Anesthesia in trauma part 2

1. Anesthesia in trauma part 2

2. Future Developments in Resuscitation: improvement in diagnosis and control of bleeding high resolution CT SCAN & focused assessment by sonography (FAST)in trauma SONOGRAPHY Angiographic embolization topical use during emergency surgery Topical preparations of thrombin and fibrinogen can facilitate immediate clot formation. Fibrin glue oozing surfaces and organs that are difficult to suture or cauterize, such as the lung or liver.

3. Continuous • Future formulations of thrombin and fibrinogen will come layered on collagen-based dressings for rapid control of large injuries to solid visceral organs or the musculoskeletal system.(Iraq and Afghanistan) • Newer hemostatic which have small hydrophilic particle Zeolite and chitosan • recombinant (rFVlla): • Factor VII in physiologic doses works by triggering a thrombin burst on the surface of platelets activated by exposed tissue factor Prospectivestudies : • Elective open prostatectomy • Rapid reverse coagulopathy in patient received warfarin Retrospective studies : GI bleeding Bleeding after cardiovascular surgery Liver transplantation and intracranial hemorrhage

4. other anticipated in development in the field of resuscitation include: • Prevention of organ damage or ischemia may be possible in future through the administration of agents that regular cellular function and humoral signaling. • Possibilities include manipulation of shock-related pathophysiologic alterations such as complement and granulocyte activation, endothelial activation, leukostasis, and edema formation with resultant organ injury. • use of oxygen carriers ,antioxidants, nitric oxide scavengers, and anti endotoxin compounds.

5. Trauma to the central nervous system: • CNS trauma accounts for almost half of all trauma deaths • TBI remains the leading cause of disability in children and young adults. • )As with hemorrhagic shock( CNS trauma: 1-primary injury tissue disrupted by mechanical force.(neuronal cell body- axon-vasculture) 2-secondary response body reaction to injury secondary brain injury accounts for much of the death and disability after trauma. (aggravated by hypoxia, ischemia and inflammatory responses) • The initial management of this patients can significantly affect the outcome.

6. Continues • Drugs such as free radical scavengers, anti-inflammatory agents, and ion channel blockers in animal . • Brain injury is classified as mild, moderate, severe • Mild: traumatic brain injury (GCS score of 13 to 15) who maintain a stable GCS for 24 h are very unlikely to deteriorate further but “postconcussive” effects is common

7. Moderate TBI: • (GCS score of 9 to 12) may be manifested as intracranial lesions that require surgical evacuation, and early cranial CT is strongly indicated. • Early intubation and mechanical ventilation • close observation because of catastrophic consequences of respiratory depression or pulmonary aspiration • Treatment of secondary brain injury is accomplished by early correction and subsequent avoidance of hypoxia, prompt fluid resuscitation, and management of associated injuries.

8. The timing of indicated non cranial surgery in this patient is highly controversial. • Recent review of surgical timing ….. Serial Monitoring of consciousness, motor and sensory Invasive ICP monitoring is indicated if: • Anesthesia longer than 2 hours • need for aggressive analgesia • prophylaxis against delirium tremens • Deterioration of the GCS is an indication for urgent repeat cranial CT to establish the need for craniotomy or invasive monitoring of ICP. • mortality from moderate TBI is low, almost all patients will suffer significant long-term morbidity.

9. Severe TBI : • is classified as a GCS score of 8 or less at the time of admission and carries a significant risk for mortality. • Early, rapid management focused on restoration of systemic homeostasis and perfusion -directed care of the injured brain will produce the best possible outcome in the difficult population

10. Airway and Ventilatory Management : • A single episode of hypoxemia (Pa02 <60 mm Hg) in a patient with severe TBI is associated with a near doubling of mortality. • Prehospital intubation? In past field intubation. Two retrospective study shown worsened outcome. The patient should be transported as rapidly as possible to a facility capable of manger sever TBI or to the nearest facility capable of intubating the patient and initiating systemic resuscitation The main point is systemic oxygenation. • The classic teaching of no or low-level positive end-expiratory pressure (PEEP) to prevent elevated ICP is inappropriate because it may fail to correct hypoxemia. • With adequate volume resuscitation, PEEP does not increase ICP or lower cerebral perfusion pressure however, it may actually decrease ICP because of improved cerebral oxygenation.

