Trauma Anesthesia

1. Trauma Anesthesia John Killpack, CRNA, MSN Director, Anesthesia Services US Air Force Center for Sustainment of Trauma and Readiness Skills (CSTARS) - Maryland RA Cowley Shock Trauma Center University of Maryland Medical System Baltimore, MD Disclaimer: Any statements or data provided in this presentation are purely the work of the author and should not be construed as reflecting on the Department of Defense, US Air Force or the University of Maryland Medical System.Disclaimer: Any statements or data provided in this presentation are purely the work of the author and should not be construed as reflecting on the Department of Defense, US Air Force or the University of Maryland Medical System.

2. The more things change, the more things stay the same.The more things change, the more things stay the same.

4. Trauma awareness Multiple organizations to study trauma care, promote prevention and educate providersMultiple organizations to study trauma care, promote prevention and educate providers

5. Interesting Trivia Direct costs of trauma ~ 7% total health care expenditures 1/3 of hospital admissions (19 million hospital days) > cardiac care, 4X > cancer Elderly = 33% of trauma care, are 5X more likely to die from trauma

6. Nationwide Incidence of Trauma by Age If any of you want to believe in the stupid male theory, this supports your prejudice Note the dramatic increase in female victims after age 74, due to increased female longevity Also note increase in percentage of death as age increases, probably due to co-morbiditiesIf any of you want to believe in the stupid male theory, this supports your prejudice Note the dramatic increase in female victims after age 74, due to increased female longevity Also note increase in percentage of death as age increases, probably due to co-morbidities

7. Nationwide Incidence and Death Rates by Mechanism of Injury Ped = Pedestrian struck Note increase in percentage of deaths with penetrating No listing for incidence of �I was just minding my own business when these two dudes came up and started beating/stabbing/shooting me��Ped = Pedestrian struck Note increase in percentage of deaths with penetrating No listing for incidence of �I was just minding my own business when these two dudes came up and started beating/stabbing/shooting me��

8. Will not guide care, but more as quality assurance/ research tool http://www.trauma.org/scores/rts.html score calculatorWill not guide care, but more as quality assurance/ research tool http://www.trauma.org/scores/rts.html score calculator

9. Pathophysiology Blood loss leads to Hypovolemia Activation of hypothalamic-pituitary-adrenal axis Renin/ angiotensin Vasopressin Acth Catecholamine release Hyperglycemia Renin released from juxtaglomerular cells in kidney Renin releases angiotensin, converted in lung to angiotensin II Angiotensin, like name indicates, causes vasoconstriction ACTH (stress hormone) released, may lead to eventual exhaustion of catecholamine Catecholamine release Increase heart rate, pump what�s still in the pipes faster, raising bp Vasoconstrict with alpha receptors Frequently see blood sugar > 150, some discussion on when to treat - improved outcomes if keep sugar 80-120 in ICU - debate still rages about acute treatment Aldosterone and Anti-diuretic Hormone late responseRenin released from juxtaglomerular cells in kidney Renin releases angiotensin, converted in lung to angiotensin II Angiotensin, like name indicates, causes vasoconstriction ACTH (stress hormone) released, may lead to eventual exhaustion of catecholamine Catecholamine release Increase heart rate, pump what�s still in the pipes faster, raising bp Vasoconstrict with alpha receptors Frequently see blood sugar > 150, some discussion on when to treat - improved outcomes if keep sugar 80-120 in ICU - debate still rages about acute treatment Aldosterone and Anti-diuretic Hormone late response

10. Blood Loss Where does blood loss happen? What is shock? Can lose significant volumes of blood from these spaces Thorax- up to entire blood volume Abdomen- up to entire blood volume, but not seen as often Pelvis/retroperitoneal- up to entire blood volume, can tamponade it with stabilization/ closure of broken pelvis Thigh- up to 1200 cc Humerus- up to 750 cc Ribs up to 150 cc/ rib fracture Street- entire blood volume Cranium closed space, usually limits itself to <400 ccCan lose significant volumes of blood from these spaces Thorax- up to entire blood volume Abdomen- up to entire blood volume, but not seen as often Pelvis/retroperitoneal- up to entire blood volume, can tamponade it with stabilization/ closure of broken pelvis Thigh- up to 1200 cc Humerus- up to 750 cc Ribs up to 150 cc/ rib fracture Street- entire blood volume Cranium closed space, usually limits itself to <400 cc

11. hypovolemia Other signs of hypovolemia - precipitous drop with administration of narcotic - severe drop in cardiovascular tone with induction out of proportion to dosage - respiratory variation >10 mm on arterial line with positive pressure ventilation -- High Peak inspiratory pressures can confound - alteration in shape of arterial line tracing (wide and round vs. tall and peaked), may be result of cardiac function, valve abnormalities - loss of dicrotic notch (not always reliable) Urine output best indicator of end organ perfusion (without pulmonary catheter and mixed venous sats %), don�t be confused by mannitol, diuretics, early/late Acute Renal Failure, etc.Other signs of hypovolemia - precipitous drop with administration of narcotic - severe drop in cardiovascular tone with induction out of proportion to dosage - respiratory variation >10 mm on arterial line with positive pressure ventilation -- High Peak inspiratory pressures can confound - alteration in shape of arterial line tracing (wide and round vs. tall and peaked), may be result of cardiac function, valve abnormalities - loss of dicrotic notch (not always reliable) Urine output best indicator of end organ perfusion (without pulmonary catheter and mixed venous sats %), don�t be confused by mannitol, diuretics, early/late Acute Renal Failure, etc.

