Anaesthesia for Trauma Patients

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Anaesthesia for Trauma Patients

• By Dr. H. O. Opere
• Consultant Anaesthesiologist
• April 2013

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INTRODUCTION

• The initial assessment of the trauma patient can
  be divided into
• Primary survey
• Secondary survey
• Tertiary survey

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PRIMARY SURVEY

• The primary survey should take 25 minutes and
  consists of the ABCDE sequence of trauma Airway,
  Breathing, Circulation, Disability, and Exposure.

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PRIMARY SURVEY Airway

• Establishing and maintaining an airway is always
  the first priority.
• Important signs of obstruction include snoring or
  gurgling, stridor, and paradoxical chest
  movements.
• The presence of a foreign body should be
  considered in unconscious patients.
• Advanced airway management (such as endotracheal
  intubation, cricothyrotomy, or tracheostomy) is
  indicated if there is apnea, persistent
  obstruction, severe head injury, maxillofacial
  trauma, a penetrating neck injury with an
  expanding hematoma, or major chest injuries.

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PRIMARY SURVEY Airway contd

• Cervical spine injury is unlikely in alert
• patients without neck pain or tenderness.
• Five criteria increase the risk for potential
• instability of the cervical spine
• Neck pain
• Severe distracting pain
• Any neurological signs or symptoms
• Intoxication
• Loss of consciousness at the scene.

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PRIMARY SURVEY Airway contd

• Laryngeal trauma makes a complicated
• situation worse. Open injuries may be
• associated with bleeding from major neck
• vessels, obstruction from hematoma or
• edema, subcutaneous emphysema, and
• cervical spine injuries.
• Closed laryngeal trauma is less obvious but
• can present as neck crepitations, hematoma,
  dysphagia, hemoptysis, or poor phonation.

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PRIMARY SURVEY Breathing

• Assessment of ventilation is best accomplished by
  the look, listen, and feel approach.
• Look for cyanosis, use of accessory muscles,
  flail chest, and penetrating or sucking chest
  injuries.
• Listen for the presence, absence, or diminution
  of breath sounds.
• Feel for subcutaneous emphysema, tracheal shift,
  and broken ribs.

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PRIMARY SURVEY Circulation

• Adequacy of circulation is based on pulse rate,
  pulse fullness, blood pressure, and signs of
  peripheral perfusion.
• Signs of inadequate circulation include
• tachycardia, weak or unpalpable peripheral
• pulses, hypotension, and pale, cool, or cyanotic
• extremities.
• The first priority in restoring adequate
• circulation is to stop bleeding.
• The second priority is to replace intravascular
• volume.

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PRIMARY SURVEY Contd

• Disability
• Evaluation for disability consists of a rapid
• neurological assessment. Because there is
  usually no time for a Glasgow Coma Scale, the
  AVPU system is used awake, verbal response,
  painful response, and unresponsive.
• Exposure
• The patient should be undressed to allow
• examination for injuries. In-line immobilization
• should be used if a neck or spinal cord injury is
• suspected.

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SECONDARY SURVEY

• The secondary survey begins only when the ABCs
  are stabilized.
• In the secondary survey, the patient is evaluated
  from head to toe and the indicated studies (eg,
  radiographs, laboratory tests, invasive
  diagnostic procedures) are obtained.
• Head examination includes looking for injuries to
  the scalp, eyes, and ears.
• Neurological examination includes the Glasgow
  Coma Scale and evaluation of motor and sensory
  functions as well as reflexes.

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SECONDARY SURVEY Contd

• The chest is auscultated and inspected again for
  fractures and functional integrity (flail chest).
• Examination of the abdomen should consist of
  inspection, auscultation, and palpation.
• The extremities are examined for fractures,
  dislocations, and peripheral pulses.
• A urinary catheter and nasogastric tube are also
  normally inserted.

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SECONDARY SURVEY Contd

• Basic laboratory analysis includes a complete
  blood count (or hematocrit or hemoglobin),
  electrolytes, glucose, blood urea nitrogen (BUN),
  and creatinine.
• Arterial blood gases may also be extremely
  helpful.
• A chest X-ray should be obtained in all patients
  with major trauma.
• The possibility of cervical spine injury is
  evaluated by examining all seven vertebrae in a
  cross-table lateral radiograph and a swimmer's
  view.

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SECONDARY SURVEY Contd

• Depending on the injuries and the hemodynamic
  status of the patient, other imaging techniques
  (eg, chest computed
• tomography CT or angiography) or diagnostic
  tests such as diagnostic peritoneal lavage (DPL)
  may also be indicated.

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TERTIARY SURVEY

• A tertiary survey is defined as a patient
  evaluation that identifies and catalogues all
  injuries after initial resuscitation and
  operative interventions.

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ANAESTHETIC CONSIDERATIONS

• General Considerations
• Regional anesthesia is inappropriate in
• hemodynamically unstable patients with
  lifethreatening
• injuries.
• If the patient arrives in the operating room
  already
• intubated, correct positioning of the
  endotracheal
• tube must be verified.
• If the patient is not intubated the same
  principles of
• airway management described above should be
• followed in the operating room. If time permits,
• hypovolemia should be at least partially
  corrected
• prior to induction of general anesthesia.

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General Considerations contd

• Invasive monitoring (direct arterial, central
• venous, and pulmonary artery pressure
• monitoring) can be extremely helpful in
• guiding fluid resuscitation, but insertion of
• these monitors should not detract from the
• resuscitation itself.
• Serial hematocrits (or hemoglobin), arterial
• blood gas measurement, and serum
• electrolytes (particularly K) are invaluable in
• protracted resuscitations.

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Head Spinal Cord Trauma

• Succinylcholine is reportedly safe during the
  first 48 hrs following the injury but is
  associated with lifethreatening
• hyperkalemia afterward.
• Chest Trauma
• Abdominal Trauma
• Extremity Trauma

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• The END
• Thank you!