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Anesthesia for the Trauma Patient

INTRODUCTION
The initial assessment of the trauma patient can be divided into :
1. 2. 3 3.

Primary survey Secondary survey Tertiary survey

PRIMARY SURVEY
The primary survey should take 25 min and consists of the ABCDE sequence of trauma: Airway, Breathing, Circulation, Disability, and Exposure.

PRIMARY SURVEY : Airway


Establishing and maintaining an airway is always the first priority i it Important signs of obstruction include snoring or gurgling, stridor and paradoxical chest movements. stridor, movements The presence of a foreign body should be considered in unconscious patients. p Advanced airway management (such as endotracheal intubation, cricothyrotomy, or tracheostomy) is indicated if there is apnea apnea, persistent obstruction obstruction, severe head injury injury, maxillofacial trauma, a penetrating neck injury with an p g hematoma, , or major j chest injuries. j expanding

PRIMARY SURVEY : Airway


Cervical spine injury is unlikely in alert patients without neck pain or tenderness. Five criteria increase the risk for potential i instability bili of f the h cervical i l spine: i 1. Neck pain 2. Severe distracting pain 3 3. Any neurological signs or symptoms 4. Intoxication 5. L Loss of f consciousness i at the h scene.

PRIMARY SURVEY : Airway

Laryngeal trauma makes a complicated situation it ti worse. O Open injuries i j i may be b associated with bleeding from major neck vessels, l obstruction b t ti from f hematoma h t or edema, subcutaneous emphysema, and cervical i l spine i injuries. i j i Closed laryngeal y g trauma is less obvious but can present as neck crepitations, , dysphagia, y p g , hemoptysis, p y , or poor p hematoma, phonation.

PRIMARY SURVEY : Breathing

Assessment of ventilation is best accomplished by the look, listen, and feel approach. Look for cyanosis cyanosis, use of accessory muscles muscles, flail chest, and penetrating or sucking chest injuries. Listen for f th the presence, absence, b or di diminution i ti of f breath sounds. Feel for subcutaneous emphysema, tracheal shift, and broken ribs.

PRIMARY SURVEY : Circulation

Adequacy of circulation is based on pulse rate, pulse l fullness, f ll blood bl d pressure, and d signs i of f peripheral perfusion. Signs of inadequate circulation include tachycardia, weak or unpalpable peripheral pulses, p , hypotension, yp , and pale, p , cool, , or cyanotic y extremities. The first priority in restoring adequate circulation i l ti is i to t stop t bleeding bl di The second priority is to replace intravascular volume. volume

Classification of Shock
1. 2. 3.

4. 5.

Hypovolemic Septic/Inflammatory Cardiogenic (Intrinsic, compressive & ) Obstructive) Neurogenic A Anaphylactic h l ti

The mainstay of therapy of hemorrhagic shock is intravenous fluid resuscitation and transfusion. Multiple short (1.52 in), large-bore (1416 gauge or 78.5F) catheters are placed in whichever veins are easily accessible. Whichever fluid is chosen, it must be warmed prior to administration. Rapid-infusion Rapid infusion systems that use large large-bore bore tubing and rapidly warm fluids are invaluable during massive transfusions. Hypotension in patients with hypovolemic shock should be gg y treated with intravenous fluids and blood p products, aggressively not vasopressors, unless there is profound hypotension that is unresponsive to fluid therapy, coexisting cardiogenic shock, or cardiac arrest.

PRIMARY SURVEY

Disability Evaluation for disability consists of a rapid neurological assessment. Because there is usually no time for a Glasgow Coma Scale Scale, the AVPU system is used: awake, verbal response, painful response, p , and unresponsive. p Exposure The p patient should be undressed to allow examination for injuries. In-line immobilization should be used if a neck or spinal cord injury is suspected. suspected

Glasgow g Coma S le Scale

SECONDARY SURVEY

The secondary survey begins only when the ABCs are stabilized. In the secondary survey, 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, scalp eyes, eyes and ears. Neurological examination includes the Glasgow Coma Scale and evaluation of motor and sensory functions as well as reflexes reflexes. The chest is auscultated and inspected again for fractures and functional integrity (flail chest). E Examination i ti of f the th abdomen bd should h ld consist i t of f inspection, i ti auscultation, and palpation. The extremities are examined for fractures, dislocations, and peripheral i h l pulses. l A urinary catheter and nasogastric tube are also normally inserted.

