Trauma Anaesthesia

Coordinator:- Dr Roopesh Kumar

Presenter:- Dr ABHISHAKE

Introduction:- Trauma is the leading cause of death among

people aged 1-38 years but above 38 are not spared.

Mortality represents only the tip of the trauma ICEBERG, it is estimated that, for each death, three people rendered permanently disabled.

The role of the anaesthesiologist in the majority of institutions is to establish a secure airway, ensure adequate ventilation, and provide anaesthesia for surgery. Added responsibility in modern scenario are as follows-

Anaesthesists’ responsibility in trauma care

1.Prehospital care2.Emergency

department Trauma team leader Trauma team

member Anaesthesiologist3.Operating roomAnaestesia

4. Postoperative care

Intensive care unit High-dependency

unit Acute pain team5. Transportation

Anaesthesiologists possess many skills, which can be used at the scene of an accident to compliment those of a paramedic in managing victims of trauma.

At accident site, two approach are used: which one is better, is under the clouds of conflicts

1. Scoop and run2. Stay and play

Prehospital care & Anaesthesiologist

Currently an anaesthesiologist should attend the scene of an accident as part of the emergency medical team should limit initial interventions to securing a patent airway, ensuring effective ventilation, controlling external hemorrhage, and expediting transfer of the patient to a hospital or trauma center.

Only exception to this are those who have head injuries when, in addition to above, IV fluids or analgesic may be required.

Prehospital general anaesthesia:- General anaesthesia may be required at

accident site as to facilitate extrication or the amputation of a nonviable limb.

All immediate life threatening injuries must be identified first and dealt with using ABC principles.

Prior to inducing anaesthesia, all physical danger to the anaesthesiologist and patient must have been eliminated as far as possible, and access to the patient is maximized.

Pulse oximetry is the bare minimum monitoring.

Ketamine is the agent of choice for prehospital general anaesthesia preceded by inj. glyco. Concurrent administration of midazolam prevents emergence phenomena.

Ketamine causes tachycardia and an increase in SBP, secondary to central sympathetic stimulation and inhibition of catecholamine uptake. However in shocked trauma patient, in whom sympathetic stimulation is already maximal and exhausted, CO & SBP may fall as it is direct cardiac depressant.

Other anaesthetic agents are# Etomidate# Propofol Despite the long list of undesired side

effects, Succinylcholine remained the agent of choice when muscle relaxation is required to facilitate tracheal intubation in emergency scenario. Now Rocuronium has given some promising results at the expense of prolonged block.

In most hospitals, Emergency department is the first contact between the anaesthesiologist and trauma patient.

Time is a crucial factor for a successful resuscitation of a severely injured patient.

Ambulance personnel or a doctor at the scene should communicate directly with emergency staff which further decide whether to alert individual specialists or the trauma team.

Anaesthesiologist in Emergency Department

Resuscitation of patient following traumaDeaths following trauma shows tri-modaldistribution; First peak in deaths is within seconds to minutes

of injury; as a result of major neurological or vascular injury. This can only be reduced by PREVENTIVE measures.

Second peak represents early deaths in which patient is dying from airway, breathing or circulatory problems. This period has been called “THE GOLDEN HOUR” to emphasize the importance of rapid timely resuscitation to reduce mortality.

Third peak of deaths in days to a few weeks later, as a result sepsis and multiple organ failure.

The traditional medical practice including history, examination and investigation is not appropriate for severely injured patient. Instead, assessment and resuscitation take place simultaneously, with the aim being to identify and treat first the greatest threats to life.

Advance Trauma Life Support (ATLS); although aimed at the single handed physician working in a rural hospital, the ATLS protocols can be easily adapted for a team approach and provide a useful frame work on which resuscitation efforts in any environment can be based.

The focus of ATLS is the managementof patients with major injuries duringthe golden hour and is considered infour phases: Primary survey Resuscitation Secondary survey Definitive care

ATLS

The primary survey and resuscitation

The primary survey includes ABCDE1. Airway with control of cervical spine2. Breathing and ventilation3. Circulation and hemorrhage control4. Disability- rapid assessment of

neurological function5. Exposure with environmental control

Airway During resuscitation of any severely injured

patient, the initial priorities are to ensure a clear, secure airway and to maintain adequate oxygenation.

If the airway obstructed, immediate basic maneuvers such as chin lift or jaw thrust along with suction may temporarily relieve the obstruction.

