Anaesthetic management of the Trauma Patient
Chapter 23
Pre operative assessment
History• C• A• M• E
• L• C• S
History• Chronic illnesses• Allergies and Addiction• Medication• Events or environment
related to injury• Last meal
Pre operative examination
Clinical Examination• Airway• Cardiac• Vascular• Respiratory• Abdomen• Limbs
• Tubes• Fluids
Pre operative assessment
Neurological Examination• A• V• P• U
• Head Trauma and Spinal cord injury must be excluded
• GCS
Neurological Examination• Alert• Vocal stimuli response• Painfull stimuli response• Unresponsive
Pre operative Assessment
Special investigations• Baseline bloods
• CSPINE• CXR• Pelvis
• FBC , UKE , Acid Base , Glucose
• Airway etc
Principles
Anatomical Considerations• Head to toe• All organ systems
Physiologic Considerations• Vital organs• Physiologic failure leads to
homeostatic failure
Principles
Pharmacological Considerations
• Xenobiotics– Recreational– Toxins
• Decreased central volume of distribution versus increased volume of distribution
• [Free drug]
Monitoring Considerations
Anaesthetic Technique
Resuscitation• Get help• A• B• C• D• E
• Airway and CSPINE• Breathing• Circulation and Coagulation• Disability• Exposure and
environmental control
Airway management and Breathing
• Chest• ETT
• Burns• Cervical Spine injury• Bronchoscopy• Intercostal drain
• Mode of Ventilation
• Expose , auscaltate• Intratracheal, size, depth, cuff,
reintubation• Swelling• Bimanual cricoid pressure• Secretions , foreign matter• Hemo , pneumo , amount ,
type• Lung protective ventilation,
vcv versus pcv
Circulation and coagulation
• Stop Haemorhage• Awake shock index
• Clinical signs of hypovolaemia
• Venous access• CVP, Art• 8.5 F Swan Ganz sheath
• Finger in artery• Pulse rate/systolic blood
pressure, N=0.5, > 10%, 33%, 50% decrease in CO
• Class 1 – 4
• 14 or 16 G X 2• Do not waste time
Circulation and Coagulation• Fluids
• Trauma induced Coagulopathy
• Crystalloids• Colloids
• Loss• Dilution• Consumption• Hyperfibrinolysis• Hypothermia• Acidosis
Circulation and Coagulation
• Haemostatic Resuscitation
• Ratio of 1:1:1:1 = Whole blood
• Target Hct 30• Clotting factors• Every 6 packed RBC• Cryoprecipitate
• Damage control resuscitation
• Packed RBC: FFP: Platelet: Fibrinogen
• RBC• FFP• Mega unit Platelets• Fibrinogen
Disability
• Neurologic
• Vascular• eyes
• Central , brain , spinal cord
• Peripheral nerves
Exposure and environmental control
• Physical
• Chemical
• Biological
Hypothermia
• Worse outcome
• Exposed, fluids, casualty, radiology, OR
• Permissive, induced
• O2, coagulation, drugs, vasoconstriction, dysrhythmias, infection, dehiscence,
• Space blanket , warm fluids, bair hugger, fluid warmers, aircon
• Brain and Spinal cord injuries
Hyperthermia
• Endogenous versus exogenous• Pontine lesions, status epilepticus• Drugs – anticholinergics, alcohol,
amphetaminoids, cocaine• Active cooling• Heat stroke
Endpoints of fluid resuscitation
• Systolic BP 90• Hct 30• No TRIC• BE improving• Lactate improving• Systolic pressure variation
Induction of anaesthesia and airway
• Resuscitation • BIS or Entropy• Cardiovascular collapse versus permissive
hypotension• Aspiration• Ketamine versus Etomidate• Suxamethonium
Maintenance of anaesthesia
• Vapour versus ketamine infusion versus opioid infusion
• Nitrous Oxide• Muscle relaxants• Analgesia – do not give NSAIDS
Emergence
• Extubation criteria• Stable versus unstable• High care versus ICU
Damage control surgery
• Damage control resus/ Haemostatic resus• Life and limb threatening first• ICU stabilization• Definitive care• Lethal triad– Hypothermia < 35 – Acidosis Ph < 7.2– Clinical Coagulopathy
Occupational health and Hazards
• Physical– Blood– Toxins– Sharp objects
• Psychological– Counselling
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