Trauma part 3 Flashcards
The Glasgow coma scale assesses for
disability/neurological status
classification of severity of head injury
Significant abnormalities on the neurological exam are an indication ofr
immediate cranial CT
________ will have a strong influence on outcome of disability
timeliness of diagnosis and treatment
The goal of care for the traumatic brain injury patient is to
prevent secondary brain damage resulting from: intracranial bleeding edema increased ICP hypoxia & shock
Classification of traumatic brain injury can be
mild TBI, moderate TBI, severe TBI
Describe the classification of mild TBI.
GCS 13-15
short period of observation usually 24 hours
Describe the classification of moderate TBI.
GCS 9-12
manifested as intracranial lesions that require surgical evacuation
early CT
high potential for deterioration requires early intubation mechanical ventilation
Describe the classification of severe TBI.
GCS less than 8 (intubate)
carries a significant rate of mortality
care is directed at perfusion of injured brain
Guidelines for severe TBI include:
after primary survey approach maintain CPP maintain a CPP 60-70 mmHg at all times fluid resuscitation- keep euvolemic correction of anemia (Hct of 30%) PaCO2--> 35 mmHg insertion of ventriculostomy & control of ICP <20 positional therapy judicious use of analgesics/sedation mannitol hypertonic saline
Describe the AW & ventilatory management of the TBI patient.
hyperventilation only if herniation is imminent
hyperventilate to PaCO2 of 30 if elevated ICP is no responsive to- sedatives, CSF drainage, NM blockade, osmotic agents, barbiturate coma
Hyperventilation to PaCO2 of 30 is indicated when elevated ICP is not responsive to
sedatives, CSF drainage, NM blockade, osmotic agents, barbiturate coma
CPP=
MAP-ICP
Anesthetic management of the patient with a TBI includes
early control of airway
establishing cardiovascular stability
management of intracranial pressure in the OR
Describe early control of the airway for the patient with a TBI
orotracheal intubation to maintain SpO2 >90%
maintain normoventilation to help in the reduction of hypercarbia and hypoxemia
judicious use of induction agents- propofol, etomidate, neuromuscular blocking agents to avoid coughing and bucking
Describe establishing cardiovascular stability for the patient with a TBI.
avoid intracranial hypertension (ICP>20)
avoid systolic hypotension
placement of an a-line in addition to standard monitors
low concentrations of sevoflurane, isoflurane or desflurane (cerebrovasodilators)
avoid nitrous oxide
Describe the management of intracranial pressure in the OR for the patient with a TBI.
mannitol 0.25-1.0 g/kg for control of ICP
consider hyperosmolar therapy as ordered by surgeon
corticosteroids increase mortality and are no longer recommended
dilantin or keppra
smooth induction & emergence
SCI can be a result of
MVA
falls
penetrating injury
Most SCI occur at the
low cervical spine-typically C4-C7
SCI injury includes
sensory deficits
motor deficits
sensory & motor
Outcomes of the SCI patient depends on 3 factors:
severity of the acute injury
prevention of exacerbation of the injury during rescue, transport, & hospitalization
avoidance of hypoxia & hypotension
Early treatment of SCI is focused on
adequate perfusion to prevent secondary injury
Autonomic hyperreflexia develops in 85% of SCI
with complete injury above T5
Treatment of SCI is aimed at
preservation of adequate perfusion
-avoid hypotension or correct immediately if encountered
_____ & _____ can further accentuate the damage sustained with SCI
Hypoxia & hypercarbia
MAP for SCI is
maintained normal to high
SCI management includes
prevention of neurogenic shock (hypotension & bradycardia)
adequate circulation
glucocorticoid bolus- controversial, might depend on surgeon dependent
C-spine evaluation should
include all 7 cervical vertebrae- C1-C2 & C7-T1 b/c difficult to image these spots
Describe emergency intubation in SCI.
100% oxygen administered immediately
simple chin lift with manual in-line stabilization
avoid extension, flexion, and rotation- direct vision laryngoscopy with MILS
Use of succinylcholine is allowable for patients with SCI if
<24 hours
When intubating for a patient with a SCI, the clinician should use equipment and techniques that are most familiar.