11. Hyperventilation therapy (paco2 of 25 mm Hg)is no longer recommended as prophylactic treatment. • Current guidelines imply a range of 30-35 mmHg hyperventilation to 30 mm Hg only for episodes of elevated ICP that can not controlled with : • Sedatives • CSF drainage • neuromuscular blockade • osmotic agents • barbiturate coma Hyperventilation during the first 24 hour is of particular concern because of critical reductions in perfusion during this timeframe. these recommendations should be taken in context and modified In unstable clinical circumstances such as expanding mass lesion or signs of immediate herniation. 10

13. Circulation: • The most challenging of all trauma patients are those with sever Trauma and coexisting hemorrhagic shock. • A single episode of hypotension, defined as systolic BP less than 90 mmHg, is associated with an increase in morbidity and doubled mortality after severe TBI. • Hypotension together with hypoxia is associated with threefold mortality. • Systolic BP less than 90 should be avoided with a goal MAP greater than 70 mm hg • Maintain in euvolemic state • Hypertonic salt solution is optimal • HCT greater than 30% • CPP 50-70 mmhg • Vasoactive if needed

14. Decompressive craniectomy • Used to Control Sever elevated ICP prevent herniation after stroke Improve mortality and morbidity Decompressive laparatomy : If “coexisting injuries” or “vigorous volume infusion” increase intra abdominal compartment pressure more than 20 mmHg increase intra abdominal compartment pressure reduce brain drainage.

15. Multiple compartment syndrome: In patient with sever TBI Fluid therapy or acute lung injury(or both) increase intra abdominal pressure and intra thoracic pressure and increase ICP. further administration of fluids or increasing Ventilatory support to treat lung injury can exacerbate this problem. Multiple compartment syndrome: Need to open abdomen Hypothermia 33 c (like hyperventilation) Active rewarming in sever TBI??

16. Spinal cord injury: • Occur in 1.5 to 3 %all major trauma. • Most spinal injuries are found in the lower cervical spine, the upper lumbar region • SCI at mid thoracic levels Is less common. • SCI is commonly accompanied by radiographically visible injury to the bony spine and concomitant disruption of the muscles, ligaments, and soft tissues that support it. • clinically significant injury to the cervical spinal cord can occur in the absence of visible skeletal injury. • This phenomenon, known as SCIWORA (spinal cord injury without radiographic abnormality), is more common in children. • Primary injury to the spinal cord sustained at the moment of trauma may be exacerbated by a number of secondary factors

17. Sensory deficit or motor deficit or both. • Incomplete deficitsmay be worse on one side than the other and may improve rapidly in the first minutes after injury. • Complete deficits-representing total disruption of the spinal cordat one level are much more ominous, with generallylittleimprovement seen over time. • Cervical spine injuries causing quadriplegia are accompanied by significant hypotensionbecause of inappropriate vasodilatation and loss of cardiac inotropy (neurogenic shock). • Functioning of lower cord levels will gradually return, with restoration of normal vascular tone.

18. Treatment: after ABC: • glucocorticoid steroid bolus, administered to any patient with a complete or partial neurologic deficit. • A bolus dose of 30 mg/kg of methylprednisolone, followed by a maintenance infusion of 5.4 mg/kg/hr,is given if the patient is less than 8 hours removed from the time of injury. • This infusion is continued for 24 hours if started within 3 hours of injury • for 48 hours if started 3 to 8 hours after injury. • High dose glucocorticoid therapy demonstrated a small, but statistically significant improvement in neurologic level after SCI in two large multicenter trials.

