Anesthesia for the Trauma Patient Chap 41
DON DANIELS
COL, MC SAUSHEC Anesthesiology Residency Program
3 May 04
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Anesthesia for the Trauma Patient Chap 41
Leading cause of death 1-35 y/o Trauma accounts for 1/3 of hospital admissions 50% of deaths occur immediately, 30% within hours of injury Anesthesiologist usually resuscitate more than anesthetize Increased likelihood of drug abusers, intoxication, and carriers of Hepatitis or HIV
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Initial Assessment
EOD specialist did not duck fast enough Restless, combative with no IV access Becomes unconscious while surgeons try to achieve right femoral vein cutdown access What is the first thing you do?
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Initial Assessment
Airway
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Initial Assessment
Airway Breathing
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Initial Assessment
Airway Breathing Circulation & Fluid Resuscitation
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Initial Assessment
Airway Breathing Circulation & Fluid Resuscitation Disability
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Initial Assessment
Airway Breathing Circulation & Fluid Resuscitation Disability
Alert Vocal stimulation Painful stimulation Unresponsive
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Secondary Survey
Does not begin until the primary survey is completed, resuscitation is initiated, and the patients ABC’s are reassessed. SS is a head-to-toe evaluation
Vital signs Roentgenograms and other special procedures are done Tubes and fingers in every orifice
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Secondary Survey
24 y/o Iraqi soldier raised his arms to surrender M1A1 fired one round, it hit his arm before exploding behind him killing his colleagues Surgeon shows you Xray to convince you to take patient to OR now
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Secondary Survey
This is how it looked. Do you (anesthesia) need to do a secondary survey? If yes, describe the SS.
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Secondary Survey
Why does anesthesia have to do primary and secondary survey?
Because the Emergency docs and/or the surgeons may miss Pneumothorax Intracranial injury Cardiac tamponade Abdominal hemorrhage Dislodged ET You become responsible for care while surgeon is operating
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Secondary Survey
Vital signs
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Secondary Survey
Vital signs AMPLE history
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Secondary Survey
Vital signs AMPLE history
Allergies Medications Past Illnesses Last Meal Events/environment related to injury
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Secondary Survey
Vital signs AMPLE history Physical Exam
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Secondary Survey
Vital signs AMPLE history Physical Exam
Head and skull Maxillofacial Neck Chest Abdomen Perineum/Rectum/Vagina Musculoskeletal Neurologic (GCS scoring) Appropriate x-rays, lab test and special studies
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Head & Spinal Cord Trauma
Brain injury suspected with altered consciousness
Glascow Coma Scale accesses level of consciousness Restlessness, convulsions and cranial nerve dysfunction are other signs of brain injury Cushing triad (HTN, bradycardia, resp disturbance) is a late sign Hypotension is rarely due to isolated head injury Avoid premed that alter mental status or neuro exam
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Head & Spinal Cord Trauma
Glascow Coma Scale
Eye Opening
• • • • 4 - spontaneous 3 - opens to speech 2 - opens to pain 1 - no response
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Glascow Coma Scale
Eye Opening
• • • • 4 3 2 1 spontaneous opens to speech opens to pain no response
Verbal response
5 - Oriented 4 - Confused 3 - Inappropriate words 2Incomprehensible 1 - none
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Glascow Coma Scale
Eye Opening
4 3 2 1 spontaneous opens to speech opens to pain no response
Best Motor
6 - Obeys, moves to command 5 - localizes to pain stim 4 - Withdraws from pain stim 3 - Abnl flexion, decorticate posture 2 - Extensor response, decerebrate 1 - no movement
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Verbal response
5 - Oriented 4 - Confused 3 - Inappropriate words 2- Incomprehensible 1 - none
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Head Injury Severity Score
Severe - GCS 60 mm Hg
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Spinal Cord Injury
In patients with Spinal Shock which of the following is/are true
a. Succinylcholine should be avoided during the first 48 hrs b. Autonomic hyperreflexia occurs following neurologic trauma below T5, and is usually manifested in the first hour of injury c. Hypertension, bradycardia, gastrointestinal motility and venous vasoconstriction of the legs is a sign of high spinal cord injury d. C3-5 injury may cause apnea
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CHEST TRAUMA
34 y/o female involved in MVA sustained a spleen injury brought to the OR for splenectomy Intraop course c/b refractory hypotension
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CHEST TRAUMA
34 y/o female involved in MVA sustained a spleen injury brought to the OR for splenectomy Intraop course c/b refractory hypotension Aggressively hydrated with crystalloid, PRBC’s & vasoactive drugs BP remains in low systolic 60’s
Pneumothorax?
