ANAESTHESIA FOR TRAUMA PATIENTS

ANAESTHESIA FOR TRAUMA PATIENTS

SPEAKER-DR. BABRAK MANUAR 2 ND YR PGT MODERATOR- DR. B HEMBRAM ASST PROF. DATE-30/06/2012

TRAUMAPhysical harm or damage to body due to the acute exchange of mechanical , thermal or other environmental energy that exceeds the body tolerance

THIRD LEADING KILLER

After heart disease & cancer. Victims are mainly belongs to young age group.It cause Mortality Morbidity Disability Financial burden

TEAM APPROACHAnaesthesiologist Surgeon ER Physician Nurses Thechnician

ROLE OF ANAESTHESIOLOGISTSecure airway Maintain adequate ventilation Give appropriate fluid Provide sedation & analgesia Operating room care Management in intensive care unit Even accompanying to radiology suit.

PREOPERATIVE ASSESSMENT & IMMIDIATE MANEGEMENTEvaluation of acute trauma patient is done by:RAPID OVERVEIW- Takes only few secs & determine whether the patient is stable, unstable, dying or dead. PRIMARY SURVEY- ABCDE Approach. SECONDARY SURVEY-Involves more elaborate systemic examination & diagnostic investigations

ABCDE APPROACHA-Airway B-Breathing C- Circulation D-Disability E-Exposure

AIRWAYASSESSMENT Inspection of upper airway for patency, presence of blood , vomitus , tissue, hematoma, odema . Recognition of upper airway obstruction by auscultation for stridor , hoarseness.

MANAGEMENT Clearance of airway- suction, finger sweep. Jaw thrust or chin-lift maneuver Oropharyngeal airway, ET intubation Surgical airway by cricothyrotomy All measure must be performed under C-spine protection.

BREATHINGASSESSMENTInspection for respiratory rate, cyanosis, tracheal shift & paradoxical ventilation. Recognition of tension pneumothorax & hemothorax by auscultation. SC emphysema, rib fracture can be diagnosed by palpation MANAGEMENT Give oxygen- FiO2 0.5-1 Assisted or controlled ventilation Decompression of tension pneumothorax Placement of chest drain for hemo / pneumothorax , flail chest, rib fracture.

CIRCULATIONASSESSMENTPalpate pulse-rate ,volume Temperature & sweatiness Capillary return Urine output Recognition of external or internal source of haemorrage -clinical & FAST, chest & pelvic X-ray

MANAGEMENT Venous access by 16 G canula in peripheral major veins or central route, venous cutdown or intraoseos route. Aggressive volume resuscitation. Surgical control of external or internal bleeding. Splinting of fracture.

DISABILITYASSESSMENT Glasgow Coma Scale (GCS) score & pupil evaluation. Mild head injury-GCS score 13 - 15. Moderate head injury-GCS score 9 - 12. Severe head injury-GCS score 8MANAGEMENT. GCS 8-Endotracheal intubation GCS 6Ventilatory support

EXPOSUREASSESMENTCompletely undress the patient to detect External evidence of injury. Inspection of back for posterior injury

MANAGEMENT Protection from hypothermia by warm blanket, heating lamp, preheated infusions.

PREOPERATIVE PREPARATION & PREMEDICATIONAll acute trauma patients are considered to be in full stomach- gastric aspiration by naso -gastric tube. Antacid should be given for aspiration prophylaxis. Sedation is usually avoided. Anti cholinergic may be given if not contraidicated. All airway equipments, drugs, fluid, monitors should be kept ready. Blood component availability in the blood bank should be verified.

