Advances in Trauma Anesthesia

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Advances in Trauma Anesthesia

• Charles E. Smith, MD
• Professor, Case Western Reserve University
• Director, Cardiothoracic and Trauma Anesthesia
• MetroHealth Medical Center
• Cleveland, Ohio
• May 2009

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Objectives

• Approach to injured pt airway, c-spine clearance
• Fluids delayed resuscitation, massive trx, FVIIa
• Cardiac great vessel injuries
• TEE TTE in trauma
• Advantages of early fracture repair femoral,
  pelvis acetabulum

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Trauma

• Leading cause of death, ages 1 - 44 yrs
• 60 million injuries annually in USA
• 3.6 million require hospitalization
• 9 million are disabling TBI, SCI, ortho,
  thoracic, abdominal
• Costs are staggering
• 100 billion annually
• 40 of health care

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Eldar Soreide, Trauma Care 2002
Prehospital
Rapid transport to appropriate facility
Prevention Helmets, ? high risk behavior,
seat belts airbags, ? substance abuse
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1o Survey

• Airway c-spine control
• Breathing, O2 sat
• Circulation, BP, pulse, stop external bleeding
• Disability Neuro exam
• Exposure/ environmental control

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LEMON LAW Ron Walls

• Look externally
• Evaluate the 3-3-2 rule
• Mallampati
• Obstruction
• Neck mobility

National Emergency Airway Course. ATLS Manual 8th
ed.
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Airway Exam

• Thyromental distance
• Obvious trauma
• Swelling, scarring
• Tracheal deviation
• Neck extension
• Subcutaneous emphysema

McIntyre Can J Anaesth 198734204-13
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Airway Management

• Usually modified RSI by experienced provider
  unless difficulty anticipated
• Anesthesia NMB allow for best intubating
  conditions in trauma especially if uncooperative,
  hypoxic, head injury
• Etomidate succinylcholine
• Propofol thiopental avoided if hypovolemia or
  shock. Roc suitable alternative to sux

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Drug Assisted Intubations outside the OR
Karlin A. Problems in Anesthesia 200113283.
MHMC failed intub- 1 ED,
OR 3- aeromedical
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Gum-Elastic Bougie

• Insert under epiglottis
• Gently advance until clicks or hold up
• 2nd operator threads ETT over bougie
• May need to rotate bougie 90o
• Ideal for Grade III view

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2o Survey

• Rest of vitals, Physical exam
• Xrays chest, pelvis, c-spine,
• FAST, CT, labs
• Done only after 1o survey completed
  resuscitation begun

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FAST

• Perihepatic
• Perisplenic
• Pelvis
• Pericardial

Focused Assessment for the Sonographic
examination of the Trauma victim
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Obtunded Head Injured Pts C-spine

• Reliable P/E cannot be done, therefore immobilize
• CT scanning from skull base to T1 (16 row
  detector) w sagittal coronal reconstruction
• Identifies bony fx, marked prevertebral soft
  tissue swelling or hematoma, malalignment
  abnormal facets
• Negative predictive value 98.9 for ligament
  injury 100 for unstable c-spine injury

Como JJ et al. J Trauma 200763544
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Traumatic unilateral jumped facet.
Kincaid Lam. Anesthesia for Spinal
Cord Trauma
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Obtunded Head Injured Pts

• MR advocated to evaluate ligamentous soft
  tissue injuries not detected by CT
• Disadvantages cost, restricted availability,
  transport issues
• Dynamic fluoroscopy w flex/ext views no longer
  done
• Plain c-spine films no longer routine
• EAST practice guidelines in press Como et al

Como JJ et al. J Trauma 200763544
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Risks of Aggressive Volume Resuscitation

• ? hemorrhage excessive hemodilution due to
  ? BP, ? blood viscosity, ? hematocrit,
  ? clotting factor concentration

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Bickell et al NEJM 19943311005

• RCT, penetrating torso trauma, urban center
  n 598
• Excluded head injury
• Std of care 2 L crystalloid prehospital vs
  delayed resuscitation no fluid until OR
• mortality, LOS complications in std of care
  vs. delayed group

