Anaesthetic management of the Trauma Patient

1. Anaesthetic management of the Trauma Patient Chapter 23

2. Pre operative assessment History History Chronic illnesses Allergies and Addiction Medication Events or environment related to injury Last meal • C • A • M • E • L • C • S

3. Pre operative examination Clinical Examination Tubes Fluids • Airway • Cardiac • Vascular • Respiratory • Abdomen • Limbs

4. Pre operative assessment Neurological Examination Neurological Examination Alert Vocal stimuli response Painfull stimuli response Unresponsive • A • V • P • U • Head Trauma and Spinal cord injury must be excluded • GCS

5. Pre operative Assessment Special investigations FBC , UKE , Acid Base , Glucose Airway etc • Baseline bloods • CSPINE • CXR • Pelvis

6. Principles Anatomical Considerations Physiologic Considerations Vital organs Physiologic failure leads to homeostatic failure • Head to toe • All organ systems

7. Principles Pharmacological Considerations Monitoring Considerations • Xenobiotics • Recreational • Toxins • Decreased central volume of distribution versus increased volume of distribution • [Free drug]

8. Anaesthetic Technique Resuscitation Airway and CSPINE Breathing Circulation and Coagulation Disability Exposure and environmental control • Get help • A • B • C • D • E

9. Airway management and Breathing • Chest • ETT • Burns • Cervical Spine injury • Bronchoscopy • Intercostal drain • Mode of Ventilation • Expose , auscaltate • Intratracheal, size, depth, cuff, reintubation • Swelling • Bimanual cricoid pressure • Secretions , foreign matter • Hemo , pneumo , amount , type • Lung protective ventilation, vcv versus pcv

10. Circulation and coagulation • Stop Haemorhage • Awake shock index • Clinical signs of hypovolaemia • Venous access • CVP, Art • 8.5 F Swan Ganz sheath • Finger in artery • Pulse rate/systolic blood pressure, N=0.5, > 10%, 33%, 50% decrease in CO • Class 1 – 4 • 14 or 16 G X 2 • Do not waste time

11. Circulation and Coagulation • Fluids • Trauma induced Coagulopathy • Crystalloids • Colloids • Loss • Dilution • Consumption • Hyperfibrinolysis • Hypothermia • Acidosis

12. Circulation and Coagulation • Haemostatic Resuscitation • Ratio of 1:1:1:1 = Whole blood • Target Hct 30 • Clotting factors • Every 6 packed RBC • Cryoprecipitate • Damage control resuscitation • Packed RBC: FFP: Platelet: Fibrinogen • RBC • FFP • Mega unit Platelets • Fibrinogen

13. Disability • Neurologic • Vascular • eyes • Central , brain , spinal cord • Peripheral nerves

14. Exposure and environmental control • Physical • Chemical • Biological

15. Hypothermia • Worse outcome • Exposed, fluids, casualty, radiology, OR • Permissive, induced • O2, coagulation, drugs, vasoconstriction, dysrhythmias, infection, dehiscence, • Space blanket , warm fluids, bair hugger, fluid warmers, aircon • Brain and Spinal cord injuries

16. Hyperthermia • Endogenous versus exogenous • Pontine lesions, status epilepticus • Drugs – anticholinergics, alcohol, amphetaminoids, cocaine • Active cooling • Heat stroke

17. Endpoints of fluid resuscitation • Systolic BP 90 • Hct 30 • No TRIC • BE improving • Lactate improving • Systolic pressure variation

18. Induction of anaesthesia and airway • Resuscitation • BIS or Entropy • Cardiovascular collapse versus permissive hypotension • Aspiration • Ketamine versus Etomidate • Suxamethonium

19. Maintenance of anaesthesia • Vapour versus ketamine infusion versus opioid infusion • Nitrous Oxide • Muscle relaxants • Analgesia – do not give NSAIDS

20. Emergence • Extubation criteria • Stable versus unstable • High care versus ICU

21. Damage control surgery • Damage control resus/ Haemostatic resus • Life and limb threatening first • ICU stabilization • Definitive care • Lethal triad • Hypothermia < 35 • Acidosis Ph < 7.2 • Clinical Coagulopathy

22. Occupational health and Hazards • Physical • Blood • Toxins • Sharp objects • Psychological • Counselling