Anaesthesia for Trauma C Berger MD FRCP(C) For NMH residents, Kabul Anaesthesia for Trauma Conduct of anaesthesia requires awareness of all sustained injuries. In the initial resuscitation focus on airway, c-spine, and cardiothoracic injuries If time permits review with trauma team leader or perform your own ABCDE assessment Initial trauma protocol O2 2 large bore IVs Investigations CBC, cross match, lytes, Coags, ABG Others according to history / physical exam Others according to history / physical exam Consider CXR, C-spine, Pelvic imaging Anaesthesia for Trauma If situation does not permit full assessment : Obtain AMPLE history A Allergies M Medications P Past medical history L Last meal E Events leading to injury And proceed with interventions Anaesthesia for Trauma Keep in mind 6 injuries that kill quickly these need to be identified and treated during primary survey Airway obstruction Open pneumothorax Tension pneumothorax Flail chest with pulmonary contusion Massive hemothorax Cardiac tamponade Anaesthesia for Trauma Other life-threatening injuries : Simple pneumothorax Pulmonary contusion Cardiac contusion Aortic disruption Diaphragmatic disruption Tracheo-bronchial disruption Esophageal disruption Anaesthesia for Trauma Airway Control : requires ETT, stylet, bougie, suction, O2 (Ambu bag ), LMA, and Cricothyroidotomy kit at the ready Consider : Full stomach Potentially difficult ( blood, cervical collar ) C-spine injury requiring in line stabilization Pneumothorax requiring decompression Closed head injury requiring adequate perfusion pressure Open eye injury to prevent vitreal extrusion Hemodynamic situation Beware nasal intubation in facial injuries Anaesthesia for Trauma Airway pre-oxygenate in line cervical stabilization, cricoid pressure Administer drugs Attempt DL 2nd attempt DL +/- appropriate airway adjuncts LMA if all above unsuccessful if all above unsuccessful Emergency cricothyroidotomy Definitive controlled tracheostomy Ventilation no benefit to supra-normal FiO2 Normocarbia in absence of closed head injury or compensating for severe metabolic acidosis Hangman Fracture Jefferson Fracture C2 pedicle MVA C1 burst axial loading Anaesthesia for Trauma Circulation class 3-4 shock will likely require massive transfusion Initial Hgb < 100, ph 1500cc ) or on-going blood loss ( > 200cc/hr x 2-4 hrs ) Large volume transfusion likely required Consider DLT for large air leak or significant haemoptysis Anaesthesia for Thoracic Trauma Tracheo-bronchial Disruption Upper bronchoscopic evaluation (SV) with placement of ETT below lesion. If very high then tracheostomy Lower lesion DLT Esophageal Disruption High mortality due to mediastnitis, empyema, sepsis DLT for surgical exposure Anaesthesia for Thoracic Trauma Aortic Disruption Devastating hemorrhage only 15% reach hospital alive Always consider in high rib fractures Massive transfusion, high incidence of associated thoracic injuries Cosider cardiopulmonary bypass Diaphragmatic Disruption NGT to decompress stomach DLT ( if possible ) improves surgical exposur Anaesthesia for Thoracic Trauma Cardiac Tamponade Consider in trauma patient ( usually penetrating ) who is not responding to fluids Kussmals sign, Becks Triad, pulsus paradoxus US is the best diagnostic tool and can assist in drainage Induction of GA may be deadly invasive pressures, maintain high CVP, high HR. consider epi infusion, ketamine induction and maintenane of spontaneous ventilation ( improve venous return ) Subxyphoid or intercostal incision PericardialEffusion Acute cases will be more easily identified by US Anaesthesia for Abdominal Trauma For haemorrhage or organ injury Bleeding can be extensive if major vascular of liver injury Damage control surgery only May need to pack and return later Consider leaving abdomen open to avoid abdominal compartment syndrome after large volume resuscitation Vac dressing VAC ( vacuum ) Dressing Anaesthesia for Orthopaedic Trauma Multiple sites may be involved Large bone fractures may lose 500-1L blood Functional examination pre-op important Careful with patient positioning Be aware of ischemic times ( tourniquet ) Monitor for rhabdomyolysis ( crush, compartment syndromes) and weigh safety of succ Stabilization only ( X fix ) and leave ( damage control ) Prophylactic fasciotomy Fat Embolism ( hypoxemia, petechial rash, cerebral dysfunction ) Anaesthesia for Closed Head Trauma Head injury often associated with other ( C-spine ) injuries High speed MVA, increased age, fall > 2m, intoxication Ensure ABCD survey complete GCS < 8, or decrease of 2 signal need for airway protection In absence of other injuries, hemodynamics normal until late Consider limited crystalloids, ? Hypertonic saline Maintenance of Cerebral Perfusion Pressure is paramount Avoid hypoxia, hyperglycemia, hypercarbia Anaesthesia for Closed Head Trauma The Cranial Vault is a closed space Occupants : Blood 10% Brain 80% CSF 10% Limited capacity to compensate for additional volume As compensatory mechanisms are exhausted, ICP increases, and CBF falls resulting in : B rain ischemia Anatomical shifts (herniation) Anaesthesia for Closed Head Trauma Manipulate CBF and hence ICP Maintain O2, CPP CPP = MAP ICP Reduced cerebral DO2 obviously deleterious PCO2 can be manipulated as a temporary measure to reduce ICP ( mmHg ; kpa ) Prolonged or severe hypocarbia may worsen cerebral ischemia Anaesthesia for Closed Head Trauma Permissive hypotension used in damage control surgery may not be appropriate in patients with closed head injury Some cooling may be permissible and protective ( > 35* ) Elevate head of bed slightly if tolerated Barituates, propofol infusion decrease cerebral mVO2 Other adjuncts ( mannitol, steroids ) not so useful in trauma Discuss with neurosurgeon Anaesthesia for Trauma In Conclusion : Initial approach to all trauma patients is the same ABC and treat immediate life threatening injuries Gather information and know your patient Avoid/treat aggressively the terrible triad Conflicting goals may occur When in doubt recall the priorities of : A before B before C before D