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Trauma
Alex Bell ST5
Contents1)Major trauma (including major haemorrhage, physiology etc)
2)NOF #
3)Burns
4)Drowning
Crossover with neurosurgery (head injuries and spinal cord injury)
Crossover with T&O and with ICU
Major trauma
• Trauma remains the most common cause of loss of life in the under 40s age in the UK.
• Major trauma centres (MTCs) and trauma units (TUs) have been established to receive patients of all ages and improve outcomes.
• Early anaesthetic involvement is beneficial at all stages and the need for significant anaesthetic input and support for these complex patients is an integral part of trauma pathway.
Trauma in the past decade
NCEPOD 2007 report
- concluded that 60 per cent of major trauma patients received a standard of care that was ‘less than good practice’
- Major Trauma Centre networks set-‐up- Guidelines and standards published
Military action 2001-‐2014
- Advances in trauma care & survivalNAO report 2010
- Still not good enough!NICE major trauma guidelines 2016...
Nice major trauma guidelines 2016
l Aim to perform RSI as soon as possible and within 45 minutes of the initial call to the emergency services, preferably at the scene of the incident.
l In hospital settings do not use crystalloids for patients with active bleeding
l Early activation of major haemorrhage protocols in hospital settings
l For adults use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.
l Use whole body CT (consisting of a vertex to toes scanogram in adults with blunt major trauma and suspected multiple injuries.
l Use damage control surgery in patients with haemodynamic instability who are not responding to volume resuscitation
l Use interventional radiology techniques in patients with active arterial pelvic haemorrhage unless immediate open surgery is needed to control bleeding from other injuries.
Trauma approach
CAcBCDE ATLS etc
Trauma team
Anaesthetist/ODP integral part of the team
Main concern is airway
Airway intubation
Indications to intubate in trauma?
Immediate UrgentLife threatening
hypoxiaTo protect from aspiration in
obtunded ptObstructed airway Inadequate ventilation
(especially in head injury)Anticipated clinical course
Humanitarian
Anaesthetic risksAirway
NAP4 evidence that trauma intubations are more difficult: there is a higher rate of failed intubation, surgical airway, and serious complications from emergency airway management
In the emergency department, nearly 10% of intubations are described as difficult after rapid sequence induction.
Breathing
Risk tension/chest injuries especially with IPPV – decompress if concerned
Circulation
Anaesthetic CV compromise /CV collapse -‐ Ketamine/blood
Disability
Risk worsening TBI/SCI -‐ maintain CPP, document movements and pupils pre-‐intubation
Exposure
Hypothermia risk and lethal triad
Physiological response to major trauma
Activation SNS and increased sympathetic tone resulting in tachycardia and increased SVR.Catecholamines, Renin, angiotensin II, aldosterone, ADH, TXA 2 response.
Trauma-‐induced coagulopathy – multifactorial due to dilution of clotting factors secondary to resuscitation with intravenous fluids; consumption of clotting factors and impairment of platelet function secondary to acidosis and hypothermia. DIC.
Acidosis – Persistent cellular hypoperfusion limits availability of ATP and causes cell membranes to become leaky. Anaerobic metabolism results in the production of lactate and free radicals.
Inflammatory response – persistent hypoperfusion and inadequate oxygen delivery to microcirculation activates vascular endothelium leading to an exaggerated inflammatory response. There is release of inflammatory mediators, cytokines and oxidants that cause secondary organ damages.
Endocrine response – Increased release of growth hormone, prolactin and ACTH from anterior pituitary; ADH from posterior pituitary; cortisol from adrenal cortex;. Results in increasing circulating serum glucose levels and promotion of gluconeogenesis and glycogenolysis. Catabolic state.
Mitigating pathological response to trauma
Early feeding is advocated by the European Society of Enteral and Parenteral Nutrition. The hypercatabolic state produced by trauma can result in muscle atrophy, a negative nitrogen balance and ketogenesis
Regional anaesthesia can be used to attenuate the sympathetic stress response to pain.
Avoid excessive IV fluid (Higher death rate, especially NaCl 0.9%)
Avoid hypothermia and acidosis
Avoid hyperglycaemia
Trauma scoring systemsGlasgow Coma ScaleOrdinal scale with greatest prognostic value in both head-‐injured and trauma patients
Advanced Trauma Life Support shock classificationHeart rate is the only reliable variable in the classification that correlates with mortality
The revised trauma scoreConsists of respiratory rate, systolic blood pressure and Glasgow Coma ScaleComplex to calculate
Injury Severity ScoreAnatomical scoring system for patients with multiple injuries
ISS greater than 15 = major traumaTriggers level 2 tariff £2913
Damage Control Resuscitation
Damage control resuscitation – targeting of key areas for resuscitation to
normalise physiology rather than complete surgical repairs.
The main strategies are ;
-‐ Time limited permissive hypotension-‐ Haemostatic resuscitation (Massive transfusion protocol) -‐ Maintain normothermia-‐ Aggressive management of acute traumatic coagulopathy – check ROTEM/TEG-‐ Tranexamic acid-‐ Treat hypocalcaemia-‐ Treat hyperkalaemia-‐ Damage control surgery
Damage control surgery
Damage control surgery – is early emergency surgery to achieve haemostasis and limit contamination of wounds while delaying definitive surger
It aims to be life/limb saving by controlling haemorrhage and preventing ongoing damage.