In semiconscious patient, an oropharyngeal or nasopharyngeal airway may help while preparing for more definitive management.

Every patient with multiple injuries should receive a high inspired O2 concentration.

Pt should always considered full stomach. Advanced airway management 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.

Every patient with significant blunt trauma, particularly above the clavicles or if unconscious, should be assumed to have a cervical spine injury until it is proved otherwise.

Five criteria that rule out cervical injury

No midline cervical pain or tendernessNo focal neurological deficitNormally alertNot intoxicatedNo severe distracting pain A cervical spine # must be assumed if

any one of these criteria is present, even if there is no known injury above the level of the clavicle.

Causes of obstructed airway or Inadequate ventilation in a Trauma patient

Airway obstruction Inadequate ventilation

Direct injury to face, mandible or neck

Hemorrhage in nasopharynx, sinuses, mouth or upper airway

Dimnished consciousness secondary to TBI, intoxication or analgesic medications

Aspiration of gastric contents or foreign body

Misapplication of an oral airway or endotracheal tube

Diminished respiratory drive secondary to TBI, shock, intoxication, hypothermia, or over sedation

Direct injury to trachea or bronchi

Pneumothorax or hemothorax

Chest wall injury Aspiration Pulmonary contusion Cervical spine injury Bronchospasm secondary to

inhalation of smoke or toxic gas

Intubation of the trachea with a cuffed tube remains the gold standard.

Technique of intubation may vary from awake to rapid sequence induction via nasal or oral route depending upon the skill, familiarity and expertise of anaesthesiologist but RSI is most commonly applied. This consists of:-

1. Manual inline stabilization of cervical spine

2. Pre-oxygenation for 2-3 min3. Administration of IV anaesthetic agent

4. Application of cricoid pressure by a separate assistant

5. Admin of rapidly acting NMBA6. Intubation of trachea7. Check the position of the tracheal tube8. Release the cricoid pressure MILS unfortunately make direct laryngoscopy

more difficult so some clinician prefer awake fibro optic intubation under local anaesthesia in these patients although the risk of pulmonary aspiration is there and patient co operation is a must.

Nasal intubation should not be tried in patients with midface or basilar skull #.

If intubation of patient proves impossible and patient can not be ventilated with face mask, other options should be considered

1. Laryngeal mask airway2. Intubating laryngeal mask3. Needle cricothyroidotomy with 14 G

followed by jet ventilation (80-300 rate, pressure 400kPa or 3000 mmHg) but hypercapnia is there

4. Tracheostomy (percutaneous/surgical)

Breathing and ventilation Assessment of ventilation is best done

by look, listen and feel approach.1. Look – for cyanosis, use of accessory

ms, flial chest and penetrating and sucking chest injuries.

2. Listen – for presence, absence or diminution of breath sounds.

3. Feel – for subcutaneous emphysema, tracheal shift and broken ribs.

Common cause of impaired ventilation in

trauma patient Gastric dilatation- pass oro/nasogastric

tube Pneumothorax- insert a chest drain Hemothorax- insert a chest drain Ruptured diaphragm- surgical

intervention Pulmonary hemorrhage- endoscopy,

consider double lumen tube if unilateral Broncho-pleural fistula- double lumen

tube

Three major chest injuries need to be excluded:-1. Tension pneumothorax:- respiratory distress

with reduced chest movement, reduced breath sounds, a hyper resonant percussion note on affected side, hypotension and tachy, neck vein distension, and tracheal shift to opposite side

Mx- immediate decompression with 14 G cannula inserted in 2nd ICS in MCL on affected side. Once IV access has been obtained, a large chest drain,36FG inserted in 5th ICS in ant. axillary line and connected to underwater seal drain.

2. Open pneumothorax:- followed by large hole in chest, air will preferentially enter the pleural cavity via the defect.

Mx- Defect should be covered and chest drain inserted to prevent the risk of a tension pneumothorax developing.

3. Flial chest:- it is an indication of severe chest injury with multiple ribs #. Hypoxia is often worsened by underlying pulmonary contusion or hemothorax may requiring intubation and mechanical ventilation. Paradoxical chest movement is characterstic of this but not present always.

Mx: Intubation with IPPV

Hemothorax:- massive when > 1500 ml blood in hemithorax, result in reduced chest movement, a dull percussion note, hypoxemia and hypovolemia.

Mx- once volume replacement is commenced, a chest drain is placed,

Cardiac tamponade:- Beck’s triad including distended neck vein, hypotension and muffled heart sound

Mx- Pericardiocentasis should be performed.

