Transcript 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
 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 Trauma
 If situation does not permit full assessment :
– Obtain AMPLE history
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A – Allergies
M – Medications
P – Past medical history
L – Last meal
E – Events leading to injury
And proceed with interventions
Anaesthesia for Trauma
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Keep in mind – 6 injuries that kill quickly
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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 Trauma
 Other life-threatening injuries :
 Simple pneumothorax
 Pulmonary contusion
 Cardiac contusion
 Aortic disruption
 Diaphragmatic disruption
 Tracheo-bronchial disruption
 Esophageal disruption
Anaesthesia for Trauma
 Airway Control : requires ETT, stylet, bougie, suction, O2 (Ambu
bag ), LMA, and Cricothyroidotomy kit at the ready
 Consider :
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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 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
C2 pedicle MVA
Jefferson Fracture
C1 burst – axial loading
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 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
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Worsens muscular ( cardiac ) function
Reduces platelet adhesion
Warm all fluids, OR, Bair hugger, irrigation
Linear relationship between extent of hypothermia and mortality
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 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
 Less than10% of blunt and 20% of penetrating trauma
require thoracotomy
 Indications :
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Persistent Haemothorax
Persistent large air leak
Tracheo-bronchial disruption
Diaphragmatic disruption
Esophageal disruption
Cardiac Tamponade
Aortic disrution
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 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 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 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
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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
VAC ( vacuum ) Dressing
Anaesthesia for Orthopaedic Trauma
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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
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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 Trauma
 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 Trauma
 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
 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 Trauma
 In Conclusion :
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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