SEMINAR :SEMINAR ANESTHETIC MANAGEMENT OF TRAUMA MODERATOR : Dr. NANDITA


TRAUMA :TRAUMA Physical harm or damage to body due to the acute exchange of mechanical, thermal or other environmental energy that exceeds the body’s tolerance


Fourth leading killer :Fourth leading killer


SPECIFIC SURGICAL DISEASE ANAESTHESIOLOGIST :SPECIFIC SURGICAL DISEASE ANAESTHESIOLOGIST SECURE AIRWAY ADEQUATE VENTILATION APPROPRIATE INTRAVENOUS FLUIDS REQUIRED SEDATION & ANALGESIA


POTENTIAL ROLE :POTENTIAL ROLE TRAUMA TEAM MEMBER TRAUMA TEAM LEADER ANAESTHETIST PAIN RELIEF PHYSICIAN PRE HOSPITAL CARE PHYSICIAN CRITICAL CARE PHYSICIAN CRITICAL CARE TRANSPORT PHYSICIAN DISASTER PLANNING


TEAM APPROACH :TEAM APPROACH ANAESTHESIOLOGIST SURGEON E R PHYSICIAN NURSES TECHINICIAN


THE GOLDEN HOUR CONCEPT :THE GOLDEN HOUR CONCEPT CLINICAL SHOCK IF NOT RESUSCITATED AND REVERSED WITHIN ONE HOUR SURVIVABILITY DROPS BELOW 10% >THAN 30 MINUTES DELAY MORTALITY RATE >BY300%


TRAUMA SCORINGREVISED TRAUMA SCORING :TRAUMA SCORINGREVISED TRAUMA SCORING


ABBREVIATED INJURY SCALE :ABBREVIATED INJURY SCALE


ADVANCED TRAUMA LIFE SUPPORT :ADVANCED TRAUMA LIFE SUPPORT 1.PRIMARY SURVEY 2.PRIMARY RESUSCITATION [PHYSIOLOGICAL SYSTEM CONTROL] 3.SECONDARY SURVEY 4.DEFINITIVE CARE [ANATOMICAL STRUCTURE CONTROL]


PHYSIOLOGICAL SYSTEM CONTROL :PHYSIOLOGICAL SYSTEM CONTROL RESPIRATION CIRCULATION NERVOUS SYSTEM METABOLISM-ACID BASE,EXCRETION HOST DEFENCES


A B C D E APPROACHA AIRWAY( assessment) :A B C D E APPROACHA AIRWAY( assessment) PATENCY BREATH SOUNDS AIR MOVEMENT PRESENCE OF BLOOD,TISSUE,VOMITUS


AIRWAY MANAGEMENT :AIRWAY MANAGEMENT CLEAR THE AIRWAY-SUCTION -FINGER SWEEP -HEMLICH’SMANOEUVRE HEAD TILT & CHIN LIFT ENDOTRACHEAL TUBE


INDICATIONS FOR ETT :INDICATIONS FOR ETT HEAD INJURY GCS< 9 SHOCK AIRWAY OBSTRUCTION COMBATIVE PATIENT REQUIRING SEDATION CHEST TRAUMA POST RESUSCITATION HYPOXIA CARDIAC ARREST


ALTERNATIVES TO ENDOTRACHEAL TUBE :ALTERNATIVES TO ENDOTRACHEAL TUBE COMBITUBE LARYNGEAL MASK AIRWAY OESOPHAGEAL OBTURATOR TRANSTRACHEAL JET VENTILATION GUM ELASTIC BOUGIE


SURGICAL AIRWAY :SURGICAL AIRWAY MASSIVE HAEMATOMA OF TONGUE DISRUPTION OF LARYNX OR TRACHEA DISRUPTION OF FLOOR OF MOUTH BLEEDING IN NECK FORMING BIG HAEMATOMA FACIO MAXILLARY INJURY