19. Continued(Treatment) • Surgery for cervical lesions • Supportive bracing or extension casting for lumbar or thoracic fracture. • Early intubation for patient with cervical spine fracture and quadriplegia(Glidoscope & fiberoptic before patient agitation) • Ventilatory support absolutely required for deficit above C4 Early intubation is recommended (patient cooperation) • Patient with levels fromC6-C7may still need support • Pneumonia is common and recurrent complication that necessitate tracheostomy to facilate pulmonary toilet

21. Intraoperative management of spinal cord injury : • Direct laryngoscopy with in-line stabilizationis appropriate in the emergency setting and in unconscious, combative, or hypoxemic patients when the status of the spine is not known. • In the OR an awake, alert, and cooperative patient can be intubated by a number of different methods known to produce less displacement of the cervical spine and presumably less risk of worsening an unstable SCI. • A common technique in current clinical practice is awake Fiberoptic intubation. • nasal route is associated with an increased risk of sinusitis in the ICU if the patient is not extubated. • Oral intubation if patient need mechanically ventilation. 20

23. Orthopedic and soft tissue trauma: • Lower extremity fractures are the leading cause of all trauma admissions. • Being familiar with regional anesthesia • Fluid balance • length of procedures attention to body positioning • Normothermia • preservation of peripheral blood flow • early stabilization of long-bon, spine and stabular fractures. • In one study in femoral fracture …..(2% vs. 38%)

24. Dislocations of the hip • are common after high-energy traumaand are frequently accompanied by fracture of the acetabulum. • significant risk factor for avascular necrosisof the femoral head. • Reduction typically requires a very deep level of sedation and may be facilitated by chemical paralysis of the patient. • Enough attention to risk of aspiration • Whereas the fracture itself can be safely managed on a delayed basis ,the dislocation is a medical emergency.

25. Unlike acetabular fractures, fracture of the “pelvis ring” requires immediate recognition and management by the trauma team. • Hemorrhage, even exsanguination, is common after major pelvic ring fracture and is a leading contributor to early deathafter motor vehicle accidents. • Bleeding occurs from multiply disrupted venous beds in the posterior pelvic bowl. • Surgical exploration is usually unrewarding because bleeding vessels not accessed. • Therapy consists of supportive volume resuscitation, external fixation of the unstable pelvis, and angiography. • In the absence of an orthopedic specialist, temporary stabilization and tamponade of some pelvic fractures can be accomplished with the use of a specially made pelvic binder, the pelvic portion of military anti shock trousers, or a bed sheet knotted tightly around the bony pelvis.

26. Continued • Open fracture should be pulse- lavaged and debrided as soon as possible even on bed side if patient is unstable • Advantages and disadvantages of GA and RA • Intraoperative TEE has shown that most patient undergoing long-bone fracture manipulation experience microembolism of fat and marrow. • some Lung dysfunction in almost always patients has range from minor laboratory abnormalities to full-blown fat embolism.(FES) 3-10%. • Coexist lung disease and multiple long bone fractures have additional risk for FES • Signs: hypoxia-mental status changes-petechia rash-tachycardia • Failure to awaken after G.A • FES should be considered if:

27. Diagnosis in the operatory room is based on clinical findings after ruling out other causes of hypoxia • fat globules in Urine are not diagnostic but lung infiltration on CXR confirm the presence of injury Treatment: • Early recognition • Administration of oxygen • Judgious of fluid management • A change in orthopedic procedure may be indicated such as converting intra medullary nailing of the femur to external fixation

30. Acute compartment syndrome: • Increased pressure within a limited space compromise the circulation and function of the tissue within that space. • With orthopedic trauma the most common cause of compartment syndrome is edema secondary to muscle injury and associated hematoma formation. Also occur as result of: • Reperfusion injury • Burns • drug over dose • prolonged limb compression • The most common fracture associated with C.S is tibia shaft and forearm.

31. Risk factors for development of compartmant syndrome: • Orthopedic Fracture and operative repair • Vascular Reperfusion injury Hemorrhage with hematoma formation Ischemia from arterial and venous injury • Soft tissue: Crush injury Burns Prolonged compressing Iatrogenic: Casts and circular dressing Use of pneumatic anti shock garments Intraosseous fluid replacement in infant and child Extravasation from venous or arteies puncture site • Miscellaneous Snakebite 30

32. Classic triad of compartment syndrome “The 5p” • Pulslessness • Pallor • Paralysis • Parasthesia • Pain Presences of these finding associated with established syndrome and Fasciotomy has poor out come. • the early presence of pain out of proportion to the injury can be the first clinical indication of compartment syndrome .

