma Anesthesia

MetroHealth Medical Center

Cleveland, Ohio

May 2009

objectives
Objectives
  • Approach to injured pt: airway, c-spine clearance
  • Fluids: delayed resuscitation, massive trx, FVIIa
  • Cardiac + great vessel injuries
  • TEE +TTE in trauma
  • Advantages of early fracture repair: femoral, pelvis + acetabulum
trauma
Trauma
  • Leading cause of death, ages 1 - 44 yrs
  • 60 million injuries annually in USA
    • 3.6 million require hospitalization
    • 9 million are disabling: TBI, SCI, ortho, thoracic, abdominal
  • Costs are staggering:
    • $100 billion annually
    • 40% of health care $

ATLS Provider Manual

slide4

Eldar Soreide, Trauma Care 2002

Prehospital

Rapid transport to appropriate facility

Prevention: Helmets, ↓ high risk behavior, seat belts+ airbags, ↓ substance abuse

1 o survey
1o Survey
  • Airway + c-spine control
  • Breathing, O2 sat
  • Circulation, BP, pulse, stop external bleeding
  • Disability: Neuro exam
  • Exposure/ environmental control
lemon law ron walls
LEMON LAW: Ron Walls
  • Look externally
  • Evaluate the 3-3-2 rule
  • Mallampati
  • Obstruction
  • Neck mobility

National Emergency Airway Course. ATLS Manual 8th ed.

airway exam
Airway Exam
  • Thyromental distance
  • Obvious trauma
  • Swelling, scarring
  • Tracheal deviation
  • Neck extension
  • Subcutaneous emphysema

McIntyre: Can J Anaesth 1987;34:204-13

airway management
Airway Management
  • Usually modified RSI by experienced provider unless difficulty anticipated
  • Anesthesia + NMB allow for best intubating conditions in trauma especially if uncooperative, hypoxic, head injury
  • Etomidate + succinylcholine
  • Propofol + thiopental avoided if hypovolemia or shock. Roc suitable alternative to sux
drug assisted intubations outside the or
Drug Assisted Intubations outside the OR

Karlin A. Problems in Anesthesia 2001;13:283. MHMC failed intub- 1% ED, OR; 3%- aeromedical

gum elastic bougie
Gum-Elastic Bougie
  • Insert under epiglottis
  • Gently advance until clicks or hold up
  • 2nd operator threads ETT over bougie
  • May need to rotate bougie 90o
  • Ideal for Grade III view

Nolan: Anaesthesia 1993;48:630; Smith: Am J Anesthesiol 2001;28:98

2 o survey
2o Survey
  • Rest of vitals, Physical exam
  • Xrays: chest, pelvis, + c-spine,
  • FAST, CT, labs
  • Done only after 1o survey completed + resuscitation begun
slide12
FAST
  • Perihepatic
  • Perisplenic
  • Pelvis
  • Pericardial

Focused Assessment for the Sonographic examination of the Trauma victim

obtunded head injured pts c spine
Obtunded Head Injured Pts + C-spine
  • Reliable P/E cannot be done, therefore immobilize
  • CT scanning from skull base to T1 (16 row detector) w sagittal + coronal reconstruction
  • Identifies bony fx, marked prevertebral soft tissue swelling or hematoma, malalignment + abnormal facets
  • Negative predictive value 98.9% for ligament injury + 100% for unstable c-spine injury

Como JJ et al. J Trauma 2007;63:544

slide14

Traumatic unilateral jumped facet. Kincaid + Lam. Anesthesia for Spinal Cord Trauma

obtunded head injured pts
Obtunded Head Injured Pts
  • MR advocated to evaluate ligamentous + soft tissue injuries not detected by CT
  • Disadvantages: cost, restricted availability, transport issues
  • Dynamic fluoroscopy w flex/ext views: no longer done
  • Plain c-spine films: no longer routine
  • EAST practice guidelines in press [Como et al]