SURGICAL AIRWAY :SURGICAL AIRWAY OPTIONS CRICOTHYROTOMY NEEDLE TUBE TRACHEOTOMY


B BREATHING(assessment) :B BREATHING(assessment) RATE OF RESPIRATION CYANOSIS TRACHEAL SHIFT ASSESS VENTILATION VENTILATORY DEFICIT FLAIL CHEST PNEUMOTHORAX SUB CUTANEOUS EMPHYSEMA MONITOR SPO2 ETCO2 WITH WAVEFORM


BREATHING MANAGEMENT :BREATHING MANAGEMENT GIVE OXYGEN FiO2 .5--1 CONTROLLED VENTILATION DECOMPRESSION WITH 14/16G ` CANNULA IN 2nd INTERCOSTAL ` ` SPACE


C CIRCULATION(assessment) :C CIRCULATION(assessment) PALPATE PULSE-rate , amplitude TEMPERATURE & SWEATINESS CAPILLARY RETURN ECG & NIBP FOLEY’S CATHETER(renal perfusion) JUGLAR VENOUS DISTENSION GRADE SHOCK - VITAL SIGNS(blood- pressure, heart rate,respiratory rate etc)


GOALS FOR EARLY RESUSCITATION :GOALS FOR EARLY RESUSCITATION Maintain systolic BP at 80-100mmHg Maintain hematocrit at 25-35% Maintain prothrombin time & partial thromboplastin time in normal ranges Maintain platelets count >50,000 Maintain normal serum ionized calcium Maintain core temperature > 35C Maintain function of pulse oximeter Prevent increase in serum lactate Prevent acidosis from worsening


Slide 29:Patient in shock SBP<90 mmHg Traumatic mechanism of injury Early management Diagnosis & primary treatment Rule out mechanical factors Control hemorrhage Support & resuscitation ABCs Laboratory samples Monitors Temperature Fluid therapy Hemorrhage controlled ? yes Late Resiscita tion No


GOALS FOR LATE RESUSCITATION :GOALS FOR LATE RESUSCITATION Maintain systolic BP > 100mmHg Maintain hematocrit above individual transfusion threshold Normalize coagulation status Normalize electrolyte balance Normalize body temperature Restore normal urine output Maximize cardiac output by invasive or noninvasive measurement Reverse systemic acidosis Document decrease in lactate to normal range


Slide 31:Hemorrhage controlled Resuscitation complete SBP>100mmHg HR> 100/min pH= 7.40 Lactate normal Urine output adequate HCT>25% PT<14 yes finished No Maximize cardiac output PA catheter Fluid bolus Resuscitation complete No Ongoing hemorrhage Yes Return To early Resusci- tation No Maintain Volume Status, Blood Composi- tion,& Cardiac Output Consider Inotropic therapy


METHODOLOGIES FOR ASSESSMENT OF SYSTEMIC PERFUSION :METHODOLOGIES FOR ASSESSMENT OF SYSTEMIC PERFUSION TECHNIQUE Vital signs Urine output Systemic acid-base status Lactate clearance Cardiac output Mixed venous oxygenation Gastric tonometry Tissue- specific oxygenation SHORTCOMINGS Will not indicate occult hypoperfusion May be confounded by intoxication, diuretic therapy, circadian variation, or renal injury Confounded by respiratory status Requires time to obtain laboratory results Requires placement of a pulmonary catheter or use of noninvasive technology Difficult to obtain, but a very accurate marker Requires time to equilibrate, subject to artifact Investigational technique; may not indicate satisfactory systemic perfusion


CIRCULATION MANAGEMENT :CIRCULATION MANAGEMENT VENOUS ACCESS-14--16G cannula CENTRAL ROUTE VENOUS CUTDOWN INTRAOSSEOUS INFUSION


PRACTICAL INTRA VENOUS FLUID MANAGEMENT :PRACTICAL INTRA VENOUS FLUID MANAGEMENT 30 % BLOOD VOLUME LOST COLLOIDS &CRYSTALLOIDS >40 % BLOOD VOLUME LOST RED BLOOD TRANSFUSION &COLLOIDS &CRYSTALLOIDS O GROUP WARMING


