Trauma Anesthesia Flashcards
Trauma is the leading cause of death between these ages?
1-46 years (young people)
What percentage of pre-hospital deaths were potentially survivable?
24%
What are the three main causes of preventable deaths?
- Hemorrhages
- Airway Obstruction
- Tension Pneumothorax
What is the leading cause of preventable death in all types of traumatic injuries
Bleeding
What components make up the “Lethal Triad”
- Coagulopathy
- Hypothermia
- Metabolic Acidosis
What are the effects of crystalloid resuscitation on blood loss?
- Increases blood loss
- Increase transfusion requirements
- Balanced blood product resuscitation decreases blood loss, transfusion requirements and improves survival
- Must have dried/thawed/liquid plasma to really do this well
What is the primary survey for Advance Trauma Life Support (ATLS)?
ID life-threatening injuries and simultaneously treat it
ATLS Framework for Airway (A)
- Stabilize cervical spine
- Assess Airway (vocal response, chin-lift, apnea)
- Intervene (suction, bag, intubate)
ATLS Framework for Breathing (B)(Inaqeduate Ventilation)
- Assess chest: inspection, palpation, percussion, auscultation
- Manage: obstruction, tension pneumo, massive, hemothorax, open pneumothorax, flail chest, tamponade
Causes of diminished respiration
- TBI
- Shock
- Intoxication
- Hypothermia
What type of trauma may cause inadequate ventilation?
- Direct injury to the trachea or bronchi
- Pneumothorax or hemothorax
- Aspiration
- Pulmonary contusion
What type of trauma may cause circulatory issues?
- Cardiac tamponade
- Aortic injury/dissection
- Penetrating trauma
- Femur/pelvic fractures
- Occult abdominal trauma (spleen, liver)
Class I Hypovolemic Shock (Hemorrhage)
- 15% blood loss
- Normal vital signs
Class II Hypovolemic Shock (Hemorrhage)
- 15-30% blood loss
- Tachycardia
- Normal SBP
Class III Hypovolemic Shock (Hemorrhage)
- 30-40% blood loss
- Significant ↓BP and Mentation
- HR > 120
- Cap refill delayed
Class IV Hypovolemic Shock (Hemorrhage)
- > 40% blood loss
- Hypotensive with narrowed pulse pressure
- UO absent
- Significantly altered mentation
Presume shock is a result of ___________
until proven otherwise
Hemorrhage
ATLS Framework for Circulation (C)
- Assess: VSV, cap refill, CBC, coags, crossmatch, peritoneal lavage, US/ films
- Manage: 2 large bore IV’s with crystalloid/O neg whole blood, direct pressure
- Surgical: thoracotomy, laparotomy
What can cause disabilities in trauma patients?
- Closed or open head injuries: until proven otherwise
- Hypoxia
- Drug/alcohol ingestion
- Hypoglycemia
ATLS Framework for Disability (D)
- Assess: pupil size, spinal cord injury level, GCS score
- Manage: CT, steroid drips
Glasgow Coma Scale: Eye-Opening Response Scores
- 4: Spontaneous
- 3: To Speech
- 2: To Pain
- 1: None
Spincy SPinach
Glasgow Coma Scale: Verbal Response Scores
- 5: Oriented to name
- 4: Confused
- 3: Inappropriate Words
- 2: incomprehensible Sound
- 1: None
ORIENTED CoWS
Glasgow Coma Scale: Motor Response Scores
- 6: Obeys commands
- 5: Localized to painful stimuli
- 4: Withdraw from painful stimulus
- 3: Abnormal Flexion (decorticate posturing)
- 2: Abnormal Extension (decerebrate posturing)
- 1: None
OLd WiFE
What is the purpose of Exposure (E)?
- Secondary survey
- Additional lab and xrays
- Detailed H & P
What are the principles of Damage Control Resuscitation (DCR)?
- Early control of hemorrhage
- Rapid transport to definitive care
- Limited crystalloid infusion
- Early and liberal use of blood products in appx of whole blood (1:1:1, PRBC:FFP:Platelets)
- Permissive hypotension (excluding TBI/SCI patients)
- Judicious and early use of tourniquets, pelvic binders, splints, compressive dressings/direct pressure
- Quick peripheral large bore IV
- Focusing on and addressing ABC’s using available adjuncts (FAST, CXR, Pelvic X-ray)
What are the two biggest complications of resuscitation?
- Abdominal Compartment Syndrome
- Hemodilution
What fluids should be used in resuscitation in DCR (rank them).
