Trauma Anesthetic ManagementHow You and Your Patient Can Survive

Copyright 2019. Dawn Borth Lewellen, MHS, CRNA. All Rights Reserved.

Disclosure Statement

Belmont Instruments: Consultant/Advisory Board Parkland uses ROTEM

Learner Outcomes

List the latest changes in Advanced Trauma Life Support and Hemostatic Resuscitation

Define and explain Hemostatic Resuscitation and Damage Control Resuscitation

Describe the lethal triad of death in trauma and anesthetic interventions to improve patient outcomes

Yorktown Memorial Hospital

https://www.youtube.com/watch?v=aCPgpTI6YDY

Brackenridge School of NursingDiploma

St Paul Hospital, DallasMICU

TWU Class of 1990

John Peter Smith Hospital, Fort Worth TexasDice Club Shoot Out 1990

The beginning of my trauma addiction…

Parkland Hospital Dallas, TXLevel 1 Trauma Center

Trauma Background

30 Years of trauma anesthesia, mostly nights *Weekly Trauma Conferences M/M Blood Utilization Review Committee Chair of subcommittee on Patient Blood Management Adjunct Faculty at Texas Wesleyan University Current DNP Student at Texas Christian University

BASIC TRAUMA PRINCIPLESCourtesy of Dr. Michael Cripps

Advanced Trauma Life Support--ATLS Started in a

Nebraska cornfield, 1976 Basic training in

trauma care Common language

and terminology

ABCD Primary SurveyA: Airway/Cervical Spine Restriction not Immobilization (not immobilization)

B: Breathing/Ventilation/Chest TubesC: Circulation/Hemorrhage ControlD: Disability: GCS, ≤ 8 needs ETT

Secondary Survey

Advanced Trauma Life Support--ATLS

FAST– Focused Assessment with Sonography

for Trauma

Chest films (and Pelvis, Spine) CT and CTAs Continuous ABCD AMPLE history

Parts of Secondary SurveyHighlights

Used with Permission from Advanced Trauma Life Support Student Course Manual (9th ed.). Chicago, IL: American College of Surgeons.

1. Secure airway2. Chest tubes for hemothorax/pneumothorax3. CONTROL BLEEDING:

– ED Thoracotomy – OR Exploratory laparotomy for unstable patients with +

FAST– Pelvic Injuries treated with binder and/or

Interventional Radiology– Tourniquets

4. Craniotomy5. Limb salvage6. Unstable/Open orthopedic injuries

Priorities of ED Trauma Care

Used with Permission from Advanced Trauma Life Support Student Course Manual (10th ed.). Chicago, IL: American College of Surgeons.

Allows assessment of bleeding location particularly heart, lungs Cross clamp the aorta

(Priority is perfusion of heart and brain) Indicated in penetrating

trauma (not so much blunt trauma)

Emergency ED Thoracotomy “Crack the Chest”

Courtesy of http://www.adhb.govt.nz/trauma/forums2011/Cross/Slide12.html

Similar to aortic cross clamp in aortic bypass surgery

Need arterial line in arm

http://www.traumaready.com/reboa/#.W5WpQkZKhaQ

REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta

2 liters NS no longer recommended (1 liter) TEG or ROTEM encouraged Video assisted laryngoscopy emphasized Cervical spine immobilization restriction MAP of 60-70 with traumatic aortic dissection RSI removed from ATLS and drug-assisted intubation is used

(with cricoid pressure) Early use of blood products in advanced hemorrhage

ATLS Update

Blunt vs. Penetrating Trauma

Photo courtesy of Dr. Babatunde Ogunnaike

Blunt TraumaMCC, MVC, MPC, Falls

TBI (Traumatic Brain Injury), spine, liver, spleen, heart, lung, kidney, bowel, diaphragm, femur, pelvis

https://upload.wikimedia.org/wikipedia/commons/9/9e/US_Army_Vet_Injury.JPG

Spleen and liver injuries travel in tandem with rib fx/pulmonary contusions Flail chest/hemothorax/pneumothorax/tension pneumothorax Spine fractures/C-collars Aortic injury? Keep MAP 60-70 Femur Fractures

