Anesthesia for Trauma
Christopher DeSantis, MD
Anesthesiology CA-3
Boston University Medical Center
October 12, 2006
Faculty Advisor: Dr. Lopes
Anesthesia for Trauma
 Trauma is the leading cause of death between
the ages of 1 and 45
 In the US preventable deaths decreased from
13% to 7% over the past decades because of
more efficient systems of trauma care
 Anesthesia Care
Airway and Resuscitation in Emergency
Department
Operating Room Care
Management in Intensive Care Unit
Prioritizing Trauma Care
Do you know your ABC’s ?
Prioritizing Trauma Care
ABCDE
Airway
Vocal Response, Auscultation
Chin Lift, Bag-Valve-Mask, 100% O2, Intubation,
Cricothyriodotomy, Tracheostomy
Breathing
Pulse Oximetry, Arterial Blood Gas, CXR
Mechanical Ventilation, Tube Thoracostomy
Prioritizing Trauma Care
Circulation
Vital Signs, Capillary Refill, Response to
Fluid Bolus, CBC, Coagulation Studies,
FAST, X-Ray
Adequate IV Access, Fluid Bolus, Pressure to
Open Wounds, Thoracotomy, Transfusion,
Surgery
Neurologic Disability
GCS, Motor/Sensory Exam, Head, Neck,
and Spine CT, Cervical Spine Films
Support Oxygenation/Perfusion, ICP Monitoring
Prioritizing Trauma Care
Exposure and Secondary Survey
Laboratory Studies, ECG, Plain Films, CT
scan, Detailed History and Physical Exam
Removal of all Cloths, Detailed Review of all
Laboratory and Radiographic Findings
Airway/Breathing
Verification of adequate airway and
acceptable respiratory mechanics is of
primary importance
Hypoxia is the most immediate threat
to life
Inability to oxygenate a patient will lead
to permanent brain injury and death
within 5 to 10 Minutes
Airway obstruction
Direct injury
Face, Mandible, or Neck
Hemorrhage
Pharynx, Sinuses, and Upper airway
Diminished Consciousness
Traumatic Brain injury, Intoxication, Analgesic
medications
Aspiration
Gastric contents, Foreign body
Misapplication of Airway/Endotracheal Tube
Esophageal Intubation
Inadequate Ventilation
Diminished Respiratory Drive
Traumatic Brain injury, Shock, Intoxication,
Hypothermia, Over Sedation
Direct Injury
Cervical Spine, Chest Wall,
Pneumo/Hemothorax, Trachea, Bronchi,
Pulmonary Contusion
Aspiration
Gastric contents, Foreign body
Bronchospasm
Smoke, Toxic Gas Inhalation
Indications for Endotracheal Intubation
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Cardiac or Respiratory Arrest
Respiratory Insufficiency
Airway Protection
Deep Sedation or Analgesia
 General Anesthesia
 Transient Hyperventilation
 Space Occupying Intracranial Lesion/Increased ICP
 Delivery of 100% O2
 Carbon Monoxide Poisoning
 Facilitation of Diagnostic Workup
 Uncooperative or Intoxicated Patient
Prophylaxis against Aspiration
 Trauma patients are always considered to have full
stomach
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Ingestion of food or liquids before injury
Swallowed blood from oral or nasal injury
Delayed gastric emptying
Administration of liquid contrast medium
 Reasonable to administer nonparticulate antacid prior to
induction
 Cricoid pressure/Sellick Maneuver should be applied
continuously during airway management
 Rapid Sequence Induction
 Avoidance of ventilation between administration of
medication and intubation
Cervical Spine Injury
Trauma Patients
No Radiological Studies
Alert, Awake, and Oriented
No Neurological Deficits
No Distracting Pain
MRI Cervical Spine
Neck Pain
Cervical Tenderness to Palpation
Cervical Spine Injury
All Other Trauma Patients
Lateral radiograph of cervical spine
Anteropostererior spinous process C2-T1
Open mouth odontoid view
Axial CT with reconstruction
Regions of questionable injury
Inadequate visualization
Protection of the Cervical Spine
 All blunt trauma victims should be assumed to
have an unstable cervical spine until proven
otherwise
 Direct laryngoscopy causes cervical motion
and the potential to exacerbate spinal cord
injury
 An “uncleared” cervical spine mandates In-line
Stabilization (Not Traction)
