Mod XII - M&M 39 - Miller 81: Trauma Management in Anesthesiology Flashcards
Miller chapter 81, Morgan and Mikhail chapter 39 for trauma Miller chapter 59 (pg 1804 only), chapter 34 (p988-989 only) and Morgan and Mikhail chapter 39 for burns
Trauma & Burn Management in Anesthesiology
Which aspect of the Nurse Anesthesiology Resident (NAR)’ background will play an important role for managing patients with trauma and burn injuries?
The critical-care background of the Nurse Anesthesiology Resident (NAR) will play an important role for managing patients with trauma and burn injuries
Trauma & Burn Management in Anesthesiology
Trauma and burn patients require thorough assessment and immediate interventions due to
Pathophysiologic changes arising from traumatic injury
Trauma & Burn Management in Anesthesiology
The bodies response to trauma and shock has been described as a
Complex series of neural and hormonal reflexes that are induced by injury
Trauma & Burn Management in Anesthesiology
Why shoould a great deal of effort be utilized to stabilize Trauma and burn patients in the operating room suite?
Trauma and burn patients are some of the most challenging patients to take care of in the operating room suite
Trauma & Burn Management in Anesthesiology
The Nurse Anesthesiology Resident (NAR) must be aware that cell injury can occur from
Alteration of normal homeostasis
Trauma & Burn Management in Anesthesiology
There needs to be emphasis on providing adequate ventilation, oxygenation, and perfusion to these patients. Why?
Trauma patients suffer from shock and hypoxic states.
Trauma & Burn Management in Anesthesiology
Proper fluid resuscitation and blood administration is vital for survival in these patients. Why?
Trauma results in hemorrhagic blood loss or sequestration of extracellular fluid in the injured tissues
Loss of circulating volume triggers a response by low-pressure baroreceptors in the carotid arteries and aorta
Understanding the Trauma Patient
Trauma is classified at which type of medical situation?
Medical emergency
The trauma patient is considered a medical emergency and these patients may present totally obtunded. The NAR may not have any background information when caring for these patients
Understanding the Trauma Patient
Rapid sequence induction should always be utilized in this population. Why?
Full-stomach
All trauma patients are treated as a full-stomach and are high risk for aspiration.
Understanding the Trauma Patient
Compromised attempts to place an ETT - why?
Head injuries - cervical spine fractures - c-spine stabilization
These patients can also suffer from head injuries etc., which can compromise any attempts to place an ETT. Also, these patients may present with cervical spine fractures and require c-spine stabilization which could also impede ETT placement.
Understanding the Trauma Patient
How would the NAR go about intubating a patient with multiple facial fractures or the patient that has a completely deviated anatomy structure from injury?
Establishing an airway is essential for these patients
The NAR should consider utilizing a GlideScope or fiberoptic measures (if needed) to establish an airway
Understanding the Trauma Patient
Most patients come to the OR suite intubated. Whose responsibility is it to verify placement? How is this done?
Is the responsibility of the CRNA to verify placement by c_hecking breath sounds_ etc.
Understanding the Trauma Patient
In the case that a patient cannot be intubated by the primary anesthesia team, the surgery team should be on standby for
Tracheostomy
Understanding the Trauma Patient
Are there certain drugs to avoid in the trauma patient?
Understanding the Trauma Patient
Are there certain drugs to avoid in the trauma patient?
…
Understanding the Trauma Patient
Due to the emergency nature of these patients, many things are often overlooked which leads to
Life-threatening outcomes
Understanding the Trauma Patient
Due to the emergency nature of these patients, many things are often overlooked which leads to life-threatening outcomes. Some of the common overlooked diagnosis include
Pneumothorax
Cardiac tamponade
Cardiac contusion
Cervical spine injury
Open/closed head injury
Major blood vessel injury
Understanding the Trauma Patient
Resuscitation efforts should be prompt! Which time frome after traumatic injury often determines if a patient will survive?