D DISABILITY 4 POINT SCALE :D DISABILITY 4 POINT SCALE A ALERT V RESPONDING TO VERBAL COMMAND P RESPONDING TO PAIN U UNRESPONSIVE ___________________________________ PUPILS SIZE SYMMMETRY & REACTION GCS DEFFERED


E EXPOSURE :E EXPOSURE ESSENTIAL TO REMOVE ALL CLOTHINGS - external evidence of injury INSPECTION OF THE BACK - posterior injuries - can bleed fatally


OPERATION THEATRE MANAGEMENT :OPERATION THEATRE MANAGEMENT AIRWAY DRUGS MONITORING HIGH RATE PERFUSION LINES FLUIDS, BLOOD &BLOOD PRODUCTS HAEMATOCRIT, BLOOD- GASES &COAGULATION STATUS


ANESTHETICS FOR INDUCTION OF ANESTHESIA :ANESTHETICS FOR INDUCTION OF ANESTHESIA Propofol & Thiopental are the mainstay in operating room, their use in trauma pts is especially problematic b’coz both the drugs are vasodilators & both have a negative inotropic effect. Etomidate is a frequently espoused alternative as it is associated with more cardiovascular stability. Ketamine continues to be popular for induction in trauma pts b’coz it causes a release of catecholamines, primarily by direct action on CNS. P2457 The dose of anesthetic must be decreased in the face of hemorrhage, down to none at all in pts with life- threatening hypovolemia. Rapid- sequence induction may be proceed with muscle relaxants alone, although onset time may be prolonged in a pt with circulatory impairment.


NEUROMUSCULAR BLOCKING DRUGS :NEUROMUSCULAR BLOCKING DRUGS Succinylcholine remains the NM blocker with fastest onset - <1min and shortest duration of action 5-10mins. These properties make it popular for rapid-sequence induction. P 2457 Alternatives to succinylcholine include rocuronium (1mg/kg) & vecuronium (0.1-0.2mg/kg). P 2458


CRITERIA FOR OPERATING ROOM OR PACU EXTUBATION OF TRAUMA PTS :CRITERIA FOR OPERATING ROOM OR PACU EXTUBATION OF TRAUMA PTS Mental status Resolution of intoxication Able to follow commands Noncombative Pain adequately controlled Airway anatomy and reflexes Appropriate cough and gag Ability to protect airway from aspiration No excessive airway edema or instability Respiratory mechanics Adequate tidal volume and respiratory rate Normal motor strength Required fiO2 < 0.50 Systemic stability Adequate resuscitated Small likelihood of return to the operating room Normothermic, without signs of sepsis


EMERGENCE AND EXTUBATION :EMERGENCE AND EXTUBATION Initial surgery in a trauma pt is followed by a period of monitoring & ongoing treatment in which the anesthesiologist is closely involved, either in the PACU or in the ICU Reversal of the effects of general anesthesia is highly desirable, particularly in pts with an altered level of consciousness or other evidence of TBI before surgery Early extubation of a trauma pt should not be taken for granted, many pts will require continued ventilator support b’coz of CNS trauma, direct pulmonary or chest wall trauma, massive transfusion, upper airway edema, or on going intoxication Appropriate analgesic medication should be given, with sedation if necessary, and the pt allowed to stabilize for next 12-24hrs P2483


PAIN MANAGENENT :PAIN MANAGENENT An anesthesiologist providing pain management for trauma must be prepared for a wide range of needs, b’coz of multiple sites of injury, protracted episodes of care, complicating psychological & emotional issue, & frequently, previous or ongoing substance abuse Pain in general & pain from traumatic injury in particular are self-perpetuating phenomena, increased receptor no. & activity in response to an ongoing painful stimulus leads to a “wind-up” of pain over time Hypotension developing in response to the appropriate administration of analgesic most commonly indicates hypovolemia & should lead to an investigation for occult hemorrhage while further resuscitation occurs The need for analgesic medication & the duration of emotional therapy will be minimized if a comprehensive emotional support is available to the pt P2483 The need for analgesic medication is also influenced by the schedule of physical therapy prescribed for the pt


