5 anesthesia for trauma patients,dr.ho opere,april2013

8/12/2019 5 Anesthesia for Trauma Patients,Dr.ho Opere,April2013

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Anaesthesia for

Trauma Patients

By Dr . H. O. Opere

Consu l tant Anaesthesio log ist

Apr i l 2013



INTRODUCTION

The initial assessment of thetrauma patient can be divided

into:

1. Primary survey

2. Secondary survey

3. Tertiary survey



PRIMARY SURVEY• The primary survey should take 2 –5

minutes and consists of the ABCDEsequence of trauma: Airway,

Breathing, Circulation, Disability, and

Exposure.



PRIMARY SURVEY: Airway

Establishing and maintaining an airway is always the

first priority.

Important signs of obstruction include snoring or

gurgling, stridor, and paradoxical chest movements.

The presence of a foreign body should be considered

in unconscious patients. Advanced airway management (such as endotracheal

intubation, cricothyrotomy, or tracheostomy) is

indicated if there is apnea, persistent obstruction,

severe head injury, maxillofacial trauma, a penetrating

neck injury with an expanding hematoma, or major

chest injuries.



PRIMARY SURVEY: Airway cont’d

Cervical spine injury is unlikely in alert

patients without neck pain or tenderness.Five criteria increase the risk for potential

instability of the cervical spine:

1.Neck pain

2.Severe distracting pain

3.Any neurological signs or symptoms

4.Intoxication

5.Loss of consciousness at the scene.



PRIMARY SURVEY: Airway cont’d

Laryngeal trauma makes a complicated

situation worse. Open injuries may beassociated with bleeding from major neck

vessels, obstruction from hematoma or

edema, subcutaneous emphysema, andcervical spine injuries.

Closed laryngeal trauma is less obvious but

can present as neck crepitations, hematoma,

dysphagia, hemoptysis, or poor phonation.



PRIMARY SURVEY: Breathing

Assessment of ventilation is best accomplished

by the look, listen, and feel approach.Look for cyanosis, use of accessory

muscles, flail chest, and penetrating or

sucking chest injuries.

Listen for the presence, absence, or

diminution of breath sounds.

Feel for subcutaneous emphysema, trachealshift, and broken ribs.



PRIMARY SURVEY: Circulation

Adequacy of circulation is based on pulse

rate, pulse fullness, blood pressure, and signsof peripheral perfusion.

Signs of inadequate circulation include

tachycardia, weak or unpalpable peripheralpulses, hypotension, and pale, cool, or cyanotic

extremities.

The first priority in restoring adequatecirculation is to stop bleeding.

The second priority is to replace intravascular

volume.



PRIMARY SURVEY Cont’d Disability

Evaluation for disability consists of a rapidneurological assessment. Because there is

usually no time for a Glasgow Coma Scale, the

AVPU system is used: awake, verbalr esponse, painful response, and unresponsive.

Exposure

The patient should be undressed to allowexamination for injuries. In-line immobilization

should be used if a neck or spinal cord injury is

suspected.



SECONDARY SURVEYThe secondary survey begins only when the

ABCs are stabilized.In the secondary survey, the patient is

evaluated from head to toe and the indicated

studies (eg, radiographs, laboratory tests,

invasive diagnostic procedures) are obtained.

Head examination includes looking for injuries

to the scalp, eyes, and ears.

Neurological examination includes the Glasgow

Coma Scale and evaluation of motor and

sensory functions as well as reflexes.



SECONDARY SURVEY Cont’d The chest is auscultated and inspected again

for fractures and functional integrity (flail chest).Examination of the abdomen should consist of

inspection, auscultation, and palpation.

The extremities are examined for fractures,dislocations, and peripheral pulses.

A urinary catheter and nasogastric tube are

also normally inserted.



SECONDARY SURVEY Cont’d

Basic laboratory analysis includes a complete

blood count (or hematocrit or hemoglobin),electrolytes, glucose, blood urea nitrogen

(BUN), and creatinine.

Arterial blood gases may also be extremelyhelpful.

A chest X-ray should be obtained in all patients

with major trauma.

The possibility of cervical spine injury is

evaluated by examining all seven vertebrae in a

cross-table lateral radiograph and a swimmer's

view.



SECONDARY SURVEY Cont’d

Depending on the injuries and the

hemodynamic status of the patient, otherimaging techniques (eg, chest computed

tomography [CT] or angiography) or diagnostic

tests such as diagnostic peritoneal lavage(DPL) may also be indicated.

TERTIARY SURVEY



TERTIARY SURVEY

A tertiary survey is defined as a patient

evaluation that identifies and cataloguesall injuries after initial resuscitation and

operative interventions.



ANAESTHETIC CONSIDERATIONS

General Considerations

Regional anesthesia is inappropriate inhemodynamically unstable patients with lifethreatening

injuries.

If the patient arrives in the operating room alreadyintubated, correct positioning of the endotracheal

tube must be verified.

If the patient is not intubated the same principles of

• airway management described above should be

• followed in the operating room. If time permits,

• hypovolemia should be at least partially corrected

• prior to induction of general anesthesia.



General Considerations cont’d

Invasive monitoring (direct arterial, central

venous, and pulmonary artery pressure

monitoring) can be extremely helpful in

guiding fluid resuscitation, but insertion of

these monitors should not detract from the

resuscitation itself.

Serial hematocrits (or hemoglobin), arterialblood gas measurement, and serum

electrolytes (particularly K+) are invaluable in

protracted resuscitations.



Head & Spinal Cord Trauma

Succinylcholine is reportedly safe during the

first 48 hrs following the injury but isassociated with lifethreatening

hyperkalemia afterward.

Chest Trauma…

Abdominal Trauma…

Extremity Trauma…



The END

Thank you

5 anesthesia for trauma patients,dr.ho opere,april2013

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