Most critically ill patients require assisted, if not controlled ventilation. AMBU usually provide adequate ventilation immediately after intubation and during period of patient transport

Coma- Glasgow coma scale≤8 Loss of protective airway reflexes Hemorrhage into the airway Ventilatory insufficiencyPaO2<60 mmHgPaCO2>45mmHg Seizures Combative patients requiring investigations General anaesthesia Cardiac arrest

Indication of tracheal intubation in trauma patients

Circulation Adequacy of circulation is based on pulse

rate, pulse fullness, blood pressure and sign of peripheral perfusion.

Symptoms and sign of shock ◦ Diaphoresis◦ Agitation or Obtundation ◦ Hypotension◦ Tachycardia◦ Prolonged Capillary Refill◦ Diminished Urine Output ◦ Narrow Pulse Pressure

The first priority in restoring adequate circulation is to stop bleeding followed by replacement of intravascular volume secondarily.

Until prove otherwise, assume shock as the result of hypovolemia secondary to hemorrhage.

Hypotension in these patients should be aggressively treated with IV fluids and blood products, not vasopressors, unless there is profound hypotension that is unresponsive to fluid therapy, coexisting cardiogenic shock, or cardiac arrest.

Pathophysiology Clinical Manifestation

Mild(<20% of blood volume lost)

Decreased peripheral perfusion only of organ able to withstand prolonged ischemia (skin, fat, muscle, and bone)

Pt complaint of feeling coldPostural hypotension and tachycardiaCool, pale, and moist skinConcentrated urine

Moderate(20-40% of blood volume lost)

Decreased central perfusion of organs able to tolerate only brief ischemia(kidney, liver)Metabolic acidosis present

ThirstSupine hypotension and tachycardia(variable)Oligouria and anuria

Severe(>40% of blood volume lost)

Decreased perfusion of heart and brainSevere metabolic acidosisRespiratory acidosis possibly present

Agitation, confusion, or obtundationSupine hypotension and tachycardia invariabaly presentRapid, deep respiration

Class I Class II Class III Class IV

Blood loss (ml) ≤750 750-1500 1500-2000 >2000

% blood loss ≤15 15-30 30-40 >40

Heart rate (bpm)

<100 >100 >120 >140

SBP N N D D

Pulse pressure N or I D D D

Capillary refill N I I I

Resp rate/ min 14-20 20-30 30-40 <35

Urine output (ml/hr)

>30 20-30 5-15 Negligible

Mental status Slightly anxious

Mildly anxious

Anxious and confused

Confused and lethargic

Fluid replacement

crystalloid

Crystalloid and blood

Crystalloid and blood

Crystalloid, and blood

ATLS CLASSIFICATION OF HEMORRHAGIC SHOCK

Cardiac temponadeTachycardia, dilated neck vein, muffled heartsoundPericardiocentesis Myocardial contusionTachycardia, cardiac dysrhythmiasCrystalloid, vasodilators, inotropes Pneumothorax or hemothoraxTachycardia, dilated neck veins, absent breathsounds, dyspnea, subcutaneous emphysemaChest tube

Other causes of hypotension in the initial phase of trauma

Spinal cord injuryHypotension without tachycardia, narrowpulse pressure, vasoconstrictionCrystalloids, vasopressor, inotropes SepsisDevelops after a few hrs after colon injurypresent as modest tachycardia, wide pulsepressure and feverAntibiotics, crystalloids, inotropes

Multiple large bore, 14-16 G cannula are placed in whichever vein are easily accessible. As placement of central line is time consuming and associated with life threatening complications, peripheral lines are usually sufficient for initial resuscitation.

Fluid therapy For the majority of hypovolemic patients in

emergency department the initial choice is less important than availability, speed and adequacy of replacement.

Fully cross matched whole blood is ideal but cross matching take a min of 45-60 min. O-negative blood can be used in case of extreme emergency.

Crystalloid solutions are easily available and inexpensive. RL and NS are commonly used fluids. Dextrose containing fluid should be avoided in TBI & in the absence of documented hypoglycemia

Colloids are far expansive but they are more efficient in rapidly restoring IV volume. Combination of both gives best results. Albumin is usually selected over dextran or hetastarch because of fear of inducing coagulopathy.

Whichever fluid is chosen, it must be warmed prior to administration. Rapid-infusion systems are available for this purpose.

