ANESTHESIA FOR MULTIPLE

TRAUMA & SHOKED PATIENTS

EZRA EJEGU
IS IT CHALLENGING ? WHY?
OBJECTIVES
At the end of this course students are
expected to:

Discuss trauma epidemiology

Identify mechanisms of trauma

Describe concepts of trauma care

Prioritize the management of trauma

cases
 INTRODUCTION
Leading cause of death b/n the ages of 1 and 45
years.

In US It accounts up to 1/3 of all hospital

admission.

30 million require hospitalization

Responsible for 125,000 death/yr. of potential life.

300,000 permanently disabled

INTRODUCTION
Greater than $100 billion in medical and other
expenses.( 40% of health care cost)

The 4th most common cause of mortality.

In Ethiopia Ministry of health reports it the first

cause of hospital visits in Addis Ababa in 1995.

Traffic accidents during the 2016/17 that ended on

July 8, has led to the deaths of 4500 people.
INTRODUCTION
Ethiopia's transport regulation system at a cost
of 95 million US dollars.

Road traffic injuries are the leading cause

followed by falls and violence.

50% of trauma deaths occur immediately;

another 30% occurs within few hours.
INTRODUCTION
Risk factors
Driving responsibility
Lack of sleep

Young age

Male

Quality of roads

Quality of cars
TRIMODAL DEATH DISTRIBUTION
Mortality due to injury occurs during one of
three times periods or peaks.
First peak
This occurs at the time of the injury. Very
few of these patients can be saved, because
of overwhelming primary injury to major
organs or structures such as the brain, heart
or great vessels. only prevention can
significantly reduce this peak of trauma-
related deaths.
TRIMODAL DEATH DISTRIBUTION

Second peak
The second peak occurs within minutes to
several hours following the injury. Trauma
care is directed at this period because many
of the causes of morbidity and mortality
during this time are preventable by
avoidance of secondary injury due to hypoxia,
hemorrhage or any process that leads to
inadequate tissue perfusion.
TRIMODAL DEATH DISTRIBUTION-
2ND PEAK

Deaths that occur during this period are

usually due to intracranial hematomas,
haemopneumothorax , major
haemorrhage from viscera, bones and
vessels.
TRIMODAL DEATH DISTRIBUTION

Third peak
This occurs several days to weeks after the
initial injury and is most often due to sepsis
and multiple organ dysfunctions.
Although this stage usually occurs in a high
dependency area, improvements on initial
management upon admission will reduce
morbidity and mortality during this period.
TRAUMA DEATHS -CAUSES
IMMEDIATE EARLY DEATH-
DEATH CAUSES CAUSES
Lacerations: oThoracic injuries
oHaemopneumothorax
Brain
oPelvic injuries
Brain stem
oAbdominal injuries
Aorta oLong bone fractures
Heart LATE DEATH
Spinal cord CAUSES
oSepsis
oMultiple organ failure
 TRAUMA DEATHS -PREVENTION
Immediate (1st peak)
injury prevention

rapid prehospital transport

Early (2nd peak)- Golden Hour

rapid assessment

prompt resuscitation

Late (3rd peak)

ICU care
 DEFINITION OF TRAUMA:
A term derived from the Greek for WOUND
A physical harm or damage to the body due to
external source of energy beyond its ability to
sustain and dissipate the energy.
It can be:
Mechanical (Penetrating, Blunt )
Thermal/ Chemical

Ionizing radiation

Nuclear radiation

Excluded: poisoning/toxic ingestion.