- Plasmalyte (most pH balanced)
- LR
- NS
Albumin (5% or 25%) provides effective and more physiologic volume expansion than other colloids, but given alone contributes to ______________.
Hemodilution
When should Hypertonic Saline be used?
- Traumatic Brain Injury (TBI)
- Evidence of raised ICP
Blood Product Resuscitation = __________________
Improved Survival
What are the components of operative damage control?
- Control hemorrhage
- Control contamination
- Temporary closure
Hemorrhage and injury cause acute _________ or ____________ (leading to the “lethal triad”).
- blood failure
- hemovascular dysfunction
DCR treats drivers of blood failure simultaneously with ____________
- Blood
- Blood products
- TXA
What is LTOWB?
- Low Titer O Whole Blood
- Contains red cells, platelets, and plasma; an ‘all in one’ transfusion therapy to treat bleeding patients.
What situations will lead to increased potassium during a trauma?
- Crush injuries
- Rhabdomylosis
Why is succinylcholine contraindicated in open-globe injuries?
The muscle fasciculations caused by succinylcholine can lead to a transient increase in intraocular pressure.
What is the best paralytic to use for trauma intubation?
Dose:
Duration of action:
- Rocuronium
- 1.2 mg/kg
- 1-2 hours
What is the delay time of Sugammadex?
3 minutes
C-spine protection during intubation
- C-spine instability presumed until cleared
- 3 providers ideal
- Collar should not be removed
- Use glide scope
Most trauma patients are young and healthy. Hypotension is most likely related to what factor?
- Interruption of sympathetic compensation
- > 40% blood loss
- Onset of PPV
What induction drug will cause trauma patients the most hemodynamic instability?
- Propofol
- Rarely used in “field”
Etomidate is often used in the field as an RSI anesthetic. What is the concern with this drug?
- Inhibits immune response
- Adrenal Suppression
- Myoclonus
Ketamine can provide analgesia and sedation in a trauma patient. What is the concern with this drug?
Myocardial depressant if catecholamines are depleted.
When will nasal intubation be contraindicated?
- Basilar skull fracture
- Cribiform plate fracture
- Sinusitis
- Suctioning/ bronchoscopy
Pathophysiology of Hemorrhagic Shock
- Decrease volume → Decrease BP
- Vasoconstrictions of the vessels
- Release of catecholamines to preserve blood flow to heart, kidney, and brain
- Peripheral vasoconstriction and decreased blood flow
- Release of hormones and inflammatory mediators for compensation
- Microcirculatory response where ischemic cells uptake interstitial fluid, leading to further depletion of intravascular space
- Lactate and free radicals are produced → Direct damage to cells
- Inflammatory factors are released
CNS response to shock
- Decrease glucose uptake
- Decrease cortical activity and reflexes
Kidney/adrenal response to shock
- Early response: maintains GFR
- Late response: inability to concentrate urine, ATN
Heart response to shock
- Cardiac dysfunction d/t negative inotropes (lactate) → Troponin elevation
- Tachycardia
Lung response to shock
- ↑ Inflammatory byproducts in capillaries
- ↑ Capillary permeability → Pulmonary Edema
- ARDS
Intestine response to shock
- ↑ Bacteria load
- Trigger of MSOF
- Earliest organs affected d/t blood been shunted away
Liver response to shock
- Reperfusion injury during recovery
- Unstable blood glucose
What organ is the main source of citrate metabolism?
Liver
What is Tranexamic Acid derived from?
Lysine
What is the function of TXA?
Inhibits fibrinolysis by blocking the lysine binding sites on plasminogen → contributes to clotting
Data shows TXA administered within _______ is associated with the largest reduction in deaths caused by bleeding.
< 1 hour
TXA treatment given __________ hours after injury was associated with an increased risk of death from bleeding.
> 3 hours
Significance of Calcium in the body
- Plays a significant role in coagulation
- Platelet adhesion
- Contractility of myocardial and smooth muscles
Which clotting factors require calcium?
- Factor II
- Factor VII
- Factor IX
- Factor X
S.N.0.T. (7,9,10,2) makes your K+/Ca+ CLOT
What substance in PRBC drops the calcium level?
Citrate
Why is citrate in PRBC?
Packed red blood cells (PRBCs) contain citrate, which is used as an anticoagulant to prevent the blood from clotting.
What factors lead to a decrease in Citrate Metabolism? What does this lead to?
- Hemorrhage → Hypothermia and Liver Injury
- Hypocalcemia
If calcium chloride is not available to treat hypocalcemia in trauma patients, what is an alternative?
