WIXLIB

Staff Nurse Anesthetist, The Johns Hopkins HospitalAssistant Professor/Assistant Program DirectorColumbia University School of NursingProgram in Nurse AnesthesiaMaribeth Massie, CRNA, MSAnesthesia for Trauma

“It’s not the speed whichkills, it’s the sudden stop”OVERVIEW

8% worldwide death rate Leading cause of death in Americansfrom 1- 45 years of age MVC’s leading cause of death Blunt penetrating Often drug abusers, acutely intoxicated,HIV and Hepatitis carriersEpidemiology of Trauma

– First hour after injury– 50% of patients die within the first secondsto minutesÆ extent of injuries– 30% of patients die in next few hoursÆmajor hemorrhage– Rest may die in weeks Æ sepsis, MOSF “Golden Hour”Epidemiology of Trauma

Resuscitation Reduction of fractures Extrication of trapped victims Amputation Uncooperative patients– Initial assessment and BLS in trauma– GO TEAM: role of CRNA’s at MarylandShock Trauma Center ABC’SPre-hospital Care

Airway maintenance with cervical spineprotection Breathing: ventilation and oxygenation Circulation with hemorrhage control Disability ExposureInitial Management Plan

ALWAYS ASSUME A CERVICAL SPINE INJURYEXISTS UNTIL PROVEN OTHERWISE Provide MANUAL IN-LINE NECKSTABILIZATION Jaw-thrust maneuver– AIRWAY Primary Survey:Initial Assessment

Cross table lateral and swimmer’s view Xray Need to see all seven cervical vertebrae Only negative CT scan R/O injury– Cervical spine evaluation Airway cont’d:Initial Assessment

BicepsAbduct shoulder,Flex elbowC6 Wrist extensorsCock wristC7 TricepsExtend elbowC8 Finger flexorsGrasp finger in palmT1 Finger abductorsSpread fingers C5– Functional assessment of cervical level Cervical spine cont’d:Initial Assessment

––––––Airway obstructionPaO2 80 mmHg or SpO2 90% with O2Shock with SBP 90 mmHgSevere head injury or unconscious (GCS 9)Anticipated surgery with multisystem injuryCombativeness Indications for intubation:ALWAYS ASSUME FULL STOMACHPRECAUTIONSÆ RAPID SEQUENCEINTUBATIONInitial Assessment

Succinylcholine: 1-2 mg/kg Zemuron: 1.2 mg/kg Vecuronium: .2 mg/kg– “Pent, Sux, Tube”– May have to decrease amount of sedative drugsand give appropriate dose of RSI muscle relaxants Use slow inspiratory flow rates (1-1.5 sec inspiratorytime) Avoid stomach distentionÆgastric inflation occurs wheninspiratory pressure exceeds EOP ( 15-18 cm H2O)– Preox Rapid sequence intubation (or modified)Initial Assessment

– MAC vs. Miller debate 10 # pressure required to seal esophagus– Remove front of C-collar and maintain inline stabilization– Cricoid pressure (Sellick’s maneuver) afterPent given Airway cont’d:Initial Assessment

Awake intubation: local, topicalsuperior laryngeal nerve blocks Awake fiberoptic: may be too bloody Awake cricothyrotomy/tracheostomy Gum elastic bougie/LMA Know your difficult airway algorithm!Initial Assessment

– Always verify correct position of ETT, evenif arrive intubated !!– 100 % O2– May have Combitube in; change to ETT– Nasal intubation: watch with basilar skullfractures BREATHINGInitial Assessment

– Control hemorrhage first!– Crystalloids vs. colloids vs. blood products?– Alot or alittle?– Early or later? CirculationInitial Assessment

– Allergies, PMH//PSH, meds, ETOH/druguse, weight, last meal After primary survey complete, attemptto complete a head-to-toe assessment Ask pertinent questions if patient ableto answerSecondary survey

Cardiac: S/S shock, EKG changes Respiratory: Breath sounds, crepitus,respiratory patterns/distress, CXR Neurologic: GCS, LOC; assume C-spineinjury until ruled outÆ Lateral C-spineXray, palpate neck Renal: monitor urine output, amountand colorTrauma/preop assessment