The main elements are –
-‐ Control of haemorrhage-‐ Splinting of fractures-‐ Decompression of compartments – cranium, thorax, abdomen and limbs-‐ Decontamination of wounds
Major haemorrhage in adults
4 litres in 24 hours > 150ml/min ≥ 40% loss of total blood volume
ACTIVATE MAJOR HAEMORRHAGE PROTOCOL
Tranexamic acid
Tranexamic acid is a synthetic lysine analogue which inhibits fibrinolysis andpromotes clot stability.
CRASH-‐2 Evidence suggests it reduces mortality from bleeding if administeredwithin 3 hours of traumatic injury. 1g over 10mins with a further 1g given over 8hours.
It should be given to all trauma patients with evidence of haemorrhage and –SBP< 110mmHg and/or HR >110
Other things to think about
Complications of major transfusion
How you'd anaesthetise a major trauma victim
Neck of femur fracture
BACKGROUND
Approximately 77 000 hip fractures occur in the UK annually (cost £0.785 billion)
Hip fracture carries a 30-‐day mortality of around 8% in the United Kingdom.
Patients suffering a hip fracture are usually elderly, with a median age of 83 years and co-‐existing chronic illnesses (70% of patients will be of ASA 3–4).
Around 30% of patients with hip fracture also suffer from cognitive dysfunction
It is well recognised that unnecessary delay to operative fixation of hip fractures is associated with increased mortality
Pre-‐operative management
Pain relief with block
MDT trauma meetings. Consider NHFS
Dedicated trauma list and staff
Optimisation of patientAAGBI guidelines
l Only FBC, U&E and ECG routine investigations. Others as required.
l Strict criteria for delaying surgery >48 hours
Nottingham Hip Fracture Score
Predicts postoperative mortality and provides theanaesthetist with information about outcome thatmay be discussed with the patient or theirrelatives
NOF anaesthetic GA v Regional
Cochrane review 2016
- 28 studies, 2976 participants.
- No difference in mortality at one month between neuraxial blocks and general anaesthesia.
- No difference in pneumonia, MI, CVA, acute confusional state, CCF, AKI or PE
- Length of surgery and length of hospital stay between these two anaesthetic techniques the same.
Bone Cement Implantation SyndromeThe incidence in hip fracture surgery is uncertain.
Characterised by hypoxia, hypotension, or both, and⁄∕or unexpected loss of consciousness, around the time of cementation, prosthesis insertion or reduction of the joint.
Several mechanisms may contribute to a multimodal aetiology, including fat⁄∕platelet⁄∕fibrin⁄∕marrow emboli and stimulated release of vasoactive mediators.
The risk of BCIS may be reduced by good surgical technique (medullary lavage, good haemostasis before cement insertion, retrograde cement insertion, venting of the femur, minimising the force applied to prosthesis during insertion)
good anaesthetic technique (including increasing the inspired oxygen concentration at the time of cementation, avoiding intravascular volume depletion, and using additional haemodynamic monitoring in high-‐risk patients).
The treatment of BCIS includes delivery of 100% oxygen, fluid resuscitation (guided by CVP
measurement) and vasoactive⁄∕inotropic support.
Burns
l Complicationsl Airwayl Fluidl Transfer to a burns centre
Burns
Risk of other trauma especially C-‐spine
Thermal/Chemical/Electrical
ComplicationsEarly Late
Airway compromise SepsisARDS Hypovolaemia
Hypothermia DVTRenal failure Chronic painDeath Stress ulcers
Airway burns
Concerning features
History- Enclosed space- Inhaled gases- Neck burns- Prolonged entrapment (carbon monoxide)
S & S – stridor, hoarse voice, soot in airways, swollen lips, tongue, singed facial or nasal hair, cough, resp distress, pulmonary oedema, confusion
Indications for intubation
Impending or actual airway obstruction (low GCS/stridor/oropharyngeal swelling)
Respiratory distress/hypoxaemia/hypercapnia
Deep facial or full thickness/circumferential neck burns
To facilitate transfer to theatre or tertiary centre
Humanitarian
Intubation
Potentially difficult (although often easy earlier)
An uncut tracheal tube (size 8.0 mm or above) toallow subsequent bronchoscopy.
Succinylcholine is safe in the first 24 h after aburn—after this time, its use is contraindicated due to the risk of hyperkalaemia This can persist up to 1 year post-‐burn.
Other problems
Difficulty applying monitors, for example, ECG electrodes unlikely to stick on burns, Oxygen saturation probes likely to be sore on burnt skin
Use alternative sites, for example nose, ear, lips
Use skin staples or subcutaneous needles attached to crocodile clips for ECG monitoring
End tidal C02 may not reflect PaC02 as increased dead space in inhalational injury
Blood pressure-‐ invasive access versus non-‐invasive BP cuff application
IV access, peripheral or central for medication..
