Trauma ABCDs Flashcards
What is Damage Control Surgery?
Staged surgical management for the severe trauma.
-Early repair is a life-saving measure, not definitive, rather a stabilizing measure to reduce OR time and morbidity: Hemorrhage control, abdominal packing, external fixators, etc
-After stabilization, patients transported to ICU for further evaluation and resuscitation
-Often patients return to the OR several times because surgical course involves several phases
-Rapid surgical control of bleeding and prevention of the lethal triad: Acidosis, Hypothermia, and Coagulopathy
-Current Research: FFP, Platelets, PRBCs (ratio 1:1:1) with minimal crystalloid administration
What is the Triad of Death?
A trauma patient’s greatest risk of death after the first 24 hours of injury stems from a combination of 3 conditions:
-Hypothermia, Acidosis, and Coagulopathy (!!!)
What is Damage Control Resuscitation (DCR)?
Combines damage control surgery with:
-body rewarming
-restriction of crystalloid fluid administration
-permissive hypotension
-balanced blood product use (the previously discussed 1 : 1 : 1 ratio)
-utilization of a massive transfusion protocol
Also want to reverse metabolic acidosis, correct coagulopathies, and utilize anti-fibrinolytics (Tranexamic Acid or TXA)
What is the RAPTOR Concept?
-Resuscitation with Angiography, Percutaneous Techniques, Operative Repair
-POC testing for blood product ratios
-Use of hybrid angiography ORs allowing patient to stay in the same location for IR and Open repairs.
What is Abdominal Trauma?
-A leading cause of M&M among all age groups
-Occult bleeding often misdiagnosed
-Abdominal sonography, CT scan, MRI, angiography
-Focused Assessment with Sonography for Trauma (FAST) examination
-Extremely unstable patients require immediate surgery
-Essential that Lg bore IV access is in place above the diaphragm prior to opening the abdomen in the event of massive hemorrhage as a result of liver or other organ injury
What are the ABCDs of Trauma Anesthesia?
Airway
Breathing (and Ventilation)
Circulation
Disability (Neurologic)
Anesthesia must facilitate rapid surgical management
Trauma is not elective!!!
Goals:
-Rapidly move the patient to the OR
-Perfusion of tissue is directly related to time
What do you need to consider for the Airway component of trauma anesthesia?
-Emergent intubation follows the general pathway of the ASA difficult airway algorithm (unable to rly examine)
-Intubation not elective, must have a controlled airway
-Aspiration risk: delayed gastric emptying and a full stomach
-Blunt or penetrating trauma to neck / face must assume C-spine instability
-Rapid Sequence Intubation (RSI) is the standard method for traumatic airway management!!
What is the standard method for traumatic airway management?
Rapid sequence intubation (RSI) is the standard method for traumatic airway management.
-RSI is the use of a muscle relaxant before knowing whether the patient can be mask ventilated.
-Muscle relaxation is associated with the highest overall rate of successful airway management and provides the greatest possibility for rapidly securing the airway.
What are indications for endotracheal intubation with trauma?
1) inadequate oxygenation/ventilation
2) loss of airway reflexes
3) decreased level of consciousness (Glasgow Coma Scale [GCS] less than 8)
4) the need for pain management and the ability to safely provide deep sedation during painful procedures.
Once it is deemed that the patient requires airway management, it should be done using RSI.
How is RSI performed?
-Provide manual in-line stabilization of the C-spine after removing the front of the C-collar
-Provide cricoid pressure (the Sellick maneuver)
-Administer medications
-Oxygenate with BVM (+/- ventilation) and laryngoscopy
Airway management is the priority, in-line stabilization and cricoid pressure should be relaxed if interfering with successful intubation.
The need for an emergent surgical airway always a possibility, so appropriate surgical resources must be immediately available.
What is the purpose of Cricoid Pressure?
To prevent both gastric insufflation during bag-valve-mask ventilation and passive reflux of gastric contents
What are the 5 Components of RSI?
1) preoxygenation
2) cricoid pressure
3) induction/muscle relaxation
4) apneic ventilation
5) direct laryngoscopy
How do you preoxygenate during RSI?
Preoxygenation provides the greatest amount of time before occurrence of hypoxemia.
-Preoxygenation is accomplished using 100% high-flow (10–15 L) oxygenation via a nonrebreather facemask, four to eight tidal volume breaths appear to provide superior preoxygenation when compared with 3 minutes of tidal breathing.
-Preoxygenation is challenging in regard to patients who are unable to breathe deeply or follow commands when obtunded. In these circumstances it is appropriate to provide controlled positive pressure bag-valve-mask ventilation throughout induction.
How do you apply Cricoid Pressure?
Compress the esophagus with the continuous ring of the cricoid cartilage.
-Maintained throughout RSI and not released until the ETT is confirmed
-30 Newtons (10 lbs of pressure) adequately occludes the esophagus.
- “Gold Standard” of prevention of aspiration of gastric contents during RSI
Describe induction medications used in RSI.
