Ex 3 - AC for trauma patients

Question 1

What are the first things you evaluate in a trauma patient?

Answer 1

1. Level of consciousness

2. ABC –> airway, breathing, circulation

Question 2

Shock treatment

Answer 2

Prevent or treat shock before anesthesia!

O2, IV/IO catheter, Fluids, Inotropes and/or vasopressors

Question 3

What is a common injury in HBC cases?

Answer 3

Thoracic injury!

Question 4

Lung Contusions (bruising)

Answer 4

Easy to miss initially –> don’t always show on rads

Can lead to:

• atelectasis
• hypoxemia/hypoventilation
• depending on severity

During anesthesia, PPV may be needed

Question 5

Pneumothorax

Answer 5

Can be open or closed

Can lead to:

• atelectasis
• hypoxemia

Question 6

PPV and pneumothorax

Answer 6

PPV –> may cause a tension pneumothorax (does not allow lungs to expand) –> acts as a one-way valve

• inc pressure in thorax –> affects CV/pulmonary fxn –> leads to CV collapse
• emergency thoracocentesis or chest tube placement may be indicated

Question 7

Signs of tension pneumothorax under anesthesia

Answer 7

1. Dec lung compliance
2. Sudden decrease in BP (due to dec venous return)
3. CV collapse

Question 8

Myocardial contusions

Answer 8

• Arrhythmia’s can occur 12-24 hours after the traumatic event
• VPCs
• anesthesia may worsen
• treat if the arrhythmia is compromising circulation (O2, volume correction, analgesia, lidocaine, etc)

*Pre-op ECG should be done

Question 9

Which drugs are arrythmogenic and thus should be avoided in myocardial contusion cases?

Answer 9

a2-agonists, thiopental (propofol), halothane

Question 10

Diaphragmatic hernia

Answer 10

• Dec FRC (desaturation of Hgb)
• Atelectasis
• Hypoxemia

Question 11

Hemorrhage

Answer 11

May not be obvious –> bleeding into body cavities or hematomas

Question 12

What can cause a hemoabdomen?

Answer 12

Fractured spleen/liver

Question 13

What are the results of acute blood loss?

Answer 13

Hypovolemia and hypotension

• As you correct the hypovolemia/hypotension w/ crystalloids, this may lower the PCV/TP –> revealing a more serious deficit than you initially thought

Question 14

Results of anemia/hypoproteinemia

Answer 14

Dec O2 delivery

Reduced drug binding

Question 15

Rupture of urinary tract

Answer 15

(Rupture of bladder is the most common)

Urine leakage into abdomen

Azotemia

Electrolyte imbalance

Question 16

What is of most concern regarding electrolyte imbalances following ruptured bladder?

Answer 16

Hyperkalemia! (raises resting membrane potential)

Try to normalize prior to anesthesia

Question 17

What does hyperkalemia cause? (ECG)

Answer 17

Bradycardia

Prolonged PR 
Tented T waves 
Loss of P waves 
Wide QRS 
Vfib or systole

Question 18

How can you treat hyperkalemia?

Answer 18

Insulin/dextrose, Ca++, Na/HCO3

cardio protection & drive K back into cells; HCO3 helps to correct acidosis which exacerbates hyperkalemia

Question 19

What do we worry about with head trauma?

Answer 19

Increased ICP!

Assess the patient’s mentation and pupil size

Question 20

What is the Cushing’s response?

Answer 20

physiological nervous system response to increased intracranial pressure (ICP) that results in Cushing’s triad of increased blood pressure, irregular breathing, and bradycardia

Question 21

How can anesthesia alter blood flow to the brain?

Answer 21

Intubation can spike ICP

*use lidocaine to prevent coughing/gagging

Question 22

What drugs increase ICP and should be avoided in head trauma cases?

Answer 22

Ketamine & a2agonist

Question 23

What should always be a top priority in the trauma patient?

Answer 23

Treating PAIN!

Everything is better when pain is treated

Question 24

What lab data is important for anesthesia?

Answer 24

Hgb levels –> O2 carrying capacity (transfuse with blood products if low)

Acid-base status

Electrolytes (K, Ca++)

Oxygenation/ventilation parameters

Question 25

What if the patient is unstable?

Answer 25

AVOID anesthesia if possible; if not possible, monitor closely and continuously

Question 26

Anesthetic Protocol (5)

Answer 26

1. CV and pulmonary sparing
2. Reversible & titratable
3. O2, O2, O2!
4. Secure airway
5. Its tailored to each patient!

Question 27

What is neuroleptanalgesia?

Answer 27

An intense analgesic and amnesic state produced by the combo of narcotic analgesics and neuroleptic drugs

Neuroleptic drugs = antipsychotic drugs, major tranquilizers

Question 28

What drug combos can be used to achieve neuroleptoanalgesia?

Answer 28

1. Opioid + sedative/tranquilizer

2. Fentanyl + midazolam/diazepam

Question 29

What induction drugs are the most CV and respiratory sparing?

Answer 29

Etomidate + midazolam/diazepam

*good in cats

Question 30

What induction drugs can be used to decrease ICP?

Answer 30

Propofol, alfaxalone

Results in hypotension, apnea, decreased ICP

Question 31

What induction drugs would increase ICP?

Answer 31

Ketamine!

*Caution in head trauma

Question 32

Why is titration so important in trauma patients?

Answer 32

These are not healthy patients! We need the ability to titrate to effect rather than give too large of a dose to quickly

Question 33

What is balanced anesthesia?

Answer 33

Using a combination of different drug classes to decrease the overall amounts/negative effects.

This results in better CV stability in our patients

Analgesics + Sedatives/muscle relaxants + small amounts of IA

*IA reduces MAC – be careful!

Question 34

What are the pros and cons of IA?

Answer 34

Pros:

• easily/quickly titratable
• minimal systemic metabolism

Cons:

• dose-dependent cardiopulmonary depression (CO, vasodilation, hypovent)
• MAC reduction is key!