1 liter or more of blood Pelvic Fractures

Patients go to Interventional Radiology (IR) or OR for preperitoneal pelvic packing2 or more liters of bloodPelvic Binder/REBOA

Scalp lacerations—Raney Clips

Blunt Trauma

Gunshots and Stabbing– Bullets do not travel in

straight lines– Consider cavitation

damage, entrance and exit sites

Penetrating Trauma

This photo demonstrates the overpenetration of a projectile against a synthetic ordnance gelatin. By Nathan Boor & Kurt Groover of Aimed Research is licensed under CC BY SA 3.0

“YOU HAVE A LEVEL 1 TRAUMA COMING, 5 MINUTES OUT”

http://roa.h-cdn.co/assets/cm/14/47/546b0fa464875_-_bmwcrash-lg.jpg

Trauma Cognitive Aids and Checklists

Ryder Checklist UptoDate Checklist

Equipment: Underbody warming blanket (forced-air) Increase room temperature Blood available? DECIDE ROLES

– Charting– Medications– Blood– Lab

Arterial line monitoring, rapid transfusor Video laryngoscopy for blunt trauma Ultrasound (for central line, arterial line)

Before the Patient Arrives

http://multimedia.3m.com/mws/media/804018P/3m-bair-hugger-adult-underbody-blanket-model-545.jpg?boundedSize=310

INDUCTION

ABCs: Is the patient breathing? Is there a pulse? If intubated, hook up ventilator and look for EtCO2. MAEX4? Pupils?

Ask Surgeons: ‘What’s injured?’ ‘What do you think you’ll find?’ (help decide lines, blood) BASIC Preop:

– Allergies– Meds– Medical history– NPO: Last food/fluid/alcohol/drugs– Quick airway check

On Arrival

Patients in shock have low Vd Etomidate?

– Adrenocorticol Suppression

Ketamine Propofol (very small dose, 1/10th) Normal dose of muscle relaxant Avoid hypertension—might blow the clot

Induction Medications

Trauma Airway Management

ED or OR, principles the same Cervical restriction Assume full stomach--RSI Most experienced person for laryngoscopy with actual cervical spine injury Make your first attempt your best

– REMOVE THE FRONT OF THE C COLLAR (so you can open mouth)– Hold manual in-line stabilization– Preoxygenation– Videolaryngoscope– Surgeons ready for cric, especially after two tries Used with Permission from Advanced Trauma Life Support

Student Course Manual (10th ed.). Chicago, IL: American College of Surgeons.

MILS Manual In-Line Stabilization

Used with Permission from Advanced Trauma Life Support Student Course Manual (9th ed.). Chicago, IL: American College of Surgeons.

Can change pulmonary dynamics in trauma significantlyHave a high index of suspicionChange simple pneumo to tensionDecrease preloadFull prep before induction? Difficult to ventilate?

Tell the surgeonsChest tubes

Post Induction/Post IntubationPositive Pressure Ventilation

Used with permission from Advanced Trauma Life Support Student Course Manual (9th ed.). Chicago, IL. American College of Surgeons

MAINTENANCE

Change in Thinking

1990 “Don’t give the yellow stuff until the big hole is plugged”“2 liters of normal saline” ATLS 8th editionTODAY: Gestalt response to hemorrhage (any hemorrhage) is to pour fluids into the patient who is bleedingBETTER: Low, slow, and no

Limit crystalloidUse blood products (red and yellow)Limit resuscitation until the big hole(s) is plugged

Also called– Permissive Hypotension– Delayed Fluid Resuscitation

Limit fluid (blood better than crystalloids) NOT indicated in TBI, Pregnancy, h/o CVA, MI Goals in hemorrhagic shock:

– SBP of 80-90 (MAP 50)– Palpable radial pulse– Awake patient who can mentate

Time limited: 90 minutes max

Hypotensive Resuscitation

Controlling hemorrhage is the priority Avoid ‘Pop the Clot’ Reduces blood loss and transfusion requirements Decreases incidence and severity of dilutional coagulopathy Decreases inflammatory cascade caused by exogenous

crystalloids Avoid hypothermia

Why Hypotensive Resuscitation?