Slide 43:Early mobilization demonstrates to the pt the “path to recovery” & contributes to an improved emotional state P2484 The choice of medications should follow the WHO’s recommendations for “stair step” therapy, beginning with the safest drugs & titrating each agent upward until the recommended maximum dose is reached before adding a new agent The anesthesiologist should be aware of the potential for addiction to occur & be prepared to offer appropriate treatment , including referral to a substance abuse specialist, should addiction develop The GIT is the preferred route of administration for analgesic medication b’coz it offers gradual & predictable absorption Pts who are NPO must usually be managed with intravenous medication and the preferred route is by pt-controlled analgesia infusion device (PCA) that allows for immediate delivery & self-titration of pain medication


SPECIFIC SITUATIONS :SPECIFIC SITUATIONS


FACIAL AND PHARYNGEAL TRAUMA :FACIAL AND PHARYNGEAL TRAUMA Poses a particular difficulties for anesthesiologists Serious skeletal derangements may be masked by apparently minor soft tissue damage Laryngeal edema is a risk in pts who have suffered chemical or thermal injury to the pharyngeal mucosa Intraoral hemorrhage, pharyngeal erythema, and change in voice are all indications for early intubation In general, both maxillary and mandibular fractures will make mask ventilation more difficult, whereas mandibular fractures will make intubation easier. P 2459 A pt arriving at the emergency deppt in the sitting or prone position b’coz of airway compromise is best left in that position until the moment of anesthetic induction and intubation.


HEAD AND NECK SURGERY :HEAD AND NECK SURGERY Anesthetic management of these pts is not substantially different from similar elective procedures, although coexisting injuries may influence pt positioning & ventilator settings Surgery on the mandible and maxilla will be facilitated by nasotracheal intubation Securing the endotracheal tube to the molar with a fine-gauge wire will help stabilize it through the operation


TRAUMA AND PREGNANCY :TRAUMA AND PREGNANCY Trauma to pregnant pts is associated with a high risk of spontaneous abortion, preterm labor, or premature delivery, depending on the location & magnitude of the mother’s injury Early consultation with an obstetrician is desirable for any pregnant trauma pt, both for immediate management & for long-term follow up Serious trauma occurring during the period of fetal organogenesis may induce birth defects or miscarriage as a result of hemorrhagic shock with uterine ischemia, radiation to pelvis, or the effects of medications


Slide 48:Trauma pts in the 1st trimester of gestation who do not spontaneously miscarry should be advised of the potential risks related to trauma & anesthesia & be referred for counseling if desired Trauma in the 2nd & 3rd trimester of pregnancy necessitate early USG examination to determine fetal age, size, & viability Monitoring of fetal heart rate is indicated if pregnancy is sufficiently advanced that the fetus would be viable if delivered Delivery by cesarean section is indicated if the mother is in extremis, if the uterus itself is hemorrhaging, or if the gravid uterus is impairing surgical control of abdominal or pelvic hemorrhage


ELDERLY TRAUMA PTS :ELDERLY TRAUMA PTS Equivalent traumatic injuries will have a markedly more serious outcome in elderly than in younger victims Decreased cardiopulmonary reserves lead to a higher incidence of postoperative mechanical ventilation in older trauma pts & a much greater risk for MOSF after hemorrhagic shock A higher hematocrit with tighter control of administered fluids is generally recommended to maintain maximized tissue oxygen delivery Post traumatic myocardial dysfunction is a significant risk, particularly if the heart rate is elevated secondary to blood loss, pain, or anxiety Elderly pts will have diminished requirements for postoperative analgesia & may respond to sedative medications with inappropriate agitation Prophylaxis against deep venous thrombosis is particularly important in pts who cannot be immediately mobilized in the postoperative period, as is aggressive pulmonary physiotherapy