Neg hyperresonance breath sounds equal Trachea was midline Portable chest neg for lung collapse Distended neck veins Chest tube?
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CHEST TRAUMA
34 y/o female involved in MVA sustained a spleen injury brought to the OR for splenectomy Intraop course c/b refractory hypotension Aggressively hydrated with crystalloid, PRBC’s & vasoactive drugs BP remains in low systolic 60’s CVP inserted showing high fluid resuscitation
Pneumothorax or Hemothorax?
Dullness to percusion was not present no flail chest by exam or portable chest
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CHEST TRAUMA
34 y/o female involved in MVA sustained a spleen injury brought to the OR for splenectomy Intraop course c/b refractory hypotension Aggressively hydrated with crystalloid, PRBC’s & vasoactive drugs BP remains in low systolic 60’s CVP inserted showing high fluid resuscitation TEE highly suspicious
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Cardiac Tamponade
Beck’s triad
Neck vein distention hypotension muffled heart tones
Pulsus paradoxus
a>10 mm Hg decline in blood pressure during spont resp
Immediate Treatment: Pericardiocentesis
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CHEST TRAUMA
If pneumothorax avoid N2O If suspect cardiac tamponade, ketamine recommended because it preserves inotropism and chronotropism. Ensuring preload is also lifesaving.
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Abdominal Trauma
Large quantity of blood can be present in the abdomen with minimal signs
Have blood in the room before cutting Have blood in the room before cutting Have blood in the room before cutting.
Nasogastric tube to prevent gastric dilation, place orally if cribiform plate fracture suspected Avoid Nitrous oxide
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Extremity Trauma
Can be life threatening due to assoc vascular injury Femur fracture can be associated with 3 unit blood loss Pelvic fractures can cause hypovolemic shock
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Extremity Trauma
Delay or indiscriminate positioning can worsen dislocations, compromise neurovascular bundles, or result in infection Fat emboli may cause pulm insufficiency, dysrhytmias, skin petechiae and mental changes wn 1-3 days of injury
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BURNS
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Rule of Nines
Upper extremities = 9% x 2 Head = 9% Lower extremities = 18% x2 Chest = 9% Abdomen = 9% Trunk = 18% Groin = 1%
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Second degree burn involving 25% total surface burn considered major burn 3rd degree burn involving 10% is considered major burn Electrical burns are worse than they look
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BURNS: What are signs of inhalational injury
Stridor Hoarsness Facial burns Singed nasal hair or eyebrows Soot in sputum or in oropharynx Respiratory distress History of combustion in a closed space
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BURNS
Circumferential thorax burns may decrease chest wall compliance True or False
Carbon monoxide inhalation shifts the oxygen-hemoglobin curve to the right
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BURNS
Answer: Carbon Monoxide shifts the O2 hemoglobin curve to the left True or False
PaO2 and skin color will remain normal
True or False
Pulse oximeters and iStat can detect carboxyhemoglobin.
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BURNS
True or False
Metabolism is markedly increased during the healing phase of a burn injury This is m/b increased O2 consumption and CO2 production. Alveolar ventilation must be increased, supplemental 02 provided to meet demand.
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BURNS
Hyperkalemia may be present during acute resuscitation phase Mafenide acetate inhibits carbonic anhydrase causing hyperchloremic acidosis Silver nitrate decreases Na, Cl and K. Methemoglobinemia is rare Electrical burns associated with severe muscle damage and myoglobinuria
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BURNS
Succinycholine contraindicated Higher doses of nondepolarizing muscle relaxants may be required Avoid halothane when epinephrine soaked bandages are used.
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