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Dutton et al J Trauma 2002521141

• RCT, blunt penetrating trauma pts w SBP lt 90, n
  110 excluded head injury
• Gp 1- fluid resusc to SBP 100
• Gp 2- fluid resusc to SBP 70
• Identical survival 93 despite ? ISS in gp 2
  23.9 v 19.5
• Lactate base deficit cleared to normal in both
  gps w similar amounts fluid blood

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Goals for Early Resuscitation

• Systolic BP 80-100 mmHg unless head or SCI
• Hematocrit 25-30
• PT, PTT, INR in normal range
• Platelet count gt 50,000
• Normal ionized calcium
• Prevent acidosis from worsening
• Core temp gt 36 C

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Room temp gt 28 oC
Soreide Smith. Hypothermia in Trauma.
In Trauma
Anesthesia, Cambridge University, 2008
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Acute Coagulopathy of Trauma (ACoTS)
Hess et al. J Trauma 2008
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Brohi et al. J Trauma 2003541127

• Retrospective review 1088 trauma pts
• Average ISS 20
• 24 had PT gt 18 s or PTT gt 60 s on arrival
• Dose- dependent prolongation of clotting times w
  hypoperfusion
• Activation of anticoagulant fibrinolytic
  pathways thrombomodulin- protein C

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Coagulopathy Initiated by Hypoperfusion
Brohi et al. Ann Surg 2007245812
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Acute Coagulopathy of Trauma Studies
Brohi et al. Curr Opin Crit Care 200713680
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Implications

• Early administration of FFP
• Damage control surgery to minimize acidosis
  hypothermia
• Massive transfusion protocols, hemostatic resusc

Hess et al. JOT 2008. Hoyt et al. JOT 2008
65755. Soeride Smith. Hypothermia in
Trauma, 2008
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Hemostatic Resuscitation Civilian

• 16 Level 1 trauma centers, n 1574. Retrospective
• 467 received massive transfusion gt10 u / 24 h
• Excluded pts who died within 30 min arrival
• Hypothesis ? plasma platelet to RBC ratio
  improves survival after shock

Holcomb et al. Ann Surg 2008248447
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Patient Information. Holcomb et al. 2008

• Mean age 39, 76 men, 65 blunt injury

Holcomb et al. Ann Surg 2008248447
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Results

• High plasma high platelet to RBC ratios
  associated w
• ? truncal hemorrhage
• ? ICU, vent days LOS
• ? survival

Holcomb et al. Ann Surg 2008248447
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24 h Survival
Holcomb et al. Ann Surg 2008248447
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MHMC Massive Transfusion Protocol

• 1st pack 4 O neg RBC 2 AB plasma
• 2nd pack 6 RBC 4 plasma. Type specific
• 3rd all subsequent MTP packs 6 RBC, 4 plasma,
  6 platelets, rFVIIa 1.2 mg

Activated by Surgeon, Emerg, Anesthesiologist
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Factor VIIa Use in Trauma

• 1999 Approved for bleeding pts with hemophilia A
  or B inhibitors to FVIII or IX
• 2001 Martinowitz case series of 7 pts
• Currently
• Multiple anecdotal reports descriptive studies
  w off label use.
• Cost of drug offset by ? trx RBC FFP
  Stein D et al. Injury 2008391054

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Dutton et al. J Trauma 200457709

• 81 coagulopathic trauma pts
• Coagulopathy reversed in 75 w 1.2 mg dose
• PT 17? 10.6 s w ? RBC FFP over 24 h
• 43.5 survived to discharge
• Thromboembolic events in 12 pts (15)
• Conclusion consider early use of FVIIa in any pt
  with uncontrolled hemorrhage who has not
  responded to surgery or blood component therapy

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Bufford et al. J Trauma 2005598

• RCT of blunt penetrating trauma. Multicenter
• Inclusion severe trauma need for 6 RBC u
  w/in 4 hr admission, n 301
• Randomized to 3 successive doses rFVIIa
  200, 100 100 ug/kg vs placebo.
  2nd 3rd dose given 1 3 h after 1rst
  dose
• Exclusion cardiac arrest before VIIa,
  GSW to head, GCS lt8, BD gt15, pH lt7,
  injury gt 12 h before randomization

