anaesthesia for trauma patient
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Anaesthesia For Trauma Patient. Wan Ahmad Asyraf bin Wan Md Adnan 2 nd May 2013 Moderator: Dr Lee Pui Kuan. Contents. Case Example Introduction Problems Associated with Trauma Initial Assessment Primary and Secondary Survey Anaesthetic Consideration & Management Take Home Messages - PowerPoint PPT PresentationTRANSCRIPT
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Anaesthesia For Trauma Patient
Wan Ahmad Asyraf bin Wan Md Adnan2nd May 2013
Moderator: Dr Lee Pui Kuan
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Case Example Introduction Problems Associated with Trauma Initial Assessment
◦ Primary and Secondary Survey Anaesthetic Consideration & Management Take Home Messages References
Contents
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17 years old boy Alleged MVA (unknown mechanism of injury)
◦ Was brought to A&E by ambulance Upon arrival to A&E:
◦ Vital signs: BP 130/78, HR 90, SpO2 93%, dscan 7.2◦ Airway: patient was intubated for airway protection
(poor conscious level), done with MILS Given IV fentanyl, IV midzola and IV suxamethonium
◦ Breathing: Equal chest movement, crepitations on right lung
◦ Circulation: no external haemorrhage, 1st FAST negative◦ Pupils 3mm bilaterall equal, response to pain stimulus
Case Example
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Further examinations:◦ Head: haematoma over occipital region (5cm x
6cm) with no active bleeding, no ENT bleeding◦ Chest: no external injuries, equal chest
movement, crepitations on right side◦ Abdomen: soft, not distended
rpt FAST -> presence of minimal free fluid over rectovesical pouch, haematuria on CBD
◦ Pelvis: no external wound◦ Spine: no obvious deformity
Case Example
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Investigations◦ CXR: right lung contusion, no pneumothorax◦ Pelvic x-ray: no fracture◦ CT brain
Mix of EDH and SD at left temporo-parietal regions (thickness 12mm)
Right basal ganglia haemorrhage◦ CT cervical
No obvious fracture seen◦ CT abdomen
Traumatic liver injuries (at least Grade IV) with haemoperitoneum and active bleeders
Bibasal lung contusions with haemothorax
Case Example
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Proceed with operation◦ Craniectomy + evacuation of blood clot◦ Exploratory laparotomy + liver packing◦ Classified as ASA IVE
Monitoring◦ NIBP + IABP◦ ECG◦ EtCO2◦ IV access: triple lumen at right femoral, 14G x 2
Case Example
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Intraoperatively:◦ Stable haemodynamically, started on noradrenaline
infusion to achieve MAP of 80◦ Difficulties to maintain oxygenation
Occasional desaturation to 86-90% Higher settings requirement (PIP 22, PEEP 14, FiO2 100%) SpO2 maintained mostly around 95%
◦ EBL: 2L◦ Fluids:
1 cycle of DIVC, 3 pints whole blood, 2 pints 0.9% saline, 2 pints venofundin
Postoperatively admitted to ICU for cerebral protection
Case Example
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Patient was ventilated on bilevel mode initially in ICU◦ Able to wean down to SIMV after 1 day
Proceed with removal of pacing after 48 hours◦ Uneventful
At D4 of admission, developed signs of sepsis (unknown source)◦ Started on antibiotics, changed a few times after a few days ◦ Recovered well afterward in terms of septic parameter
Extubated on D8 of admission, transferred out to general ward 2 days later
Patient stay for another 5 days in general ward before discharged home
Case Example
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Trauma is the leading cause of death in young people worldwide, including Malaysia
Mainly involved in motor vehicle accidents
Introduction
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Trimodal Death Distribution (50%, 30%, 20%)◦ 1st phase: major severe injuries◦ 2nd phase: treatable life threatening injuries ◦ 3rd phase: infection, multiple organ failure
The concept of ‘golden hour’ ◦ The importance of resuscitation from the arrival of
patient to health care provider◦ Hence, the development of ATLS: framework for
immediate management for trauma patient
Introduction
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Multiple injuries (life threatening) Compromised airway, breathing and
circulation needing urgent/ongoing resuscitation
Limited time for preparation (dealing with life threatening situation)
Inadequate history or trauma circumstances in comatose / restless patient
Problems Associated with Trauma Patient
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Risk of aspiration◦ Inadequate fasting time◦ Pregnancy◦ Pain
Potential difficult airway Co-existing disease Coagulopathy
◦ Massive blood loss◦ On anticoagulant therapy◦ Dilutional coagulopathy
Problems Associated with Trauma Patient