Fluid replacement
Fluid
Parkland formula
I.V. fluid resuscitation is required in adults if the burn involves more than 15% BSA
4 ml/kg x %burn which predicts the fluid requirement for the first 24 h after the burn injury. Starting from the time of burn injury half of the fluid is given in the first 8 h and the remaining half is given over the next 16 h.
The fluid of choice is Hartmann's solution.
A urinary catheter should be inserted and hourly urine output is a used as a guide to resuscitation. In adults, at least 0.5 ml kg−1 h−1 should be passed.
Burns centre referral
ICU careMDT approach including physio, OT, dieticians
Infection control paramount as sepsis is (along with multi-‐organ failure) the most frequently reported cause of death
Good analgesia/pain management-‐multimodal approach-‐ involve acute pain service
Lung protection strategies to prevent ARDS
Early enteral nutrition to maintain gut integrity and PPI for stress ulcer prophylaxis
Maintain normal electrolyte and normoglycaemia
Maintain normothermia (prone to hypothermia as skin large barrier contributing to heat conservation)
Ensuring before extubation that the endotracheal cuff is deflated and that a leak is present or early tracheostomy as likely to be slow wean
Drowning
l Pathophysiologyl Intubationl Complicationsl Management
BACKGROUND
Drowning is the second leading cause of unnatural death after RTA
Drowning occurs in a predominantly healthy and young population
Often occurs with trauma +/-‐ hypothermia
Primary event is hypoxia due to aspiration of liquid. Secondary pulmonary and neurological injury determines patient survival and subsequent quality of life.
History
Victim informationAge, sex, medical history, allergies, drug history
Precipitating eventstrauma, alcohol, drugs
Scene information Time of incident, submersion time, witnessed water type, temperature, contaminants
Pre-‐hospital care Initial ABC and GCS CPR—time started, any delay
Management
Early intubation and ventilation
ARDS in drowning victims should follow a protective lung ventilation strategy with low tidal volumes (6 ml/kg ideal body weight), plateau pressure below 30 cm H2O, and with PEEP and FIO2 titrated to PaO2. Caution should be exercised with regard to the use of permissive hypercapnoea if neurological injury is a possibility
Consider ECMO referral
No evidence for prophylactic steroids or antibiotics (unless evidence of infection)
CV support
Neuroprotective strategies
Hypothermia is common after drowning – warm passively/actively. Remember ALS is different.
March 2016A 45-‐year-‐old man has a major haemorrhage
following significant trauma and is admitted to your emergency department. He does not have a head injury.
a) Give one definition of major haemorrhage. (1 mark) b) What are the principles of management of major haemorrhage in this patient? (11 marks)
c) What complications might follow a massive blood transfusion? (8 marks)
March 2012A 90-‐year-‐old woman sustains a fractured neck of
femur following a fall. She is scheduled for surgery.
a) What aspects of this patient’s care will have the highest impact on outcome? (45%)
b) Outline the recommendations made by The National Institute for Heath and Clinical Excellence (2011) on the management of pain in this patient. (30%)
c) What causes of a fall in this patient might impact on the anaesthetic management? (25%)
May 2006A 20 year old male was assaulted and sustained a
bilateral fractured mandible which requires surgical fixation. Following the assault he was unconscious for 5 minutes. You are asked to see him the next day. He has no other injuries.
a) Outline your preoperative assessment of this patient. (55%)
b) What are anaesthetic options for surgery? (45%)
March 2014An elderly patient has sustained a fractured neck
of femur following a fall and is scheduled for surgery.
a) Which aspects of this patient’s care have a significant impact on outcome? (45%)
b) Outline the recommendations of best practice for the management of pain in this patient. (30%)
c) What causes of a fall in this patient might impact on the anaesthetic management? (25%)
March 2017You are asked to assess a 24-‐year-‐old male who has been admitted to the Emergency Department with 30% burns from a house fire.a) What clinical features would lead you to
suspect significant inhalational injury? (10 marks)
b) List the indications for early tracheal intubation to secure the airway. (4 marks)
c) Which investigations would you use to assess the severity of the inhalational injury (3 marks) and what are the likely findings? (3 marks)
October 2008A 70 kg, 30 year-‐old man presents with burns following a house fire. The burns are confined to his torso and upper limbs, but exclude his head and neck.a) State the Parkland formula used for burns fluid resuscitation. (10%)b) His burns are estimated at 40% of his body surface area. Using the Parkland formula, what
volume of which fluid will he require in the first 8hours after injury? (10%)c) What additional fluids in excess of the volume predicted in (b) might he require and why? (25%)d) What monitoring and investigations are required in the first 24 hours? (45%)
March 2013You are asked to assess a 24-‐year-‐old male who has been admitted to the Emergency Department with 30% burns from a house fire.a) What would lead you to suspect significant inhalational injury? (40%)b) Which investigations would you use to assess the severity of the inhalational injury and what are the likely findings? (30%)c) List the indications for early tracheal intubation to secure the airway. (20%)d) How do burns injuries influence the use of suxamethonium?(10%)
Thank you!
