wan ahmad asyraf bin wan md adnan 2 nd may 2013 moderator: dr lee pui kuan
TRANSCRIPT
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