 The front of the cervical collar may be
removed for greater mouth opening and jaw
displacement
Protection of the Cervical Spine
Emergency Awake Fiberoptic Intubation
Requires less manipulation of the neck
Generally very difficult
Airway Secretions
Hemorrhage
Rapid Desaturation
Lack of Patient cooperation
Induction of Anesthesia
 Propofol/Thiopental
 Vasodilator, Negative Inotropic effect
 May Potentate hypotension/Cardiac Arrest
 Etomidate
 Increased cardiovascular stability
 Ketamine
 Direct myocardial depressant
 Catecholamine release
 Hypertension/Tachycardia
 Midazolam
 Reduced Awareness
 Hypotension
 Scopolamine (Tertiary Amine)
 Inhibits memory formation
 Muscle relaxants alone
 Recall of Intubation/Recall of Emergency procedures
Neuromuscular Blocking Drugs
 Succinylcholine
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Fastest onset <1 min
Shortest Duration5-10 min
Potassium increase 0.5-1.0mEq/L
Potassium increase >5mEq/L
 After 24 hours
 Safe in acute airway management
 Burn Victims
 Muscle Pathology
 Direct Trauma
 Denervation
 Immobilization
 Increase intraocular pressure
 Caution in patients with ocular trauma
 Increase ICP
 Controversial in head trauma
Circulation
Hemorrhage is the next most pressing
concern
Ongoing blood loss will be fatal in
minutes to hours
Shock is presumed to be a consequence
of hemorrhage until proven otherwise
Symptoms of Shock
What are the symptoms of shock ?
Symptoms of Shock
Pallor
Diaphoresis
Agitation or Obtundation
Hypotension
Tachycardia
Prolonged Capillary Refill
Diminished Urine Output
Narrow Pulse Pressure
Early Resuscitation
Maintain SBP at 80-100 mm Hg
Maintain Hematicrit at 25-30%
Maintain PT/PTT in normal range
Maintain Platelet count > 50,000
Maintain Normal serum ionized calcium
Maintain core temperature > 35°C
Prevent increase in serum lactate
Prevent Acidosis
Intravenous Access
Order of Desirability
Large-bore (16g or greater) antecubital vein
Other large-bore peripheral veins
Subclavian vein
Femoral vein
Internal jugular vein (Requires removal of
cervical collar and neck manipulation)
Intraosseous (Tibia or distal end of femur)
Fluid Infusion System
 Active fluid administration up to 1500 ml/min
 Compatible with crystalloid, colloid, RBC,
plasma, washed/salvaged blood (Not platelets)
 Reservoir allows for mixing of products
 Controlled temperature (38°-40°C)
 Able to pump through multiple IV lines
 Fail safe detection system to prevent infusion
of air
 Accurate recording of volume administered
 Portable to travel with patients between units
Risks of Aggressive Volume
Replacement
Increased blood pressure
Decreased blood viscosity
Decreased hematocrit
Decreased Clotting factors
Greater transfusion requirements
Electrolyte imbalance
Direct immune suppression
Premature reperfusion
Glasgow Coma Score
What is the Glasgow Coma Score ?
Glasgow Coma Score
 Eye Opening Response
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4=Spontaneous
3=To Speech
2=To Pain
1=None
 Verbal Response
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5=Oriented to Name
4=Confused
3=Inappropriate Speech
2=Incomprehensible Sounds
1=None
Motor Response
6=Follows Commands
5=Localizes to Pain
4=Withdraws from Pain
3=Abnormal Flexion
(Decorticate Posturing)
2=Abnormal Extension
(Decerebrate Posturing)
1-None
Traumatic Brain Injury
Anesthetic Management
Avoidance of Hypoxemia
Intubation
 Airway protection
 Controlled Hyperventilation
 Uncooperative/Combative Patient
 GCS < 8
Control Hemodynamics
Avoid Hypotension
Fluid Administration
Vasopressors
Arterial Line
Traumatic Brain Injury
Management of Cerebral Circulation
Hyperventilation
PaCO2 at 35 mmHg
PaCO2 at 30 mmHg for episodes of elevated ICP
Mannitol
0.5-1g/kg
Barbiturate
Traumatic Brain Injury
Temperature
Avoid Severe Hypothermia
Do not warm aggressively
Hyperthermia increases CMRO2
Position Therapy
Elevation of Patients Head
Facilitate venous drainage
Lower ICP
Improved Ventilation/Perfusion