Anaesthetic management of the Trauma Patient

Chapter 23

Pre operative assessment

History• C• A• M• E

• L• C• S

History• Chronic illnesses• Allergies and Addiction• Medication• Events or environment

related to injury• Last meal

Pre operative examination

Clinical Examination• Airway• Cardiac• Vascular• Respiratory• Abdomen• Limbs

• Tubes• Fluids

Pre operative assessment

Neurological Examination• A• V• P• U

• Head Trauma and Spinal cord injury must be excluded

• GCS

Neurological Examination• Alert• Vocal stimuli response• Painfull stimuli response• Unresponsive

Pre operative Assessment

Special investigations• Baseline bloods

• CSPINE• CXR• Pelvis

• FBC , UKE , Acid Base , Glucose

• Airway etc

Principles

Anatomical Considerations• Head to toe• All organ systems

Physiologic Considerations• Vital organs• Physiologic failure leads to

homeostatic failure

Principles

Pharmacological Considerations

• Xenobiotics– Recreational– Toxins

• Decreased central volume of distribution versus increased volume of distribution

• [Free drug]

Monitoring Considerations

Anaesthetic Technique

Resuscitation• Get help• A• B• C• D• E

• Airway and CSPINE• Breathing• Circulation and Coagulation• Disability• Exposure and

environmental control

Airway management and Breathing

• Chest• ETT

• Burns• Cervical Spine injury• Bronchoscopy• Intercostal drain

• Mode of Ventilation

• Expose , auscaltate• Intratracheal, size, depth, cuff,

reintubation• Swelling• Bimanual cricoid pressure• Secretions , foreign matter• Hemo , pneumo , amount ,

type• Lung protective ventilation,

vcv versus pcv

Circulation and coagulation

• Stop Haemorhage• Awake shock index

• Clinical signs of hypovolaemia

• Venous access• CVP, Art• 8.5 F Swan Ganz sheath

• Finger in artery• Pulse rate/systolic blood

pressure, N=0.5, > 10%, 33%, 50% decrease in CO

• Class 1 – 4

• 14 or 16 G X 2• Do not waste time

Circulation and Coagulation• Fluids

• Trauma induced Coagulopathy

• Crystalloids• Colloids

• Loss• Dilution• Consumption• Hyperfibrinolysis• Hypothermia• Acidosis

Circulation and Coagulation

• Haemostatic Resuscitation

• Ratio of 1:1:1:1 = Whole blood

• Target Hct 30• Clotting factors• Every 6 packed RBC• Cryoprecipitate

• Damage control resuscitation

• Packed RBC: FFP: Platelet: Fibrinogen

• RBC• FFP• Mega unit Platelets• Fibrinogen

Disability

• Neurologic

• Vascular• eyes

• Central , brain , spinal cord

• Peripheral nerves

Exposure and environmental control

• Physical

• Chemical

• Biological

Hypothermia

• Worse outcome

• Exposed, fluids, casualty, radiology, OR

• Permissive, induced

• O2, coagulation, drugs, vasoconstriction, dysrhythmias, infection, dehiscence,

• Space blanket , warm fluids, bair hugger, fluid warmers, aircon

• Brain and Spinal cord injuries

Hyperthermia

• Endogenous versus exogenous• Pontine lesions, status epilepticus• Drugs – anticholinergics, alcohol,

amphetaminoids, cocaine• Active cooling• Heat stroke

Endpoints of fluid resuscitation

• Systolic BP 90• Hct 30• No TRIC• BE improving• Lactate improving• Systolic pressure variation

Induction of anaesthesia and airway

• Resuscitation • BIS or Entropy• Cardiovascular collapse versus permissive

hypotension• Aspiration• Ketamine versus Etomidate• Suxamethonium

Maintenance of anaesthesia

• Vapour versus ketamine infusion versus opioid infusion

• Nitrous Oxide• Muscle relaxants• Analgesia – do not give NSAIDS

Emergence

• Extubation criteria• Stable versus unstable• High care versus ICU

Damage control surgery

• Damage control resus/ Haemostatic resus• Life and limb threatening first• ICU stabilization• Definitive care• Lethal triad– Hypothermia < 35 – Acidosis Ph < 7.2– Clinical Coagulopathy

Occupational health and Hazards

• Physical– Blood– Toxins– Sharp objects

• Psychological– Counselling