FACTORS AFFECTING TYPES OF
INJURY
Ability of body to disperse energy delivered
Force and energy
Size of object
Velocity
Acceleration or deceleration
Affected body area
Duration and direction
The larger the area of force dissipation, the more
pressure is reduced to a specific spot.
Position of victim
MECHANISM OF INJURY
How a person can be injured
Blunt trauma

MVA
Fall
Penetrating trauma
MECHANISM OF INJURY
The importance of knowing mechanisms
of injury helps to:
Predict extent of injuries
Priority decision
Type of assessments
Treatment
Transport
 MECHANISM OF INJURY

Blunt injury: caused by high-/low-

velocity impact from generally dull objects
Penetrating injury: result of sharp
objects (knives, bullets, )
BLUNT TRAUMA
Blunt trauma
Blunt trauma can occur following:
Motor vehicle crushes(MVC)
Pedestrian vs. vehicle

Falls

Result of direct impact, deceleration, continuous

pressure, shearing, and rotary forces
Associated with injuries from high-speed
collisions and falls from heights
MECHANISM OF INJURY
Motor vehicle crashes(MVC) are classified as
head on, rear impact, side impact, rotational
impact, and rollover
Falls: vertical high-velocity injuries (depend:
distance of the fall, body part that impacts first,
type of landing surface)
Burns: thermal, electrical or chemical
MECHANISM OF INJURY
Compression injuries from motor vehicle
crushes includes:
First, vehicle impact, will occur when the car
hits the tree; frontal brain contusion

Second , body impact, will occur when the

occupant hits some structure inside the car (eg.,
windshield, steering wheel, or dashboard);
rupture of the left hemi diaphragm, small bowl
rupture, liver rupture

MECHANISM OF INJURY
Third, organ impact, will occur within the
body of the occupant, when movable organs
(i.e., brain, heart, liver, spleen, or intestines)
impact with the supporting structures i.e., the
skull, sternum, ribs, spine, or pelvis)
MECHANISM OF INJURY

Deceleration injuries from MVC:

Aortic tear
Fixed descending aorta
Mobile arch

Kidney avulsion
Splenic pedicle
MECHANISM OF INJURY
Classification of MVAs:
Frontal rear end
Lateral

Rotational

Rollovers
MECHANISM OF
INJURY

Frontal
Driver continues to travel
forward at the same speed
as the vehicle.
Up and over injuries
Head, neck, chest,
abdomen and possible
ejection
Down and under injuries
Knees, femurs, hips,
acetabulum and femur
MECHANISM OF INJURY
Rear end impacts
Whiplash
Streching or training of
anterior ligaments
Have the most
survivors
Whiplash injury is
common.
Energy is imparted to
the front vehicle
MECHANISM OF INJURY
Coup
contracoup
MECHANISM OF INJURY
Lateral impacts
Intrusion into the side
of a vehicle impinging
upon the occupants
Injuries
Head, shoulder, lateral
chest, lateral abdomen,
lateral pelvis and femur
 MECHANISM OF INJURY
Rotational
Vehicle spins at the point of
impact
If occupants were
unrestrained, they may have
many injuries
Occurs when a lateral crash is
off center
The vehicles forward motion
stops, but the side continues
in rotational motion
MECHANISM OF INJURY
Rollover
Occupants change the
direction every time the
vehicle does.
Suspect multiple
injuries
Possible ejection
Crush injuries from
vehicle
Run over by another

vehicle
MECHANISM OF INJURY

Vehicle pedestrian
collision child:
Child turns toward on
oncoming vehicle
Frontal injuries
Femur, chest, abdomen
and head
Low center of gravity
Usually thrown infront
of the vehicle
May be run by the Same
vehicle
MECHANISM OF INJURY
Vehicle pedestrian collision adult:
Turns away from vehicle causing most impacts
to the side of the body.
Injuries
Lower leg tibia-fibula, back, chest, shoulder, arms,
and abdomen
Possible head and facial injuries from windshield
MECHANISM OF INJURY
Fall down injuries
Feet first falls
Falls greater than 20ft.
Possible affect on internal
organs
Compression travels up the
spinal column
Thrown backwards look for
injuries to head, back and
pelvis
MECHANISM OF INJURY

Head first falls

Head injuries
Hyperextension of the head
Compression of the cervical spine
Chest, lower spine and neck injuries are also common
MECHANISM OF INJURY
Penetrating injuries
Often requires surgical intervention