12. Resuscitation Responder vs. non-responder When is enough enough? Fluid choice �I can�t see the benefit of putting water into a leaking wine skin� Responder vs. non-responder Administer fluid challenge (500-1000 ml) and note results Responder SBP, HR return to normal Transient- SBP, HR approach normal, gradually drop Indicates ongoing blood loss Non-Responder- no response to challenge Indicates high loss of blood, may not be able to replace blood as fast as its lost Surgery most likely best answer, too unstable to CT scan/ other monitoring Lab Tests for adequate resuscitation Mixed venous saturations (>70%) Rarely have swan in place Lactate/ base deficit May rise as tissue reperfuses Monitor trend Hgb may not indicate volume status body will vasoconstrict to counteract blood loss/ hypovolemia. As Hgb is measurement of concentration, and concentration has not changed (less total Hgb, but still 10 gm/dL in less volume), total Hgb may appear artificially high. will frequently see drop in Hgb with adequate resuscitation PULSE OXIMETER TEST- MULTIPLE PULSE OXIMETERS ON EAR, NOSE, FINGERS TO TRY AND PICK UP PULSE Adequte Early Resuscitation will decrease late MODS Oxygen Debt Develops as tissue deprived of circulation, oxygen Needs to be repaid early to avoid bad outcome Hct> 30 correlates with better outcome Lactate normal at 24 hours = best response Lactate elevated at 48 hours = worst MODS/mortality Vital signs may also confuse you Tachycardia with pain, drugs, strong emotions, etc. Normotensive vs. hypotensive Increased SBP may pop off clot, resume bleeding Improved outcomes with SBP of 80 in liver injuries (one center), penetrating thoracic (one urban city) Unclear if hypotension benefits blunt trauma Crystal vs. colloid Crystalloid 1:3 replacement crystal cheaper no reactivity LR slightly hypo-osmotic transient intravascular, contributes to edema excess normal saline leads to hyperchloremic acidosis may worsen lactic acidosis, coagulopathy Colloid 1:1 replacement remains intravascular (hopefully) more expensive than crystalloid shows worse outcomes (albumin, mainly from tissue leakage) can worsen/ cause coagulopathy possible allergic reactions Blood replaces oxygen carrying capability replaces coag factors risk of infection risk of reaction chilled, must be warmed excess citrate leads to hypocalcemia religious/ personal refusal expensive to gather, test, store HBOC Obtained from bovine/ genetically altered bacterium Carry oxygen similar to RBC encapsulated hgb Encapsulated to circulate at sub-micron level Sterile, non-disease transmitting Can be stored 3-6 months Can cause vasoconstriction (scavenge nitric oxide in vessels) Undefined effect in trauma, currently have several Level III trials ongoing Perfluorcarbon Related to Teflon Can be oxygenated, circulated Rapidly breaks down in circulation Rarely able to re-oxygenate in lung Performs like hemoglobin Mainly useful in PTCAResponder vs. non-responder Administer fluid challenge (500-1000 ml) and note results Responder SBP, HR return to normal Transient- SBP, HR approach normal, gradually drop Indicates ongoing blood loss Non-Responder- no response to challenge Indicates high loss of blood, may not be able to replace blood as fast as its lost Surgery most likely best answer, too unstable to CT scan/ other monitoring Lab Tests for adequate resuscitation Mixed venous saturations (>70%) Rarely have swan in place Lactate/ base deficit May rise as tissue reperfuses Monitor trend Hgb may not indicate volume status body will vasoconstrict to counteract blood loss/ hypovolemia. As Hgb is measurement of concentration, and concentration has not changed (less total Hgb, but still 10 gm/dL in less volume), total Hgb may appear artificially high. will frequently see drop in Hgb with adequate resuscitation PULSE OXIMETER TEST- MULTIPLE PULSE OXIMETERS ON EAR, NOSE, FINGERS TO TRY AND PICK UP PULSE Adequte Early Resuscitation will decrease late MODS Oxygen Debt Develops as tissue deprived of circulation, oxygen Needs to be repaid early to avoid bad outcome Hct> 30 correlates with better outcome Lactate normal at 24 hours = best response Lactate elevated at 48 hours = worst MODS/mortality Vital signs may also confuse you Tachycardia with pain, drugs, strong emotions, etc. Normotensive vs. hypotensive Increased SBP may pop off clot, resume bleeding Improved outcomes with SBP of 80 in liver injuries (one center), penetrating thoracic (one urban city) Unclear if hypotension benefits blunt trauma Crystal vs. colloid Crystalloid 1:3 replacement crystal cheaper no reactivity LR slightly hypo-osmotic transient intravascular, contributes to edema excess normal saline leads to hyperchloremic acidosis may worsen lactic acidosis, coagulopathy Colloid 1:1 replacement remains intravascular (hopefully) more expensive than crystalloid shows worse outcomes (albumin, mainly from tissue leakage) can worsen/ cause coagulopathy possible allergic reactions Blood replaces oxygen carrying capability replaces coag factors risk of infection risk of reaction chilled, must be warmed excess citrate leads to hypocalcemia religious/ personal refusal expensive to gather, test, store HBOC Obtained from bovine/ genetically altered bacterium Carry oxygen similar to RBC encapsulated hgb Encapsulated to circulate at sub-micron level Sterile, non-disease transmitting Can be stored 3-6 months Can cause vasoconstriction (scavenge nitric oxide in vessels) Undefined effect in trauma, currently have several Level III trials ongoing Perfluorcarbon Related to Teflon Can be oxygenated, circulated Rapidly breaks down in circulation Rarely able to re-oxygenate in lung Performs like hemoglobin Mainly useful in PTCA