Como JJ et al. J Trauma 2007;63:544

risks of aggressive volume resuscitation
Risks of Aggressive Volume Resuscitation
  • ↑ hemorrhage + excessive hemodilution due to ↑ BP, ↓ blood viscosity, ↓ hematocrit, ↓ clotting factor concentration
bickell et al nejm 1994 331 1005
Bickell et al: NEJM 1994;331:1005
  • RCT, penetrating torso trauma, urban center: n =598
  • Excluded head injury
  • Std of care: 2 L crystalloid prehospital vs delayed resuscitation: no fluid until OR
  • ­ mortality, LOS + complications in std of care vs. delayed group
dutton et al j trauma 2002 52 1141
Dutton et al J Trauma 2002;52:1141
  • RCT, blunt + penetrating trauma pts w SBP < 90, n = 110; excluded head injury
  • Gp 1- fluid resusc to SBP 100
  • Gp 2- fluid resusc to SBP 70
  • Identical survival: 93% despite  ISS in gp 2 [23.9 v 19.5]
  • Lactate + base deficit cleared to normal in both gps w similar amounts fluid + blood
goals for early resuscitation
Goals for Early Resuscitation
  • Systolic BP 80-100 mmHg unless head or SCI
  • Hematocrit 25-30%
  • PT, PTT, INR in normal range
  • Platelet count > 50,000
  • Normal ionized calcium
  • Prevent acidosis from worsening
  • Core temp > 36 C
slide20

Room temp > 28 oC

Soreide + Smith. Hypothermia in Trauma. In: Trauma Anesthesia, Cambridge University, 2008

acute coagulopathy of trauma acots
Acute Coagulopathy of Trauma (ACoTS)

Hess et al. J Trauma 2008

brohi et al j trauma 2003 54 1127
Brohi et al. J Trauma 2003;54:1127
  • Retrospective review 1088 trauma pts
  • Average ISS 20
  • 24% had PT > 18 s or PTT > 60 s on arrival
  • Dose- dependent prolongation of clotting times w hypoperfusion
  • Activation of anticoagulant + fibrinolytic pathways: thrombomodulin- protein C
coagulopathy initiated by hypoperfusion
Coagulopathy Initiated by Hypoperfusion

Brohi et al. Ann Surg 2007;245:812

acute coagulopathy of trauma studies
Acute Coagulopathy of Trauma Studies

Brohi et al. Curr Opin Crit Care 2007;13:680

implications
Implications
  • Early administration of FFP
  • Damage control surgery to minimize acidosis + hypothermia
  • Massive transfusion protocols, hemostatic resusc

Hess et al. JOT 2008. Hoyt et al. JOT 2008; 65:755. Soeride + Smith. Hypothermia in Trauma, 2008

hemostatic resuscitation civilian
Hemostatic Resuscitation: Civilian
  • 16 Level 1 trauma centers, n= 1574. Retrospective
  • 467 received massive transfusion [ >10 u / 24 h]
  • Excluded pts who died within 30 min arrival
  • Hypothesis: ↑ plasma + platelet to RBC ratio improves survival after shock

Holcomb et al. Ann Surg 2008;248:447

patient information holcomb et al 2008
Patient Information. Holcomb et al. 2008
  • Mean age 39, 76% men, 65% blunt injury

Holcomb et al. Ann Surg 2008;248:447

results
Results
  • High plasma + high platelet to RBC ratios associated w
    • ↓ truncal hemorrhage
    • ↓ ICU, vent days + LOS
    • ↑ survival

Holcomb et al. Ann Surg 2008;248:447

24 h survival
24 h Survival

Holcomb et al. Ann Surg 2008;248:447

mhmc massive transfusion protocol
MHMC Massive Transfusion Protocol
  • 1st pack: 4 O neg RBC + 2 AB plasma
  • 2nd pack: 6 RBC + 4 plasma. Type specific
  • 3rd + all subsequent MTP packs: 6 RBC, 4 plasma, 6 platelets, rFVIIa 1.2 mg

Activated by Surgeon, Emerg, Anesthesiologist

factor viia use in trauma
Factor VIIa Use in Trauma

1999: Approved for bleeding pts with hemophilia A or B + inhibitors to FVIII or IX

2001: Martinowitz: case series of 7 pts

Currently:

Multiple anecdotal reports + descriptive studies w off label use.

Cost of drug offset by ↓ trx RBC + FFP [Stein D et al. Injury 2008;39:1054]

dutton et al j trauma 2004 57 709
Dutton et al. J Trauma 2004;57:709
  • 81 coagulopathic trauma pts
  • Coagulopathy reversed in 75% w 1.2 mg dose
  • PT 17→ 10.6 s w ↓ RBC + FFP over 24 h
  • 43.5% survived to discharge
  • Thromboembolic events in 12 pts (15%)
  • Conclusion: consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bufford et al j trauma 2005 59 8
Bufford et al. J Trauma 2005;59:8
  • RCT of blunt + penetrating trauma. Multicenter
  • Inclusion: severe trauma + need for 6 RBC u w/in 4 hr admission, n = 301
  • Randomized to 3 successive doses rFVIIa: 200, 100 + 100 ug/kg vs placebo. 2nd + 3rd dose given 1 + 3 h after 1rst dose
  • Exclusion: cardiac arrest before VIIa, GSW to head, GCS <8, BD >15, pH <7, injury > 12 h before randomization
results of bufford et al j trauma 2005
Results of Bufford et al. J Trauma 2005
  • 2.6 u ↓ in RBC trx requirement (blunt gp, P=0.02)
  • ↓ need for massive trx (blunt gp: 14 vs 33%)
  • Trend toward ↓ MOF, ARDS + death
  • No diff in AEs, vent days, ICU days
  • Trend toward ↓ RBC trx requirement (penetrating gp, P =0.10)