Endocrine: release of stress hormones(catecholamines and glucose) Hematologic: hypovolemic shock;coagulopathies– Gastric emptying slows or stops at time oftrauma Gastrointestional: FULL STOMACH!!!!Trauma/preop assessment

CBC, electrolytes, urinalysis, PT/PTT,lactate, baseline ABG (as conditionpermits); T&C for at least 4 units CXR, lateral C-spine, CT/MRI 12 lead EKG FAST: focused abdominal sonographyfor trauma DPL: diagnostic peritoneal lavageLaboratory/diagnostic tests

– Versed in small doses (.5-1 mg IV)– Bicitra 30 cc preop Preop: Sedation rarely necessaryAnesthetic management of traumapatient

Standard monitors Preoxygenation Basic airway and difficult airwayadjuncts RSI with cricoid pressure Invasive monitors as indicatedInduction

Thiopental 3-4 mg/kg; reduce doses inunstable patients; most commonly used intrauma Ketamine 0.5-1 mg/kg; useful for burn andhypovolemic patients; avoid with headinjuried Etomidate 0.1-0.3 mg/kg; reduce doses withhypovolemia; ?myoclonus effects Propofol 1-2 mg/kg in stable patients; reducedoses in hypovolemiaInduction agents

– May give nondepolarizing dose prior to Suxto inhibit fasciculations (esp. with SCI) Succinylcholine:1-2 mg/kg; useful forRSI/emergency; contraindicated inburns, spinal cord injury and crushinjuries 24-48 hours after injuryMuscle relaxants

– Vecuronium .28 mg/kg (250-300mcg/kg)high dose; onset in 80 secs;duration 75-90 min; good cardiovascularstability without histamine release– Rocuronium 1.2 mg/kg high dose; onset45-60 secs; duration 67 minutes NondepolarizersMuscle relaxants

O2/air/Forane mixture Avoid N2O if any question ofpneumothorax, pnuemocephalus,pneumomediastinum, bowel injury Fentanyl 1- 10 mcg/kg/hr Monitor fluids and administer carefully Prepare to give blood products ifnecessaryMaintenance

Forced air warming systems Heat moisture exchangers– Level 1: warms IVF and blood to 42*C anddelivers at 75-30,000 ml/hr– Rapid infusion system (RIS): warms to 42*C andcan deliver products as bolus and various rates,up to 3000ml/min; cell saver can be attached tosystem Common with traumatic injuries and relatedprocedures Warm all IV fluidsHypothermia

Normal extubation criteria Hemodynamically unstable, elderly withrib and long bone fractures, those whohave received massive fluid and bloodresuscitation, severe burns, and thosewith coagulopathies should remainintubatedEmergence

– Hypothermia, atelectasis, V/Q mismatch,coagulopathyLong-acting opioidsEpidural infusionsIntercostal blocksComplications:– Correct acid-base imbalances and electrolytedisturbances Monitored and labs followed closelyPostop

Blunt trauma: caused by high-velocity orlow-velocity impact from generally dullobjects Penetrating trauma: result of sharp objectspiercing through tissue, such as stab woundsproduced by knives or bullet woundsproduced by gunfire Impalement injuries: combination of bluntand penetrating trauma Falls: vertical high-velocity injuries Burns: thermal, electrical or chemicalMechanism of injury

Airway burns and smoke inhalationinjuries: associated with carbon dioxidepoisoning Environmental injuries: poisonousinsects and snakes, animals orconsequences of nature Biological, chemical or nuclear warfareMechanism of injury cont’d

Result of direct impact, deceleration,continuous pressure, shearing, and rotaryforces Associated with injuries from high-speedcollisions and falls from heights Motor vehicle crashs (MVC) are classified ashead on, rear impact, side impact, rotationalimpact, and rollover Injuries commonly much more severe thanpenetratingBlunt trauma

– Type of wounding instrument– Velocity of instrument at time of impact– Type of tissue that instrument passesthrough (organs, vessels, nervous tissue,muscle, fat, bone) Often requires surgical intervention Damage depends on 3 factors:Penetrating trauma

Blunt or penetrating trauma Most ominous sign: hypoxia fromtension pneumothorax, hemothorax,flail chest, hypovolemia, cardiactamponade Chest wall trauma can result in aboveThoracic injuries