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Initial Assessment
Primary
Survey
Resuscitation
Secondary Surve
y
Definitiv
e Care
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Airway with cervical spine control Breathing and ventilation Circulation and haemorrhage control Disability (neurological function) Exposure
Primary SurveyInitial Assessment
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Aim: patent airway to maintain adequate oxygenation
Beware of airway obstruction features:◦ Respiratory distress, stridor, cyanosis
Oxygen therapy Assess need for intubation
◦ Upper airway obstruction◦ Severe lung contusion, with ventilatory compromise◦ Poor GCS◦ Airway protection (e.g. Bleeding intraorally)◦ Impending airway obstruction (e.g. Inhalational injury)
Manual in-line stabilisation (C-spine protection)
Airway with C-spine control
Initial Assessment: Primary Survey
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Establish responsiveness Airway assessment: look, listen and feel Airway opening and maintenance
◦ Jaw thrust vs head tilt, chin lift ◦ Suction airway adjunct (OPA, NPA)◦ Definitive: ETT, surgical airway
Maintenance of ventilation Common problems encountered:
◦ Tongue obstruction (fall back)◦ Secretion◦ Laryngospasm
Airway with C-spine control
Initial Assessment: Primary Survey
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Cervical spine assessment◦ 2 criteria available
National Emergency X-Radiography Utilisation Study (NEXUS) Low Risk Criteria
Canadian C-spine ◦ CCS is superior than NEXUS criteria in terms of sensitivity
and specificity * Difficult in unconscious patient
◦ Need of imaging: cervical x-ray, CT cervical, MRI Who to clear?
◦ Radiologist◦ Anaesthesiologist/Intensivist◦ Surgeon (Neurosurgery / Orthopaedic)
Airway with C-spine control
Initial Assessment: Primary Survey
*IG Stiell et al; The Canadian C-Spine Rule versus the NEXUS Low Risk Criteria in Patients with Trauma. N Engl J
Med, 2003:349:2510-8
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NEXUS Low Risk Criteria Canadian C-spine Rule
C-spine AssessmentInitial Assessment: Primary Survey
Neurological Deficit
Distracting injuries
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High Risk Factor•Age >65•Dangerous mechanism•Paraesthesias in Extremities
Low Risk Factor(for safe assessment of ROM)
•Simple rearend MVA•Sitting position in A&E•Ambulatory at any time•Delayed onset of neck pain•Absence of midline c-spine tenderness
ROM•Able to rotate 45 degree left and right
NO
YES
C-spine AssessmentInitial Assessment: Primary Survey
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Assess breathing efforts◦ Approach: look, listen, feel◦ Respiratory rate, breathing pattern, use of
accessory muscles, flail chest◦ Chest spring, chest expansion◦ Reduced/absent breath sound
Breathing and VentilationInitial Assessment: Primary Survey
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Life threatening injuries:◦ Tension pneumothorax
Reduced chest movement, reduced breath sound With respiratory distress, tachycardia, hypotension,
tracheal deviation, distended neck veins Mx: needle thoracocentesis, followed by chest tube
◦ Open chest injury Occlusive dressing, sealed on 3 sides
◦ Massive haemothorax Reduced chest movement, dull percussion note With hypoxaemia and hypovolaemia Mx: fluid resuscitation + chest drain
Breathing and VentilationInitial Assessment: Primary Survey
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Watch out for signs of shock◦ Cold peripheries, delayed capillary return, pallor,
low pulse volume, tachycardia, hypotension◦ Secure external haemorrhage◦ Large bore IV cannulation + blood investigations◦ Rule out cardiac tamponade
Beck’s triad: hypotension, distended neck vein, muffled heart sound
◦ 1st priority stop bleeding & replace intravascular volume
◦ Shock in trauma patient is hypovolaemic in nature, until proven otherwise
Circulation & Haemorrhage Control
Initial Assessment: Primary Survey
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Classification of hypovolaemic shock
Circulation & Haemorrhage Control
Initial Assessment: Primary Survey
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Pupils for size and reaction to light Rapid neurological assessment
◦ Awake◦ Verbal response◦ Painful response◦ Unconscious
DisabilityInitial Assessment: Primary Survey
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Undress patient for through examination of other injuries
Prevent hypothermia◦ Increased oxygen requirement◦ Myocardial depression◦ Altered drug metabolism
ExposureInitial Assessment: Primary Survey
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Parameter GoalBlood pressure
Systolic 80 mmHg, mean 50-60 mmHg