The first 60 minutes after traumatic injury
Understanding the Trauma Patient
Resuscitation efforts should be prompt! The first 60 minutes after traumatic injury often determines if a patient will survive. This is known as:
The “golden hour”
Understanding the Trauma Patient
The chances of survival during the The “golden hour” are decreased in patients in
Hemorrhagic shock
Understanding the Trauma Patient
To provide some genuine advice I would advise all NARs to do what prior to intubating these patients?
Stabilize the cervical spine
Understanding the Trauma Patient
if no c-collar is in place
Stabilize and document
Have another provider to hold the neck
Have another provider to hold the neck if no c-collar is in place
Document this thoroughly in the chart to protect your license
Unfortunately, everything is blamed on “ANESTHESIA” in the OR suite and no NAR would like to be blamed from exacerbating a c-spine injury that was present in the first place
Please stabilize and document that intervention! ALWAYS!
Understanding the Trauma Patient
T/F: Trauma patients require both invasive and non-invasive monitoring
True
Understanding the Trauma Patient
Access required to assist with resuscitative efforts by the CRNA
Cordis (central venous sheath)
These patients usually require a cordis (central venous sheath) to assist with resuscitative efforts by the CRNA
Two large bore peripheral IVs
Although a cordis is frequently placed in these patients, a good rule of thumb is to place two large bore peripheral IVs
Understanding the Trauma Patient
Trauma patients require frequent monitoring of:
Urinary output
Chest tube output (if applicable)
ETCO2 monitoring
Temperature
Blood pressure via arterial line and NIBP
SPO2
EKG
Many trauma centers monitor CVP, CO etc. during the trauma process
Understanding the Trauma Patient
Advanced hemodynamic monitoring is used for:
To guide fluid/blood resuscitation
Understanding the Trauma Patient
There also needs to be frequent lab work completed to
Guide blood administration and
Guide usage of electrolyte replacement such as calcium, etc
In the OR; we usually do serial I-STATs every 30 minutes until patient is stabilized
Understanding the Trauma Patient
In the OR; we usually do serial I-STATs how frequently until patient is stabilized?
every 30 minutes
Most Common Problems in Trauma
- Hypotension
- Desaturation
- Hypertension
- Tachyarrhythmias and Brady-arrhythmias
- Sudden Cardiac Arrest
Most Common Problems in Trauma
Hypotension is u sually caused by
Hypovolemia
It is imperative that the CRNA or NAR initiate fluid resuscitation to combat hypotension
Vasoactive medications are usually utilized to help maintain adequate acceptable MAP goals
Be certain to rule out major vessel tears that can be the primary cause of hypotension
In rare situations, trauma patients are transported to the Interventional Radiology (IR) suite to both located and eliminate a major vessel tear
Most Common Problems in Trauma
In rare situations, where are trauma patients transported to both located and eliminate a major vessel tear?
Interventional Radiology (IR) suite
Most Common Problems in Trauma
Desaturation - When desaturation occurs check for
Adequate FIO2, ventilation, and perfusion
Look for signs of a pneumothorax (distended neck veins, tracheal deviation)
Rule out pulmonary contusions, mucous plugs etc.
Patient may require a STAT chest x-ray to rule out more pertinent issues
Most Common Problems in Trauma
Hypertension - When do Trauma Patients frequently become hyperdynamic?
After resuscitation
Most Common Problems in Trauma
How is Hypertension is mostly treated?
By deepening the anesthetic or offering opioid therapy
Most Common Problems in Trauma
What should be considered first when these issues Tachyarrhythmias and Brady-arrhythmias arise?
Hypoxemia and hypercarbia
Monitoring lab work for electrolyte imbalances should also be utilized for prompt correction
Most Common Problems in Trauma
Sudden cardiac arrest is often a strong indication for
Open thoracotomy
To inspect the heart for pericardial tamponade
Surgeons often have to open the chest and perform a cardiac massage
Most Common Problems in Trauma
In addition to monitoring lab work for trauma patients; the CRNA must pay close attention to blood glucose levels - why?