The ATLS curriculum advocates rapid infusion of up to 2 L of warmed isotonic crystalloid solution in any hypotensive patient with the goal of restoring normal blood pressure.

Risks associated with aggressive volume

replacement during early resuscitation Increased blood pressure Decreased blood viscosity Decreased hematocrit Decreased clotting factor concentration Greater transfusion requirement Disruption of electrolyte balance Direct immune suppression Premature reperfusion Increased risk of hypothermia

The aggressive fluid admin is often result in transient rise in BP, followed by increased bleeding, another episode of hypotension and need for more volume administration.

ATLS manual categorized these patient as “TRANSIENT RESPONDERS”

Resuscitation of these pts should be considered in two phases:-

1. Early, while active bleeding is still ongoing.

2. Late, once all hemorrhage is controlled

Maintain SBP at 80-100 mmHg Maintain hematocrit at 25-30% Maintain the PT & PTT in normal ranges Maintain the platelet count at >50000/ HPF Maintain normal serum ionized calcium Maintain core temp higher than 35 C Maintain function of the pulse oximeter Prevent an increase in serum lactate prevent acidosis from worsening Achieve adequate anaesthesia and analgesia

Goals for early resuscitation

Maintain SBP>100mmHg Maintain hematocrit above individual

transfusion thresold Normalize coagulation status Normalize electrolyte balance Normalize body temperature Restore normal urine output Maximize CO by invasive or noninvasive means Reverse systemic acidosis Document decrease in lactate to normal range

Goals of late resuscitation

Prevention of hypothermia in seriously injured

patients during surgery Use of forced air-warming device Use of heat and moisture exchanger(HME) b/w

anaesthetic gases and breathing system Cover all body surfaces except surgical site

including the head Maintain the operating room temprature as

warm as possible Warm all fluid, both IV and those used for

lavage by the surgeons Place the patient on a warming blanket

The amount of fluid administered is based on improvement of clinical signs, particularly BP, HR and pulse pressure. Central venous pressure and urinary output also provide indication of restoration of vital organ perfusion.

Disability A rapid assessment of neurological

function Level 1- AVPU systemA- AlertV- Verbal responseP- Painful responseU- Unresponsive Level 2- Glasgow Coma ScaleScore ≤8 Deep coma, severe head injury, poor

outcomeScore 9-12 Conscious patient with moderate injuryScore 13-15 Mild injury

Eye-Opening Response 4 = Spontaneous    3 = To speech    2 = To pain    1 = None Verbal Response 5 = Oriented to name    4 = Confused    3 = Inappropriate speech    2 = Incomprehensible sounds    1 = None Motor Response 6 = Follows commands    5 = Localizes to painful stimuli    4 = Withdraws from painful stimuli    3 = Abnormal flexion (decorticate posturing)    2 = Abnormal extension (decerebrate posturing)    1 = None

GLASGOW COMA SCALE

There is usually no time for Glasgow Coma Scale, the AVPU system alone may used in hurry. But if time permit, GCS should be done as it is reliable, reproducible and dynamic measurement, the trend in the conscious level is more important than one static reading.

Exposure The patient should be undressed to allow examination of entire body surface for injuries. In-line immobilization should be used if a neck or spinal cord injury is suspected.

The objective of secondary survey are:- Examine the patient Head to toe Front to back Obtain a complete medical history in regard of- Allergies Medications Past medical history Last food or fluid Events of the incident and environment Obtain all clinical, laboratory, and radiological

information Formulate a management plan

Secondary Survey

The secondary survey begins only when ABCs are stabilized and patient is evaluated from head to toe and the indicated studies ie radiographs, laboratory tests, invasive diagnostic procedures, are obtained.

Head examination includes looking for injury to the scalp, eyes and ears. Neurological examination includes GCS and evaluation of motor and sensory function as well as reflexes.

Chest is auscultated and inspected again for #s and function integrity. A normal initial examination does not exclude the posiblity of flial chest, pneumothorax, hemothorax or cardiac temponade

Abdominal examination is done under the heads of inspection, auscultation and palpation.

Extremities should be examined for #s, dislocation and peripheral pulses.

A urinary catheter and nasogastric tube are also inserted.

Basic laboratory analysis includes CBC, electrlyte, glucose, BUN and creatinine. ABG may extremely helpful. X-ray chest and cross table lateral radiograph and a swimmer’s view are must.

.