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Results of Bufford et al. J Trauma 2005

• 2.6 u ? in RBC trx requirement (blunt gp, P0.02)
• ? need for massive trx (blunt gp 14 vs 33)
• Trend toward ? MOF, ARDS death
• No diff in AEs, vent days, ICU days
• Trend toward ? RBC trx requirement (penetrating
  gp, P 0.10)

http//www.trauma.org/archive/resus/FactorVIIa.htm
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Concerns with rFVIIa

• Microvascular thrombosis
• 431 events reported to FDA 1999-2004
• Stroke, MI, PE, other arterial venous
  thromboembolism, clotted devices.
• Incidence AE lt 1
• Dosing not well established. Usually give 4.8 mg
  1 vial. Repeat x 1 or 2 if needed
• Lower doses 1.2 mg, 90 ug/kg effective w ? risk
• Ongoing trials case registry

http//www.trauma.org/archive/resus/FactorVIIa.htm
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Concerns with Blood in Trauma

• Each unit of blood product biologically active
  ? risk of infections ARDS
• Chaiwat et al. Anesthesiology 2009110351,
  n14,070 pts, NSCOT database, retrospective
• Older blood assoc w ? infection, LOS, MOSF
  death Weinberg et al. J Trauma 200865279

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Storage Days of pRBCs, MHMC
Kroll A. et al. N385 trauma pts requiring
surgery w/in 24 h admission _at_ MHMC, 2003-4
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Stab wound to LV. Ketamine-sux induction.
Adenosine 6-12 mg boluses to allow surgeon time
to suture. Lim et al. Ann Thorac Surg 2001711714
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Penetrating Cardiac Injuries

• GSW usually die
• Stab usually present with tamponade
• Dx history, Beckss triad, JVD, ? BP, pulsus,
  echo
• JVD- may be absent if hypovolemic

Tx Surgical repair. May need adenosine bypass
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Royse C Royse A. Ultrasound in trauma. In
Trauma Anesthesia. Cambridge Univ, 2008
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Pericardial Effusion Tamponade

• Pericardial pressure gt cardiac chamber pressure
• RV or LV diastolic collapse
• RA or LA systolic collapse
• Plethora of IVC (gt 2.5 cm)
• ? tricuspid E w inspiration ( ? mitral E)

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Pericardial Effusion
Large, loculated hemopericardium w RA collapse
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TG SAX LV Fractional Area
Diastole
FAC (EDA-ESA)/EDA 100 Normal gt
50 Hypovolemia EDA lt 8 cm2 Normal EDA 8-14
Dilated EDA gt14
Systole
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Transthoracic Echo TTE

• TTE easiest least invasive way to image
  cardiac structures great vessels
• Harmonics contrast improved TTE exam
• TTE still suboptimal in many pts due to obesity,
  chest tubes, dressings PPV
• Vignon et al, Chest 19941061829

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TEE

• TEE has improved sensitivity specificity
• Valvular pathology
• Interatrial shunt
• Endocarditis
• Prosthetic valve dysfunction
• Aortic dissection, rupture
• LAA pathology
• Cardiac source of emboli
• TEE is semi-invasive

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Median sternotomy
Lt anterior thoracotomy
Pericardiocentesis not usually done. Aydin et al.
Cardiac and great vessel trauma. In Trauma
Anesthesia, Cambridge Univ. 2008
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Blunt Cardiac Trauma

• New segmental WMA
• ? RV /or LV function
• Laceration of valvular annuli
• Ruptured chordae
• Pericardial effusion

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BCI Myocardial Contusion
AB small, localized C Extensive. May need
milrinone, epi, norepi, vasopressin to maintain
CPP RV fct. Delay non-cardiac surgery 24-48 h
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Thoracic Aorta Trauma

• 2nd most common cause of death 8000 deaths/yr,
  USA
• Majority (80-85) die at scene
• Etiology MVAs, falls, crush, pedestrian struck,
  airplane crash
• Mechanism deceleration, osseous pinch