Trauma patients may need insulin to bring glucose levels to an acceptable level in the OR
On the other hand, trauma patients rapidly consume their gluconeogenic substrate which causes significant hypoglycemia to occur
However, these patients are more likely to experience hyperglycemia than hypoglycemia
Data has shown that preexisting hyperglycemia increases damage of ischemic/hypoxic events
Most Common Problems in Trauma
What are the most common causes of coagulopathy in the trauma patients?
Dilutional thrombocytopenia
Hypofibrinogenemia
Most Common Problems in Trauma
Dilutional thrombocytopenia is the most common cause of coagulopathy in the trauma patient, followed by hypofibrinogenemia. These conditions are treated with
Platelets, FFP, and cryo as indicated
In the OR we use the level one infuser via massive transfusion protocol (MTP) [1:1 PRBCs/FFP] until the patient is stabilized
Most Common Problems in Trauma
T/F: Remember when giving platelets to never run them through the warmer
True
Never run them through the warmer!!!
Trauma management in Anesthesiology
For trauma patients its very important to know the pathophysiology behind the mechanism of injury - Trauma caused by high-velocity or low-velocity impact, generally from dull objects is known as:
Blunt trauma
Trauma management in Anesthesiology
For trauma patients its very important to know the pathophysiology behind the mechanism of injury - Trauma that results from the piercing of tissues by sharp objects such as knives or bullets is known as:
Penetrating trauma
Trauma management in Anesthesiology
In which type of injuries are Mixed blunt and penetrating trauma often seen?
Impalement injuries
Trauma management in Anesthesiology
Falls from substantial heights can cause which types of injuries?
Vertical high-velocity injuries
Burn Management in Anesthesiology
Burns are caused by which types of exposures?
Thermal, electrical, or chemical exposure
Burn Management in Anesthesiology
Airway burns and smoke inhalation injuries are often associated by poisoning from which gas?
Carbon monoxide
Burn Management in Anesthesiology
T/F: Chemical, biological, and nuclear injuries are other forms of trauma
True
Burn Management in Anesthesiology
Environmental injuries can be caused by events such as
Poisonous insect bites
Animal bites
Venomous snake bites
Common Mechanisms of Injury in the Trauma Patient
- Penetrating Injury/Blunt Trauma
- Motor Vehicle Accident Trauma
- Thoracic Trauma
- Abdominal Trauma
- Orthopedic Trauma
- Head Injury
- Spinal Cord Injury
Penetrating Injury/Blunt Trauma
Unfortunately the CRNA may experience this type of trauma from:
Gun shots or stab wounds
These injuries are often fatal unless thorough assessment and interventions for stabilization are used
Penetrating Injury/Blunt Trauma
These patients usually undergo an open-chest or open abdomen by the trauma surgeon to assess for
Major vessel tears
Penetrating Injury/Blunt Trauma
These patients my have to have chest tubes - why?
often times the bullets penetrate the lungs which compromises oxygenation in these patients
The patient suffering from these type of injuries must have their organs assessed for damages that could lead to irreversible damage if missed
Penetrating Injury/Blunt Trauma
Some patients experience this type trauma from head injuries and may require
an emergency craniotomy
Penetrating Injury/Blunt Trauma
As a CRNA you have to be ready for anything that hits the door - Gun shots wounds to the chest and head are extremely stressful cases - When you are in these cases sometimes very little help is available to stabilize these patients - You have to be on your A-game and intervene quickly - Many times you will have to use your critical-care background to guide care - Answering which important questions could guide care delivery?
Does the patient needs a bi-carb drip?
Did I start TXA?
Did we give antibiotics?
Does the patient need to have a vasopressin gtt started?
Does the patient need to be transported to IR?
Is the patient bleeding somewhere else that the surgeon may have missed or overlooked?
Is the blood pooling in the peritoneum?