SECONDARY SURVEY

Basic laboratory analysis includes a complete blood count (or hematocrit or hemoglobin) hemoglobin), electrolytes, electrolytes glucose glucose, blood urea nitrogen (BUN), and creatinine. Arterial blood gases may also be extremely helpful. A chest X-ray should be obtained in all patients with major trauma. Th possibility The ibilit of f cervical i l spine i injury i j is i evaluated l t d by b examining all seven vertebrae in a cross-table lateral radiograph and a swimmer swimmer's s view. Depending on the injuries and the hemodynamic status of the patient, other imaging techniques (eg, chest computed t tomography h [CT] or angiography) i h ) or diagnostic di ti tests t t such h as diagnostic peritoneal lavage (DPL) may also be indicated.

Tertiary Survey

A tertiary survey is defined as a patient evaluation that identifies and catalogues all injuries after initial resuscitation and operative interventions. Many trauma centers also advocate a tertiary trauma survey (TTS) to avoid missed injuries. Between 2% and 50% of traumatic injuries may be missed by primary and secondary surveys, particularly following blunt multiple trauma The tertiary survey occurs prior to discharge to reassess and confirm known injuries and identify occult ones.

ANESTHETIC CONSIDERATIONS

General Considerations

Regional anesthesia is inappropriate in hemodynamically unstable patients with lifelife threatening injuries. If the patient arrives in the operating room already intubated, correct positioning of the endotracheal tube must be verified. 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

Invasive monitoring (direct arterial, central venous, and d pulmonary l artery pressure monitoring) can be extremely helpful in guiding d fluid fl d resuscitation, but b insertion of f these monitors should not detract from the resuscitation itself. Serial hematocrits (or hemoglobin), arterial blood gas measurement, and serum electrolytes (particularly K+) are invaluable in protracted resuscitations.

Head & Spinal p Cord Trauma


Any trauma victim with altered consciousness must be considered to have a brain injury The level of consciousness is assessed by serial Glasgow Coma Scale evaluations Common injuries requiring immediate surgical intervention include epidural hematoma, acute subdural bd l hematoma, h and d some penetrating brain b injuries and depressed skull fractures. Intracranial hypertension is controlled by a combination of fluid restriction (except in the presence of hypovolemic shock), diuretics (eg, mannitol, 0.5 g/kg), barbiturates, and deliberate hypocapnia (PaCO2 of 2832 mm Hg).

SUBDURAL HEMATOMA

PENETRATING BRAIN INJURY

Depressed skull fracture

Head & Spinal p Cord Trauma

Nasal passage of an endotracheal tube or nasogastric tube in patients with basal skull fractures risks cribriform plate perforation and CSF infection. infection Because autoregulation of cerebral blood flow is usually impaired in areas of brain injury, injury arterial hypertension can worsen cerebral edema and increase intracranial pressure. Patients with severe head injuries are more prone to arterial hypoxemia from pulmonary shunting and ventilation/perfusion mismatching.

Signs of base of skull fracture

Head & Spinal p Cord Trauma


Lesions of the cervical spine may involve the phrenic nerves (C3C5) and cause apnea. apnea High thoracic injuries will eliminate sympathetic innervation of the heart (T1T4), (T1 T4), leading to bradycardia. Acute high spinal cord injury can cause spinal shock, a condition diti characterized h t i d by b loss l of f sympathetic th ti tone t in the capacitance and resistance vessels below the level of the lesion, resulting in hypotension, bradycardia, areflexia, and gastrointestinal atony. Succinylcholine is reportedly safe during the first 48 h f ll i the following th injury i j but b t is i associated i t d with ith lifelif threatening hyperkalemia afterward.

Head & Spinal p Cord Trauma

Short-term high-dose g corticosteroid therapy with methylprednisolone (30 mg/kg followed by 5.4 5 4 mg/kg/h for 23 h) improves the neurological outcome of patients with spinal cord trauma. Autonomic hyperreflexia is associated with lesions above T5 but is not a problem during acute management.

CHEST TRAUMA

Trauma to the chest may severely compromise the function of the heart or lungs lungs, leading to cardiogenic shock or hypoxia. A tension pneumothorax develops from air entering the pleural l l space through th h a one-way valve l in i the th lung l or chest h t wall. As a result, the ipsilateral lung completely collapses and the mediastinum and trachea are shifted to the contralateral side. Multiple rib fractures may compromise the functional integrity of the thorax thorax, resulting in flail chest chest. Pulmonary contusion results in worsening respiratory failure over time. Hemothorax is differentiated from pneumothorax by dullness to percussion over silent lung fields.