http://www.trauma.org/archive/resus/FactorVIIa.html

concerns with rfviia
Concerns with rFVIIa
  • Microvascular thrombosis
  • 431 events reported to FDA 1999-2004
    • Stroke, MI, PE, other arterial + venous thromboembolism, clotted devices.
    • Incidence AE < 1%
  • Dosing not well established. Usually give 4.8 mg [1 vial]. Repeat x 1 or 2 if needed
  • Lower doses [1.2 mg, 90 ug/kg] effective w ↓ risk
  • Ongoing trials + case registry

http://www.trauma.org/archive/resus/FactorVIIa.html

concerns with blood in trauma
Concerns with Blood in Trauma
  • Each unit of blood product biologically active + ↑ risk of infections + ARDS
    • [Chaiwat et al. Anesthesiology 2009;110:351, n=14,070 pts, NSCOT database, retrospective]
  • Older blood assoc w ↑ infection, LOS, MOSF + death [Weinberg et al. J Trauma 2008;65:279]
storage days of prbcs mhmc
Storage Days of pRBCs, MHMC

Kroll A. et al. N=385 trauma pts requiring surgery w/in 24 h admission @ MHMC, 2003-4

slide38

Stab wound to LV. Ketamine-sux induction. Adenosine 6-12 mg boluses to allow surgeon time to suture. Lim et al. Ann Thorac Surg 2001;71:1714

penetrating cardiac injuries
Penetrating Cardiac Injuries
  • GSW: usually die
  • Stab: usually present with tamponade
  • Dx: history, Becks’s triad, JVD,  BP, pulsus, echo
  • JVD- may be absent if hypovolemic

Tx: Surgical repair. May need adenosine + bypass

pericardial effusion tamponade
Pericardial Effusion + Tamponade
  • Pericardial pressure > cardiac chamber pressure
  • RV or LV diastolic collapse
  • RA or LA systolic collapse
  • Plethora of IVC (> 2.5 cm)
  • ↑ tricuspid E w inspiration (+ ↓ mitral E)
pericardial effusion
Pericardial Effusion

Large, loculated hemopericardium w RA collapse

tg sax lv fractional area
TG SAX: LV Fractional Area

Diastole

FAC: (EDA-ESA)/EDA *100

Normal: > 50%

Hypovolemia: EDA < 8 cm2

Normal: EDA 8-14

Dilated: EDA >14

Systole

transthoracic echo tte
Transthoracic Echo [TTE]
  • TTE easiest + least invasive way to image cardiac structures + great vessels
  • Harmonics + contrast: improved TTE exam
  • TTE still suboptimal in many pts due to obesity, chest tubes, dressings + PPV

[Vignon et al, Chest 1994;106:1829]

slide45
TEE
  • TEE has improved sensitivity + specificity
    • Valvular pathology
    • Interatrial shunt
    • Endocarditis
    • Prosthetic valve dysfunction
    • Aortic dissection, rupture
    • LAA pathology
    • Cardiac source of emboli
  • TEE is semi-invasive
slide46

Median sternotomy

Lt anterior thoracotomy

Pericardiocentesis not usually done. Aydin et al. Cardiac and great vessel trauma. In: Trauma Anesthesia, Cambridge Univ. 2008

blunt cardiac trauma
Blunt Cardiac Trauma
  • New segmental WMA
  • ↓ RV +/or LV function
  • Laceration of valvular annuli
  • Ruptured chordae
  • Pericardial effusion
bci myocardial contusion
BCI + Myocardial Contusion

A+B: small, localized

C: Extensive. May need milrinone, epi, norepi, vasopressin to maintain CPP + RV fct.