13. Hypothermia Cause Effects Increased Oxygen demand Decreased peripheral perfusion Coagulopathy Decreased immune response/ healing Treatments Effects of hypothermia body attempts to conserve heat by shifting blood to core, leading to peripheral vasoconstriction O2 delivery reduced, cellular metabolism may increase faster than O2 delivery may worsen anaerobic metabolism, dropping pH, worsening coagulopathy May have higher rates wound infection, slower healing Coagulopathy cold reduces actions enzymes 10% per degree C below 35 decreased liver flow may reduce production/ distribution coag factors. Actions to raise Temp Best treatment is prevention KEEP PATIENT COVERED!! simple, but frequently missed Warm fluids Ranger, Hot Line, Level One Raise room temp (let the surgeon complain, it�s easier than chasing your tail with DIC) Warm lavage w/ foley, NG tube Extreme cases � Venous-Venous bypass. Effects of hypothermia body attempts to conserve heat by shifting blood to core, leading to peripheral vasoconstriction O2 delivery reduced, cellular metabolism may increase faster than O2 delivery may worsen anaerobic metabolism, dropping pH, worsening coagulopathy May have higher rates wound infection, slower healing Coagulopathy cold reduces actions enzymes 10% per degree C below 35 decreased liver flow may reduce production/ distribution coag factors. Actions to raise Temp Best treatment is prevention KEEP PATIENT COVERED!! simple, but frequently missed Warm fluids Ranger, Hot Line, Level One Raise room temp (let the surgeon complain, it�s easier than chasing your tail with DIC) Warm lavage w/ foley, NG tube Extreme cases � Venous-Venous bypass.

14. ARDS High incidence in trauma victims Long bone fractures Head injuries Multiple transfusions Pulmonary/ thoracic injuries sepsis Signs and symptoms? Onset? Intraoperative measures? Signs/symptoms Cotton candy on Xray Leakage of plasma and erythrocytes into interstitial and alveolar spaces Complement activation with release toxic oxygen radicals and lysosomal proteases Micro emboli Early signs Tachypnea Dyspnea ABG- respiratory alkalosis (hyperventilation, mild hypoxemia) Later signs Hypoxemia refractory to oxygen administration Right to left shunt from fluid filled/ collapsed alveoli Increased peak inspiratory pressures Onset 12-24 hours after injury Treatment goals Reduce peak inspiratory pressures Maintain oxygenation Increase PEEP (keep <10 cm water) Increase inspiratory time (inverse I:E ratios) Goal is to increase mean airway pressures without increasing Peak inspiratory pressures/ PEEP APRV mode used at our facility Signs/symptoms Cotton candy on Xray Leakage of plasma and erythrocytes into interstitial and alveolar spaces Complement activation with release toxic oxygen radicals and lysosomal proteases Micro emboli Early signs Tachypnea Dyspnea ABG- respiratory alkalosis (hyperventilation, mild hypoxemia) Later signs Hypoxemia refractory to oxygen administration Right to left shunt from fluid filled/ collapsed alveoli Increased peak inspiratory pressures Onset 12-24 hours after injury Treatment goals Reduce peak inspiratory pressures Maintain oxygenation Increase PEEP (keep <10 cm water) Increase inspiratory time (inverse I:E ratios) Goal is to increase mean airway pressures without increasing Peak inspiratory pressures/ PEEP APRV mode used at our facility

15. Assume: Full Stomach Cervical Spine Injury with Blunt Force hypotension with tachycardia from hypovolemia altered LOC from injury/ hypoperfusion/hypoxia, not just intoxication hypothermia �The worst until proven otherwise�

16. requirements Method to secure airway Induction drugs/ amounts? Sniffing position? 2 large bore IV Subclavian vs. IJ cortis Method to deliver high fluid volumes Ris vs. level one Inductions drugs Most any acceptable Pentothal �guaranteed kill� in Vietnam, we routinely give it (at 100-200 mg) Propofol has increased hypotensive effect Ketamine usually good, can cause hypotension if catecholamines exhausted Etomidate can cause hypotension if enough given Lidocaine usually good to blunt airway response Frequently only induction drug is Lidocaine/ succinylcholine Reduce dosages in hypotension More on airway later IV access Often have subclavian/ femoral access for central line If working on chest/ doing CPR, femoral easy to get at Don�t rely on it if have intra-abdominal injury Access above and below injury Subclavian over IJ as neck usually not cleared If do subclavian, keep syringe flat to chest (no hooking it under clavicle) Place in side with chest tube in place 1-5% chance pneumothorax, put it in a side where they can�t blame you Double or triple lumen slow to infuse, even 14/16 g catheters Try to get it in place before drapes go up Level one expensive (~$200/ kit), shouldn�t be used with crystalloid bags (may push in air embolism) Rapid Infusion System Reservoir Can mix products, crystalloid, blood Warms as infuses Fastest rate ~1.5 liters/ minuteInductions drugs Most any acceptable Pentothal �guaranteed kill� in Vietnam, we routinely give it (at 100-200 mg) Propofol has increased hypotensive effect Ketamine usually good, can cause hypotension if catecholamines exhausted Etomidate can cause hypotension if enough given Lidocaine usually good to blunt airway response Frequently only induction drug is Lidocaine/ succinylcholine Reduce dosages in hypotension More on airway later IV access Often have subclavian/ femoral access for central line If working on chest/ doing CPR, femoral easy to get at Don�t rely on it if have intra-abdominal injury Access above and below injury Subclavian over IJ as neck usually not cleared If do subclavian, keep syringe flat to chest (no hooking it under clavicle) Place in side with chest tube in place 1-5% chance pneumothorax, put it in a side where they can�t blame you Double or triple lumen slow to infuse, even 14/16 g catheters Try to get it in place before drapes go up Level one expensive (~$200/ kit), shouldn�t be used with crystalloid bags (may push in air embolism) Rapid Infusion System Reservoir Can mix products, crystalloid, blood Warms as infuses Fastest rate ~1.5 liters/ minute