Damage depends on 3 factors:

Type of wounding instrument
Velocity of instrument at time of impact + angle of

penetration
Type of tissue that instrument passes through (organs,

vessels, nervous tissue, muscle, fat, bone)

MECHANISM OF INJURY

Penetrating injuries
Gun shot wounds

Stab wounds

Impalement
MECHANISM OF INJURY
Penetrating injuries
Gunshot wounds: mechanism
Energy transfer
Shape/size of bullet
Distance to target
velocity
MOI-PENETRATING TRAUMA

Damage depends on two factors

Trajectory- path or motion of projectile during its
travel
Dissipation of energy- way energy is transferred to
the body
Affected by
Drag wind resistance
Profile impact point of view

Cavitations pathway expansion

MOI-PENETRATING TRAUMA

Stab injury
Damage to immediate area of impact

Extent of injury
Weapon size, length, sharpness, penetration
Severe injury
Chest and abdomen
Length of object in stabbing should be included when
reporting to the hospital staff.
Impalement
The same mechanism of injury as stab, with much greater
force of impact(KE)
MOI-PENETRATING TRAUMA
APPROACHES OF TRAUMA PATIENT

Prioritizing victims into

categories based on severity
of injury, likelihood of
survival, and urgency of
care
Sorting of patients based
on the need of treatment
and the available resources
to provide that treatment
is called Triage.
TWO TYPES OF TRIAGE

1. MULTIPLE CASUALITIES

Number and severity of patients do not exceed

the ability of the facility to render care.

Patients with life-threatening problems and

sustaining multiple system injury are treated
first
2.MASS CASUALTIES

Number and severity of patients exceed

the capability of the facility and staff.

Patients with greatest chance of survival

and with the least expenditure of time,
equipment, supplies, and personel are
managed first.
 TRAUMA SCORING SYSTEMS
To evaluate trauma management and outcome one
needs to assess
Anatomical scoring systems
Abbreviated injury score
Injury severity score

Physiological scoring systems

Glasgow coma scale
Revised trauma score
Trauma score

TRISS methodology
THE REVISED TRAUMA SCORE
Systolic
Glasgow Respirator
Blood RTS
Coma Scale y Rate
Pressure Value
(GCS) (RR)
(SBP)
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
REVISED TRAUMA SCORE
.
GLASGOW COMA SCORE
INITIAL ASSESSMENT
 INITIAL ASSESSMENT
Requires clear recognition of management
priorities and the goal is to determine/ identify
those life-threatening injuries such as:
airway obstruction
chest injuries with breathing difficulties
severe external or internal haemorrhage
abdominal injuries.
 INITIAL ASSESSMENT
If there is more than one injured patient then
treat patients in order of priority (Triage).
Simultaneous treatment of injuries can occur
when more than one life-threatening state exists.
Itcan be divided into primary, secondary, and
tertiary surveys.
The primary survey should take 25 min and
consists of the CABCDE/ABCDE sequence of
trauma care:
.
 PRIMARY SURVEY

C: haemorrhage control

A: Airway maintenance with cervical spine

protection

B: Breathing and ventilation

C: Circulation with haemorrhage control

D: Disability : Neurologic status

E: Exposure / Environment control

 C. HEMORRHAGIC CONTROL

Extensive External hemorrhage should be

identified and controlled first by:

Manual compression

Splint

Elastic bandage
A. AIRWAY MAINTENANCE WITH
CERVICAL SPINE PROTECTION

1. Rapid assessment for sign of airway

obstruction look, listen & feel for ;
snoring or gurgling

stridor or abnormal breath sounds

Agitation, cyanosis (hypoxia)

using the accessory muscles of

ventilation/paradoxical chest movements

 AIRWAY MAINTENANCE ...

