anestesi for trauma

8/10/2019 Anestesi for Trauma

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41 Anesthesia for the Trauma Patient

R1


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INITIAL ASSESSMENT

initial assessprimary surveysecondarytertiary survey

primary surveyCPRA,B,C,D.E.

trauma resuscitation2additional

phase: control of hemorrhage, definitive repair of

the injury


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Primary survey

Airway cervical spine Fx.

: neck hyperextension

jaw-thrust maneuver aspirationrisk endotrachealtubetracheotomy

: neck hyperextensionexcessive axial traction manual immobilization of the head & neck

(manual-in-line stabilization)nasal intubation : blind or fiberoptic

( )midface or basilar skull Fx.


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laryngeal trauma

larynx

, direct laryngoscopy

fiberoptic

bronchoscopy with topical anesthetics

endotracheal tube(6.0)

awake intubation

upper airway trauma

acute obx. :

tracheotomy, cricothyrotomy, percutaneous,

surgical tracheostomy


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Breathing

assisted ventilation.

bag-valve device intubaion

ventlation head trauma ICP hyperventilation


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Circulation

A. Hemorrhage

shock : vital organ perfusioncirculatory failure

, hypovolemia

hemorrhage -> tachycardia, poor capillary

perfusion, decrease in pulse pressure

tohypotension, tachypnea, and dilirium


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Hct

Hb

acute bleeding

ER

OR

hypotension

motality

rate

hemorrhagic shock

IV fluid resuscitation

transfusion

.

: multiple short(1.5-2 inches), large-bore(14-

16gauge or 7-8.5F) catheter

line

massive hemorrhage

cardiovascular integrity

fluid interstitial compartment

intravascular

shift

cell

anaerobic metabolism

ATP

ATP-

dependent Na-K pump

dysfunction

->

progressive cellular edema


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B. Fluid Therapy

initial fluid therapy

abailability

: fully cross-matched whole blood

typing

cross-match

45~60

crystalloid solutions

, inexpensive

intravascular compartment

.

.

colloid solution

expensive. but

intravascular

volume

warming

(hypothermia

acid-base disorders, coagulopathies,

myocardia function

)

oxygen-hemoglobin curve

left

shift

lactate, citrate, anesthetic drug

.


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Fluid Therapy (2)

sign(BP, pulse pressure, HR)

inadequate organ perfusion

aerobic metabolism

lactic acid metabolic acidosis

hypovolemic shock

hypotension

IV

fluid

.

, coexisting

cardiogenic shock, cardiac arrest

vasopressor

.


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DISABILITY

:rapid neurological assessment

AVPU SYSTEM

(Awake,Verbal response,Pain stimuli

Unresponsive)


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SECONDARY SURVEY

A,B,C

neurologic exam : evaluation of consciousness,

pupuillary sign, motor function,

sensory loss

hidden injury

TERTIARY SURVEY init. resuci., op.injury


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ANESTHETIC CONSIDERATIONS

HEAD SPINAL CORD TRAUMA

brain injury

Glasgow Coma Scale evaluation

head trauma mental status neurologic exam premedication

cerebral hemorrhage or edema ICP .

intracranial hypertension : fluid restriction, diuretics, barbiturate,hypocapnea

intubation hypertension or tachycardiaiv lidocain fentanyl

head trauma autoregulation arterial

hypertensioncerebral edema ICP .hypotensionregional cerebral ischemia

-> cerebral perfusion pressure 60mmHg.


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spinal cord injurylesionlevel

: c-spine injury phrenic nerve(C3-C5)- apnea

intercostal function: pulmonary reserve cough

high thoracic injury sympathetic innervation(T1-T4 )

: bradycardia

spinal shock

: acute high spinal cord injury

sympathetic tone

hypotension, bradycardia, areflexia, and G-I atony: aggressive fluid therapy.

high-dose corticosteroid therapy with methylprednisolone

(30mg/kg followed by 5.4mg/kg/hour for 23hours)


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CHEST TRAUMA

, , cardiogenic shockhypoxia

simple pneumothorax : hyperresonant to percussion, breathing sound , chest

X-raylung collapse 4, or 5intercostal spacechest tube insertion

tension pneumothorax : ipsilateral lung collapse, mediastinuma & tracheashift

hyperresonant to percussion, ipsilateral abscence ofbreathing sound, contralateral tracheal shift, distended neckvein

14G needle cathetermidclavicular line2ndintercostal space tension pneumothoraxopenpneumothorax

chest tube placement


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- Cardiac tamponade : life-threatening chest injury

Beck's triad (neck vein distension, hypotension,muffled heart tone)pulsus paradoxus(spontaneous inspiraton 10mmHg)pericardiocentesis : temporary relief

: thoracotomy - Hemothorax anesthetic management : cardiac inotropism,

chronotropism, preloadmaximize-> ketamineinduction agent

: : ischemiaEKG , cardiacenzyme ,

elective surgeryheart injury sign


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aortictransection or dissection, avulsion of subclavianartery, aortic or mitral valve disruption, traumaticdiaphragmatic hernia, esophageal rupture

Acute respiratory distress synd(ARDS): delayed pumlonary complication of trauma: sepsis, direct thoracic injury, aspiration, headinjury, fat embolism, massive transfuion, oxygen

toxicitymortality rate 50%


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ABDOMINAL TRAUMA

: abdominal X-rayfree air, peritoneal lavagebloodaspiration

: exploratory laparotomyabdomenextravasated bloodtamponading effethypotension .

bowel distension nitrous oxide

massive abdominal hemorrhage packing abdominal aorta clamping.prolonged aortic clampingliver, kidney, intestineischemic injury compartment synd..

injury and fluid resuscitationbowel edema.tight abdominal closureabdominal compartment synd.renaland splanchnic ischemiaedema48-72open secondaryclosure


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EXTREMITY TRAUMA

.

fat embolism : pelvic & long bone Fx.

1-3pul. insufficiency, dysrhythmias,petechiae, mental deterioration

reimplantation: isolated injuryregional techniquesympathetic innervation pph. blood flow

perfusion

shivering

anestesi for trauma

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