Calcium Gluconate (needs 3x more)
Aggressive fluid resuscitation with crystalloid to achieve BP >100mm Hg or massive RBC replacement with random FFP/platelet addition will result in:
- Dilution of red cell mass
- Hypothermia
- Coagulopathy
- Increased hemorrhage d/t increased blood pressure
Effects of Coagulopathy with worsened acidosis and hypothermia
- Impaired coagulation factors
- Drop in fibrinogen levels
- Drop in platelet levels
- ↑ risk factors for death
Hematocrit comparison b/w Components vs. Whole Blood.
Components: Hct 29%
Whole Blood: Hct 38-50%
Coag factor comparison b/w Components vs. Whole Blood.
Components: 65% normal coag factors
Whole Blood: 100% normal coag factors
Plt comparison b/w Components vs. Whole Blood.
Components: 80K
Whole Blood: Normal plt range
Fibrinogen comparison b/w Components vs. Whole Blood.
Components: 1 G
Whole Blood: 1 G
Citrate comparison b/w Components vs. Whole Blood.
Components: Significant amount
Whole Blood: Lower
Calcium needed comparison b/w Components vs. Whole Blood.
Components: Need IV Calcium
Whole Blood: Calcium is not needed
What is the most common type of tourniquet?
C.A.T.
Meow
Combat Action Tourniquet
How long can tourniquets safely stay on?
Less than 2 hours
What is REBOA?
- Resuscitative Endovascular Balloon Occlusion (of the) Aorta
- REBOA is a technique used in trauma for patients who are rapidly bleeding to death from injuries to their chest, abdomen, or pelvis.
What would be indications for a REBOA?
Torso Hemorrhage
What would be contraindicated for a REBOA?
- Pericardial Tamponade
- Aortic Dissection
How much does REBOA increase cardio-cerebral perfusion?
150-200%
Do not leave REBOA in for more than _________ minutes
no more than 30 minutes
GCS for Mild TBI
- 13-15
- Postconcussive effects
- Half the patients will have functional limitations
GCS for Moderate TBI
- 9-12
- Early CT…may be surgical
- Early intubation/ventilation
- Low mortality
- Long-term morbidity significant
GCS for Severe TBI
- 8 or less
- High risk of mortality
An epidural hematoma usually occurs due to a tear in which artery?
Middle meningeal artery
Surgical Emergency
Presentation of an epidural hematoma
- In and out of LOC
- Lucid intervals
What are the symptoms of brain herniation
- Cushing’s Reflex
- Irregular Breathing
- Hypertension
- Bradycardia
- Mydriasis
A subdural hematoma is due to a tear in which vessel?
Sagittal Sinus veins
What are the presentations of a Subdural Hematoma?
- HA
- Progressive drowsiness
- Visual disturbances
- Gait disturbances
How do you ventilate patients with/ TBI?
- Keep PaCO2 30-35 mmHg
- Intermittent hyperventilation if ICP elevates despite treatment
What is the mortality rate of a TBI patient with one hypoxic episode?
2x Mortality rate
What is the mortality rate of a TBI patient with a hypoxic episode with hypotension
3x Mortality rate
Why would the patient need to stay intubated with an injury above C4?
Diaphragm weakness
Why would the patient need to stay intubated with an injury above C6-7?
Increased secretion and pneumonia
What is the benefit of early stabilization of long bone fractures?
Reduces pulmonary complications and length of stay
Advantages of Regional Anesthesia for Orthopedics
- Allows continued assessment of mental status
- Increased vascular flow
- Improved postoperative mental status (Especially in geriatrics)
- Decreased incidence of deep venous thrombosis
Disadvantages of Regional Anesthesia for Orthopedics
- Peripheral nerve function difficult to assess
- Not suitable for multiple body regions
- May wear off before procedure(s) conclude
Advantages of General Anesthesia for Orthopedics
- Speed of onset
- Duration
- Allows multiple procedures for multiple injuries
- Greater patient acceptance
- Allows positive-pressure ventilation
Disadvantages of General Anesthesia for Orthopedics
- Impairment of global neurologic examination
- Requirement for airway instrumentation
- Hemodynamic management is more complex
- Increased potential for barotrauma
Complications of Orthopedic Trauma
- Pulmonary Embolism
- Acute Compartment syndrome
- Crush Syndrome
Pulmonary Embolism presentation
- Hypoxia
- Tachycardia
- Petechial rash on upper chest
- PAP elevates with decrease CI
What are the 5 P’s of Acute Compartment Syndrome
- Pallor
- Paralysis
- Paresthesia
- Pain
- Pulselessness
Edema d/t muscle injury
Most common site for Acute Compartment Syndrome
Distal Tibia
What procedure is likely for penetrating trauma between the mandible and clavicle?