17. Skills to Master Fluid Management Hypothermia Coagulopathies Electrolyte disturbances Effects of rapid transfusion on multiple organ systems

18. Skills to Master, Cont Inline Intubation/ Control Traumatized Airway

19. Airway Management challenges RSI Cervical spine injury Airway injury Suboptimal conditions Options? Awake nasal intubation RSI required on all trauma victims No one waits until after their accident to go to McDonalds Do not allow assistant to release cricoid until you tell them Everyone is excited, it�s your job to make sure things go smoothly Cervical spine injury 1-3% all major trauma 10% in head first fall/ high speed MVA X-Ray, CT, painful neck Makes life exciting All victims will get inline stabilization Assistant will kneel to left side and hold neck (full contact, no Vulcan mind meld fingertip to the temple) Once head secure, remove collar Assistant may not release head until collar replaced May be several minutes, suggest sitting on stool at side Some may stabilize from below, institution preference Usually so much is going on that they�ll be in the way Airway injury Edema Blood Mucking about by pre-hospital providers / ED docs/ med students Through and through GSW of neck with dissection infra-glottal Good view with direct laryngoscopy, but no breath sounds/ EtCO2 Unable to locate rings with surgical airway Passed tube through entry wound Suboptimal conditions Blood, foreign objects Over bed/ under objects Neutral neck, cricoid pressure, inline stabilization, no shoulder/ head bump Options Fiberoptic Usually don�t have time Blood/ secretions make it more difficult than other times Bullard Slightly easier to use than fiber optic Expensive, may not have available FASTrac LMA Cricoid pressure deforms pharyngo-laryngeal space, makes it more difficult to use Hard to find all the pieces in the heat of the moment Concerns over aspiration risks Gum elastic bougie/ Eschmann Useful in Grade III/IV views Blindly pass under epiglottis, feel for tracheal rings from bent tip place ETT over bougie, advance with rotation motion Awake nasal intubation Contraindicated in basalar skull fracture Underlying coagulopathy may lead to unacceptable bleeding RSI required on all trauma victims No one waits until after their accident to go to McDonalds Do not allow assistant to release cricoid until you tell them Everyone is excited, it�s your job to make sure things go smoothly Cervical spine injury 1-3% all major trauma 10% in head first fall/ high speed MVA X-Ray, CT, painful neck Makes life exciting All victims will get inline stabilization Assistant will kneel to left side and hold neck (full contact, no Vulcan mind meld fingertip to the temple) Once head secure, remove collar Assistant may not release head until collar replaced May be several minutes, suggest sitting on stool at side Some may stabilize from below, institution preference Usually so much is going on that they�ll be in the way Airway injury Edema Blood Mucking about by pre-hospital providers / ED docs/ med students Through and through GSW of neck with dissection infra-glottal Good view with direct laryngoscopy, but no breath sounds/ EtCO2 Unable to locate rings with surgical airway Passed tube through entry wound Suboptimal conditions Blood, foreign objects Over bed/ under objects Neutral neck, cricoid pressure, inline stabilization, no shoulder/ head bump Options Fiberoptic Usually don�t have time Blood/ secretions make it more difficult than other times Bullard Slightly easier to use than fiber optic Expensive, may not have available FASTrac LMA Cricoid pressure deforms pharyngo-laryngeal space, makes it more difficult to use Hard to find all the pieces in the heat of the moment Concerns over aspiration risks Gum elastic bougie/ Eschmann Useful in Grade III/IV views Blindly pass under epiglottis, feel for tracheal rings from bent tip place ETT over bougie, advance with rotation motion Awake nasal intubation Contraindicated in basalar skull fracture Underlying coagulopathy may lead to unacceptable bleeding

20. Interesting Airway Consults 16 y.o. male riding ATV collided with tree Walked 1.5 miles to home, called ems Vs stable, Speech slightly slurred, gcs 15 Left radial pulse < right 100 % SAT on 10 L/min nrb Reported �stick in the neck� 16 year old male riding 4 wheel ATV ran into tree. Walked 1.5 miles to his home and called EMS. EMS report �stick in neck�, Speech slightly slurred Oxygenation 100% on NRB 10 L/min VS stable 16 g. IV to left anterocubital vein This is how he presented How do you control this airway? This is what we did We called in a tree surgeon and performed a limb salvage procedure16 year old male riding 4 wheel ATV ran into tree. Walked 1.5 miles to his home and called EMS. EMS report �stick in neck�, Speech slightly slurred Oxygenation 100% on NRB 10 L/min VS stable 16 g. IV to left anterocubital vein This is how he presented How do you control this airway? This is what we did We called in a tree surgeon and performed a limb salvage procedure

