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Anaesthesia for Trauma. C Berger MD FRCP(C) For NMH residents, Kabul. Anaesthesia for Trauma. Conduct of anaesthesia requires awareness of all sustained injuries. In the initial resuscitation – focus on airway, c-spine, and cardiothoracic injuries

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Anaesthesia for trauma

Anaesthesia for Trauma

C Berger MD FRCP(C)

For NMH residents, Kabul

Anaesthesia for trauma1
Anaesthesia for Trauma

  • Conduct of anaesthesia requires awareness of all sustained injuries. In the initial resuscitation – focus on airway, c-spine, and cardiothoracic injuries

  • If time permits – review with trauma team leader or perform your own ABCDE assessment

  • Initial trauma protocol –

    • O2

    • 2 large bore IV’s

    • Investigations – CBC, cross match, lytes, Coags, ABG

      Others according to history / physical exam

    • Consider – CXR, C-spine, Pelvic imaging

Anaesthesia for trauma2
Anaesthesia for Trauma

  • If situation does not permit full assessment :

    • Obtain AMPLE history

    • A – Allergies

    • M – Medications

    • P – Past medical history

    • L – Last meal

    • E – Events leading to injury

      And proceed with interventions

Anaesthesia for trauma3
Anaesthesia for Trauma

  • Keep in mind – 6 injuries that kill quickly

    • these need to be identified and treated during primary survey

      • Airway obstruction

      • Open pneumothorax

      • Tension pneumothorax

      • Flail chest with pulmonary contusion

      • Massive hemothorax

      • Cardiac tamponade

Anaesthesia for trauma4
Anaesthesia for Trauma

  • Other life-threatening injuries :

    • Simple pneumothorax

    • Pulmonary contusion

    • Cardiac contusion

    • Aortic disruption

    • Diaphragmatic disruption

    • Tracheo-bronchial disruption

    • Esophageal disruption

Anaesthesia for trauma5
Anaesthesia for Trauma

  • Airway Control : requires ETT, stylet, bougie, suction, O2 (Ambu bag ), LMA, and Cricothyroidotomy kit at the ready

  • Consider :

    • Full stomach

    • Potentially difficult ( blood, cervical collar )

    • C-spine injury requiring in line stabilization

    • Pneumothorax requiring decompression

    • Closed head injury requiring adequate perfusion pressure

    • Open eye injury to prevent vitreal extrusion

    • Hemodynamic situation

    • Beware nasal intubation in facial injuries

Anaesthesia for trauma6
Anaesthesia for Trauma

  • Airway

    • pre-oxygenate

    • in line cervical stabilization, cricoid pressure

    • Administer drugs

      • Attempt DL

      • 2nd attempt DL +/- appropriate airway adjuncts

      • LMA

        if all above unsuccessful

      • Emergency cricothyroidotomy

      • Definitive controlled tracheostomy

  • Ventilation

    • no benefit to supra-normal FiO2

    • Normocarbia in absence of closed head injury or compensating for severe metabolic acidosis

  • Hangman Fracture Jefferson Fracture

    C2 pedicle MVA C1 burst – axial loading

    Anaesthesia for trauma7
    Anaesthesia for Trauma

    Circulation – class 3-4 shock will likely require massive transfusion

    • Initial Hgb < 100, ph <7.15, Coagulopathy all indicators of massive blood loss

    • IV fluids to be warmed

    • After initial bolus give crystalloid judiciously

    • Blood products – give as soon as the necessity is recognized

    • Depending on blood bank – MT protocols save lives !

      • Type specific whole blood ( fresh blood richer in procoagulants )

      • Packed cells, Plasma, Platelets in equal ratios for MT ( 1:1:1 )

      • Tranexamic acid within first two hours

    • Colloids controversial and no better than crystalloid

      • Beware the terrible triad ; treat aggressively

        Hypothermis Coagulopathy Acidosis

    Anaesthesia for trauma8
    Anaesthesia for Trauma

    • Acidosis– usually due to low perfusion and lactate production

      • impaired myocardial function and response to catecholamines

      • Wosens coagulopathy

    • Coagulapathy – may be worsened by large volume crystalloids (dilution of pro-coagulants ) and artificial colloids

      ( reduced platelet adherence )

    • Hypothermia – contributes to coagulopathy

      • Worsens muscular ( cardiac ) function

      • Reduces platelet adhesion

      • Warm all fluids, OR, Bair hugger, irrigation

      • Linear relationship between extent of hypothermia and mortality

    Anaesthesia for trauma9
    Anaesthesia for Trauma

    • Initial Surgery

      • Life saving interventions only

      • Damage Control Surgery

      • Ongoing physiological, hemostatic resuscitation

      • Do not over – resuscitate – permissive hypotension

        • Normal or supranormal BP may dislodge clot

        • Exception – closed head injury requires adequate CPP

      • Continue resuscitation in ICU

      • Supplemtal surgeries as required

        • packing change, debridements, washouts, re-anastamosis

    Anaesthesia for trauma10
    Anaesthesia for Trauma

    • Useful Drugs in Trauma :

      • None – consider in moribund patient, add as tolerated

      • Ketamine – indirect alpha and beta sympathomimetic

        • Direct negative inotrope – careful in moribund patients

        • Most recent studies suggest it is safe in CHI patients

      • Volatile Anaesthetics – use sub MAC doses and titrate carefully

        • Best to avoid N2O for closed space reasons

      • Rocuronium – alternative to succ

        • 1mg/Kg to decrease onset time

      • Vasopressors – as temporizing agents to support BP

      • Succinylcholine – usual contraindications apply

        • Safe in sc injury and major burns in first 24 hrs

    Anaesthesia for thoracic trauma
    Anaesthesia for Thoracic Trauma

    • Less than10% of blunt and 20% of penetrating trauma require thoracotomy

    • Indications :