JEHOVAH’S WITNESS PTS :JEHOVAH’S WITNESS PTS Early identification & control of hemorrhage are obviously important, as for any trauma pt, deliberate hypotension to limit bleeding is even more appropriate Preoperative & intraoperative phlebotomy should be minimized The use of salvaged red cells can be considered if pts allow Early hemodynamic monitoring is indicated to help determine the role of colloid therapy, pressors, and inotropes in maintaining tissue oxygen delivery at the highest possible level Use of rFVlla & HBOCs can be considered Postoperatively the use of erythropoietin to promote red cell growth will shorten the period of anemia


ORTHOPEDIC AND SOFT TISSUE TRAUMA :ORTHOPEDIC AND SOFT TISSUE TRAUMA Musculoskeletal injuries with life or limb-threatening potential or significant functional impairment are present in more than 50% of all hospitalized trauma pts Lower extremity #s are the leading cause of all trauma admissions A musculoskeletal trauma pt can be classified into one of the three distinct types Isolated closed musculoskeletal injury that requires surgical intervention on elective basis Multiple #s of major bones & joints or significant injury potential Multiple #s of the major long bones, spinal cord, & joints associated with multisystem injuries


REGIONAL ANESTHESIA FOR TRAUMA PTS :REGIONAL ANESTHESIA FOR TRAUMA PTS ADVANTAGES Allows for continued mental status assessment Increased vascular flow Avoidance of airway instrumentation Improved postoperative mental status Decreased incidence of DVT Decreased blood loss Improved postoperative analgesia Better pulmonary toilet Earlier mobilization DISADVANTAGES Peripheral nerve function difficult to assess Pt refusal is common Requirement for sedation Longer time to achieve anesthesia Not suitable for multiple body regions Difficult to judge length of procedure


GENERAL ANESTHESIA FOR TRAUMA PTS :GENERAL ANESTHESIA FOR TRAUMA PTS ADVANTAGES Speed of onset Duration-can be maintained as long as needed Allows multiple procedures for multiple injuries Greater pt acceptance Allows for positive-pressure ventilation DISADVANTAGES Impairment of neurologic examination Requirement for airway instrumentation Hemodynamic management more complex Increased potential for barotrauma


TRAUMA TO CENTRAL NERVOUS SYSTEM :TRAUMA TO CENTRAL NERVOUS SYSTEM


TRAUMATIC BRAIN INJURY :TRAUMATIC BRAIN INJURY Brain injury after trauma is classified as mild moderate or severe, depending on the GCS score on admission Mild traumatic brain injury (GCS 13-15) Moderate traumatic brain injury (GCS 9-12) p 2470 Severe traumatic brain injury (GCS 8 or <)


AIRWAY AND VENTILATORY MANAGEMENT :AIRWAY AND VENTILATORY MANAGEMENT TBI pts should be transported as early as possible to a facility capable of managing severe TBI or to the nearest facility capable of intubating the pt & initiating systemic resuscitation Pts with isolated head injuries can be managed with traditional ventilatory strategies, but those with chest trauma, aspiration, or massive resuscitation after shock are at high risk for acute lung injury The classic teaching of no or low-level PEEP to prevent elevated ICP is inappropriate b’coz it may fail to correct hypoxemia, however it may actually decrease ICP b’coz of improved cerebral oxygenation Hyperventilation therapy is no longer an appropriate treatment unless signs of imminent herniation are present


MANAGEMENT OF INTRACRANIAL AND CEREBAL PERFUSION PRESSURE :MANAGEMENT OF INTRACRANIAL AND CEREBAL PERFUSION PRESSURE Positional therapy Analgesic and sedatives Neuromuscular blocking drugs Mannitol therapy Hypertonic saline solution Barbiturate coma Decompressive craniotomy Hypothermia