33. Treatment: Fasciotomy is indicated when: • compartment pressure approaches 20-30 mmhg below diastolic pressure in any patient with worsening clinical condition. • major soft tissue injury • history of 4-6 hours of total ischemia of an extremity. Prophylactic Fasciotomy may be indicated: • in patient with warm ischemic time in excess of 4-6 hours • ligation of the major veins in the popliteal region or distal part of the thigh • crush injury.

34. Crush syndrome: • Crush syndrome is the general manifestation of crush injury caused by continuous prolonged pressure on one or more extremitiesin patients who have been trapped in one position for an extended period • myoglobinuria, which can lead to acute renal failure and electrolyte disturbances. • The most critical treatment consists of crystalloid fluid resuscitation a total body fluid deficit of 15 L may occur in sever rhabdomyolysis. • Osmotic diuresis with mannitol and alkalization of urine with sodium bicarbonate is controversial. • The preferred therapy for renal failure secondary to rhabdomyolysis continuous renal replacement therapy.

35. Soft tissue trauma: • May be jeopardized by: Avulsion at the time of injury Ischemia from elevated compartment pressure bacterial infection • All dead or devitalized tissue must be : debrided wound irrigated to reduce the load of bacteria contaminants. When muscle or fascia involvement is significant at 1-3-day interval debridment needed. Vacuum dressing for large soft tissue wounds When serial debridement establish viable tissue at all marginsclosure can be made. Closure : • Split thickness graft • Free tissue transfer

36. Anesthesia: Vacuum dressing can be made at the bed side with light sedation or anesthesia • Need for repeated surgery is an important consideration for the anesthetic technique • Anesthesia for free tissue transfer is protracted • Keeping the patient warm, euvolemic and comfortable and maintain HCT in “rheological favorable” range of 25-30% • Every effort should be made to facilate perfusion Of the graft vessels. • Use of epidural anesthesia and analgesia is controversial : 1-Vasodilatory effect 2-Steal phenomenon (limit flow in denervated tissue) Amputation is occasionally necessary for Massive crush injury (**strong emotional) • Regional anesthesia limit development of phantom limb pain • GA is better accept.

38. Head and neck surgery: • Except zone II most repair of head and neck trauma will occur in sub acute phase after complete resuscitation and diagnostic studies • Nasotracheal intubation for mandible and maxillary fracture • Switch oral to nasal? • Oral tube secured behind the second molar (to allow dental occlusion) • Tracheostomy • surgery lead to significant soft tissue swelling after operation thus: Needs several days of intubation and sedation until sufficient venous drainage has occurred to allow safe extubation. • Air leak when the endotracheal tube cuff is deflated

40. Chest Injuries-Rib Fractures: • Are the most common injury from blunt chest trauma. • The fracture itself generally requires no specific treatment and will heal spontaneously over a period of several weeks. • Therapy is directed at minimizing pulmonary complications secondary to these fractures: • Pain • atelectasis • hypoxemia • Pneumonia • elderly (older than 55 years). • Elderly patients have twice the mortality and thoracic morbidity. Epidural anesthesia should be liberally used: • in patients with severe pain • elderly • patients with preexisting compromised pulmonary function. • Some data support a decrease in morbidity and mortality in the elderly by 6% when epidural anesthesia is used. • And decreased Hypoxia ,hypoventilation ,tracheal intubation and mechanical ventilation decreased.

41. Continued • Fracture of multiple neighboring ribs will result inflail chest syndrome, characterized by paradoxical chest wall motionduring spontaneous ventilation. • ventilation and positive pressure for internal chest stabilization, and endotracheal intubationshould be reserved for those who meet the usual criteria. • Patients who are not initially intubatedshould be closely observed in the ICU for signs of worsening respiratory function. • Increasing numbers of reports have described the use of noninvasive positive-pressure ventilation(NIPPV) for lung injury caused by trauma. • NIPPV is associated with • fewer cases of pneumonia • which may lead to fewer tracheostomies • therefore decreased ICU length of stay.

42. Continued • Concomitant pulmonary injury ,specially lung contusionis commonly associated with flail chest. • Pulmonary contusion lead toshunting, this syndrome may progress rapidly in hours to days. • Clear CXR doesn't exclude possibility of the contusion • Treatment of hypoxemia • High degree of suspicion along with a continues search for missed injuries. • Early and aggressive implementation of lung protective strategy is crucial in the treatment of patients with significant pulmonary contusion to minimize progression to ARDS or concomitant ventilator associated lung injury .