All of this falls on you as the CRNA
Penetrating Injury/Blunt Trauma
As a CRNA you have to be ready for anything that hits the door - Gun shots wounds to the chest and head are extremely stressful cases - When you are in these cases sometimes very little help is available to stabilize these patients - You have to be on your A-game and intervene quickly - Many times you will have to use your critical-care background to guide care - You have to be very aggressive and firm in your decision-making - Why?
One near-miss can lead to a fatal outcome
Motor Vehicle Accident Trauma
These are the patients who come in with multi-system deviations due to the impact associated with motor vehicle crashes (MVCs) - These deviations include:
Orthopedic injuries
These patients usually suffer from a variety orthopedic injuries
Cervical spine injury
The cervical spine absorbs a large energy impact and may be compromised
Severe head injuries & Laryngeal fractures
Patients hitting the dashboard can suffer from severe head injuries and could possible have laryngeal fractures direct impact on the trachea
Spinal cord injury
Further spinal cord injury occurs from hyperflexion, hyperextension, or direct compression
Motor Vehicle Accident Trauma
Unfortunately, when the body moves forward during impact which part of the body suffers the first point of contact?
the Head
Motor Vehicle Accident Trauma
Chances of survival are decreased significantly in patients who do not wear
a seat belt
Thoracic Trauma
Blunt thoracic trauma often results when drivers do not wear a […….] and collide with the [………] during the MVC
Blunt thoracic trauma often results when drivers do not wear a seatbelt and collide with the steering wheel during the MVC
Thoracic Trauma
Injuries to thoracic structures compromise anesthesia care by affecting
Gas exchange &
Cardiac output
Chest injuries may be the result of continued hemodynamic and ventilatory compromise
Thoracic Trauma
Which Life threatening conditions may develop when the pleural cavity is punctured, and presents as creation of a one-way valve that controls the flow of air into this cavity
Tension pneumothorax
Life threatening conditions such as tension pneumothorax may develop when the pleural cavity is punctured, creating a one-way valve that controls the flow of air into this cavity
Thoracic Trauma
How does Tension pneumothorax manifest?
With each breath more air becomes trapped in this the pleural cavity, increasing intrapleural pressure to the point that it eventually exceeds all other intrathoracic pressures
This causes the ipsilateral lung to collapse and shift structures of the mediastinum (trachea, great vessels, heart) into the opposite hemothorax which compresses the contralateral lung
Thoracic Trauma
Which ventilation technique increases the size of the pneumothorax?
Positive pressure ventilation
The size of the pneumothorax rapidly increases during positive pressure ventilation
Thoracic Trauma
Why is the use of nitrous oxide contraindicated in these patients?
it helps to expand the already present pneumothorax
Thoracic Trauma
Patients with a pneumothorax often present with which S/S?
Hypotension
Subcutaneous emphysema of the neck or chest
Unilateral decrease in breath sounds
Diminished chest-wall motion
Distended neck veins
Tracheal shift
Thoracic Trauma
Which will provide a definite diagnosis for pneumothorax?
A chest x-ray
Thoracic Trauma
A chest x-ray will provide a definite diagnosis but in emergency situations, what can be done to relieve tension from the pneumothorax?
a large-bore intravenous catheter is inserted into the second superior portion of the intercostal space along the midclavicular line
Thoracic Trauma
Another life threatening emergency caused by bleeding from the heart and great vessels is known as
Massive Hemothorax
Thoracic Trauma
The life threatening emergency that restricts filling of the cardiac chambers during diastole and produces a fixed low cardiac output is known as
Pericardial tamponade
Immediate correction is needed which require a pericardiocentesis
Abdominal Trauma
Extremely unstable patients with abdominal trauma usually come to the OR for which procedure?
Exploratory laparotomy
Abdominal Trauma
Extremely unstable patients with abdominal trauma usually come to the OR for and Exploratory laparotomy. What’s an appropriate initial intervention for the CRNA?
