Case 77 - Abdominal Trauma

Question 1

What is the Glasgow Coma Scale?

Answer 1

• quick assessment of neuro function when TBI suspected
  
  • predicts mortality
• eye opening, verbal and motor responses
• top score - 15, worst score - 3

Eye opening

• 1 - 4 : none, to pain, to loud noise, spontaneously

Verbal

• 1 - 5 : none, moaning, incomprehensible words, confused/disoriented, alert and oriented

Movement

• 1 - 6 : none, decerebrate extension, decorticate flexion, whidraws, localizes, obeys commands

Question 2

What is Primary Survery

Answer 2

A, B, C, D, E

A = Airway mainteance with c-spine protection

B = breathing and ventilation

C = circulation with hemorrhage control

D = Disability (neuro eval)

E = exposure and enviornmental control

Question 3

In Primary survey, what is important about airway mainteance with c-spine protection?

Answer 3

A = Airway mainteance with cervical spine protection

• Is patient hypoxic, hypercarbic?
• lack of airway reflexes
• intoxicated, combative, and actively bleeding?
• worsening stridor?
• constant oropharyngeal bleeding?

Tx:

• airway takes precedense over c spine injury
• manual in-like stabilization, minimize neck extension, experienced laryngoscopist

Question 4

Describe in Primary Survey, B, C, D and E

Answer 4

B = breathing & ventiliaton

• b/l breath sound vs unilateral b/s
  
  • main stem intubaiton vs pneumo
• supplmental oxyen can lead to adequate saturation but patient may still be hypoventilating

C = Circulation + hemorrhage control

• Blood Pressure!
• arterial line, large bore IV access

D = Disability (neuro eval)

• GCS score
• GCS < 8 = unable to protect airway –> intubate
• document neuro exam, cranial nerve function, pupil size

E = Exposure and environmental control

• undress patient fully, place warm blankets

Question 5

What are anesthestic considerations during induction of a trauma patient?

Answer 5

1) Awake FOB or Asleep intubation (RSI)

• trauma pts are full stomach and c-spine collar
• awake FOB provides not superior to asleep intubation
  
  • awake FOB –> takes time to topicalize, bleeding can distort view, valsalva and coughing can worsen IOP and ICP (due to increase CVP)
• asleep intubation –> RSI + in-line cervical stabilization

2) induction agents

• etomidate or ketamine for unstable patients
• propofol in unstable pts:
  
  • severe hypotension 2/2 dec SVR, myocardial depression, knocking out high sympathetic (compensatory) drive

3) muscle relaxant

• difficult intubation –> use Sux (1.5 mg/kg)
  
  • allows greater likelihood of resuming spont vent before hypoxia ensues
• risk of hyperkalemia –> use Roc (1.2 mg/kg)

Question 6

What is considered adequate pre-oxygenation?

Answer 6

• pre-oxygenation allows for denitrogenation –> replace nitrogen in FRC of lungs with 100% oxygen
  
  • goal - patient maintains adequate saturation for a longer period of time with apnea due to increase oxygen reserve in lungs
• 3 min of spont vent or 8 max breaths in 60 seconds
• in head trauma pts, consider mild hyperventilation before intubation

Question 7

Patient with massive trauma comes to the OR, he is hypotensive, what are your goals for resuscitation?

Answer 7

1) anticipate and avoid severe anemia

• dilutional anemia 2/2 IVF resuscitation + mobilization of interstial and intracellular fluid into intravasc space
• in severe, uncontrolled bleeding, transfused with PRBC aggressively:
  
  • if no T&S, use O Neg Blood
  • limit O Neg blood to < 4 U, and switch to Type Specific blood
• in less severe bleeding –> use transfusion triggers (HcT, HD stability, end-organ function)

2) Tx coagulopathy

• 2/2 dilutoinal, hypothermia, acidosis
• also due to inflammatory response from trauma

3) avoid severe hypovolemia

• nonbleeding –> isotonic crystalloid
  
  • LR - can cause hyperkalemia in AKI, Calcium can cause clotting in blood IV lines, hypotonicity can exacerate cerebral edema in TBI
• ongoing bleeding -> blood products

Question 8

Patient is severely bleeding, he is in your OR, what are your markers for endpoints of resuscitation?

Answer 8

• not one single test is best
• two groups: markers of global perfusion, markers of regional perfusion

Global Perfusion

• MAP
• Lactate, pH
• Base deficit
• SVO2 -> PAC
• Core Temp -> hypothermia is late marker of shock
• CO -> PAC, TEE
• respiratory systolic pressure variation

Regional perfusion

• UOP
• EKG
• ECHO

Question 9

What is massive transfusion protocol?

Answer 9

• Define = infusion of ONE BLOOD VOLUME in 24 hours (65 mL/kg)
• objective = keep up with blood loss, speed is essential
  
  • serves to expediate blood product availability, especially FFP and PLT
• 1 U PRBC : 1 U FFP: 1 pack PLT
  
  • same as 6 U PRBC: 6 U FFP : 1 U PLT
  • 1 Unit of PLT = 6 pack
  • continue this transfusion ratio until 1: adequate surgical hemostasis, 2: HD stability, 3: adequate markers of end organ perfus

Question 10

pt with multiple trauma comes to your OR for damage control, what are your intraop priorities?

Answer 10

1) immobility and amnesia
* neuromuscular blockade + anesthestic agents (titrated to maintain adquate BP)
2) Large bore IV access + CVC
* large-bore (introducer) necessary for massive transfusion
3) Arterial line - monitor ABP
* beat to beat monitoring, abg samples, calculate CPP
4) Manage CPP

• pts with TBI, ICP monitoring should be initiated
• CPP = MAP - ICP; maintain CPP > 55 mmHg
• use pressors as needed
• decrease ICP with mannitol, lasix, ventric drain

5) maintain normothermia

• shock assoc with hypothermia
• IV fluid warmer, inc OR temp, blanket warmers

6) electrolyte abnormalities