goals: achieve tracheal intubation while minimizing motion of C-spine
preserve the ability to assess neurologic function after positioning
No evidence that DL worsens outcomes
The gold standard for a patient with an SCI intubation wise is
awake fiberoptic intubation as long as patient is cooperative
-oral vs. nasal intubation–> oral is challenging but better suited if pt requires post-op ventilation
A frequent indication for operative management in trauma patients is
orthopedic and soft tissue trauma
Three types of orthopedic and soft tissue trauma include
isolated closed
open fractures of major long bones & joints
multiple fractures of major long bones, spinal column, and joints associated with multisystem injuries
If a closed fractures is fixed within
the first 24 hours, there will be a decrease in ARDS, PNA, & fat emboli complications
An open fracture should be fixed within
12 hours to prevent infection
Ortho trauma includes
dislocated hip- needs fixation because avascular necrosis of femoral head can develop
fracture pelvis- requires stabilization, very high bleeding cases, T & C for at least 4 units
crush injuries-> will see myoglobinuria
open fractures
long bone fractures are high risk for DVT
Compartment syndrome
Ortho trauma anesthesia management includes
most frequently requires GA
anesthetic requirements comparable to those of non-trauma patient- if lower requirements are being used consider if your patient has hypovolemia
controlled hypotension (MAP 20 mmHg below baseline) if not contraindicated
allow spontaneous ventilations at near end of procedure to guide narcotic use
Advantages of regional anesthesia
- allows for continued mental status assessment
- increased vascular flow
- avoidance of airway instrumentation
- improved postoperative mental status
- decreased blood loss
- decreased incidence of DVT
- improved postoperative analgesia
- better pulmonary toilet
- earlier mobilization
Disadvantages of regional anesthesia
- peripheral nerve function difficult assess
- patient refusal is common
- requirement for sedation
- longer time to achieve anesthesia
- not suitable for multiple body regions
- difficult to judge length of surgical procedures
Advantages of general anesthesia
speed on onset
duration-can be maintained as long as needed
-allows multiple procedures for multiple injuries
-greater patient acceptance
-allows for positive-pressure ventilation
Disadvantages of general anesthesia
- impairment of neurological examination
- requires airway instrumentation
- hemodynamic management more complex
- increased potential for barotrauma
Chest injuries include
pulmonary
traumatic aortic injury
rib fractures
cardiac injury
Pulmonary injuries may require a
chest tube
thoracotomy
double lumen tube- but often after initial intubation via RSI with standard ETT
Thoracotomy for pulmonary injuries indications include
indicated if drainage greater than 1500 mL in first several hours
when tracheal or bronchial injury or massive air leak are noted
hemodynamic instability from thoracic injury
Traumatic aortic injury has a high
incidence of morbidity and mortality- particularly if complete transection
Traumatic aortic injury must be ruled out if patient has
suffered a high energy injury such as a MVA or fall
Diagnosis of traumatic aortic injury is made through
CXR, angiography, CT, and TEE
Surgery for traumatic aortic injury is indicated due to
high risk of rupture in hours to days
Anesthetic treatment of traumatic aortic injury includes
partial bypass technique using inflow from the left atrium, a centrifugal pump and outflow to descending aorta
_____ repair is now more common for a traumatic aortic injury
endovascular
With traumatic aortic injury, it is important to keep systolic BP
<100 to keep injury from extending
Most common injury from blunt chest trauma is
rib fractures
A flail chest is the result of
comminuted fractures of at least 3 ribs
Flail chest is characterized by
paradoxical respiration
For flail chest consider
pain management or epidural placement to maintain ventilation/perfusion
Cardiac injury includes
penetrating trauma–> have a high pre-hospital mortality
cardiac tamponade
Bruising or contusion is functionally
indistinguishable from MI
_____ can be used to diagnose cardiac injury
TTE or TEE
Cardiac injury is managed as
ischemic cardiac injury with careful control of volume, vasodilators, monitoring and treatment of rhythm disturbances
Cardiac injuries may require
a cardiology consult if appropriate
Describe management for the trauma patient who is a Jehovah’s witness
- deliberate hypotension
- use of salvaged blood cells from intra-op or chest tube collection
- early hemodynamic monitoring
- post-op use of erythropoietin
Describe management for the trauma patient who is elderly.
-more serious outcomes in the elderly for equivalent trauma
-decreased cardio-pulmonary reserve higher incidence of postop mechanical ventilation
MOSF after hemorrhagic shock
-post traumatic myocardial dysfunction
-cannot tolerate as much volume
Describe management of the trauma patient who is pregant
high incidence of spontaneous abortion, pre-term labor, or premature delivery
OB consult for immediate management and follow-op
requires rapid & complete resuscitation of the mother
in the 2nd or 3rd trimester–> left lateral decubitus to get uterus off of great vessels
spontaneous abortion requires D&C
if Rh negative will need to get Rhogam if fetus is positive
Criteria for extubation post-op includes
mental status
airway anatomy and reflexes
respiratory mechanics
systemic stability
Criteria for extubation in regards to mental status includes
resolution of intoxication
able to follow commands
non-combative
pain adequately controlled
Criteria for extubation in regards to airway anatomy & reflexes includes
appropriate cough & gag
ability to protect airway from aspiration
no excessive airway edema or instability
Criteria for extubation in regards to respiratory mechanics includes
adequate tidal volume & respiratory rate
normal motor strength
required FiO2 less than 50%
Criteria for extubation in regards to systemic stability includes
adequately resuscitated
small likelihood of urgent return to the operating room (at least in very 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 ventilation severe traumatic brain injury spinal cord injury with quadriplegia massive transfusion hemorrhagic shock occult hypoperfusion wound or body cavity infection
Recommendations for ventilator settings in acutely injured patients include
tidal volumes 6-8 mL/kg PEEP 10-15 cm H2O limit peak pressures to <40 cmH2O adjust I:E ratio as necessary wean Fio2 to obtain PaO2 of 80-100, sats 93-97%
Post-operative complication concerns for trauma patients includes
infection/sepsis
thromboembolism
abdominal compartment syndrome
ARDS