Penetrating trauma in 598 adults Control (standard care) vs delayed resuscitation until surgical

control of bleeding Improved mortality in (70% vs 62%) Shorter hospitalization

In 1918 Walter Cannon stated, “Injection of a fluid that will increase blood pressure has dangers in itself…if the pressure is raised before the surgeon is ready to check any bleeding that might take place, blood that is sorely needed may be lost”

Preliminary analysis showed decrease in mortality with hypotensive resuscitation

Terminated. Study-futile Unable to keep patients in treatment arms (High MAP vs LMAP)

– Patient’s self regulated their MAP Is it possible to conduct RCTs?

European Guidelines 2013

“We recommend a target systolic blood pressure of 80 to 90mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury.” (Grade 1C)

“We recommend that a mean arterial pressure ≥80mmHg be maintained in patients with combined hemorrhagic shock and severe TBI (GCS ≤ 8).” (Grade 1C)

Hemostatic ResuscitationPriority Use of Clotting factors

– Yellow stuff from blood bank Platelets Plasma Cryo (fibrinogen)

– Pharmacologic factors TXA (tranexamic acid Factor 7 PCC (Prothrombin plasma concentrates)

Use ROTEM or TEG for guidance

Damage Control Resuscitation

Hypotensive Resuscitation + Hemostatic Resuscitation =

Damage Control Resuscitation

Talk to SurgeonsYou must know when bleeding is ongoing or

has stopped

Goals are to control hemorrhage and contamination

Surgery is limited and patient is taken to ICU for rewarming and resuscitation

– Bleeding is controlled– Bowel spillage is contained– Other injuries deferred– Temporary closure of abdomen

Damage Control Surgery

Five Places Chest Abdomen Retroperitoneal (Pelvic Injuries) Thighs (Femur) Outside the Body

– At the scene– Under the drapes

Where Do Patients Bleed?

Used with Permission from Advanced Trauma Life Support Student Course Manual (10th ed.). Chicago, IL: American College of Surgeons.

Limit crystalloids (worsens outcomes) Blood (red and yellow) Hypertonic saline—no conclusive

benefit Hydroxyethyl starch (HES)—no

conclusive benefit No albumin with TBI (SAFE Study)

What fluid should be used in massive trauma?

Parkland’s Massive Transfusion Protocol MTP

Used with permission Parkland Transfusion Services Dallas TX

What is the Optimal Ratio of Blood Products?

Plasma:Platelets:PRBC Somewhere between 1:1:1

and 1:1:2 Parkland’s is 3:3:5

– With Cryoprecipitate

Shock, very little anesthetic required After bleeding controlled: high-dosed Fentanyl IVs: Think Poiseuille’s Law: Short, large bore IVs No nasal gastric tubes in head injuries/any blunt trauma No nitrous in blunt trauma Remember antibiotic, redose > 1500 EBL Delegate Delegate Delegate

Maintenance

Diagnostic, NOT Therapeutic Surgeons can place a femoral line Brachial is an option

Do NOT Delay Resuscitation to Place Arterial Line

Arterial Lines

Vasopressors in Trauma

Are we treating the monitor or the patient? Does an increase in BP correlate with improved end organ

perfusion? Vasopressors are markers for poor outcomes Yes, if pregnant, head injury, spinal cord injury, geriatric to keep

MAP >70 *Trauma patients start out vasocontricted but as shock

progresses vasoplegia develops

Vasopressors in Trauma

– Volume resuscitate first– Use a balanced approach– Use vasopressors carefully, do not create HTN– What to use? Your choice Vasopressin (low dose infusion 0.04units/min to start) Epinephrine (10 mcg/mL bolus)

– BRADYCARDIA or EtCO2 (<15mmHg) dropping Ominous sign, imminent arrest Must give epinephrine

Vasopressors in Trauma--Caveats

Dead SpaceHigh V/Q

Lung Protective Strategies

Low tidal volume– 6-8 mL/Kg

RR of 10 to allow adequate exhalation PEEP

– 0 cm H2O at the beginning of the case– Increase to 5 cm when BP is normalized

Permissive hypercarbia is OK if not acidotic

LETHAL TRIAD OF TRAUMA

ACIDOSIS

ACIDOSIS

Tissue hypoperfusion and anaerobic metabolism

Mixed metabolic and respiratory Acidosis causes:

– Reduced coagulation– Vasopressors don’t work

(Vasopressin does. In works with hypoxia and severe acidosis)

Treatment:Titrate ventilation to arterial CO2 (increased dead space ventilation with shock)Optimize perfusionPrevent hypothermiaAfter bleeding controlled, open microcirculation with high dosed Fentanyl (see Dutton’s Podcast)NaHCO2 with pH < 7.1

COAGULOPATHY

Coagulopathy

CausesACT--Acute Trauma CoagulopathyAcidosis (tissue injury and shock)HypothermiaPlatelet dysfunctionHemodilutionHyperfibrinolysisConsumption of clotting factorsHypocalcemia

TreatmentImprove perfusion (euvolemia, Fentanyl)Keep them warmUse red and yellow stuffAvoid crystalloidsConsider TXA (tranexamic acid)Use TEG or ROTEM to direct resuscitationNormalize calcium

HCT 30 is Optimal for Hemostasis

Platelets flow at the vascular margin Size and number of RBCs determine the

platelets’ activity Platelets will function optimally with an

adequate number of RBCs (Hct 30)Oxygen delivery is adequate at HCT 21 in a

stable patient, but HCT of 30 is optimal for hemostasis By John Alan Elson (http://www.3dham.com/animal/bloodcompare.html) [CC BY-SA

3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Used to treat hyperfibrinolysis: Blocks the conversion of plasminogen to plasmin. Stops the breakdown of fibrin clot

CRASH 2 Trial: Still some controversy (some patients have fibrinolytic shutdown)

If given within 3 hours of the injury—the risk of death is decreased 2 doses

1 Gm bolus over 30 mins1 Gm infusion over 8 hours

Best to use ROTEM/TEG

Tranexamic Acid (TXA) Antifibrinolytic

Four Horseman of the Trauma Apocalypse*

Moore KM. The Four Horsemen of the Apocalypse of Trauma. Journal of Emergency Nursing.2011;37:294-295.

Hypothermia Coagulopathy

HypocalcemiaAcidosis

Viktor Mikhailovich Vasnetsov

CalciumHypocalcemia very common in trauma Why?

– FFP and PRBC have a citrate load (anticoagulant)– Fast infusions of blood products– Poor metabolism of citrate Liver retraction Hypothermia Shock state ETOH intoxication

Hypocalcemia

Signs– Narrow PP– Low BP– Prolonged QT– Decreased contractility– Impaired coagulation

Higher mortality with hypocalcemia Hyperkalemia also common Give calcium chloride by labs. Consider 1 gram every MTP

shipment or when BP drops and QT lengthens

Combined hyperkalemia and hypocalcemia from by Jer5150, used under CC BY-SA 3.0 by Dawn Lewellen modified from original

HOW TO FIGURE HOW WHAT YELLOW BLOOD PRODUCTS TO GIVE?

Determine phases of clotting of WHOLE blood

POC, fast turnaround Allows for targeted resuscitation of

coagulation deficiencies (Yellow stuff: platelets, plasma, or cryo)

Alleviate (in part) blind blood component resuscitation therapy.

Rapid TEG another option available

ROTEM Thromboelastography

72

Normal Trace– Short CT (stem)– Wide MCF (body)Red Wine Glass

Used with permission from https://www.rotem.de/en/methodology/result-interpretation-rotem-delta-und-sigma/

ROTEM Intepretation

Amplitudein (mm)

The greater the amplitude the firmer the clot

Time in Minutes

Thromboelastography (TEG)

HYPOTHERMIA

HYPOTHERMIAProblems with hypothermia: Shift of oxygen-hemoglobin

dissociation curve (hemoglobin won’t given up oxygen to the tissues)

Vasoconstriction Decreased cardiac contractility Decreased response to catecholamines Liver can’t metabolize citrate, ETOH Platelets and clotting factors don’t

work

Treatment Warm room Warm IV fluids and blood

with rapid infusor Finish surgery and take to

ICU By Ratznium at English Wikipedia. (Transferred from en.wikipedia to Commons.) [Public domain], via Wikimedia Commons

