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
Author/Yr Patients Problems
Talucci 1988 260 No hemodynamic or neuro complications
Stene, 1991 gt3000 None noted
Rotondo, 1993 204 No difference from OR
Karlin, 2001 647 No difference from 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
Number of pts ISS Definition of coagulopathy coag Author, year
1,088 20 PTgt18, PTT gt60 24 Brohi, 03
10,790 9 PT gt14, PTT gt 35 28 MacLeod, 03
8,724 24 Quick test lt70 34 Maegle, 07
208 17 PTgt18, PTT gt60 10 Brohi, 07
88 22 INRgt1.6, PTTgt60 28 Rugeri, 07
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

HR 114 SBP 107
Base def -11.7 pH 7.20
INR 1.6 Temp 36
GCS 9 ISS 32
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
l
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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
l
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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
Author, Yr N Comments Complications
Buz, 2008 74 ? mortality vs open 20 vs 7 1 aneurysm 1 aortic wall injury
Day, 2008 27 Success in 26 96 4 endoleaks 1 maldeployment
McPhee, 2007 27 No paraplegia 1 ext iliac dissection
Peterson, 2005 11 No paraplegia No endoleaks
Marty, 2003 9 No paraplegia 1 endoleak
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
Early, n233 Late, n412
Age 40 y 40 y
ISS 28 25
Pulmonary (ARDS, pneumonia) 21(9) 73 (18)
MOSF death 1 (0.4) 5 (1.2)
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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