Drop an NG/OG tube to decompress the stomach
Abdominal Trauma
Retroperitoneal injuries can damage which structures?
Abdominal aorta
Inferior vena cava
Kidneys
Pancreas
Duodenum
Abdominal Trauma
Intraperitoneal injuries can occur to which organs?
Spleen, liver, stomach, small bowel, colon, or rectum
Abdominal Trauma
Anesthetic problems in patients with abdominal trauma include
hemorrhage,
hypothermia,
sepsis, and
interference with ventilation
Abdominal Trauma
Hypothermia is a common complication of abdominal trauma surgery because of
increased heat loss through the open mesentery and
reduced heat production associated with shock
Abdominal Trauma
For all trauma patients all fluids should be warmed -why?
Hypothermia is a common complication of abdominal trauma surgery
Abdominal Trauma
Which drugs are used to prevent shivering?
Neuromuscular blocking agents
Do not be afraid to have the circulating RN to turn up the temperature in the room
Abdominal Trauma
Why must shivering be prevented in trauma patients?
Shivering increases oxygen consumption by 200-400%
without improving oxygen delivery
Do not be afraid to have the circulating RN to turn up the temperature in the room
Orthopedic Trauma
Ideal time to repair open fractures operatively is
within the first few hours after injury
Orthopedic Trauma
Certain secondary vascular injuries commonly occur because
Sharp edges of fractured bones are forced into neighboring blood vessels and nerves
Assessment for nerve damage should be included in the plan of care for these patients
Orthopedic Trauma
Massive hemorrhage can associated with pelvic fractures - why?
Pelvic fractures can cause major blood loss into the retroperitoneal space
Although blood loss from pelvic fractures involving the iliac artery is notorious, significant blood loss can also occur from fractures associated with disruption of axillary, brachial, femoral, and popliteal arteries
Orthopedic Trauma
Which respiratory complication is common from long-bone factrures? what’s its cause?
Hypoxic respiratory failure
The hypoxia results from continuous seeding of marrow fat into the venous circulation
Long-bone fractures also carryout the risk the patient developing a FAT EMBOLISM
It is imperative to have serial blood gases/I-stat lab work to guide care to initiate therapy
Orthopedic Trauma
What’s the Theory #1 (mechanical) Pathophysiology for Fat Embolism?
Large fat droplets are released into the venous system
These droplets are deposited in the pulmonary capillary beds and travel through arteriovenous shunts to the brain
Microvascular lodging of droplets produces local ischemia and inflammation, with concomitant release of inflammatory mediators, platelet aggregation, and vasoactive amines
Orthopedic Trauma
What’s the Theory #2 (biochemical) Pathophysiology for Fat Embolism?
Hormonal changes caused by trauma and/or sepsis induce systemic release of free fatty acids as chylomicrons
Acute-phase reactants, such as C-reactive proteins, cause chylomicrons to coalesce and create the physiologic reactions described above
The biochemical theory helps explain nontraumatic forms of fat embolism syndrome

Orthopedic Trauma
What are the Signs of Fat Embolism Under General Anesthesia?
Acute decrease in ETCO2
Hypoxia/increased A-a gradient
Tachycardia
Petechial rash on the upper portions of the body
(petechiae occur in only 20-50% of patients but are virtually diagnostic)
Pulmonary compliance will likely decrease
PA pressures will rise and cardiac output will fall

Orthopedic Trauma
Although there is no literature that provides a treatment regimen for fat embolism, which Protocol can be utilized to treat fat embolism?