FAST scan: Focused assessment with sonography for trauma scan is a rapid, bedside, ultrasound examination performed to identify intraperitoneal hemorrhage or pericardial tamponade

FAST scan examine four area for free fluid

1. Prehepatic/ hepatorenal space2. Perisplenic space3. Pelvis4. Pericardium CT, angioraphy or DPL may also be

indicated if any doubt persists.

Tertiary trauma survey TTS B/w 2-50% traumatic injuries may be

missed in primary and secondary surveys so some centre advocate a tertiary survey.

It occurs prior to discharge to reassess and confirm known injuries and identify occult one.

Includes complete head to toe examination and careful observation of all laboratory and radiological examinations.

Regional anaesthesia is usually impractical and inappropriate in hemodynamically unstable patients with life threatening injuries.

In hemodynamically stable patient specially #s and injuries to extremities,regional anaesthesia can be a choice.

Anaesthetic Consideration

Regional anaesthesia for traumaAdvantages Disadvantages

Allows continued assessment of mental status

Peripheral nerve function difficult to assess

Increased vascular flow Patient refusal common

Avoidance of airway instrumentation

Requirement for sedation

Improved postoperative mental status

Hemodynamic instability with placement

Decreased blood loss Longer time to achieve anaesthesia

Decreased incidence of DVT Not suitable for multiple body lesion

Improved post operative analgesia

May wear off before procedures conclude

Better pulmonary toilet

Earlier mobilization

If patient arrives in the operating room already intubated, correct position of endotracheal tube must be verified.

If the patient is not intubated the same principle as described before should be followed. If time permits, hypovolemia should be partially corrected prior to induction.

Commonly used induction agents for trauma patients include ketamine and etomidate. Dose of propofol are greatly reduced (80-90%) in patient with major trauma.

General anaesthesia for trauma

Advantages Disadvantages

Speed of onset Impairment of global neurological examination

Duration can be maintained as long as needed

Requirement for airway instrumentation

Allows multiple procedures for multiple injuries

Hemodynamic management more complex

Greater patient acceptance

Increased potential for barotrauma

Allows positive pressure ventilation

Severely injured patients requiring anaesthesia

and intubation can be divided into three gps:-

1. Those with severely hypotensive (SBP<80 mmHg), with ongoing resuscitation and are severely neurologically obtunded. Induction agent are not usually required, but NMBA is used to facilitate tracheal intubation.

2. Those who are hypotensive (SBP 80-100 mmHg),hemodynamically unstable or inadequately resuscitated. A reduce dose of IV induction agent is used. A NMBA is used for intubation.

3. Patients with isolated head injury, with sign of raised ICT. Normal dose of an inducing agent, NMBA and analgesic are administered. Induction may also be preceded by IV bolus of lignocaine.

Maintenance of anaesthesia in unstable patients may consist use of muscle relaxants with general anaesthetic titrated as tolerated in an effort to provide at least amnesia. Small doses of ketamine, propofol along with <0.5 MAC of volatile anaesthetic are used.

Histamine releasing NMBA like atracurium and mivacurium better be avoided as they may lead to hypotension.

The rate of rise of alveolar conc of inhalational anaesthetic is greater in shock because of lower CO & increased ventilation. So higher alveolar anaestheic partial pressure lead to higher arterial partial pressurer and greater myocardial depression.

The effect of IV anaesthetic are exaggerated as they are injected into a smaller intravascular volume

The key of safe anaesthetic management of shock patients is to administer small incremental doses of which ever agents are selected.

Criteria for operating room or Postanaestesia Care Unit Extubation of trauma patient Mental statusResolution of intoxicationAble to follow commandsNoncombativePain adequqtely controlled Airway anatomy and

reflexesAppropriate cough and gagAbility to protect the

airway from aspirationNo excessive airway

edema or instability

Respiratory mechanics

Adequate tidal volume and respiratory rate

Normal motor strengthRequired FiO2 is <0.5 Systemic stabilityAdequately resuscitatedSmall likelihood of

urgent return to the operating room

Normothermia, without signs of sepsis

TRIAGE The sorting of and allocation of treatment to the

patients and especially battle and disaster victims according to a system of priorities designed to maximise the number of survivors

Divison of patients for priority of care, usually into three groups

1. those who will not survive even with treatment 2. those who will survive even without tretment 3. those whose survival depends on treatment If triage is applied, treatment of the patients

requiring it is not delayed by useless or unnecessarily treatment of those in other groups.