Anesthesia for Trauma dictated slides 70-102

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Splenic laceration:

Splenic laceration Most common injury in blunt abdominal trauma and with penetrating wounds of left lower thorax and upper abdomen Routine splenectomy rare Splenorrhaphy (repairing the spleen) more common Decreases incidence of sepsis Can take to angiography to embolize lac

Liver laceration:

Liver laceration Second most common injury associated with abdominal trauma Exsanguniating hemorrhage can occur Majority of liver injuries (85-90%) heal spontaneously and may only require surgical drainage

Pelvic fractures:

Pelvic fractures Result in major hemorrhage 25% of time Exsanguination 1% of time Bleeding results from disruption of veins from bone fragments Emergent or elective external fixation can be followed by angiography Arterial bleeding can be embolized Bladder injuries often associated with pelvic fracture Urethrogram should be performed before foley inserted

Abdominal and pelvic trauma:

Abdominal and pelvic trauma Anesthetic concerns revolve around hemorrhage, hypothermia, sepsis/peritonitis and impairment of ventilation Warming measure are crucial since large heat loss from open mesentery and shock Avoid N20 to prevent bowel distention Fluid resuscitation imperative The pelvis can hold up to 3 liters

Extremity trauma:

Extremity trauma Usually not immediately life-threatening and part of secondary survey Can be associated with vascular injuries causing hemorrhage, shock, sepsis, fat emboli, and thromboembolic hypoxic respiratory failure

Open fractures:

Open fractures Ideal to repair in first few hours post injury so full stomach precautions Should repair within 6 hours to lessen incidence of sepsis If obvious hemorrhage, hold pressure manually; can have MAST pants applied while in field

Vascular trauma:

Vascular trauma S/S Pain Pulselessness Pallor Paresthesias Paresis Confirmed with angiography

Compartment syndrome:

Compartment syndrome Characterized by severe pain in affected extremity Calf pain on dorsiflexion of foot Emergency fasciotomy must be done to prevent irreversible muscle and nerve damage Diagnosis confirmed by compartment pressures > 40 cm H20

Long bone fractures:

Long bone fractures Commonly lead to thromboembolic hypoxic respiratory failure due to fat globules or fracture debris reaching pulmonary vascular bed Fat embolism syndrome: Fever Petechaie Dysrhythmias Fat globules in urine, plasma, retinal vessels Mental deterioration 1-3 days post trauma

Fat embolism syndrome cont’d:

Fat embolism syndrome cont’d Diagnosis: elevated serum lipase, fat in urine, and thrombocytopenia Treatment: early fracture stabilization is key to prevention Aggressive cardiovascular and pulmonary support

Anesthetic concerns with extremity trauma:

Anesthetic concerns with extremity trauma Positioning Associated injuries Tourniquets

Crush injuries:

Crush injuries Can occur with blunt and penetrating trauma Increased risk of myoglobinuria, leading to rhabdomyolisis Always check urine and document color with trauma patients; inform surgeon immediately if becoming bloody Need to hydrate, osmotic diuretics, alkalinize urine to protect kidneys Follow lactate; > 2 can be sign of under resuscitation

Head injury: Leading cause of death from trauma:

Head injury: Leading cause of death from trauma Goal is prevention of secondary brain damage resulting from intracranial bleeding, increased ICP, edema TBI: Traumatic Brain Injury ICI: Intracranial Injury Management should include early control of airway, cardiovascular stability, and avoidance of increased ICP Patients with suspected head injury should be placed head up position to promote venous drainage and decrease ICP; moderate hyperventilation to 30 mmHg

Treatment to lower ICP:

Treatment to lower ICP Elevation of head Sedation and analgesia Normothermia Normocapnea Normotension Osmotic diuresis CSF Drainage Induced coma Decompressive craniotomy

Treatment not beneficial:

Treatment not beneficial Steroids Anti-inflammatory pharmaceuticals Secondary brain injury is an inflammatory disease New monitoring systems Tissue oxygen tension with microanalysis of lactate may guide anti-inflammatory therapy

8 sensitivity indicators that predicted ICI:

8 sensitivity indicators that predicted ICI B Behavior abnormal E Emesis intractable A Age > 65 years N Neurologic deficit B Bleeding disorder A Altered mental status S Skull fracture H Hematoma scalp Mower WR, Hoffman JR, Herbert M, et al, for the Nexus II Investigators. Developing a decision instrument to guide computed tomographic imaging of blunt head injury patients. J Trauma. 2005;59:954-959.

Anticoagulated head injury:

Anticoagulated head injury Warfarin reversal Mortality rate 5 times > than those not anticoagulated CT  2 units of fresh frozen plasma (FFP) thawed while the patient was in CT  If CT positive, given FFP and vitamin K  additional 2 units FFP 2 hours later  admitted to ICU or taken to surgery  If CT scan was negative, the patients were admitted for 24 hours of observation Mortality decreased from 50% to 10% Ivascu FA, Howells GA, Junn FS, Blair HA, Bendick PJ, Janczyk RJ. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma. 2005;59:1131-1139.

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