1. Hypovolemic Shock2. Obstructive Shock:

1. Tension Pneumothorax2. Cardiac Tamponade3. Abdominal Compartment Syndrome

3. Cardiogenic Shock (MI, Blunt cardiac injury)4. Distributive Shock

1. Septic2. Neurogenic

5. Exhaustion of Hypothalamic-Pituitary-Adrenal Axis (give hydrocortisone)

Differential of Shock in Trauma

CASE STUDY 1: GSW TO RIGHT SUBCLAVIAN

CASE STUDY: Hypotensive Resuscitation

27 yo man robbing a house. In Texas. Alert, GCS 15, BP 68/48 2 missile wounds in back Large hematoma anterior to right shoulder No pulse in right arm

GSW to Thorax

Chest tube placed– 900 ml out of chest tube

3 units of PRBC given– BP up to 100/70

Now what?– OR?– CT scan?– IR?

Open exposure of RSCA

From Ernst C: Exposure of the subclavian arteries. Semin Vasc Surg 2:202, 1989

Treatment Plan

Used low volume resuscitation– Only alternating PRBC and FFP to keep SBP>90

Patient not intubated– Avoid losing sympathetic tone and dropping venous return

Taken to hybrid OR with trauma and vascular– Placed a stent across the subclavian artery– Avoided difficult major thoracic surgery– Limited transfusion

CASE STUDY 2: GSW TO GROIN

86

GSW Right Groin

• 19 YO GSW to right infra-inguinal region with major vascular injury ‘bleeding to death’

• Taken immediately to OR• MTP Activated• ROTEM Sent from ED• 11.2/33

Time Point 1ED OTW to OR

OR Arrival

pH 6.96, PaCO2 71, PaO2 528, HCO3 16, BE-16EtCO2 46K+ 6.8, Ca++ 2.6Glucose 417H/H 12.2/36 Lactate 10.962/45 HR 120

Right femoral and vein injury. Hemorrhage control not established

Time Point 230 minutes in OR

Products Given:PRBCs 22FFP 15Platelets 2Cryo 1Factor VII-a 2 mg

pH 7.12 PaCO2 51 PaO2 546 HCO3 17 BE -13EtCO2 37 Lactate 9.5K+ 7.5 Ca++2.6Glucose 396H/H 14.3/4290/65 HR 100

In OR

Additional products given in OR after ROTEM results, totals in ():PRBCs 5 (27)FFP 11 (26)Platelets 1 (3)Cryo 2 (3)Factor VII 2mg (4mg)

Time Point 3ROTEM #3 80 minutes in OR

Hemorrhage controlledShunts placed/Fasciotomies7.33/37/49/20/-6K+ 5.6 Ca++ 3.7EtCO2 32 Lactate 6.9Glucose 202H/H 11.6/34To ICU to warm, definitive repair in 24 hoursLeft AMA in 7 days

92

Outcomes in trauma depend on time between injury and definitive care If your hospital cannot give definitive care, then do the following:

– ABCs – Take CXR– Chest tubes if needed– Send blood with patient– TRANSPORT

CT imaging delays transport by 90 minutes

Rural Hospital: Transfer to Definitive Care

How to Prepare Your Yourself and Your Facility Trauma Checklists Standard roles for anesthesia providers

(shared mental model) Trauma Mock Drills in situ Mentally practice your steps (never time to

prepare for trauma) Forced functions (calcium on top of cart,

remove crystalloids) Get to know your blood bank Get the cell phone of someone who can

interpret ROTEM/TEG

Trauma Resources

Dutton’s Podcast https://emcrit.org/emcrit/trauma-resuscitation-dutton/ ROTEM algorithms and MTP:

https://drive.google.com/drive/folders/1WxDJJecxxlZdOiMM5UcTY1UE9gutOVlm?usp=sharing

Thanks

To all of my fellow CRNAs at Parkland!! You are the best! To Dr. Michael Cripps for slides and mentoring