Tracheal location
External trauma
Inability
to oxygenate a patient will lead to
permanent brain injury and death within 5 to
10 Minutes.
 AIRWAY MAINTENANCE ...
Can patient talk and breathe freely? If obstructed,
the steps to be considered are:
Chin lift/jaw thrust (tongue is attached to the
jaw)
Suction /remove foreign body
Guedel airway/nasopharyngeal airway
Definitive airway (intubation, cricothyrotomy,
tracheostomy)
Reassess frequently

keep the neck immobilized in neutral position

If Cervical-spine injury cant be rule
out : use the following manoeuvre
 AIRWAY MAINTENANCE ...
In patients who have a decreased level of
consciousness, the tongue can fall backward and
obstruct the hypopharynx.
This form of obstruction can be corrected readily by
the chin-lift or jaw-thrust maneuvers.
The airway can then be maintained with an
oropharyngeal or nasopharyngeal airway.
Maneuvers used to establish an airway can produce
or aggravate c-spine injury, so inline immobilization
of the c-spine is essential during these procedures.
 AIRWAY MAINTENANCE...
2. Protection of Cervical- spine
Assume C -spine injury in any patient with ;

Unconscious
Multiple system trauma
Blunt injury above clavicle (head and neck)
Pain of neck with neurologic deficit.
Unable to active flexion of neck due to pain.
 AIRWAY MAINTENANCE...
Neck hyperextension and
excessive axial traction
must be avoided
whenever cervical spine
instability is suspected.
Manual immobilization
of the head and neck by
an assistant should be
used to stabilize the
cervical spine during
laryngoscopy
 AIRWAY MAINTENANCE...

Role out Cervical spine injury by;

Active neck flexion if the patient cooperate
(not tender)
Film x-ray lateral C-spine is normal.
Neurological examination alone does not exclude
Cervical-spine injury.
 AIRWAY MAINTENANCE...

Definitive airway ( Advanced )

Three Varities:
1. Orotracheal intubation
2. Nasotracheal intubation
3. Surgical airway. ( Cricothyroidotomy , Tracheostomy )
 AIRWAY MAINTENANCE...
INDICATIONS FOR INTUBATION
o Obstruction unresponsive to manoeuvres
(persistent)
o SpO2 < 90% on supplemental oxygen
o Shock (e.g. BP syst < 90 mm Hg)
o Head injury / unconsciousness (GCS < 8)
o Penetrating neck trauma with haematoma
(expanding)
o Maxillofacial injury
o Chest trauma and apnoea
SURGICAL CRICOTHYROIDOTOMY

Thisis indicated in any patient where

intubation has been attempted and failed and
the patient cannot be ventilated.
SURGICAL CRICOTHYROIDOTOMY
The cricothyroid
membrane is
identified by
palpation; a skin
incision that
extends through the
cricothyroid
membrane is made.
An artery forceps is
inserted to dilate
the incision. A size
4-6 endotracheal
tube (or small
tracheostomy tube)
is inserted.
 NEEDLE CRICOTHYROIDOTOMY
Puncture the skin in the midline with a 12- or 14-gauge
needle attached to a syringe, directly over the cricothyroid
membrane
Remove the syringe and withdraw the stylet, while gently
advancing the catheter downward into position, taking care
not to perforate the posterior wall of the trachea
TAKE HOME POINTS
Suspect
impending airway
obstruction
C-spine
immobilization
Provide definitive
airway
Check patency,
tube position
Intubation
unsuccessful
surgical
airway
Address life
threatening injuries
 B. BREATHING

Always verify correct position of ETT, even if

arrive intubated
100 % O2

May have Combitube in; change to ETT

Nasal intubation: watch with basilar skull

fractures
BREATHING..
Expose chest & Look (inspect) for:
cyanosis
penetrating injury
presence of flail chest
sucking chest wounds
use of accessory muscles?
BREATHING..
Palpation (FEEL) for
tracheal shift
broken ribs
subcutaneous emphysema
Percussion is useful for diagnosis of haemothorax
and pneumothorax.
Auscultation should be performed to assure gas
flow in lungs (decreased sound on the affected
side)
BREATHING..