21. Pre Hospital Report Mechanism of injury Glascow Coma Score (GCS) including extremity check A. M. P. L. E. Lethal six Report should include mechanism of injury, including: Extraction time Death at scene Bulls eye of windshield Deformation of car With head on crash suspect: Sub dural hemorrhage/ Closed head injury Skull fracture (including basilar, no NG or nasal intubation) Facial/ mandibular fracture from impact dash/ steering wheel mandible fx easier to intubate as can lift whole jaw, look for misaligned/missing teeth Facial fracture frequently very bloody Look for foreign objects/ teeth Cervical spine injury Clavicular/ neck vascular injury from seatbelt Flail chest/ rib fractures/ pneumothorax Aortic dissection (ligamentum arteriosum), spot where aorta has most mobility Frequently die at scene, but may survive to hospital Cardiac contusion/ tamponade/ pulmonary contusion from impact w/ steering wheel Signs/Symptoms of cardiac and pulmonary contusion dysrhythmias, increased cardiac enzymes, decreased cardiac output, CHF symptoms pulmonary edema, pulmonary secretions, decreased saturations, pain May develop into ARDS Occult Pneumo may become significant with positive pressure ventilation Wrist/ forearm fracture from bracing self on dash Femur neck fracture Pelvis (open book, can be life threatening due to blood loss) Knees/lower extremity/ankles due to entrapment, force on brake pedal or dead pedal Side Impact Epidural Closed head injury (wake up and die) due to frequent injury of temporal bone/ middle meningeal artery causing epidural bleed C-Spine Aortic dissection Shoulder/ humerus/ clavicle injury It takes significant force to break humerus, suspect underlying pulmonary contusion/ rib fractures Pelvis (crush) femur unilateral lower extremity Ejection All bets are off Fall Aortic dissection Pelvic (shearing) bilateral calcaneal fracture head/chest/ abdomen possible impalement Penetrating Assume the worst More likely to have hollow organ injury AMPLE Allergies Medications including tobacco, ETOH, street drugs Prior medical/surgical history Last meal (a waste of time, assume full stomach) What if injury occurred > 8 hours ago? Increased sympathetic tone from catecholamine release (pain, shock, fear, anxiety) will reduce gastric emptying/ motility, so stomach still assumed full Events that lead to injury (did the patient have loss of consciousness, amnesia) Other questions Should also try to obtain name, contact number of family Where does it hurt? Lethal 6- lacerations of brain, brain stem, upper spinal cord, heart, aorta or other large vessels (decapitation, aortic dissection, penetrating brain stem injury, massive hemorrhage) Package up w/ backboard, C-Collar, IV, O2 don�t use sandbags, can shift and push on C-Spine Nasal Cannula usually not adequate high O2 demand, NRB necessary Should be able to turn patient on side without motion in spineReport should include mechanism of injury, including: Extraction time Death at scene Bulls eye of windshield Deformation of car With head on crash suspect: Sub dural hemorrhage/ Closed head injury Skull fracture (including basilar, no NG or nasal intubation) Facial/ mandibular fracture from impact dash/ steering wheel mandible fx easier to intubate as can lift whole jaw, look for misaligned/missing teeth Facial fracture frequently very bloody Look for foreign objects/ teeth Cervical spine injury Clavicular/ neck vascular injury from seatbelt Flail chest/ rib fractures/ pneumothorax Aortic dissection (ligamentum arteriosum), spot where aorta has most mobility Frequently die at scene, but may survive to hospital Cardiac contusion/ tamponade/ pulmonary contusion from impact w/ steering wheel Signs/Symptoms of cardiac and pulmonary contusion dysrhythmias, increased cardiac enzymes, decreased cardiac output, CHF symptoms pulmonary edema, pulmonary secretions, decreased saturations, pain May develop into ARDS Occult Pneumo may become significant with positive pressure ventilation Wrist/ forearm fracture from bracing self on dash Femur neck fracture Pelvis (open book, can be life threatening due to blood loss) Knees/lower extremity/ankles due to entrapment, force on brake pedal or dead pedal Side Impact Epidural Closed head injury (wake up and die) due to frequent injury of temporal bone/ middle meningeal artery causing epidural bleed C-Spine Aortic dissection Shoulder/ humerus/ clavicle injury It takes significant force to break humerus, suspect underlying pulmonary contusion/ rib fractures Pelvis (crush) femur unilateral lower extremity Ejection All bets are off Fall Aortic dissection Pelvic (shearing) bilateral calcaneal fracture head/chest/ abdomen possible impalement Penetrating Assume the worst More likely to have hollow organ injury AMPLE Allergies Medications including tobacco, ETOH, street drugs Prior medical/surgical history Last meal (a waste of time, assume full stomach) What if injury occurred > 8 hours ago? Increased sympathetic tone from catecholamine release (pain, shock, fear, anxiety) will reduce gastric emptying/ motility, so stomach still assumed full Events that lead to injury (did the patient have loss of consciousness, amnesia) Other questions Should also try to obtain name, contact number of family Where does it hurt? Lethal 6- lacerations of brain, brain stem, upper spinal cord, heart, aorta or other large vessels (decapitation, aortic dissection, penetrating brain stem injury, massive hemorrhage) Package up w/ backboard, C-Collar, IV, O2 don�t use sandbags, can shift and push on C-Spine Nasal Cannula usually not adequate high O2 demand, NRB necessary Should be able to turn patient on side without motion in spine