All induction agents will cause dose-dependent decreases in blood pressure in the hypovolemic, hemorrhaging patient.
-Decreased dose Propofol (1/10-1/2 induction dose)
-Ketamine as an alternative
-Etomidate is discouraged 2o adrenal suppression
-Succ (1.5 mg/kg) versus Rocuronium (1.2 mg/kg)
-Succinylcholine administration may cause lethal hyperkalemia in patients with neurologic deficits from spinal cord injury, but not until 24 to 48 hours after injury.
-Roc at 1.2 has similar onset time to succ, but much prolonged duration and will require sedation and make neuro assessment difficult.
What is Apneic Ventilation?
The concept of pulmonary ventilation using high-flow oxygen and based on Boyle’s law. -To work appropriately, apneic ventilation assumes that the airway is patent and that a high concentration of oxygen can be reliably administered in which gas leaves the facemask, fills the lungs, and exchanges in the lungs based upon the concentration gradient of gases in the alveoli.
-RSI intended to reduce risk of aspiration, yet unable to take deep breaths prior to induction
-Modified RSI: ventilate through cricoid pressure
-In traditional RSI, refrain from positive pressure ventilation during induction.
Describe Direct Laryngoscopy during RSI.
-Blade choice is provider dependent
-Successful ETT placement confirmed by capnometry
-Consider use of a video-assisted technique
-Bougie, intubating LMA, FOB, or combination techniques
-Follow the ASA difficult algorithm
-Unable to intubate/ventilate, then a surgical airway should be considered
Describe Airway management for a C-Spine Injury
-The incidence of cervical spine injury after trauma is relatively rare at 2% to 4% of all trauma
-20% of which are spinal cord injuries, 10% are reported as multi-level cervical spine injuries, and 10% are categorized as purely ligamentous injuries.
-Cervical spine injury should be assumed until proven otherwise.
-Immobilization of the neck is essential. To that end, in-line stabilization is essential because it allows for removal of the front of the cervical collar, allowing more area for jaw and mouth movement, while limiting the risk for further injury.
-Management of a cervical spine injury may be done with the concepts of “emergent,” which involves in line stabilization and RSI (possible video-assisted techniques), versus “controlled,” which involves an awake fiber optic technique.
What is the most common lung injury?
Pulmonary contusions.
-70% of blunt trauma patients
-Alveolar injury without gross disruption of the pulmonary architecture
-Protein-rich fluid from ruptured capillaries settles into the alveolar membrane / interstitial space reducing gas diffusion, may develop into ARDS
What is ARDS?
An acute, diffuse, inflammatory lung injury caused by a number of systemic or pulmonary insults.
-It is a common problem in trauma care and may be a result of injury or the resuscitation of the patient.
-Pathologically, ARDS is a result of protein-rich fluid leaving the pulmonary capillaries.
-As the disease progresses, the pulmonary capillary leakage is compounded by embolic events, which further increase intracapillary pressure and intensify interstitial leakage.
-ARDS culminates in hypoxia and decreased pulmonary compliance. Ventilation is challenging!!
What are ARDS ventilation strategies?
-Low tidal volume reducing peak pressures
-PEEP
-Permissive hypercapnia
-Conservative fluid management in patients without shock
-Prone positioning
-Neuromuscular blockade
-High frequency oscillation ventilation
-Consider ECMO
High FiO2 has toxic effects over time, worsening gas exchange.
What is the leading cause of early and late mortality after trauma?
Hemorrhagic Shock.
What is Hemorrhagic Shock?
A pathologic event that is triggered by the loss of circulating blood volume and results in a reduction in oxygen delivery to the tissue.
-Physiologic response is a dynamic and complex process
-Reductions in blood volume cause an immediate change in vascular tone and global systemic vascular resistance (SVR).
-Blood is shunted from low metabolic “ischemia-tolerant” vascular beds such as skin and bone, to highly metabolic tissues (e.g., brain, heart, gut) with the intent of maintaining cellular perfusion and aerobic respiration.
-Early shunting compensates for relative hypovolemia.
-If short-lived, compensated shock has very few long-term sequelae.
What happens with uncontrolled hemorrhage, as the degree of blood loss worsens?
-As the degree of blood loss worsens, vascular shunting increases.
-In this state, patients rapidly progress from a compensated state to decompensated shock.
-Blood is directed away from lower metabolic organs, such as the kidneys and gut, in an attempt to maintain perfusion in higher metabolic structures.
-During decompensated shock, changes to SVR are inadequate to maintain perfusion.
-The body attempts to further compensate a dwindling stroke volume and cardiac output by increasing heart rate and contractility.
-Prolonged reductions in perfusion will result in cellular injury.
-In an attempt to maintain energy production cells transition from aerobic to anaerobic respiration, lactic acid and free radicals are produced.
-Cellular injury: intracellular energy-dependent pumps fail with reduction in cell wall integrity
