Anesthesia for Trauma Christopher DeSantis, MD Anesthesiology CA-3

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Anesthesia for Trauma Christopher DeSantis,
MDAnesthesiology CA-3

• Boston University Medical Center
• October 12, 2006
• Faculty Advisor Dr. Lopes

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Anesthesia for Trauma

• Trauma is the leading cause of death between the
  ages of 1 and 45
• In the US preventable deaths decreased from 13
  to 7 over the past decades because of more
  efficient systems of trauma care
• Anesthesia Care
• Airway and Resuscitation in Emergency Department
• Operating Room Care
• Management in Intensive Care Unit

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Prioritizing Trauma Care

• Do you know your ABCs ?

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Prioritizing Trauma Care

• ABCDE
• Airway
• Vocal Response, Auscultation
• Chin Lift, Bag-Valve-Mask, 100 O2, Intubation,
  Cricothyriodotomy, Tracheostomy
• Breathing
• Pulse Oximetry, Arterial Blood Gas, CXR
• Mechanical Ventilation, Tube Thoracostomy

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Prioritizing Trauma Care

• Circulation
• Vital Signs, Capillary Refill, Response to Fluid
  Bolus, CBC, Coagulation Studies, FAST, X-Ray
• Adequate IV Access, Fluid Bolus, Pressure to Open
  Wounds, Thoracotomy, Transfusion, Surgery
• Neurologic Disability
• GCS, Motor/Sensory Exam, Head, Neck, and Spine
  CT, Cervical Spine Films
• Support Oxygenation/Perfusion, ICP Monitoring

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Prioritizing Trauma Care

• Exposure and Secondary Survey
• Laboratory Studies, ECG, Plain Films, CT scan,
  Detailed History and Physical Exam
• Removal of all Cloths, Detailed Review of all
  Laboratory and Radiographic Findings

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Airway/Breathing

• Verification of adequate airway and acceptable
  respiratory mechanics is of primary importance
• Hypoxia is the most immediate threat to life
• Inability to oxygenate a patient will lead to
  permanent brain injury and death within 5 to 10
  Minutes

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Airway obstruction

• Direct injury
• Face, Mandible, or Neck
• Hemorrhage
• Pharynx, Sinuses, and Upper airway
• Diminished Consciousness
• Traumatic Brain injury, Intoxication, Analgesic
  medications
• Aspiration
• Gastric contents, Foreign body
• Misapplication of Airway/Endotracheal Tube
• Esophageal Intubation

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Inadequate Ventilation

• Diminished Respiratory Drive
• Traumatic Brain injury, Shock, Intoxication,
  Hypothermia, Over Sedation
• Direct Injury
• Cervical Spine, Chest Wall, Pneumo/Hemothorax,
  Trachea, Bronchi, Pulmonary Contusion
• Aspiration
• Gastric contents, Foreign body
• Bronchospasm
• Smoke, Toxic Gas Inhalation

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Indications for Endotracheal Intubation

• Cardiac or Respiratory Arrest
• Respiratory Insufficiency
• Airway Protection
• Deep Sedation or Analgesia
• General Anesthesia
• Transient Hyperventilation
• Space Occupying Intracranial Lesion/Increased ICP
• Delivery of 100 O2
• Carbon Monoxide Poisoning
• Facilitation of Diagnostic Workup
• Uncooperative or Intoxicated Patient

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Prophylaxis against Aspiration

• Trauma patients are always considered to have
  full stomach
• Ingestion of food or liquids before injury
• Swallowed blood from oral or nasal injury
• Delayed gastric emptying
• Administration of liquid contrast medium
• Reasonable to administer nonparticulate antacid
  prior to induction
• Cricoid pressure/Sellick Maneuver should be
  applied continuously during airway management
• Rapid Sequence Induction
• Avoidance of ventilation between administration
  of medication and intubation

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Cervical Spine Injury

• Trauma Patients
• No Radiological Studies
• Alert, Awake, and Oriented
• No Neurological Deficits
• No Distracting Pain
• MRI Cervical Spine
• Neck Pain
• Cervical Tenderness to Palpation

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Cervical Spine Injury

• All Other Trauma Patients
• Lateral radiograph of cervical spine
• Anteropostererior spinous process C2-T1
• Open mouth odontoid view
• Axial CT with reconstruction
• Regions of questionable injury
• Inadequate visualization

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Protection of the Cervical Spine

• All blunt trauma victims should be assumed to
  have an unstable cervical spine until proven
  otherwise
• Direct laryngoscopy causes cervical motion and
  the potential to exacerbate spinal cord injury
• An uncleared cervical spine mandates In-line
  Stabilization (Not Traction)
• The front of the cervical collar may be removed
  for greater mouth opening and jaw displacement