AIRWAY MANAGEMENT IN TRAUMAAirway management in trauma patient can be challenging due to: Full stomach prone to pulmonary aspiration Airway & maxillofacial injuries Cervical spine injury making intubation procedure risky Central nervous system injury impairing ability to breath Hypovolaemic patient unable to tolarate rapid sequence intubation

AIRWAY MANAGEMENT IN TRAUMAAll patient should be pre- oxgenated with 100% O2 If immediate secure airway is require- orotracheal intubation under direct laryngoscopy by experienced person. Manual in-line stabilization should be done by trained assistants throughout the procedure. Sellicks maneuver is to be applied both during mask ventilation & intubation. Nasotracheal route should be contraindicated in presence of skull base fracture.

AIRWAY MANAGEMENT IN SPECIFIC TRAUMAIn less emergent situations individual technique for intubation is based on specific type of trauma It may involve use of pharmacological agents, special or alternate airway devices, planned awake intubation technique or surgical airway. Conditions are: Maxillofacial trauma Laryngeal injury Cervical spine injury Head injury

AIRWAY MANAGEMENT IN MAXILLOFACIAL TRAUMAAirway patency is the priority. Sedation in these pt is catstrophic as airway may suddenly lost. Suction, lateral posture & insertion Oropharyngeal airway may be done. If there is severe obstruction immediate orotracheal intubation by skilled person is indicated. Emergency cricothyrotomy may done to save life. \If intubation is likely to be difficult time consuming surgical airway is recommended.

AIRWAY MANAGEMENT IN LARYNGEAL INJURY

Maintain spontaneous ventilation if possible. Positive pressure ventilation done only after securing the airway. Awake fibreoptic intubation or surgical airway is recommended if expert person available. Ensure that the ETT cuff is below the site of injury(distal to injury). Avoid cricoesophageal pressure when injury is in proximity to the cricoid ring

AIRWAY MANAGEMENT IN CERVICAL SPINE INJURYPrecaution should be taken to immobilize the spine. Head tilt is contraindicated but chin lift & jaw thrust maneuvers may be done. Manual inline stabilization reduces movement at C1-C2 level by 60%. Flexible fibreoptic technique, vediolaryngoscope , glidescope are useful in visualizing larynx without significant neck movement in both awake & unconscious pt. Bouge , illuminated stylet , intubating LMA can be used.

MANUAL IN-LINE STABILIZATION

AIRWAY MANAGEMENT IN HEAD INJURYRapid Sequence Intubation should be performed by experienced person by quickest possible way to minimize further rise in ICP. Anesthetic agents that increase ICP should be avoided In unconscious patient precautions must be taken to minimize the movements of cervical spine. In severe head injury mild hyperventilation reduces ICP.

PERIOPERATIVE MONITORINGFollowing intraoperative monitoring done:ECG NIBP Pulse oximetry Temperature probe End tidal CO2 Stethoscope Urine out put CVP IBP ABG

INDUCTION OF ANAESTHESIAThiopental, propofol & midazolam are used head injury patiets . Ketamine is avoided in head injury. Propofol , thiopental are best avoided in hypotensive unstable patients. In this situation etomidate is preferred. Ketamine can be used hypotensive pt. There is no absolute contraindications of any inhalational agent but newer agents are preferred.

INDUCTION OF ANAESTHESIASuccinylcholine remains muscle relaxant of choice for rapid sequence intubation. It can be used safely in 24-48 hrs following trauma. Rocuronium bromide is alternative to succinylcholine . Atracurium , mivacurim (release histamine) generally avoided in patients with hypovolemic shock . As analgesic opioids-fentanyl may be used.

MAINTENANCE OF ANAESTHESIAHigh FiO2 should be provided to all hypovolemic & haemodiluted pt to improve O2 carrying capacity. Maintenance may be done by opioid only in unstable pt to inhalational or propofol infusion with N2O in stable pt. N2O is contraindicated in pneumothorax , pneumoencephalus , large dilated bowel loops. Temperature monitoring done by elevation of OT temperature , using warm irrigating/IV fluids, blood.