A-OK protocol (off-label protocol) may assist with stabilization
A = atropine 1mg IV
(blocks the vagal reflexes and prevents systemic hypotension)
O = ondansetron 8mg IV
(Impedes serotonin activity in the lungs and inflammatory system resulting from platelet activation)
K = Ketorolac 30mg IV
(Inhibits thromboxane and halts activation of the coagulation cascade)
Also use appropriate vasoactive drugs to help stabilize the patient

Head Injury
Anesthesia management of the head-injured patient includes
Early control of the airway to maintain SPO2 greater than 90%
Establishing cardiovascular stability
Intracranial hypertension (> 20mmHg) and systolic hypotension (<90 mmHg) should be avoided
Head Injury
Which Neuro assessment data should be carefully documented before therapeutic maneuvers are initiated
Baseline evaluation of Glasgow Coma Scale (GCS) score,
Pupillary reactivity and
Motor function
Head Injury
What may Patients with head injury need to have placed to monitor and troubleshoot rising intracranial pressures (ICP)?
External Ventricular Drain (EVD)
Head Injury
As an NAR you will have to know how to care for the patient that is undergoing a craniotomy - These are very critical operations and prompt interventions need to occur to get the patients safely through surgery and to the Neuro-ICU afterwards - Which drugs should be avoided during these procedures?
KETAMINE and Nitrous oxide
Spinal Cord Injury (SCI)
The leading cause of death in patients with Spinal Cord Injury (SCI) is:
Aspiration pneumonia
Spinal Cord Injury (SCI)
SCI have many devastating physical and psychological effects - Avoidance of hypoxia and systemic hypotension is crucial in these patients because
it can further compromise neural function
Hypoxia and hypercarbia can further accentuate the damage sustained with SCIs
Spinal Cord Injury (SCI)
REMEMBER THAT INJURIES AT C1 AND C2 level result in
Complete Respiratory Paralysis
Death can happen quickly if an airway isn’t established
Tubing these patients are critical
Spinal Cord Injury (SCI)
Why is Succinylcholine is not recommended for intubation of the patient with acute SCI?
Muscle fasciculation may exacerbate the SCI
Spinal Cord Injury (SCI)
The CRNA/NAR should be aware of the six (6) conditions that are highly correlated with SCIs:
- Paralysis
- Pain
- Position
- Paresthesias
- Ptosis
- Priapism
Spinal Cord Injury (SCI)
Why it is imperative to have someone hold in-line stabilization of the head to intubate these patients and to get a cervical collar ordered STAT for these patients?
Care should be used to avoid extension, flexion, or rotation of the neck
Consider using a GlideScope to minimize neck movement with someone holding c-spine
Spinal Cord Injury (SCI)
What vertebral level is the most common site of injury for SCI patients?
C-7
Spinal Cord Injury (SCI)
Patient with SCIs at which level have severely impaired CNS function?
T6 level or higher
Spinal Cord Injury (SCI)
CV effects of Spinal Cord Injury (SCI) include:
Decreased cardiac output
Hypotension
The SCI also interrupts sympathetic pathways from the hypothalamus (temperature control center) to peripheral blood vessels
Spinal Cord Injury (SCI)
Respiratory effects of Spinal Cord Injury (SCI) include:
Rapid development of pulmonary edema if their fluids are vasoactive drug therapy is not guided
Spinal Cord Injury (SCI)
What makes neurologic recovery from SCI very difficult but possible?
Spinal cord flow is disrupted from injury
There may be decreased blood flow to needed vessels
This can lead to irreversible damage
Spinal Cord Injury (SCI)
Which complication from Spinal Cord Injury (SCI) manifest as a sudden massive sympathetic discharge resulting from stimulation below the level of spinal-cord transections
Autonomic Hyperreflexia
Spinal Cord Injury (SCI)
Hyperreflexia is seen in 85% of SCI patients with lesions above
T5
Spinal Cord Injury (SCI)
Signs and symptoms of Autonomic Hyperreflexia include:
Paroxysmal hypertension
Bradycardia
Cardiac dysrhythmias in response to stimuli below the level of the transection
Spinal Cord Injury (SCI)
Signs and symptoms of Autonomic Hyperreflexia are not usually seen until after
The spine shock phase has passed
Spinal Cord Injury (SCI)
The CRNA/NAR must control the massive hypertensive spikes of these patients by
Deepening anesthesia or
Giving a medication to treat hypertension