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Anaesthesia for Trauma

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

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  1. Anaesthesia for Trauma C Berger MD FRCP(C) For NMH residents, Kabul

  2. 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

  3. 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

  4. 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

  5. Anaesthesia for Trauma • Other life-threatening injuries : • Simple pneumothorax • Pulmonary contusion • Cardiac contusion • Aortic disruption • Diaphragmatic disruption • Tracheo-bronchial disruption • Esophageal disruption

  6. 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

  7. 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

  8. Hangman Fracture Jefferson Fracture C2 pedicle MVA C1 burst – axial loading

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. Pericardial Effusion Acute cases will be more easily identified by US

  19. 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

  20. VAC ( vacuum ) Dressing

  21. 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 )

  22. 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

  23. 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

  24. Anaesthesia for Closed Head Trauma

  25. 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

  26. 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

  27. 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

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