22. Monitors Standard BP HR Sat Respiratory rate and effort Use your eyes, can tell BP by peripheral pulses, will note deterioration in mental status, change in respiratory pattern/ effort What�s your name? What happened? Airway open/ clear Has enough breath to answer your questions Perfusing to head If can process question and respond appropriately, then doing ok for nowStandard BP HR Sat Respiratory rate and effort Use your eyes, can tell BP by peripheral pulses, will note deterioration in mental status, change in respiratory pattern/ effort What�s your name? What happened? Airway open/ clear Has enough breath to answer your questions Perfusing to head If can process question and respond appropriately, then doing ok for now

23. Assessment Rapid Identification and Treatment of life threatening injuries Primary Survey Airway w/ CSpine Breathing Circulation w/ Hemorrhage Control Disability Expose Secondary Survey Head to toe, full assessment/ XRays, tubes Primary Survey � Fast (<30 seconds) identify and treat life threatening injuries Occluded Airway Hypoxemia Tension Pneumothorax Cardiac Tamponade Hypovolemia/ ongoing bleeding Closed head injury Holes in the back where patient is leaking When to intubate? GCS< 8 Unable to clear/ maintain airway ETOH classic If need to do RSI, need to place OG Severe head injury Airway trauma �Social Intubation� Injury to self, providers Pain control Secondary Survey- Two minutes, identify all obvious injuries Rapid Identification and Treatment of life threatening injuries Primary Survey Airway w/ CSpine Breathing Circulation w/ Hemorrhage Control Disability Expose Secondary Survey Head to toe, full assessment/ XRays, tubes Primary Survey � Fast (<30 seconds) identify and treat life threatening injuries Occluded Airway Hypoxemia Tension Pneumothorax Cardiac Tamponade Hypovolemia/ ongoing bleeding Closed head injury Holes in the back where patient is leaking When to intubate? GCS< 8 Unable to clear/ maintain airway ETOH classic If need to do RSI, need to place OG Severe head injury Airway trauma �Social Intubation� Injury to self, providers Pain control Secondary Survey- Two minutes, identify all obvious injuries

24. Pre-operative assessment IDEAL The preoperative visit is ideally accomplished 1-2 days before�surgery, ideally by the anesthesia provider who will be providing the anesthetic. During the visit, the preoperative status of the patient is evaluated by a thorough review of the chart and interview followed by a physical examination. REALITY Found down, no history

25. Intra Operative Anesthesia is anesthesia is anesthesia Our job is not that different from out patient/ �healthy� anesthesia, just different techniques Be more aware of potential complications i.e. new onset/ worsening pneumothorax, continuing blood loss, etc May be difficult to maintain CSpine precautions, document that CSpine under care of surgeons, pre and post neuro checks Monitor room temperature (surgeons will prep belly, then take 20 minutes to scrub, want the thermostat at near artic levels, etc) Minimum requirements (Cardiac anesthesia easy, drugs/lines in place. It�s not hard to give the right dosage of a drug, it is challenging to find the drug, place the IV under the drapes on a body that is already vasoconstricting, etc., mix the drug, find the IV pump, etc.) 2 Large bore IV�s, Central cortis a plus (Triple or double lumen doubly dangerous, slow to infuse and give a false sense of security) CVP/PA cath not always necessary to judge resuscitation, rarely placed initially +/- Arterial line depending on situation (large, ongoing blood loss, neuro, pulmonary status, across midline GSW, etc. If in doubt, place it) Foley (poor man�s CVP) Make sure blood products (6 red, 4-6 yellow depending on injury) immediately available, not �sending someone to get it� Volunteer got lost, intercity employee took cigarette break, forgot patient ID, etc. Most hospitals take forever to get type and cross Hourly labs (will probably give Calcium, FFP, Blood and adjust vent based on labs. Rainbow (chem 10, CBC, Lactate, Coags) Pneumothorax my appear/ worsen, BP may drop as warm up/vasodilate, increased lactate as reperfuse, pulmonary status may worsen d/t underlying damage, pulmonary edema, etc. Exhaustion of catecholamines S/S hypocalcemia Hypotension not responsive to fluid challenge Tachycardia/normocardia with hypotension New/worsening pneumothorax Embolism Hypovolemic shock Worsening epidural bleed Tamponade Hypocalcemia/ hyperkalemia ARDS/aspiration Brain stem herniation Anesthesia is anesthesia is anesthesia Our job is not that different from out patient/ �healthy� anesthesia, just different techniques Be more aware of potential complications i.e. new onset/ worsening pneumothorax, continuing blood loss, etc May be difficult to maintain CSpine precautions, document that CSpine under care of surgeons, pre and post neuro checks Monitor room temperature (surgeons will prep belly, then take 20 minutes to scrub, want the thermostat at near artic levels, etc) Minimum requirements (Cardiac anesthesia easy, drugs/lines in place. It�s not hard to give the right dosage of a drug, it is challenging to find the drug, place the IV under the drapes on a body that is already vasoconstricting, etc., mix the drug, find the IV pump, etc.) 2 Large bore IV�s, Central cortis a plus (Triple or double lumen doubly dangerous, slow to infuse and give a false sense of security) CVP/PA cath not always necessary to judge resuscitation, rarely placed initially +/- Arterial line depending on situation (large, ongoing blood loss, neuro, pulmonary status, across midline GSW, etc. If in doubt, place it) Foley (poor man�s CVP) Make sure blood products (6 red, 4-6 yellow depending on injury) immediately available, not �sending someone to get it� Volunteer got lost, intercity employee took cigarette break, forgot patient ID, etc. Most hospitals take forever to get type and cross Hourly labs (will probably give Calcium, FFP, Blood and adjust vent based on labs. Rainbow (chem 10, CBC, Lactate, Coags) Pneumothorax my appear/ worsen, BP may drop as warm up/vasodilate, increased lactate as reperfuse, pulmonary status may worsen d/t underlying damage, pulmonary edema, etc. Exhaustion of catecholamines S/S hypocalcemia Hypotension not responsive to fluid challenge Tachycardia/normocardia with hypotension New/worsening pneumothorax Embolism Hypovolemic shock Worsening epidural bleed Tamponade Hypocalcemia/ hyperkalemia ARDS/aspiration Brain stem herniation

