anaesthetic management of the trauma patient
DESCRIPTION
Anaesthetic management of the Trauma Patient. Chapter 23. Pre operative assessment. History. History. Chronic illnesses Allergies and Addiction Medication Events or environment related to injury Last meal. C A M E L C S. Pre operative examination. Clinical Examination. Tubes - PowerPoint PPT PresentationTRANSCRIPT
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