Heart rate <120 bpmOxygenation SaO2 >95%Urine output >0.5ml/kg/hrMental state Obey commandLactate level <1.6 mmol/LBase deficit >-5Haemoglobin
>8.0 g/dl
Goals for resuscitation for trauma patient before haemorrhage has been controlled
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Detailed examination (head-to-toe) after primary survey is completed and vital signs are relatively stable
Complete anatomical evaluation◦ Head◦ Chest◦ Abdomen◦ Pelvis◦ Spine◦ Extremities
History: AMPLE
Secondary SurveyInitial Assessment
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Assess conscious level according to GCS Scalp: lacerations, haematoma, depressed
skull fractures Signs of basal skull fracture
◦ Racoon eye, bruising over mastoid process, otorrhoea & rhinorrhoea
Presence of maxillofacial injury Imaging: CT scan
Head Injury Initial Assessment: Secondary Survey
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Rule out lethal conditions◦ Pulmonary contusion
Hypoxaemia (reduced PaO2/FiO2 ratio) CXR: patchy infiltrates
◦ Cardiac contusion Cardiac arrhythmia, ST changes on ECG
◦ Tracheobronchial disruption Hoarseness, SC emphysema, palpable fracture crepitus
◦ Diaphragmatic rupture Diminished breath sounds, chest and abdominal pain,
respiratory distress◦ Eosophageal rupture◦ Aortic rupture
Chest Injury Initial Assessment: Secondary Survey
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Examine for laceration, bruising, distension, tenderness
Imaging modalities◦ Ultrasound, CT scan
Abdominal Injury Initial Assessment: Secondary Survey
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Difficult to diagnose Suspicious in patient who is pale and
hypotensive with no obvious source of bleeding
Imaging modalities: pelvic x-ray
Pelvic Fracture Initial Assessment: Secondary Survey
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Assume cervical injury until excluded Quick neurological assessment of upper and
lower limbs Imaging: cervical x-rays Log roll: examination of whole spinal length
Spinal Injury Initial Assessment: Secondary Survey
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Examine all limbs for any fractures or any damages towards nerve, tendon, blood vessel
Exclude compartment syndrome in closed fractures
ExtremitiesInitial Assessment: Secondary Survey
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Thorough preoperative evaluation and resuscitations
Blood samples including GXM Type of anaesthesia
◦ General anaesthesia◦ Regional anaesthesia◦ Peripheral nerve block
Anaesthetic Considerations
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Identify potential airway problems◦ Rapid sequence induction with cricoid pressure
Minimise risk of aspiration◦ If anticipate difficult airway, may consider other modalities
Awake fibre optic Inhalational induction Surgical airway
◦ MILS for cervical spine protection Preoxygenation with 100% over 3-5 minutes Choice of IV induction agent
◦ Thiopentone and propofol (head injury patient)◦ Ketamine (in hypotensive patient)◦ Etomidate
General AnaesthesiaAnaesthetic Considerations
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Muscle relaxant◦ Use suxamethonium unless contraindicated◦ Alternative: rocuronium
Maintenance◦ Avoid nitrous oxide in hypotension, hypovolaemic,
hypoxia Fluid resuscitation
◦ Secure large bore IV line prior to starting operation◦ Blood products readily available when needed◦ Volume status must be continuously assessed
throughout and after operation
General AnaesthesiaAnaesthetic Considerations
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Monitoring◦ ECG◦ NIBP or IABP in critical patient◦ SpO2◦ End tidal CO2◦ Temperature◦ Urine output ◦ CVP
Consider intra-op investigation◦ E.g. ABG may help with resuscitation process
General AnaesthesiaAnaesthetic Considerations
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Reversal in usual manner at the end of surgery◦ Decision for extubation depends on the condition
of patient Consider ICU admission post operative
◦ Severe head injury for cerebral protection◦ Severe chest injury◦ Polytrauma◦ Unstable haemodynamic status◦ Massive blood loss
General AnaesthesiaAnaesthetic Considerations
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Systematic patient assessment◦ Primary survey◦ Secondary survey
Rapid sequence intubation◦ Reduce risk of aspiration
Continuous haemodynamic assessment of patient intraoperatively
Take Home Messages
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The End
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C Y Lee; Manual of Anaesthesia. McGraw-Hill Education (2008).
G E Morgan, M S Mikhail, M J Murray; Clinical Anaesthesiology (4th Edition). Lange Medical Books (2006)
K G Allman, I H Wilson; Oxford Handbook of Anaesthesia (3rd Edition). Oxford Medical Publications (2012)
References