(High dose Opioids in Trauma) Sikoski et al. (2014). Choice of General Anesthetics for Trauma Patients. Current Anesthesiology Reports, 4:225-232

King DR. Initial Care of the Severely Injured Patient. The New England Journal of Medicine. 2019;380:763-770. Behrens, V., Dudaryk, R., Nedeff, N., Tobin, J. M., & Varon, A. J. (2016). The Ryder Cognitive Aid Checklist for

Trauma Anesthesia. Anesthesia & Analgesia, 122(5), 1484-1487. doi:10.1213/ANE.0000000000001186 Beloncle, F., Meziani, F., Lerolle, N., Radermacher, P., & Asfar, P. (2013). Does vasopressor therapy have an

indication in hemorrhagic shock? Annals of Intensive Care, 3(1), 1-6. doi:10.1186/2110-5820-3-13 Bickell, W. H., Matthew, J. W., Jr., Pepe, P. E., Martin, R. R., Ginger, V. F., Allen, M. K., & Mattox, K. L. (1994).

Immediate versus delayed fluid resuscitation for hyptotensive patients with penetrating torso injuries. The New England Journal of Medicine, 331(17), 1105.

(VASOPRESSIN) Tobin J, Varon A. Update in Trauma Anesthesiology: Perioperative Resuscitation Management. Anesthesia and Analgesia . 2012;115:1326-1333.

References

References Download Ryder Trauma Checklist at:

http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/AA/B/AA_2016_03_30_BEHRENS_AAJ-D-16-01066_SDC1.pdf

Kaafarani, H. M. A., & Velmahos, G. C. (2014). Damage Control Resuscitation In Trauma. Scandinavian Journal of Surgery, 103(2), 81-88.

Hypotensive Resuscitation: Cotton B, Reddy N, Hatch Q, et al. Damage Control Resuscitation Is Associated With a Reduction in Resuscitation

Volumes and Improvement in Survival in 390 Damage Control Laparotomy Patients. Annals of Surgery. 2011;254:598-605.

Hess JR, Holcomb JB, Hoyt DB. Damage control resuscitation: the need for specific blood products to treat the coagulopathy of trauma. Transfusion. 2006;46:685-686

Holcomb J, Jenkins D, Rhee P, et al. Damage control resuscitation: Directly addressing the early coagulopathy of trauma - Commentary. Journal of Trauma-Injury Infection and Critical Care. 2007;62:307-310

Glen, J., Constanti, M., Brohi, K., Guideline Development Grp, & Guideline Development Group. (2016). Assessment and initial management of major trauma: Summary of NICE guidance. BMJ, 353, i3051-i3051. doi:10.1136/bmj.i3051

Nevin DG, Brohi K. Permissive hypotension for active haemorrhage in trauma. Anaesthesia. 2017;72:1443-1448.

References Janelle GM, Shore-Lesserson L, Smith CE, Levy JH, Shander A. What Is the PROPPR Transfusion

Strategy in Trauma Resuscitation? Anesthesia & Analgesia. 2016;122:1216-1219. Galvagno SM, Nahmias JT, Young D. Advanced Trauma Life Support® Update 2019. Anesthesiology

Clinics. 2018;2019;37:13-32. Carrick, M. M., Morrison, C. A., Tapia, N. M., Leonard, J., Suliburk, J. W., Norman, M. A., . . . Mattox, K.

L. (2016). Intraoperative hypotensive resuscitation for patients undergoing laparotomy or thoracotomy for trauma: Early termination of a randomized prospective clinical trial. The journal of trauma and acute care surgery, 80(6), 886.

Dutton, R. P. (2012). Resuscitative strategies to maintain homeostasis during damage control surgery. British Journal of Surgery, 99(S1), 21-28. doi:10.1002/bjs.7731

MacLeod, J. B., Lynn, M., McKenney, M. G., Cohn, S. M., & Murtha, M. (2003). Early coagulopathy predicts mortality in trauma. J Trauma, 55(1), 39-44. doi:10.1097/01.ta.0000075338.21177.ef

UptoDate: – Anesthesia for adult trauma patients– Acute coagulopathy associated with trauma

Questions?