26. Post operative Continually reassess patient Serial labs Post op intubation likely Possible transfer to major center Resuscitation is ongoing Monitor lactate/ base deficit vs. mixed venous Need experienced caregivers that recognize hypoxemia/ hypovolemia Run of the mill PACU nurses probably not adequate Don�t let surgeon arrogance kill the patient Patient one has 16 IV pumps Patient two has nine chest tubes, down from 12 the day before On striker frame to prone, unload lungsResuscitation is ongoing Monitor lactate/ base deficit vs. mixed venous Need experienced caregivers that recognize hypoxemia/ hypovolemia Run of the mill PACU nurses probably not adequate Don�t let surgeon arrogance kill the patient Patient one has 16 IV pumps Patient two has nine chest tubes, down from 12 the day before On striker frame to prone, unload lungs

27. Abdominal Trauma Signs/ symptoms Peritoneal signs Rigid abdomen Pain on palpation May be subtle/ overshadowed by ETOH, altered LOC, other painful areas Diagnostic Techniques Focused Abdominal Ultrasonagraphy Test (FAST) Coming into vogue Requires operator proficiency Does not show blood, only liquid in abdomen May show hemopneumothorax Military using in backpack portable ED/ OR (MFAST/ FAST teams) Direct Peritoneal Lavage Hole in abdomen wall, infuse liter Normal Saline, withdraw fluid May show intrabdominal blood Going out of favor in preference to FAST CAT Scan Gold standard for blood throughout abdomen, retroperitoneal New helical scans take < 60 seconds for abdomen/ head/ neck Requires interpretation/ availability of CT Known as �Tunnel of Death� due to extubation (circuits not long enough to travel through scanner), deterioration from ongoing blood loss, hypoxemia from new onset airway compromise, etc. Blunt vs. Penetrating Blunt more likely to affect solid organ (liver, spleen) Stiffer, limited flexibility, stiff outer coating encapsulated more likely to suffer acceleration /deceleration injuries Squeezing a golf ball vs. a tennis ball Stomach may be affected when struck against seat belt, steering wheel New techniques in angiography often allow embolization of bleeding without open surgery Penetrating more likely to hit hollow organs (more of them in abdomen) Usually need to open if wound penetrates abdominal peritoneum Obvious bowel extrusion Obvious omental extrusion Entry wound variation by sex Males from high to low Females low to high Abdominal stabs often hit diaphragm, suspect pneumothorax Celiotomy Celiac plexus Level of T12-L1 Blockage/ removal limits: Pancreatic pain Increases intestinal motility Regions of the Abdomen Upper abdomen- bony thorax, diaphragm, liver, spleen, stomach and transverse colon Retroperitoneal space- aorta, vena cava, pancreas, kidneys, ureters, portions of the colon and duodenum Pelvis- rectum, bladder, illiac vessels, internal genitalia (females)Signs/ symptoms Peritoneal signs Rigid abdomen Pain on palpation May be subtle/ overshadowed by ETOH, altered LOC, other painful areas Diagnostic Techniques Focused Abdominal Ultrasonagraphy Test (FAST) Coming into vogue Requires operator proficiency Does not show blood, only liquid in abdomen May show hemopneumothorax Military using in backpack portable ED/ OR (MFAST/ FAST teams) Direct Peritoneal Lavage Hole in abdomen wall, infuse liter Normal Saline, withdraw fluid May show intrabdominal blood Going out of favor in preference to FAST CAT Scan Gold standard for blood throughout abdomen, retroperitoneal New helical scans take < 60 seconds for abdomen/ head/ neck Requires interpretation/ availability of CT Known as �Tunnel of Death� due to extubation (circuits not long enough to travel through scanner), deterioration from ongoing blood loss, hypoxemia from new onset airway compromise, etc. Blunt vs. Penetrating Blunt more likely to affect solid organ (liver, spleen) Stiffer, limited flexibility, stiff outer coating encapsulated more likely to suffer acceleration /deceleration injuries Squeezing a golf ball vs. a tennis ball Stomach may be affected when struck against seat belt, steering wheel New techniques in angiography often allow embolization of bleeding without open surgery Penetrating more likely to hit hollow organs (more of them in abdomen) Usually need to open if wound penetrates abdominal peritoneum Obvious bowel extrusion Obvious omental extrusion Entry wound variation by sex Males from high to low Females low to high Abdominal stabs often hit diaphragm, suspect pneumothorax Celiotomy Celiac plexus Level of T12-L1 Blockage/ removal limits: Pancreatic pain Increases intestinal motility Regions of the Abdomen Upper abdomen- bony thorax, diaphragm, liver, spleen, stomach and transverse colon Retroperitoneal space- aorta, vena cava, pancreas, kidneys, ureters, portions of the colon and duodenum Pelvis- rectum, bladder, illiac vessels, internal genitalia (females)