Objective Signs Inadequate

Ventilation:
Asymmetric chest rise

Labored breathing

Absent breath sounds

Tachypnea

Pulseoximeter (indirect measure)

BREATHING..
Severe life threatening condition resulting
in inadequate breathing:
Tension pneumothorax
one-way-valve air leak

blunt or penetrating mechanism

CLINICAL DIAGNOSIS- decompress by

insertion of a needle (2nd ICMCL) until Chest
tube is placed.
BREATHING..
Tension pneumothorax
signs
Respiratory distress
Tachycardia
Hypotension
Distended neck veins
Resonant percussion note
Tracheal deviation
Air entry
BREATHING..
Needle thoracocentesis
Technique
1. Administer high flow oxygen and ventilate as
necessary
2. Identify site of insertion - 2nd intercostal space in
the mid clavicular line on the side of the tension
pneumothorax
3. Prepare the skin and insert local anaesthetic if time
permits
4. Use a 14 16 gauge IV cannula insert through the
skin and direct just superior to the rib into the
pleural space.
5. Remove the stylet and listen for an escape of air,
leave the plastic cannula in position and prepare for
insertion of a chest tube.
 .

BREATHING..
Open pneumothorax
defect of chest wall

air passes
preferentially through
defect
hypoxia & hypercarbia

occlusive dressing on 3
sides until CT placed

Clinical diagnosis
close the sucking
wound and chest tube
 .

BREATHING..
Flail chest
segment without
bony continuity
asymmetric
movement
crepitus

pulmonary
contusion-hypoxia
Clinical diagnosis
Need
emergency
intervention
 C. CIRCULATION

Rapid assessment of hemodynamic status

LEVEL OF CONSCIOUSNESS
PULSE (central and peripheral, bilaterally)
BP
Skin color, capillary refill, temperature
 CIRCULATION
Adequacy of circulation: is based on pulse rate
blood pressure, signs of peripheral perfusion
Signs of inadequate circulation: tachycardia,
weak or un palpable pulses, hypotension, and
pale cool, or cyanotic extremities
The first priority is to restore adequate
circulation to stop bleeding
The second is to replace intravascular volume
CIRCULATION
HEMORRHAGE
Obvious sites of hemorrhage should be identified
and controlled with direct pressure on the
wound.
Bleeding from the extremities is easily controlled
with pressure dressings and packs; tourniquets
can cause reperfusion injuries.
CIRCULATION
Sites Of Blood Loss
Closed Femoral # 1.5-2 litres
Closed Tibial # 500 ml
Pelvic # 3 litres
Rib # (each) 150 ml
Haemothorax 2 litres
Hand sized wound 500 ml
Fist sized clot 500 ml
 CIRCULATION
Shock is defined as inadequate organ
perfusion and tissue oxygenation.
Predominant cause of treatable deaths

Hypotension = hypovolemia until proven

otherwise
CIRCULATION
Remember
If the patient is in shock due to trauma and
bleeding cant be controlled, give only
enough small fluid boluses to restore the
radial pulse (SBP 80-90mmhg) or preferably
give blood products than IV fluids.
If bleeding can be controlled, control
bleeding first and then administer enough
fluid to restore normal BP.
CIRCULATION-VERIFY PULSES, BILATERAL
BLOOD PRESSURES

Radial pulse = SBP 90

mmHg

Femoral pulse = SBP 70-

80 mmHg

Carotid pulse = SBP 60

mmHg
 CIRCULATION

Clinical findings:-
Hypotension ,

Tachycardia ,

Tachypnea, or

Consciousness change?

sign of poor peripheral perfusion (skin

color, capillary refill, temperature)
CIRCULATION
Steps to be considered
Stop external haemorrhage
Establish 2 large-bore IV lines (14 or 16 G)
if possible
Administer fluid if available.
Venous access
basilic or saphenous venous cutdown (adult)/
intraosseous (pediatrics)
 CIRCULATION