      • Persistent Haemothorax

      • Persistent large air leak

      • Tracheo-bronchial disruption

      • Diaphragmatic disruption

      • Esophageal disruption

      • Cardiac Tamponade

      • Aortic disrution

    Anaesthesia for thoracic trauma1
    Anaesthesia for Thoracic Trauma

    • Hemothorax

      • Thoracotomy usually indicated for massive haemothorax ( > 1500cc ) or on-going blood loss

        ( > 200cc/hr x 2-4 hrs )

      • Large volume transfusion likely required

      • Consider DLT for large air leak or significant haemoptysis

    Anaesthesia for thoracic trauma2
    Anaesthesia for Thoracic Trauma

    • Tracheo-bronchial Disruption

      • Upper – bronchoscopic evaluation (SV) with placement of ETT below lesion. If very high then tracheostomy

      • Lower lesion – DLT

    • Esophageal Disruption

      • High mortality due to mediastnitis, empyema, sepsis

      • DLT for surgical exposure

    Anaesthesia for thoracic trauma3
    Anaesthesia for Thoracic Trauma

    • Aortic Disruption

      • Devastating hemorrhage – only 15% reach hospital alive

      • Always consider in high rib fractures

      • Massive transfusion, high incidence of associated thoracic injuries

      • Cosider cardiopulmonary bypass

    • Diaphragmatic Disruption

      • NGT to decompress stomach

      • DLT ( if possible ) improves surgical exposur

    Anaesthesia for thoracic trauma4
    Anaesthesia for Thoracic Trauma

    • Cardiac Tamponade

      • Consider in trauma patient ( usually penetrating ) who is not responding to fluids

      • Kussmal’s sign, Becks Triad, pulsus paradoxus

      • US is the best diagnostic tool and can assist in drainage

      • Induction of GA may be deadly – invasive pressures, maintain high CVP, high HR. consider epi infusion, ketamine induction and maintenane of spontaneous ventilation ( improve venous return )

      • Subxyphoid or intercostal incision

    Pericardial Effusion

    Acute cases will be

    more easily identified

    by US

    Anaesthesia for abdominal trauma
    Anaesthesia for Abdominal Trauma

    • For haemorrhage or organ injury

    • Bleeding can be extensive if major vascular of liver injury

    • Damage control surgery only

    • May need to pack and return later

    • Consider leaving abdomen open to avoid abdominal compartment syndrome after large volume resuscitation

    • Vac dressing

    Anaesthesia for orthopaedic trauma
    Anaesthesia for Orthopaedic Trauma

    • Multiple sites may be involved

    • Large bone fractures may lose 500-1L blood

    • Functional examination pre-op important

    • Careful with patient positioning

    • Be aware of ischemic times ( tourniquet )

    • Monitor for rhabdomyolysis ( crush, compartment syndromes)

      and weigh safety of succ

    • Stabilization only ( X –fix ) and leave ( damage control )

    • Prophylactic fasciotomy

    • Fat Embolism ( hypoxemia, petechial rash, cerebral dysfunction )

    Anaesthesia for closed head trauma
    Anaesthesia for Closed Head Trauma

    • Head injury often associated with other ( C-spine ) injuries

    • High speed MVA, increased age, fall > 2m, intoxication

    • Ensure ABCD survey complete

    • GCS < 8, or decrease of 2 signal need for airway protection

    • In absence of other injuries, hemodynamics normal until late

    • Consider limited crystalloids, ? Hypertonic saline

    • Maintenance of Cerebral Perfusion Pressure is paramount

    • Avoid hypoxia, hyperglycemia, hypercarbia

    Anaesthesia for closed head trauma1

    The Cranial Vault is a closed space

    Occupants :

    Blood 10%

    Brain 80%

    CSF 10%

    Limited capacity to compensate for additional volume

    As compensatory mechanisms are exhausted, ICP increases, and CBF falls resulting in :

    Brain ischemia

    Anatomical shifts (herniation)

    Anaesthesia for Closed Head Trauma

    Anaesthesia for closed head trauma3

    Manipulate CBF and hence ICP

    Maintain O2, CPP

    CPP = MAP – ICP

    Reduced cerebral DO2 obviously deleterious

    PCO2 can be manipulated as a temporary measure to reduce ICP ( 30 -35 mmHg ; 4- 4.6 kpa )

    Prolonged or severe hypocarbia may worsen cerebral ischemia

    Anaesthesia for Closed Head Trauma

    Anaesthesia for closed head trauma4
    Anaesthesia for Closed Head Trauma

    • Permissive hypotension used in damage control surgery may not be appropriate in patients with closed head injury

    • Some cooling may be permissible and protective ( > 35* )

    • Elevate head of bed slightly if tolerated

    • Barituates, propofol infusion decrease cerebral mVO2

    • Other adjuncts ( mannitol, steroids ) not so useful in trauma

    • Discuss with neurosurgeon

    Anaesthesia for trauma11
    Anaesthesia for Trauma

    • In Conclusion :

      • Initial approach to all trauma patients is the same

      • ABC and treat immediate life threatening injuries

      • Gather information and know your patient

      • Avoid/treat aggressively the terrible triad

      • Conflicting goals may occur –

        • When in doubt recall the priorities of :

          A before B before C before D