Trauma Part 2 Flashcards
3 sequential components of trauma evaluation
- rapid overview (takes a few patients, stable v unstable)
- primary survey (rapid eval for function crucial to survival and includes ABCDE)
- secondary survey (detailed and systemic evaluation of each anatomic region and continued resuscitation if needed)
surgical priorities in trauma patients (in order)
- aw management (cric?)
- control of exsanguinating hemorrhage
- increacranial mass excision (threatened limb or eyesight, high risk of sepsis, control of ongoing hemorrhage)
- early patient mobilization
classification of TBI: mild
GCS 13-15
short period of observation, usually 24h
classification of TBI: moderate
GCS 8-12
manifested as intracranial lesions that require surgical evacuation, early CT, high potential for deterioration requires early intubation and mechanical ventilation
classification of TBI: severe
GCS <8
carries 3x higher rate of mortality
care directed at perfusion of injured brain
2 hours post TBI, there is an increase in
amyloid B peptide or amyloid plaques
severe TBI guidelines for managment/tx
after primary survey approach maintain CPP
maintain CPP 60-70 at all times
fluid resuscitation- keep euvolemic
correction of anemia (HCT of 30%)
PaCO2 35mmHg (normocarbia but on lower side of normo)
insertion of ventric drain and control of ICP (or lumbar drain)
positional therapy (HOB 30 degrees)
judicious use of analgesics/sedation
mannitol
hypertonic saline
(may need PRBC, inotropic support, increased FiO2)
TBI aw and ventilatory management
hyperventilate only if hernia is imminent
hyperventilate to PaCO2 of 30 if elevated ICP is not responsive to sedatives, CSF drainage, NMB, osmotic agents, barbiturate coma (hyperventilation is not a continuous measure, only an intermediate measure)
CPP=MAP-ICP
anesthetic management of TBI: early control of aw
orotracheal intubation to maintain SpO2 >90%
maintain norm-ventilation to help in reduction of hypercarbia and hypoxemia
judicious use of induction agents (prop, etomidate), NMB agents to avoid coughing and bucking)
anesthetic management of TBI: establishing CV stability
avoid intracranial HTN (ICP >20)
avoid systolic hypotension
placement of aline in addition to standard monitors
low concentrations of sevo, iso, des (remember theyre cerebrovasodilators. this is more acceptable when dura is open but otherwise TIVA is great option)
avoid nitrous oxide (pneumoenchephalogram)
anesthetic mangement of TBI: management of ICP in OR
mannitol .25-1mg/kg for control of ICP
consider hyper osmolar therapy as ordered by surgeon
corticosteroids increase in mortality (may order antiseizure meds)
most SCI’s occur at
low cervical spine
outcome of SCI patient depends on 3 factors
severity of acute injury
prevention of exacerbation of injury during rescue, transport, hospitalization
avoidance of hypoxia and HoTN
autonomic hyperreflexia occurs in 85% of SCI with complete injury above
T5
early tx of SCI is focused on
preservation of adequate perfusion to prevent secondary injury. avoid HoTN or correct immediately if encountered. avoid hypoxemia.
maintain MAP normal to high
manage neurogenic shock
maintain adequate circulation
glucocorticoid bolus
c spine eval should include all 7 vertebrae
intubation and SCI: emergency intubation
100% oxygen administered immediately
simple chin lift with manual in line stabilization
avoid extension, flexion, and rotation with DVL with manual in line stabilization
intubation and SCI: awake fiberoptic intubation
oral versus nasal: oral is challenging but better suites if patient requires postop ventilation
goals of intubation of patient with SCI
achieve tracheal intubation while minimizing motion of c spine. preserve ability to assess neurologic function after positioning. no evidence that DL worsens outcomes
SCI and succinylcholine
can use in first 24h
orthopedic and soft tissues trauma and 3 types
frequent indication for operative management in trauma patients
1. isolated (closed), 2. open fx of major long bones and joints, 3. multiple fx of major long bones, spinal column, and joints associated with multi system injuries
orthopedic trauma examples
dislocated hip fractured pelvis crush injuries open fractures long bone fractures (high risk for DVT) compartment syndrome
ortho trauma and anesthesia managment
most frequently require GA
anesthetic requirements comparable to those of non trauma patients (if lower requirements are being used, consider if patient has hypovolemia)
controlled HoTN (MAP 20mmHg below baseline) if not contraindicated
allow spontaneous ventilations near end of procedure to guide narc use
advantages of regional anesthesia for trauma
allows for continued mental status assessment increased vascular flow avoidance of aw instrumentation improved postop mental status decreased blood loss decreased incidence of DVT improved postop analgesia better pulmonary toileting earlier mobilization
disadvantages of regional anesthesia for trauma
peripheral nerve function difficult to assess
patient refusal common
requirement for sedation
longer time to achieve anesthesia
not suitable for multiple body regions
difficult to judge length of surgical procedure
advantages of GA for trauma
speed of onset
duration-can be maintained for as long as needed
allows multiple procedures for multiple injuries
greater patient acceptance
allows for PPV
disadvantages of GA for trauma
impairment of neuro exam
requires aw instrumentation
hemodynamic mangement more complex
increased potential for barotrauma
chest injuries include
pulmonary
traumatic aortic injury
rib fx
cardiac injury
pulmonary injuries and trauma considerations
may require chest tube
thoracotomy possible
double lumen tube, but often after initial intubation via RSI with standard ETT
thoracotomy indications
indicated if drainage >1500mL in first several hours
when tracheal or bronchial injury or massive air leak are noted
hemodynamic instability from thoracic injury
traumatic aortic injury
high incidence of morbidity and mortality
must be r/o if paitent has suffered high energy injury such as MVA or fall
dx made through CXR, angiography, CT and TEE
surgery indicated d/t high risk of rupture in hours to days
anesthetic tx includes partial bypass technique using inflow from left atrium, centrifugal pump and outflow to descending aorta
endovascular repair now more common
rib fractures
most common injury from blunt chest trauma
flail chest is an example (commuted fx of at least 3 ribs, paradoxical respirations, consideration pain management or epidural over mechanical ventilation first)
cardiac injury
penetrating trauma has high pre hospital mortality
cardiac tamponade
bruising or contusion is functionally indistinguishable from MI
TEE or TTE can be used to diagnose
managed as ischemic cardiac injury with careful control of volume, vasodilators, monitoring, and tx of rhythm disturbances
consider cardiac consult
special cases: trauma and pregnancy
high incidence of spontaneous abortion, pre term labor, or premature delivery
OB consult for immediate management and follow up
requires rapid and complete resuscitation of mom
criteria for extubation postoperatively includes
mental status resolution of intoxication able to follow commands non combative pain adequately controlled maintain airway anatomy and reflexes appropriate cough and gag ability to protect aw from aspiration no excessive aw edema or instability respiratory mechanics: adequate TV and RR, normal motor strength, required FiO2 <50% systemic stability: adequately resuscitated, small likelihood of urgent return to OR in short term, normovolemic without signs of sepsis
risk factors for development of ARDS after trauma
elderly preexisting physiologic impairment direct pulmonary or chest wall injury aspiration of blood or stomach contents prolonged mechanical ventialtion severe TBI SCI with quadriplegia massive transfusion hemorrhagic shock occult hypoperfusion wound or body cavity infection
ventilator settings recommendations for acutely injured patients
Vt 6-8ml/kg PEEP 10-15cmH2O limit peak pressure to <40cmH2O adjust I:E as necessary wean FiO2 to obtain PaO2 80-100 sats 93-97%
postop complication concerns
infection/sepsis
thromboembolism
abdominal compartment syndrome
ARDS