Consider Central line

o Adult: up to 2 liters warmed lactated Ringer's
within 15min
o Child: up to 2 x 20 ml/kg warmed lactated
Ringer's
o Inadequate response:
o consider transfuse; type specific : O ve,
o Airway- 100% O2
D. DISABILITY

Rapid and brief neurologic examination

AAlert

V Responds to Vocal stimuli

PResponds to Painful stimuli

UUnresponsive

Pupillary size & reaction

More detailed evaluation -during the secondary

survey (GCS)
 E. EXPOSURE

Undress the patient and look for any other

injured body part.
Prevent Hypothermia

IV should be warmed before infusion and warm

environment
SECONDARY SURVEY
Thesecondary survey does not begin until
the primary survey (ABCDEs) is completed,
resuscitative efforts are under way, and the
normalization of vital functions has been
demonstrated.
SECONDARY SURVEY
When additional personnel are available,
part of the secondary survey may be
conducted while the other personnel attend
to the primary survey. In this setting the
conduction of the secondary survey should
not interfere with the primary survey, which
takes first priority.
Documentation is required for all procedures
undertaken.
SECONDARY SURVEY
The secondary survey begins only when the
ABCs are stabilized.
In the secondary survey, the patient is evaluated
from head to toe and the indicated studies (eg,
radiographs, laboratory tests, invasive diagnostic
procedures) are obtained.
Head examination includes looking for injuries to
the scalp, eyes, and ears.
SECONDARY SURVEY
History

Every complete medical assessment includes a

history of the mechanism of injury.
Often, such a history cannot be obtained from a
patient who has sustained trauma; therefore,
pre-hospital personnel and family must be
consulted to obtain information that can
enhance the understanding of the patients
physiologic state.
 SECONDARY SURVEY
TheAMPLE history is a useful mnemonic for this
purpose:
A - Allergies
M- Medications currently used
P- Past illnesses/Pregnancy
L- Last meal
E- Events/Environment related to the injury
SECONDARY SURVEY
Neurological examination includes:
the Glasgow Coma Scale(GCS)
evaluation of motor and sensory functions as

well as reflexes.
The chest is auscultated and inspected
again for fractures and functional
integrity (flail chest).
Examination of the abdomen should
consist of inspection, auscultation, and
palpation
SECONDARY SURVEY
The extremities are examined for
fractures, dislocations, and peripheral
pulses.
A urinary catheter and nasogastric tube
are also normally inserted.
 SECONDARY SURVEY
Basic laboratory analysis includes
a complete blood count (hct or hgb),
electrolytes,

glucose,

blood urea nitrogen (BUN), creatinine,

arterial blood gase.

A chest x-ray should be obtained in all patients

with major trauma.
Thepossibility of cervical spine injury is
evaluated by examining all seven vertebrae in a
cross table lateral radiograph.
 SECONDARY SURVEY
Depending on the injuries and the
hemodynamic status of the patient, other
imaging techniques:
chest computed tomography (CT)
angiography
diagnostic tests such as diagnostic peritoneal
lavage(DPL) may also be indicated.
Focused assessment sonography trauma(FAST)
 SECONDARY SURVEY

Head examination
scalp and ocular Neck examination
abnormalities penetrating wounds
external ear and tympanic
membrane subcutaneous
periorbital soft tissue emphysema
injuries. tracheal deviation
Head injury patients are neck vein appearance.
suspected to have cervical
spine injury until proven
otherwise
SECONDARY SURVEY
Neurological examination
brain function assessment using the GCS
spinal cord motor activity
sensation and reflex.
Chest examination
clavicles and all ribs
breath sounds and heart tones
ECG monitoring (if available).
SECONDARY SURVEY
Abdominal examination
penetrating wound of abdomen requiring
surgical exploration
blunt trauma a nasogastric tube is inserted
(not in the presence of facial trauma)
rectal examination
insert urinary catheter (check for meatal
blood before insertion).
SECONDARY SURVEY