PERIOPERATIVE FLUID THERAPYFirst priority is restoration of circulating blood volume. Followed by restoration of O2 carrying capacity. Lastly to restore coagulation status. But timing of fluid therapy is controversial aspects in trauma pt. Early & aggressive fluid therapy may Disruption of electrolyte balance. Decrease blood viscosity , hematocrit & clotting factors. Blow-out of haemostatic plugs can restart bleeding.

PERIOPERATIVE FLUID THERAPYSo currently permissive hypotensive resuscitation has been advocated(except pregnancy & head injury). Here until the bleeding is surgically controlled resuscitation is aimed to- Restoration of radial pulse. Restoration of mental function. Systolic BP 80 mm of Hg (except pregnancy & Head injury).

PERIOPERATIVE FLUID THERAPYAvailable options for fluid therapy: Crystalloids Colloids Hypertonic solutions Blood transfusion Oxygen carriers

CRYSTALLOIDSNormal Saline, Lactated Ringers are used as first line of management in fluid therapy. Replacement of crystalloids requires almost three times fluid volume than blood volume lost. Glucose containing solutions are avoided in head trauma because hyperglycemia aggravate CNS injury.

CRYSTALLOIDSEffects of crystalloid solution on the coagulation system are biphasic. With haemodilution up to 20% -40% with crystalloids produce hypercoagulable state. After 60% haemodilution it produce a hypocoagulable state.

COLLOIDSColloid solutions are more effective plasma expender. They increase the plasma oncotic pressure. Retain water in the intravascular compartment. They minimizes interstitial & tissue edema, pain, nausea, vomiting. They produce coagulopathy at relative to lower degree of haemodilution compaired to crystalloids.

COLLOIDS

HYPERTONIC SOLUTIONHypertonic solutions efficiently restore intravascular volume. Decrease extravascular volume & tissue edema. They decrease ICP & increase CPP. They are specially useful in prehospital resuscitation & in severe head trauma.

BLOOD TRANSFUSIONBlood transfusion is considered when:Despite resuscitation with crystalloid & colloid, there is a concern about tissue hypoxia & organ dysfunction. Increasing base deficit & serum lactate. Low venous oxygen saturation. Organ ischaemia is anticipated in case of rapid ongoing bleeding.

BLOOD TRANSFUSIONFully cross matched whole blood is preferred in acute blood loss. Partially cross match or O ve blood may be given in emergency . In such instances packed RBC should be used. Although blood transfusion is life saving measure in many trauma patient but not risk free.

OXYGEN CARRIERSThey are still not readily available & expensive. They can be perfluorocarbon based (Oxygent , Oxycyte , Perftec) or haemoglobin based (Hemopure , Oxyglobin , Polyheme). They have longer half life & remain in circulation for about 72 hrs. Oxygen carrier, even if widely available , would not eliminate the use of human blood , which, besides O2 transport, also performed various other function.

OXYGEN CARRIERS

PERIOPERATIVE ANALGESIAMultimodal therapy. Usually NSAID are used for mild to moderate pain. Once pt is intubated & is being ventilated sedative analgesic like fentanyl ,morphine may be used. Local, regional as well as neuroaxial analgesia may be used in various type of major trauma.

ITU MANAGEMENTGoal of ITU management:Airway Ventilatory management Volume resuscitation & inotropic support. Infection control Providing proper enteral or perenteral nutrition. Postural care Oral hygin maintenance Nursing care

ITU MANAGEMENTFollowing monitoring done in ITU- Pulse oxymetry ECG Invasive & Noninvasive Blood Pressure ETCO2 CVP Body Temperature Urine outputArterial blood gas analysis Haematocrit Blood glucose Serum electrolyte Urea & creatinine

CONCLUSIONMaintain systolic BP at 80 - 100 mm of Hg. Maintain hematocrit at 25% - 30%. Maintain PT & APTT in normal ranges. Maintain platlet count > 50000 Maintain normal serum electrolyte balance. Mintain temperature > 35C. Maintain SpO2. Prevent acidosis. Achieve adequate anaesthesia & analgesia.