–––– Treatment:: needle decompression second intercostalspace midclavicular lineÆ chest tube 4th or 5th ICS,midaxillary linechest wall hyperresonant to percussionBreath sounds decreased or absent unilaterallySubcutaneous emphysemaCXR confirms Accumulation of air between parietal andvisceral pleura Results in severe V/Q mismatch and hypoxia S/S:Pneumothorax

Can be caused from bleeding of heartand great vessels Fluid load before chest tube placement Differentiated from pneumothorax bydullness to percussion with absentbreath soundsHemothorax

Develops from air entering pleural cavitythrough a one way valve in lung or chest wall With each inspiration, more air becomestrapped in thorax, increasing intrapleuralpressure Eventually the ipsilateral lung collpases andthe mediastinum and trachea shift tocontralateral sideTension pneumothorax

Hyperresonance to percussion of chest wallIpsilateral absence of breath soundsContralateral tracheal shiftDistended neck veins?Differentiated from cardiac tamponade byhyperresonance to percussion over tensionpneumo– 14 gauge catheter 2nd ICS midclavicular lineÆchest tube Treatment––––– S/STension pneumothorax cont’d

– Paradoxical chest wall movement and/or splintingdue to intense pain Results from comminuted fractures of at leastthree adjacent ribs with associatedcostochondral separation or sternal fracture Accompanied by hemothorax or pulmonarycontusion Patients with 3 or more rib fractures havegreater likelihood of hepatic or splenic injury S/SFlail chest

IV thoracic epidural intercostal blocks– O2 with humidification– Pain meds: Chest Xray and ABG confirm diagnosis TreatmentFlail chest cont’d

– If worsening respiratory failure, intubation withPEEP, frequent suctioning to avoid bronchialplugging and atelectasis, and careful volumeresuscitation Intra-alveolar hemorrhage and edemaresulting from sudden increase in intraalveolar pressure and rupture of alveolarcapillary interface Difficult to diagnosis; high index os suspicionwith thoracic injuries TreatmentPulmonary contusion

Later pulmonary complication Attributed to direct thoracic injury,sepsis, aspiration, head injury, massivetransfusion, oxygen toxicity, and fatembolism Mortality rate reaching 50%ARDS

– Dysrhythmias: heart block to Vfib; ST segmentelevation– Elevated CPK-MB; ? troponin elevation– CHF– Anginal pain which may or may not respond tonitrates Associated with blunt trauma Contusion most often right ventricle since liesdirectly posterior to sternum S/SMyocardial contusion

– Management of dysrhythmias– Increase CVP to optimize right ventricularoutput TreatmentMyocardial contusion cont’d

– Dyspnea– Orthopnea– tachycardia Life-threatening emergency Bleeding into pericardial space, whichrestricts cardiac filling during diastoleand creates a low cardiac output state Initial symptomsCardiac tamponade

If advanced too far, will see ectopyRequires thoracotomyFluid load and treat with pressors if necessaryAvoid bradycardia; Ketamine useful agent– Pericardiocentesis: 16 g catheter inserted at thexiphochondral junction toward left scapula at 45*angle Treatment May not be evident in hypovolemia– Beck’s triadÆ neck vein distention, hypotension,muffled heart sounds– Pulsus paradoxus: 10 mmHg decrease in bloodpressure during spontaneous inspiration Classic symptomsTamponade cont’d

Aortic ruptureValvular ruptureSeptal ruptureDiaphragmatic herniationEsophageal ruptureAssociated thoracic injuries

High risk for exsanguinating hemorrhage andperitonitis Results from blunt and penetrating trauma Retroperitoneal injuries can damageabdominal aorta, IVC, kidneys, pancreas,duodenum Intraperitoneal injuries can injure spleen,liver, stomach, small bowel, colon, rectumAbdominal and Pelvic trauma

Intraabdominal injuries associated withparalytic ileus and peritoneal irritation(muscle guarding, tenderness to percussion,abdominal distention) 1-3 liters of blood can sequester inabdomen/retroperitoneal space with minimalsigns Diagnosis confirmed with free air on Xray orFAST or CT or by bloody DPLAbdominal and pelvic injuries cont’d