Trauma : Anesthetic Issues

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Trauma Anesthetic Issues

• R2 Hong SK

2
Preoperative Evaluation (1)

• History
• Mental status
• Glasgow Coma Scale
• Trauma Scale
• NPO time m/c full stomach

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Preoperative Evaluation (2)

• Physical Examination
• Ask deep breathing
• Palpate radial pulse
• Orthostatic testing
• Neck injury check
• Early bladder catheterization
• Chest trauma check

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Laboratory Studies

• First procedure
• lateral cervical spine C1, C7, body
• AP CXR
• Blood Hgb
• ECG
• Second
• Routine Lab

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Preparation

• Operaing room warming
• Supply cart
• Large-bore (14G or 16G) cannula
• Transtracheal jet ventilation
• central line set
• Premedication
• Sedative analgesics
• Antacid Tx
• Cimetidine MX 30 60 min before induction

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Monitoring

• ECG lead II V5 , continuous ST analysis
• Sphygmomanometer
• Core temperature
• Urinary catheterization
• A-line
• CVP, PAC, ICP

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Airway Management (1)

• Cervical spine intact check
• Pulmonary aspiration risk high
• Sellicks maneuver

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Airway Management (2)

• Caution
• Poor ventilation or oxygenation
• decreased or changing mental status
• airway obstruction sign stridor, snoring
• airway burn soot in nares,
• singed nasal hairs
• Shock
• combativeness

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Airway Management (3)

• Breathe 100 O2
• at least 2 min before intubation
• Mask holding with Sellicks maneuver
• Orotracheal intubation fail
• -gt transtracheal jet ventilation buy time
• -gt emergency cricothyroidotomy

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Induction and Maintenance of Anesthesia (1)
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Induction and Maintenance of Anesthesia (2)

• Succynylcholine CIx
• Severe burn or crush injury gt 24 hr
• s-K level increase
• denervating dis. major stroke,
• Multiple Sclerosis
• serious intra-abdominal infection
• myotonic dystrophy

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Induction and Maintenance of Anesthesia (3)

• Regional anesthesia
• no hypovolemic or Hrr
• no coagulopathy
• alert cooperative patient

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Fluid Management (1)

• Crystalloid solution component

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Fluid Management (2)

• Resuscitation fluid choice
• Crystalloid
• blood oxygen-carrying capacity restore
• coagulation status normalization
• Volume loss calculation
• acute blood loss
• tissue loss during surgery 4 8 mg/kg/hr
• crystalloid replacement 2 3 times of blood
  loss
• anesthetic increase intravascular capacity
• Lasix in the RR is preferable to CPR in the OR

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Fluid Management (3)

• Colloid replacement
• Blood products, high molecular wt dextran
• Albumin, hetastarch solution
• positive side
• intra vascular longer -gt less edema
• increase cardiac output
• negative side
• Allergic or immune reaction
• Electrolytic imbalances
• Toxic effect citrate toxicity, nephro toxicity,
  crossmatch problems, coagulopathy

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Coagulopathies (1)

• M/C dilutional thrombocytopenia
• -gt later deficiency of fibronogen or other
  coagulation factor
• Cause transfusion lost blood with anything
  other than whole blood
• Dx PLT lt 70,000 abnormal bleeding
• Tx replacement

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Coagulopathies (2)

• DIC or consumption coagulopathy (1)
• Cause
• Rapid consumption PLT, fibrinogen,
• Factor V VIII
• triggered by phospholipid
• (PLT Factor III or tTP)
• Dx
• PLT fibrinogen(lt 150 mg.dl/L) decrease,
• fibrin-spirit product (), aPTT aNL

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Coagulopathies (3)

• DIC or consumption coagulopathy (2)
• Tx
• 1. underlying dis.
• 2. replacement PC, FFP,cryoprecipitate
• Goal
• 1. PLT gt 100,000
• 2. normal aPTT
• 3. fibrinogen gt 200 mg/dL

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Hypothermia (1)

• Advantage
• metabolic rate decrease
• oxygen demand decrease
• blood flow shifting
• Disadvantage
• cardiac problem sinus bradycardia, AF,
• prolong PR QT interval, widen QRS
• -gt nodal rhythm, frequent PVC, AV block, VF
• 2. hypoxic pul. Vasoconstriction attenuation
• 3. plasma volume decrease
• 4. PLT dysfunction thrombycytopenia -gt DIC

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Hypothermia (2)

• Prevention
• OR warming
• warmed humidified respiratory gase
• IV replacement
• irrigation fluid warming (37?)
• Air-filled patient warmer