28. Surgeon vs. radiologist Exploratory laparatomy Penetrating Blunt with evidence internal bleed Injured diaphragm Injury to bladder, ureters CT evidence of pancreatic, GI, kidney Unstable liver/ spleen bleed Laparatomy not always indicated No peritonitis/ pain, CT negative, just observe Grade I/II splenic or hepatic laceration may not require intervention May observe, do serial CT scans �Emergent� abdominal surgery only for unstable bleed Give couple liters in 5 minutes, if no response, to OR Prep from knees to shoulders Get cold quickly Cover ekg leads with opsite/ tape Be prepared to go into chest Have everything ready because opening the abdomen may release tamponade, drop cardiac return and make you scramble Many trauma centers will embolize spleen, RA Cowley will also do liver Personal experience with operative liver is 4/6 (grade V-VI, coagulopathic) 15 blood volumes (75 Liters blood/ blood products) Epinephrine wide open Puddle of blood 4 inches deep around bedLaparatomy not always indicated No peritonitis/ pain, CT negative, just observe Grade I/II splenic or hepatic laceration may not require intervention May observe, do serial CT scans �Emergent� abdominal surgery only for unstable bleed Give couple liters in 5 minutes, if no response, to OR Prep from knees to shoulders Get cold quickly Cover ekg leads with opsite/ tape Be prepared to go into chest Have everything ready because opening the abdomen may release tamponade, drop cardiac return and make you scramble Many trauma centers will embolize spleen, RA Cowley will also do liver Personal experience with operative liver is 4/6 (grade V-VI, coagulopathic) 15 blood volumes (75 Liters blood/ blood products) Epinephrine wide open Puddle of blood 4 inches deep around bed

29. neurotrauma Cerebral perfusion pressure (CPP) = Mean Arterial Pressure (MAP) � Intracranial Pressure (ICP), keep CPP > 70 mm Assume ICP in head injured at least 20 cm water (normal <5 cm) Reduce ICP by: promote venous drainage raise the head of the bed 45 degrees keep the neck neutral, not turned/ kinked monitor neck constriction by collar, ETT tape, etc. Minimize PEEP if on positive pressure ventilation (and probably should be) reduce blood flow keep MAP just right may, in extreme cases, not routinely, hypoventilate to EtCO2 30-35 mm (hypocarbia will constrict all vessels, leading to decreased blood flow to damaged areas and worse outcomes) Give Mannitol osmotic diuretic, pulls fluid from interstitial/ intercellular, reducing edema may have direct cellular benefit each 50 cc bottle of 25% solution equals 12.5 gm (give 25-50 gm/ dose, or 2-4 bottles) replace 1 cc Normal Saline per 1 cc Urine output Place drain with adjustable valve, drain CSF Decompressive Craniotomy Decompressive Laparotomy Anticipate phenytoin in closed head injured, steroid in spinal injured Closed head injuries associated with basaler skull fractures no NG, nasal intubation anticipate antibiotic therapyCerebral perfusion pressure (CPP) = Mean Arterial Pressure (MAP) � Intracranial Pressure (ICP), keep CPP > 70 mm Assume ICP in head injured at least 20 cm water (normal <5 cm) Reduce ICP by: promote venous drainage raise the head of the bed 45 degrees keep the neck neutral, not turned/ kinked monitor neck constriction by collar, ETT tape, etc. Minimize PEEP if on positive pressure ventilation (and probably should be) reduce blood flow keep MAP just right may, in extreme cases, not routinely, hypoventilate to EtCO2 30-35 mm (hypocarbia will constrict all vessels, leading to decreased blood flow to damaged areas and worse outcomes) Give Mannitol osmotic diuretic, pulls fluid from interstitial/ intercellular, reducing edema may have direct cellular benefit each 50 cc bottle of 25% solution equals 12.5 gm (give 25-50 gm/ dose, or 2-4 bottles) replace 1 cc Normal Saline per 1 cc Urine output Place drain with adjustable valve, drain CSF Decompressive Craniotomy Decompressive Laparotomy Anticipate phenytoin in closed head injured, steroid in spinal injured Closed head injuries associated with basaler skull fractures no NG, nasal intubation anticipate antibiotic therapy

30. Neuro trauma, cont. Develop proficiency in reading Xrays, otherwise will look like thisDevelop proficiency in reading Xrays, otherwise will look like this

31. Lessons I have Learned Epinephrine is your friend Know your vascular anatomy Always Double Glove! One 14 g in the AC is worth two triple lumens in the IJ Bullets and blades make little %$#@ out of everyone Universal Precautions aren�t just for JCAHO visits Trauma providers are lifeguards for the shallow end of the gene pool

32. Questions?