Anesthesia for Trauma dictated slides 52-78

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Penetrating trauma :

Penetrating trauma Often requires surgical intervention Damage depends on 3 factors: Type of wounding instrument Velocity of instrument at time of impact Type of tissue that instrument passes through (organs, vessels, nervous tissue, muscle, fat, bone)

Most common emergency surgeries in order of urgency:

Most common emergency surgeries in order of urgency Surgery to secure or open airway  most urgent Exploratory laparotomy or thoracotomy  exsanquinating hemorrhage Decompressive craniotomy subdural or epidural hematoma Extremities threatened by vascular injuries Abdomen control contamination Unstable orthopedic injuries Spinal/pelvic stabilization I & D of open fractures Intramedullary nail fixation of long bone fractures

“Damage Control”: Priority treatment:

“Damage Control”: Priority treatment Exploratory laparotomy: Pack 4 quadrants  hemostasis Resect organs Diffuse hemorrhage Topical fibrin sealants Procoagulant dressings Cover abdomen with mesh staged closure Possible angiography

“Damage Control”: Priority treatment:

“Damage Control”: Priority treatment Permissive hypotension Animal models demonstrate better outcomes when a lower than normal BP (MAP 60-70 mmHg) used as target for fluid resuscitation Permits in vivo coagulation Avoidance of bolus crystalloids preserves normothermia and prevents excessive dilution of RBC’s and clotting factors

“Damage Control”: Priority treatment:

“Damage Control”: Priority treatment Early transfusion  supply of O negative “universal donor” blood Early use of plasma and platelets Data from Iraq support use of plasma to RBC units of 1:1 Type AB “universal donor” plasma should be kept pre-thawed Pro-coagulant therapy External Hemorrhage: fibrin sealant bandages, chitosan, zeolite based agents; under investigation for open procedures Recombinant human clotting factor VIIa (FVIIa) Prothrombin complex concentrates (PCCs) Complications: MI, stroke, pulmonary embolus Look beyond HR and BP  arterial base deficit, pH, LACTATE Normal lactate during resuscitation better outcomes

Thoracic injuries:

Thoracic injuries Blunt or penetrating trauma Most ominous sign: hypoxia from tension pneumothorax, hemothorax, flail chest, hypovolemia, cardiac tamponade Chest wall trauma can result in above

Pneumothorax:

Pneumothorax Accumulation of air between parietal and visceral pleura Results in severe V/Q mismatch and hypoxia S/S: chest wall hyperresonant to percussion Breath sounds decreased or absent unilaterally Subcutaneous emphysema CXR confirms Treatment:: needle decompression second intercostal space midclavicular line  chest tube 4 th or 5 th ICS, midaxillary line

Hemothorax:

Hemothorax Can be caused from bleeding of heart and great vessels Fluid load before chest tube placement Differentiated from pneumothorax by dullness to percussion with absent breath sounds

Tension pneumothorax:

Tension pneumothorax Develops from air entering pleural cavity through a one way valve in lung or chest wall With each inspiration, more air becomes trapped in thorax, increasing intrapleural pressure Eventually the ipsilateral lung collapses and the mediastinum and trachea shift to contralateral side

Tension pneumothorax cont’d:

Tension pneumothorax cont’d S/S Hyperresonance to percussion of chest wall Ipsilateral absence of breath sounds Contralateral tracheal shift Distended neck veins? Differentiated from cardiac tamponade by hyperresonance to percussion over tension pneumo Treatment 14 gauge catheter 2 nd ICS midclavicular line  chest tube

Flail chest:

Flail chest Results from comminuted fractures of at least three adjacent ribs with associated costochondral separation or sternal fracture Accompanied by hemothorax or pulmonary contusion Patients with 3 or more rib fractures have greater likelihood of hepatic or splenic injury S/S Paradoxical chest wall movement and/or splinting due to intense pain

Flail chest cont’d:

Flail chest cont’d Chest X-ray and ABG confirm diagnosis Treatment O2 with humidification Pain meds: IV thoracic epidural intercostal blocks

Pulmonary contusion:

Pulmonary contusion Intra-alveolar hemorrhage and edema resulting from sudden increase in intra-alveolar pressure and rupture of alveolar-capillary interface Difficult to diagnosis; high index of suspicion with thoracic injuries Treatment If worsening respiratory failure, intubation with PEEP, frequent suctioning to avoid bronchial plugging and atelectasis, and careful volume resuscitation

ARDS:

ARDS Later pulmonary complication Attributed to direct thoracic injury, sepsis, aspiration, head injury, massive transfusion, oxygen toxicity, and fat embolism Mortality rate reaching 50%

Myocardial contusion:

Myocardial contusion Associated with blunt trauma Contusion most often right ventricle since lies directly posterior to sternum S/S Dysrhythmias: heart block to Vfib; ST segment elevation Elevated CPK-MB; ? troponin elevation CHF Anginal pain which may or may not respond to nitrates

Myocardial contusion cont’d:

Myocardial contusion cont’d Treatment Management of dysrhythmias Increase CVP to optimize right ventricular output

Cardiac tamponade:

Cardiac tamponade Life-threatening emergency Bleeding into pericardial space, which restricts cardiac filling during diastole and creates a low cardiac output state Initial symptoms Dyspnea Orthopnea tachycardia

Tamponade cont’d:

Tamponade cont’d Classic symptoms Beck’s triad  neck vein distention, hypotension, muffled heart sounds Pulsus paradoxus: > 10 mmHg decrease in blood pressure during spontaneous inspiration May not be evident in hypovolemia Treatment Pericardiocentesis: 16 g catheter inserted at the xiphochondral junction toward left scapula at 45* angle If advanced too far, will see ectopy Requires thoracotomy Fluid load and treat with pressors if necessary Avoid bradycardia; Ketamine useful agent

Associated thoracic injuries:

Associated thoracic injuries Aortic rupture Valvular rupture Septal rupture Diaphragmatic herniation Esophageal rupture

Abdominal and Pelvic trauma:

Abdominal and Pelvic trauma High risk for exsanguinating hemorrhage and peritonitis Results from blunt and penetrating trauma Retroperitoneal injuries can damage abdominal aorta, IVC, kidneys, pancreas, duodenum Intraperitoneal injuries can injure spleen, liver, stomach, small bowel, colon, rectum

Abdominal and pelvic injuries cont’d:

Abdominal and pelvic injuries cont’d Intraabdominal injuries associated with paralytic ileus and peritoneal irritation (muscle guarding, tenderness to percussion, abdominal distention) >1-3 liters of blood can sequester in abdomen/retroperitoneal space with minimal signs Diagnosis confirmed with free air on X-ray or FAST or CT or by bloody DPL

Diagnostic peritoneal lavage (DPL):

Diagnostic peritoneal lavage (DPL) Performed when abdominal injury suspected from mechanism of injury Not performed routinely now that FAST available FAST and DPL can prevent unnecessary exploratory lap Can use local with sedation

DPL cont’d:

DPL cont’d Peritoneum lavaged with fluid that is then drained by gravity and examined for presence of RBC’s, bile, amylase, and WBC’s Positive finding: >10 cc gross blood >100,000 RBC’s/ml > 500,000 WBC’s/ml Amylase > 200 units Bacteria False positive results < 2%

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