- Emergency Exploration
- May suture the ETT in place
What is the purpose of a tube thoracostomy (chest tube)?
- Relieves tension
- Drains accumulated blood
- Keep suction on until the leak resolves
What is a Thoracotomy?
A procedure that allows a surgeon to look into your chest cavity to diagnose or treat illnesses. A thoracostomy (chest tube) may be inserted after to facilitate drainage.
When will a Thoracotomy be necessary?
- Mediastinal injury
- Chest tube output exceeds 1500 ml in first hours
- Tracheal or bronchial injury with massive air leak
- Hemodynamically unstable with obvious chest trauma
Complications of Blunt Chest Trauma
- Bilateral pulmonary contusions (require ↑ FiO2/PEEP)
- Subcutaneous Emphysema
- Pneumomediastinum
- Pneumopericardium
Where do traumatic aortic injuries most commonly occur?
Distal to the takeoff of the left subclavian tethered by the ligamentum arteriosum
What is used to diagnose traumatic aortic injuries?
- CXR (wide mediastinum)
- CT
- Angiography
What is the most common injury from blunt chest trauma?
Rib Fractures
Fractures heal over several weeks
What is the main concern w/ Rib Fractures?
- Pulmonary Complications (w/ multi rib fx)
- Flail Chest (prone to go into ARDS)
What type of ventilation will be necessary for Flail Chest?
PPV
From an anesthesia standpoint, what type of block will be beneficial for rib fracture patients?
Erector Spinae to mitigate pain and avoid pulmonary complications
Anesthesia Management of Blunt Cardiac Trauma
- Control of fluid
- Coronary vasodilators (nitrate infusion)
- Treatment of rhythm disturbance
- Possible ASA/heparin
- If new hypotension or dysrhythmia develops….TTE/TEE
Hallmark signs of pericardial tamponade
- Beck’s Triad
- Hypotension
- Muffled Heart Tones
- Distended neck veins
What does FAST stand for?
Focused Assessment (by) Sonography (for) Trauma
What is the SBP goal if bleeding is non-compressible (chest, abdomen injury)?
90 mmHg
Where are the four areas in the body where non-compressible bleeding can occur?
- Chest (Thoracic Cavity)
- Abdomen (Abdominal Cavity)
- Pelvis
- Retroperitoneal Space
What three areas of the body are semi-compressible or difficult to compress?
- Neck
- Groin
- Axillia
What a ”well resuscitated” trauma looks like.
SBP:
O2 Sat:
Temp:
U/O:
Hb:
Base Deficit:
Lactate:
INR:
SBP: 100mmHg (if no TBI)
O2 Sat: >92%
Temp: > 95 (35)
U/O: > 30 (0.5 ml/kg/h)
Hb: > 8.0
Base Deficit > -0.4
Lactate < 2.5
INR < 1.5
What risks are involved with Trauma and Pregnancy?
- Spontaneous Abortion
- Preterm labor
- Premature delivery
Considerations for 1st-trimester trauma patients?
- HCG in female trauma
- Birth defects/miscarriage d/t radiation and medications
Considerations for 2nd/3rd-trimester trauma patients?
- US exam
- B-agonists/magnesium for preterm labor
- Emergency CS for uterine hemorrhage or gravid uterus in the way
- Left lateral displacement
- Long spine board
Anesthesia Considerations for Jehovah’s Witness and Trauma.
- Early ID and control of hemorrhage
- Deliberate hypotension
- Limited preoperative phlebotomy
- Some patients may accept cell saver, albumin
- Factor VII
Criteria for Extubating Trauma Patient (Mental Status standpoint)
- Resolution of intoxication
- Able to follow commands
- Non-combative
- Pain adequately controlled
Criteria for Extubating Trauma Patient (Airway Anatomy and Reflexes standpoint)
- Appropriate cough and gag
- Ability to protect the airway from aspiration
- No excessive airway edema or instability
Criteria for Extubating Trauma Patient (Respiratory Mechanics standpoint)
- Adequate Vt and respiratory rate
- Normal motor strength
- Required FiO2 less than 0.50
- Systemic Stability
Criteria for Extubating Trauma Patient (Systemic standpoint)
- Aqeduately resuscitated
- Normothermic w/o signs of sepsis