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Descending Thoracic Aorta Injury
Ped vs. car. Sax view of DA 5 cm distal to arch
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Pathophysiology

• Intimal tears small, thin, mobile intraluminal
  appendages of aortic wall
• Rupture intima media involved, adventitia
  intact
• Intramural hematoma rupture of vaso vasorum w ?
  wall thickness
• Ascending 7 2 mm
• Descending 15 6 mm

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Axial
CT. Traumatic aortic disruption.
Aydin et al. In Trauma Anesthesia, 2008
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Multi-planar
Volumetric 3d
CTA. Traumatic aortic disruption.
Aydin et al. In Trauma Anesthesia,
2008
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Desc Thoracic Injury Tx Options

• Open repair Lt thoracotomy, OLV, aortic XC
  partial bypass
• Endoluminal repair has replaced open repair when
  feasible
• Non-operative risk of pseudoaneurysm rupture
• Delayed stabilization of other injuries
• Control of BP mandatory ß- blockers, CCB, SNP,
  NTG, dex

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Clevidipene for HTN

• Dihydropyridine IV CCB
• Rapid and titratable BP control
• Fast termination of effect metabolised by blood
  and tissue esterases
• Selective action on arteriolar resistance vessels

Levy et al. AA 2007105918. Aronson et al. AA
20081071110
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Endovascular Repair Stent graft

• Avoids thoracotomy, OLV, aortic XC bypass.
• Minimizes BP shifts, blood loss, spinal cord
  visceral organ ischemia
• Requirement for anticoagulation minimal
• Excellent mid-term results low M M

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Review of Endovascular Studies
Stent graft repair of descending thoracic aorta
injury.
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Endovascular repair. Aydin et al. In Trauma
Anesthesia, 2008
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Orthopaedic Trauma

• Busiest service _at_ MHMC
• Occurs in 80 multiple trauma pts
• Incidence ortho trauma 2x thoracic
  4x abdominal
• Team approach

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Goals of Surgery

• Restore perfusion limb alignment
• Debride open wounds
• Repair traumatic amp
• Relieve compartment syndrome
• Repair vascular nerve injury
• Treat pain
• Manage fractures delayed vs. emergent

Vallier HA. Percutaneous intramedullary nailing.
In Trauma Anesthesia. Cambridge Univ, 2008
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Unstable Pelvic Acetabulum Fx

• Major risk of bleeding
• Associated injuries head, spine, chest, GI,
  urogenital
• Invasive monitoring routine
• CVP, Art line SPV, ABGs

Open book- widened symphysis pubis. Dislocated Rt
SI joint. Vallier Jenkins. In
Trauma Anesthesia. 2008
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Blood supply of pelvis
Donatiello et al. Anesthesia considerations for
orthopedic trauma. In Trauma Anesthesia. 2008
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Selective Internal Iliac Angiograms
Blush
2 steel coils
Pre Post Embolization of right internal iliac
artery. Buehner Parr. Damage control in severe
trauma. In Trauma Anesthesia, 2008
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Complications Early vs Late
Unstable Pelvic Acetabular Fx. Vallier HA et
al. MHMC
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Fracture Fixation

• Early definitive fixation of pelvis acetabulum
  assoc w ? complications
• Eliminates need for traction, recumbency
• Controls bleeding, provides pain relief
• Easier to reduce better quality of reduction

Vallier, Wilber, et al. MHMC
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ORIF Unstable Pelvic Fx
Screws to stabilize SI joint Anterior external
fixator applied Restores alignment of pelvic ring
Vallier Jenkins. Musculoskeletal trauma.
In Trauma Anesthesia, 2008
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Summary

• Airway modified RSI safe
• CT scanning to r/o c-spine injury if obtunded
• Bleeding resuc to SBP 80-100 unless head or SCI
• Many pts will have coagulopathy of trauma need
  early use of FFP, platelets, FVIIa
• TTE TEE timely detailed info about heart
  great vessels
• Endoluminal stent repair preferred. Control BP
• Femur pelvic fx fixation early usually better

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