Delay non-cardiac surgery 24-48 h

thoracic aorta trauma
Thoracic Aorta Trauma
  • 2nd most common cause of death [8000 deaths/yr, USA]
  • Majority (80-85%) die at scene
  • Etiology: MVAs, falls, crush, pedestrian struck, airplane crash
  • Mechanism: deceleration, osseous pinch
descending thoracic aorta injury
Descending Thoracic Aorta Injury

Ped vs. car. Sax view of DA 5 cm distal to arch

pathophysiology
Pathophysiology
  • Intimal tears: small, thin, mobile intraluminal appendages of aortic wall
  • Rupture: intima +media involved, adventitia intact
  • Intramural hematoma: rupture of vaso vasorum w ↑ wall thickness
    • Ascending: 7 + 2 mm
    • Descending: 15 + 6 mm
slide52

Axial

CT. Traumatic aortic disruption. Aydin et al. In: Trauma Anesthesia, 2008

slide53

Multi-planar

Volumetric 3d

CTA. Traumatic aortic disruption. Aydin et al. In: Trauma Anesthesia, 2008

desc thoracic injury tx options
Desc Thoracic Injury Tx Options
  • Open repair: Lt thoracotomy, OLV, aortic XC + partial bypass
  • Endoluminal repair: has replaced open repair when feasible
  • Non-operative: risk of pseudoaneurysm + rupture
  • Delayed: stabilization of other injuries
  • Control of BP mandatory: β- blockers, CCB, SNP, NTG, dex
clevidipene for htn
Clevidipene for HTN
  • Dihydropyridine IV CCB
  • Rapid and titratable BP control
  • Fast termination of effect: metabolised by blood and tissue esterases
  • Selective action on arteriolar resistance vessels

Levy et al. A+A 2007;105:918. Aronson et al. A+A 2008;107:1110

endovascular repair stent graft
Endovascular Repair [Stent graft]
  • Avoids thoracotomy, OLV, aortic XC + bypass.
  • Minimizes BP shifts, blood loss, spinal cord + visceral organ ischemia
  • Requirement for anticoagulation minimal
  • Excellent mid-term results + low M + M
review of endovascular studies
Review of Endovascular Studies

Stent graft repair of descending thoracic aorta injury.

orthopaedic trauma
Orthopaedic Trauma
  • Busiest service @ MHMC
    • Occurs in 80% multiple trauma pts
    • Incidence ortho trauma = 2x thoracic 4x abdominal
    • Team approach
goals of surgery
Goals of Surgery
  • Restore perfusion + limb alignment
  • Debride open wounds
  • Repair traumatic amp
  • Relieve compartment syndrome
  • Repair vascular + nerve injury
  • Treat pain
  • Manage fractures [delayed vs. emergent]

Vallier HA. Percutaneous intramedullary nailing. In: Trauma Anesthesia. Cambridge Univ, 2008

unstable pelvic acetabulum fx
Unstable Pelvic + Acetabulum Fx
  • Major risk of bleeding
  • Associated injuries: head, spine, chest, GI, urogenital
  • Invasive monitoring routine
  • CVP, Art line: SPV, ABGs

Open book- widened symphysis pubis. Dislocated Rt SI joint. Vallier + Jenkins. In: Trauma Anesthesia. 2008

blood supply of pelvis
Blood supply of pelvis

Donatiello et al. Anesthesia considerations for orthopedic trauma. In: Trauma Anesthesia. 2008

selective internal iliac angiograms
Selective Internal Iliac Angiograms

Blush

2 steel coils

Pre + Post Embolization of right internal iliac artery. Buehner + Parr. Damage control in severe trauma. In: Trauma Anesthesia, 2008

complications early vs late
Complications: Early vs Late

Unstable Pelvic + Acetabular Fx. Vallier HA et al. MHMC

fracture fixation
Fracture Fixation
  • Early definitive fixation of pelvis + acetabulum assoc w ↓ complications
  • Eliminates need for traction, recumbency
  • Controls bleeding, provides pain relief
  • Easier to reduce + better quality of reduction

Vallier, Wilber, et al. MHMC

orif unstable pelvic fx
ORIF Unstable Pelvic Fx

Screws to stabilize SI joint

Anterior external fixator applied

Restores alignment of pelvic ring

Vallier +Jenkins. Musculoskeletal trauma. In: Trauma Anesthesia, 2008

summary
Summary
  • Airway: modified RSI safe
  • CT scanning to r/o c-spine injury if obtunded
  • Bleeding: resuc to SBP 80-100 unless head orSCI
  • Many pts will have coagulopathy of trauma + need early use of FFP, platelets, FVIIa
  • TTE +TEE: timely + detailed info about heart + great vessels
  • Endoluminal stent repair preferred. Control BP
  • Femur + pelvic fx fixation: early usually better