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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


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    1. 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

    2. 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

    3. 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

    4. Eldar Soreide, Trauma Care 2002 Prehospital Rapid transport to appropriate facility Prevention: Helmets, ↓ high risk behavior, seat belts+ airbags, ↓ substance abuse

    5. 1o Survey • Airway + c-spine control • Breathing, O2 sat • Circulation, BP, pulse, stop external bleeding • Disability: Neuro exam • Exposure/ environmental control

    6. LEMON LAW: Ron Walls • Look externally • Evaluate the 3-3-2 rule • Mallampati • Obstruction • Neck mobility National Emergency Airway Course. ATLS Manual 8th ed.

    7. Airway Exam • Thyromental distance • Obvious trauma • Swelling, scarring • Tracheal deviation • Neck extension • Subcutaneous emphysema McIntyre: Can J Anaesth 1987;34:204-13

    8. 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

    9. Drug Assisted Intubations outside the OR Karlin A. Problems in Anesthesia 2001;13:283. MHMC failed intub- 1% ED, OR; 3%- aeromedical

    10. 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

    11. 2o Survey • Rest of vitals, Physical exam • Xrays: chest, pelvis, + c-spine, • FAST, CT, labs • Done only after 1o survey completed + resuscitation begun

    12. FAST • Perihepatic • Perisplenic • Pelvis • Pericardial Focused Assessment for the Sonographic examination of the Trauma victim

    13. 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

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

    15. 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

    16. Risks of Aggressive Volume Resuscitation • ↑ hemorrhage + excessive hemodilution due to ↑ BP, ↓ blood viscosity, ↓ hematocrit, ↓ clotting factor concentration

    17. 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

    18. 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

    19. 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

    20. Room temp > 28 oC Soreide + Smith. Hypothermia in Trauma. In: Trauma Anesthesia, Cambridge University, 2008

    21. Acute Coagulopathy of Trauma (ACoTS) Hess et al. J Trauma 2008

    22. 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

    23. Coagulopathy Initiated by Hypoperfusion Brohi et al. Ann Surg 2007;245:812

    24. Acute Coagulopathy of Trauma Studies Brohi et al. Curr Opin Crit Care 2007;13:680

    25. 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

    26. 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

    27. Patient Information. Holcomb et al. 2008 • Mean age 39, 76% men, 65% blunt injury Holcomb et al. Ann Surg 2008;248:447

    28. 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

    29. 24 h Survival Holcomb et al. Ann Surg 2008;248:447

    30. 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

    31. 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]

    32. 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

    33. 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

    34. 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

    35. 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

    36. 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]

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

    38. 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

    39. 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

    40. Royse C+ Royse A. Ultrasound in trauma. In: Trauma Anesthesia. Cambridge Univ, 2008

    41. 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)

    42. Pericardial Effusion Large, loculated hemopericardium w RA collapse

    43. 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

    44. 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]

    45. 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

    46. Median sternotomy Lt anterior thoracotomy Pericardiocentesis not usually done. Aydin et al. Cardiac and great vessel trauma. In: Trauma Anesthesia, Cambridge Univ. 2008

    47. Blunt Cardiac Trauma • New segmental WMA • ↓ RV +/or LV function • Laceration of valvular annuli • Ruptured chordae • Pericardial effusion

    48. 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

    49. 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

    50. Descending Thoracic Aorta Injury Ped vs. car. Sax view of DA 5 cm distal to arch