Anesthesia for Trauma dictated slides 25-51

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Initial Assessment:

Initial Assessment Airway cont’d: Cervical spine evaluation Cross table lateral and swimmer’s view X-ray Need to see all seven cervical vertebrae Only negative CT scan R/O injury

Initial Assessment:

Initial Assessment Cervical spine cont’d: Functional assessment of cervical level C5 Biceps Abduct shoulder, Flex elbow C6 Wrist extensors Cock wrist C7 Triceps Extend elbow C8 Finger flexors Grasp finger in palm T1 Finger abductors Spread fingers

Initial Assessment:

Initial Assessment ALWAYS ASSUME FULL STOMACH PRECAUTIONS  RAPID SEQUENCE INTUBATION Sux 1.5 mg/kg, Vec 0.2 mg/kg, Roc 1.5 mg/kg If unsuccessful, change something BOUGIE (intubating stylet) Indications for intubation: Airway obstruction PaO2 < 80 mmHg or SpO2 < 90% with O2 Shock with SBP < 90 mmHg Severe head injury or unconscious (GCS <9) Anticipated surgery with multisystem injury Combativeness

Initial Assessment:

Initial Assessment Rapid sequence intubation (or modified) Preox Use slow inspiratory flow rates (1-1.5 sec inspiratory time) Avoid stomach distention gastric inflation occurs when inspiratory pressure exceeds EOP (~15-18 cm H2O) “Pent, Sux, Tube” May have to decrease amount of sedative drugs and give appropriate dose of RSI muscle relaxants Succinylcholine: 1-2 mg/kg Zemuron: 1.2 mg/kg Vecuronium: .2 mg/kg

Initial Assessment:

Initial Assessment Airway cont’d: Remove front of C-collar and maintain in-line stabilization Cricoid pressure (Sellick’s maneuver) after Pent given 10 # pressure required to seal esophagus MAC vs. Miller debate

Initial Assessment:

Initial Assessment Awake intubation: local, topical superior laryngeal nerve blocks Awake fiberoptic: may be too bloody Awake cricothyrotomy/tracheostomy Gum elastic bougie/LMA Know your difficult airway algorithm!

Initial Assessment:

Initial Assessment BREATHING Always verify correct position of ETT, even if arrive intubated !! 100 % O2 May have Combitube in; change to ETT Nasal intubation: watch with basilar skull fractures

Initial Assessment:

Initial Assessment Circulation Control hemorrhage first! Crystalloids vs. colloids vs. blood products? A lot or a little? Early or later?

Secondary survey:

Secondary survey After primary survey complete, attempt to complete a head-to-toe assessment Ask pertinent questions if patient able to answer Allergies, PMH//PSH, meds, ETOH/drug use, weight, last meal

Trauma/preop assessment:

Trauma/preop assessment Cardiac: S/S shock, EKG changes Respiratory: Breath sounds, crepitus, respiratory patterns/distress, CXR Neurologic: GCS, LOC; assume C-spine injury until ruled out  Lateral C-spine X-ray, palpate neck Renal: monitor urine output, amount and color

Trauma/preop assessment:

Trauma/preop assessment Gastrointestional: FULL STOMACH!!!! Gastric emptying slows or stops at time of trauma Endocrine: release of stress hormones (catecholamines and glucose) Hematologic: hypovolemic shock; coagulopathies

Laboratory/diagnostic tests:

Laboratory/diagnostic tests CBC, electrolytes, urinalysis, PT/PTT, lactate, baseline ABG (as condition permits); T&C for at least 4 units CXR, lateral C-spine, CT/MRI 12 lead EKG FAST: f ocused a bdominal s onography for t rauma DPL: diagnostic peritoneal lavage

Anesthetic management of trauma patient:

Anesthetic management of trauma patient Preop: Sedation rarely necessary Versed in small doses (.5-1 mg IV) Bicitra 30 cc preop


Induction Standard monitors Preoxygenation Basic airway and difficult airway adjuncts RSI with cricoid pressure Invasive monitors as indicated

Induction agents:

Induction agents Thiopental 3-4 mg/kg; reduce doses in unstable patients; most commonly used in trauma Ketamine 0.5-1 mg/kg; useful for burn and hypovolemic patients; avoid with head injured Etomidate 0.1-0.3 mg/kg; reduce doses with hypovolemia; ?myoclonus effects Propofol 1-2 mg/kg in stable patients; reduce doses in hypovolemia

Muscle relaxants:

Muscle relaxants Succinylcholine:1-2 mg/kg; useful for RSI/emergency; contraindicated in burns, spinal cord injury and crush injuries > 24-48 hours after injury May give nondepolarizing dose prior to Sux to inhibit fasciculation's (esp. with SCI)

Muscle relaxants:

Muscle relaxants Nondepolarizers Vecuronium .28 mg/kg (250-300 mcg/kg)high dose; onset in 80 secs; duration 75-90 min; good cardiovascular stability without histamine release Rocuronium 1.2 mg/kg high dose; onset 45-60 secs; duration 67 minutes


Maintenance O2/air/Forane mixture Avoid N2O if any question of pneumothorax, pnuemocephalus, pneumomediastinum, bowel injury Fentanyl 1- 10 mcg/kg/hr Monitor fluids and administer carefully Prepare to give blood products if necessary


Hypothermia Common with traumatic injuries and related procedures Warm all IV fluids Level 1: warms IVF and blood to 42*C and delivers at 75-30,000 ml/hr Rapid infusion system (RIS): warms to 42*C and can deliver products as bolus and various rates, up to 3000ml/min; cell saver can be attached to system Forced air warming systems Heat moisture exchangers


Emergence Normal extubation criteria Hemodynamically unstable, elderly with rib and long bone fractures, those who have received massive fluid and blood resuscitation, severe burns, and those with coagulopathies should remain intubated

Postop :

Postop Monitored and labs followed closely Correct acid-base imbalances and electrolyte disturbances Long-acting opioids Epidural infusions Intercostal blocks Complications: Hypothermia, atelectasis, V/Q mismatch, coagulopathy

Mechanism of injury:

Mechanism of injury Blunt trauma: caused by high-velocity or low-velocity impact from generally dull objects Penetrating trauma: result of sharp objects piercing through tissue, such as stab wounds produced by knives or bullet wounds produced by gunfire Impalement injuries: combination of blunt and penetrating trauma Falls: vertical high-velocity injuries Burns: thermal, electrical or chemical

Mechanism of injury cont’d:

Mechanism of injury cont’d Airway burns and smoke inhalation injuries: associated with carbon dioxide poisoning Environmental injuries: poisonous insects and snakes, animals or consequences of nature Biological, chemical or nuclear warfare

Blunt trauma:

Blunt trauma Result of direct impact, deceleration, continuous pressure, shearing, and rotary forces Associated with injuries from high-speed collisions and falls from heights Motor vehicle crashs (MVC) are classified as head on, rear impact, side impact, rotational impact, and rollover Injuries commonly much more severe than penetrating

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