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Protection of the Cervical Spine

• Emergency Awake Fiberoptic Intubation
• Requires less manipulation of the neck
• Generally very difficult
• Airway Secretions
• Hemorrhage
• Rapid Desaturation
• Lack of Patient cooperation

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Induction of Anesthesia

• Propofol/Thiopental
• Vasodilator, Negative Inotropic effect
• May Potentate hypotension/Cardiac Arrest
• Etomidate
• Increased cardiovascular stability
• Ketamine
• Direct myocardial depressant
• Catecholamine release
• Hypertension/Tachycardia
• Midazolam
• Reduced Awareness
• Hypotension
• Scopolamine (Tertiary Amine)
• Inhibits memory formation
• Muscle relaxants alone
• Recall of Intubation/Recall of Emergency
  procedures

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Neuromuscular Blocking Drugs

• Succinylcholine
• Fastest onset lt1 min
• Shortest Duration5-10 min
• Potassium increase 0.5-1.0mEq/L
• Potassium increase gt5mEq/L
• After 24 hours
• Safe in acute airway management
• Burn Victims
• Muscle Pathology
• Direct Trauma
• Denervation
• Immobilization
• Increase intraocular pressure
• Caution in patients with ocular trauma
• Increase ICP
• Controversial in head trauma

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Circulation

• Hemorrhage is the next most pressing concern
• Ongoing blood loss will be fatal in minutes to
  hours
• Shock is presumed to be a consequence of
  hemorrhage until proven otherwise

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Symptoms of Shock

• What are the symptoms of shock ?

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Symptoms of Shock

• Pallor
• Diaphoresis
• Agitation or Obtundation
• Hypotension
• Tachycardia
• Prolonged Capillary Refill
• Diminished Urine Output
• Narrow Pulse Pressure

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Early Resuscitation

• Maintain SBP at 80-100 mm Hg
• Maintain Hematicrit at 25-30
• Maintain PT/PTT in normal range
• Maintain Platelet count gt 50,000
• Maintain Normal serum ionized calcium
• Maintain core temperature gt 35C
• Prevent increase in serum lactate
• Prevent Acidosis

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Intravenous Access

• Order of Desirability
• Large-bore (16g or greater) antecubital vein
• Other large-bore peripheral veins
• Subclavian vein
• Femoral vein
• Internal jugular vein (Requires removal of
  cervical collar and neck manipulation)
• Intraosseous (Tibia or distal end of femur)

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Fluid Infusion System

• Active fluid administration up to 1500 ml/min
• Compatible with crystalloid, colloid, RBC,
  plasma, washed/salvaged blood (Not platelets)
• Reservoir allows for mixing of products
• Controlled temperature (38-40C)
• Able to pump through multiple IV lines
• Fail safe detection system to prevent infusion of
  air
• Accurate recording of volume administered
• Portable to travel with patients between units

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Risks of Aggressive Volume Replacement

• Increased blood pressure
• Decreased blood viscosity
• Decreased hematocrit
• Decreased Clotting factors
• Greater transfusion requirements
• Electrolyte imbalance
• Direct immune suppression
• Premature reperfusion

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Glasgow Coma Score

• What is the Glasgow Coma Score ?

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Glasgow Coma Score

• Eye Opening Response Motor Response
• 4Spontaneous 6Follows Commands
• 3To Speech 5Localizes to Pain
• 2To Pain 4Withdraws from Pain
• 1None 3Abnormal Flexion
• (Decorticate Posturing)
• Verbal Response 2Abnormal Extension
• 5Oriented to Name (Decerebrate Posturing)
• 4Confused 1-None
• 3Inappropriate Speech
• 2Incomprehensible Sounds
• 1None

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Traumatic Brain Injury

• Anesthetic Management
• Avoidance of Hypoxemia
• Intubation
• Airway protection
• Controlled Hyperventilation
• Uncooperative/Combative Patient
• GCS lt 8
• Control Hemodynamics
• Avoid Hypotension
• Fluid Administration
• Vasopressors
• Arterial Line

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Traumatic Brain Injury

• Management of Cerebral Circulation
• Hyperventilation
• PaCO2 at 35 mmHg
• PaCO2 at 30 mmHg for episodes of elevated ICP
• Mannitol
• 0.5-1g/kg
• Barbiturate

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Traumatic Brain Injury

• Temperature
• Avoid Severe Hypothermia
• Do not warm aggressively
• Hyperthermia increases CMRO2
• Position Therapy
• Elevation of Patients Head
• Facilitate venous drainage
• Lower ICP
• Improved Ventilation/Perfusion

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• The End