SPINAL CORD INJURY :SPINAL CORD INJURY The mechanical patterns of SCI are often predictive of the resulting deficit There are four major patterns of injury: Distraction Compression Torsion Penetration Blunt SCI is most common in regions of the cord that are more flexible, especially at the junction between flexible and inflexible segments Most spinal injuries are found in the lower cervical spine ,just above the thorax, or in the upper lumber region, just below the thorax


Slide 59:Primary injury to the spinal cord sustained at the moment of trauma may be exacerbated by a number of secondary factors like : disruption of spinal vasculature cellular edema systemic perturbations and intubation (most common ) SCI includes sensory deficits, motor deficits, or both Cervical spine injuries causing quadriplegia are accompanied by significant hypotension b’coz of inappropriate vasodilatation and loss of cardiac inotropy( neurogenic shock)


EARLY SUPPORTIVE CARE :EARLY SUPPORTIVE CARE B’coz the spinal cord is susceptible to secondary injury in the same way that brain tissue is, early treatment of a pt with SCI is focused on preservation of adequate perfusion Hypoxia must be avoided at all costs, & MAP should be maintained at a normal to high level Early intubations is almost universally required for pts with cervical spine injury, with inclusion of manual in-line axial stabilization In the acute settings (<24hrs) succinylcholine can be safely given


Slide 61:Fluid administration is indicated subject to the end points of resuscitation Circulatory management is followed by a glucocorticoid steroid bolus, administered to any pt with a complete or partial neurologic deficit A bolus dose of 30mg/kg of methylprednisolone, followed by a maintenance infusion of 5.4mg/kg/hr, is given if the pt is less than 8hrs removed from the time of injury and continued for 24hrs if started within 3 hrs of injury and for 48hrs if started 3-8 hrs after injury Ventilatory support is absolutely required for pts with a deficit above C4 b’coz they will lack diaphragmatic function, and b/w C4 to C7 b’coz of lost chest wall innervation, paradoxical respiratory motion, and an inability to clear secretions Spontaneous ventilation and extubation may be possible after surgical stabilization and resolution of spinal shock


CHEST INJURIES :CHEST INJURIES Blunt thoracic trauma requiring pneumonectomy is often associated with abdominal & pelvic trauma Double-lumen endotracheal intubation is desirable during urgent thoracotomy, such intubation should not be the initial approach Rapid-sequence intubation with a large-caliber conventional endotracheal tube will permit diagnostic bronchoscopy & will protect the pt from aspiration until passage of a gastric tube can reduce stomach contents Volume replacement must be judicious,& the use of a pulmonary artery catheter or TEE may be beneficial ECG will also play an important role in assessing rt. ventricular function and pulmonary hypertion


Slide 63:Rib fractures are the most common injury resulting blunt chest trauma Therapy is directed at minimizing pulmonary complications secondary to these fractures, such as pain, splinting, atelectasis, hypoxemia, & pneumonia Epidural anesthesia should be liberally used in pts with severe pain Endotracheal intubation is reserved for pts who are unable to oxygenate or ventilate or who require protection of the airway


ACUTE RESPIRATORY DISTRESS SYNDROME AFTER TRAUMA :ACUTE RESPIRATORY DISTRESS SYNDROME AFTER TRAUMA Old age Preexisting physiologic impairment Direct pulmonary or chest wall injury Aspiration of blood or stomach contents Prolonged mechanical ventilation Severe traumatic brain injury Spinal cord injury with quadriplegia Massive transfusion Hemorrhagic shock Occult hypoperfusion Wound or cavity infection


CRITICAL CARE AREA ANAESTHESIOLOGIST :CRITICAL CARE AREA ANAESTHESIOLOGIST AIRWAY VENTILATORY MANAGEMENT VOLUME RESUSCITATION SURGEON continued care


CONCLUSION :CONCLUSION LEADING CAUSE OF MORTALITY PHYSIOLOGICAL SYSTEM CONTROL COMPRESSION OF TIME A B C D E APPROACH COORDINATION& TEAM APPROACH


Slide 67:THANK YOU