Wan Ahmad Asyraf bin Wan Md Adnan 2 nd May 2013 Moderator: Dr Lee Pui Kuan

Anaesthesia For Trauma Patient

Wan Ahmad Asyraf bin Wan Md Adnan2nd May 2013

Moderator: Dr Lee Pui Kuan

Case Example Introduction Problems Associated with Trauma Initial Assessment

◦ Primary and Secondary Survey Anaesthetic Consideration & Management Take Home Messages References

Contents

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

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

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

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

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

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

Trauma is the leading cause of death in young people worldwide, including Malaysia

Mainly involved in motor vehicle accidents

Introduction

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

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

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

Initial Assessment

Primary

Survey

Resuscitatio

n

Secondar

y Survey

Definitiv

e Care

Airway with cervical spine control Breathing and ventilation Circulation and haemorrhage control Disability (neurological function) Exposure

Primary SurveyInitial Assessment

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

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

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

NEXUS Low Risk Criteria Canadian C-spine Rule

C-spine AssessmentInitial Assessment: Primary Survey

Neurological Deficit

Distracting injuries

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

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

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

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

Classification of hypovolaemic shock

Circulation & Haemorrhage Control

Initial Assessment: Primary Survey

Pupils for size and reaction to light Rapid neurological assessment

◦ Awake◦ Verbal response◦ Painful response◦ Unconscious

DisabilityInitial Assessment: Primary Survey

Undress patient for through examination of other injuries

Prevent hypothermia◦ Increased oxygen requirement◦ Myocardial depression◦ Altered drug metabolism

ExposureInitial Assessment: Primary Survey

Parameter Goal

Blood pressure

Systolic 80 mmHg, mean 50-60 mmHg

Heart rate <120 bpm

Oxygenation SaO2 >95%

Urine output >0.5ml/kg/hr

Mental state Obey command

Lactate level <1.6 mmol/L

Base deficit >-5

Haemoglobin

>8.0 g/dl

Goals for resuscitation for trauma patient before haemorrhage has been controlled

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

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

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

Examine for laceration, bruising, distension, tenderness

Imaging modalities◦ Ultrasound, CT scan

Abdominal Injury Initial Assessment: Secondary Survey

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

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

Examine all limbs for any fractures or any damages towards nerve, tendon, blood vessel

Exclude compartment syndrome in closed fractures

ExtremitiesInitial Assessment: Secondary Survey

Thorough preoperative evaluation and resuscitations

Blood samples including GXM Type of anaesthesia

◦ General anaesthesia◦ Regional anaesthesia◦ Peripheral nerve block

Anaesthetic Considerations

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

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

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

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

Systematic patient assessment◦ Primary survey◦ Secondary survey

Rapid sequence intubation◦ Reduce risk of aspiration

Continuous haemodynamic assessment of patient intraoperatively

Take Home Messages

The End

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