43. : Chest Injuries-Cardiac Injury • Blunt cardiac injury is a rare and poorly understood phenomenon Bruising or edema of the myocardium is functionally indistinguishable from IHD Blunt cardiac injury can be safely excluded if: • patient ishemodynamically stable ECG does not demonstrate : • conduction disturbances “ • or tachyarrhythmias • new tachyarrhythmia • conduction disturbance • unexplained hypotension (other causes should be ruled out) Right ventricular dysfunction resulting in hypotension may be overlooked transthoracic echocardiography should be performed. TEE is superior to TTE in obese patients .

44. Continues • Treatment: blunt cardiac injury should be managed as ischemic cardiac injury • Completion of resuscitation • Careful control of fluid volume • Administration of coronary vasodilator • Monitoring and symptomatic treatment of rhythm disturbance • Anticoagulant with aspirin and heparin?(approached on case by case) • Cardiology consultationpatient might benefit from coronary angiography followed by angioplasty or stenting of stenotic vessels

45. Continues • Penetrating cardiac trauma and blunt traumacausing rupture of one or more chambers (usually the atria) • Patients who do not die immediately of free exsanguination into the thoracic cavity will have “pericardial tamponade” and can be extremely unstable in the first minutes after admission. • Relief of tamponade • Cardiopulmonary bypass may be required.

46. Chest Injuries-Pulmonary • Injuries to the lung parenchyma producing a Pneumothorax • Can be managed by tube thoracostomy. • Bleeding from the low-pressure pulmonary circulation is usually self-limited. • Thoracostomy : • evidence of mediastinal injury • chest tube output exceeds 1500 mL in the first hours • tracheal or bronchial injury and massive air leak • hemodynamically unstable with evident thoracic pathology.

47. Continued • Hemorrhage necessitating surgery may be from injured intercostal or internal mammary arteriesas well as from the lung parenchyma. • Although double-lumen endotracheal intubation is desirable during urgent thoracotomy, such intubation should not be the initial approach . • Rapid-sequence intubation with a large-caliber (at least 8.0-mm internal diameter) conventional endotracheal tube will permit diagnostic bronchoscopy and will protect the patient from aspiration until passage of a gastric tube can reduce stomach contents. • The change to a double lumen tube can then be done under controlled conditions, that is, in the presence of adequate oxygenation, anesthesia, and muscle relaxation.

48. continued • Tolerance of single-lung ventilationis variable in the trauma population • chest trauma requiring pneumonectomy has historically resulted in mortality approaching 100%. Intraoperative deaths are the result of : • uncontrollable hemorrhage • acute right ventricular failure • air embolism. • Blunt thoracic trauma requiring pneumonectomy is often associated with abdominal and pelvic trauma. • Volume replacement must be judicious • Treat right ventricular failure and pulmonary hypertension

49. Tracheobronchial injury can result from either blunt force or penetrating trauma (more promptly diagnosed). • Blunt trauma most commonly results in an injury to the Tracheobronchial treewithin 2.5 cm of the carinaand may initially be unrecognized. The presence of : • subcutaneous emphysema • pneumomediastinum • Pneumopericardium • Pneumoperitoneum • Despite helical CT scan and bronchoscopy small injury never be delineated. • Complete and incomplete tracheobronchial injury

50. Chest Injuries-Traumatic Aortic Injury: • Traumatic aortic injury must be ruled out in high-energy injury fall & motorcyclet accident • Aortic injury occurs most commonly just distal to the left subclavian artery Diagnosis: CXR (screen) followed by Definitive Angiography CT TEE • Surgical or endovascular repair is indicated for most patients with traumatic aortic injury because of high risk for rupture in the hours and days after injury. • Various techniques have been described for it ,with the best result the reports recently attributed to partial bypass techniques. • Reports of selective nonoperative managementof high-risk patients with traumatic aortic injury have appeared in the recent literature. • ß blockade to minimize the cardiac rate-pressure product. • Endovascular repair.