TENSION PNEUMOTHORAX

CHEST TRAUMA

Hemomediastinum, like hemothorax, can also result in hemorrhagic shock. shock Massive hemoptysis may require isolation of the affected lung with a double-lumen tube (DLT) to prevent t bl blood d from f entering t i the th healthy h lth lung. l Air leakage from traumatized bronchi can track an open pulmonary vein causing pulmonary and systemic air embolism. Cardiac tamponade p is a life-threatening g chest injury j y that must be recognized early. The presence of Beck's triad (neck vein distention, hypotension, and muffled heart tones), pulsus paradoxus (a > 10 mm Hg decline in blood pressure during spontaneous inspiration), and a high index of suspicion will help make the diagnosis.

CHEST TRAUMA

Pericardiocentesis provides temporary relief. Myocardial contusion is usually diagnosed by electrocardiographic changes consistent with ischemia (ST-segment elevation), cardiac enzyme elevations ( (creatine ti kinase ki MB or troponin t i levels), l l ) or an abnormal b l echocardiogram.

Other possible injuries following chest trauma include aortic transection or aortic dissection, avulsion of the left subclavian artery, aortic or mitral valve disruption, traumatic diaphragmatic herniation, herniation and esophageal rupture. rupture Acute respiratory distress syndrome (ARDS) is usually a delayed pulmonary complication of trauma The mortality rate of ARDS approaches 50%.

Cardiac Tamponade

ABDOMINAL TRAUMA

Up to 20% of patients with intraabdominal injuries do not have pain or signs of f peritoneal irritation (muscle guarding, percussion tenderness, or ileus) on first f examination. Large quantities of blood (acute hemoperitoneum) may be present in the abdomen (eg, hepatic or splenic injury) with minimal signs. Abdominal trauma is usually divided into penetrating (eg, gunshot or stabbing) and nonpenetrating (eg, deceleration, crush, or compression injuries).

ABDOMINAL TRAUMA

1. 2. 3.

Penetrating abdominal injuries are usually ll obvious b i with i h entry marks k on the h abdomen or lower chest. The most commonly injured organ is the liver. Patients tend to fall into three subgroups: Pulseless Hemodynamically unstable Stable

Penetrating abdominal injuries

ABDOMINAL TRAUMA

Blunt abdominal trauma is the leading cause of morbidity and mortality y in trauma, , and the leading g cause of intraabdominal injuries. Splenic tears or ruptures are most common. A positive FAST scan in a hemodynamically unstable patient with blunt abdominal trauma is an indication for immediate surgery. P f Profound dh hypotension t i may f follow ll opening i of f the th abdomen bd as the tamponading effect of extravasated blood (and bowel distention) is lost. Nitrous oxide is avoided to prevent worsening of bowel distention. A nasogastric asogast c tube ( (if not ot a already eady p present) ese t) will help ep p prevent e e t gastric dilation but should be placed orally if a cribriform plate fracture is suspected.

Injury Pancreatic

ABDOMINAL TRAUMA

The potential for massive blood transfusion should be anticipated anticipated, particularly when abdominal trauma is associated with vascular, hepatic, splenic, or renal injuries, pelvic fractures, or retroperitoneal h hemorrhage. h Massive abdominal hemorrhage may require packing of bleeding areas and/or clamping of the abdominal aorta until bleeding sites are identified and the resuscitation can catch up with the blood loss. Prolonged aortic clamping leads to ischemic injury to the liver, kidneys, intestines, and, in some instances, a compartment syndrome d of f the h lower l extremities. ii

Injury Hollow Viscus

ABDOMINAL TRAUMA

Progressive bowel edema from injuries and fluid resuscitation may preclude abdominal closure at the end of the procedure. Tight abdominal closures markedly increase intraabdominal pressure, resulting in an abdominal compartment syndrome that can produce renal and splanchnic ischemia. Oxygenation and ventilation are often severely compromised, even with complete muscle paralysis. Oliguria and renal shutdown follow.

EXTREMITY TRAUMA

Extremity injuries can be life-threatening because of associated vascular injuries and secondary infectious complications. Vascular injuries j can lead to massive hemorrhage g and threaten extremity viability. Fat emboli are associated with pelvic and long-bone fractures and may cause pulmonary insufficiency, insufficiency dysrhythmias, skin petechiae, and mental deterioration within 13 days y after the traumatic event A compartment syndrome can also occur following large intramuscular hematomas, crush injuries, fractures, and amp tation injuries. amputation inj ies

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