Pelvis and limbs

fractures
peripheral pulses
cuts, bruises and other minor injuries.
SECONDARY SURVEY
X-rays (if possible and where indicated)
chest X-ray and cervical spine films (important to see
all 7 vertebrae)
pelvic and long bone X-rays
skull X-rays may be useful to search for fractures
when head injury is present without focal neurologic
deficit
order others selectively.
NB chest and pelvis X-rays may be needed
during primary survey.
 TERTIARY SURVEY
A tertiary survey is defined as a patient
evaluation that identifies and catalogues all
injuries after initial resuscitation and operative
interventions.
It typically occurs within 24 h of injuries. This
delayed evaluation normally results in a more
awake patient who is able to fully communicate
all complaints, more detailed information on the
mechanism of injury, and a detailed examination
of the medical record to determine preexisting
comorbidities.
TERTIARY SURVEY
The tertiary survey occurs prior to
discharge to reassess and confirm known
injuries and identify occult ones.
It includes another "head-to-toe
examination" and a review of all laboratory
and imaging studies. Missed injuries can
include extremity and pelvic fractures,
spinal cord and head injuries, and
abdominal and peripheral nerve injuries.
ANAESTHETIC
MANAGEMENT OF TRAUMA
PATIENT
ANAESTHETIC MANAGEMENT OF
TRAUMA PATIENT

Preoperative assessment

Respiratory:

Air way

Obstruction use manoeuvres'

Inadequate ventilation- causes

Breath sounds: crepitus

respiratory patterns/distress,

CXR
 ANAESTHETIC MANAGEMENT...
Cardiac:

Sign/symptom of shock,

Cardiac arrest
ANAESTHETIC MANAGEMENT...
Gastrointestinal:
Full stomach !!!
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 non-particulate antacid
prior to induction
ANAESTHETIC MANAGEMENT...
Neurologic:
GCS

loss of consciousness

assume C-spine injury until ruled out Lateral C-

spine X-ray,

palpate neck

Renal:
monitor urine output, amount and colour
ANAESTHETIC MANAGEMENT...
Endocrine:

release of stress hormones (catecholamine and

glucose)

Hematologic:

hypovolemic shock,

coagulopathy
 ANAESTHETIC MANAGEMENT...

Diagnostic tests
CBC, electrolytes, urinalysis, PT/PTT, lactate,
baseline ABG (as condition permits)
Cross match for at least 4 units
CXR, lateral C-spine, CT/MRI ,
12 lead EKG
FAST: focused abdominal sonography for trauma
DPL: diagnostic peritoneal lavage
ANAESTHETIC MANAGEMENT...
Preparation:
Sedation rarely necessary

Scopolamine-0.4 mg amnesic agent for the

hemodynamically unstable
Prophylaxis- antacid

Standard monitors

Preoxygenation

Basic airway and difficult airway adjuncts

RSI with cricoid pressure

Invasive monitors as indicated

INDUCTION AGENTS

Thiopental:
3-4 mg/kg;
reduce doses in unstable patients;

most commonly used in trauma

Etomidate:
0.1-0.3 mg/kg;
reduce doses with hypovolemia; ?myoclonus effects
INDUCTION AGENTS
Ketamine:
0.5-1 mg/kg;
useful for burn and hypovolemic patients;

avoid with head injured

Propofol:
1-2 mg/kg in stable patients;
reduce doses in Hypovolemia
 INDUCTION AGENTS
Thecombination of ketamine and propofol (i.e.,
ketofol) is gaining popularity for induction of
trauma anesthesia and as an intravenous
infusion to supplement regional anesthesia for
repair of traumatic injury.

Typically,
200 mg of propofol is mixed with 40
100 mg of ketamine in the same syringe (the
drugs are compatible).
 MUSCLE RELAXANTS
Succinylcholine: 1-2 mg/kg;
useful in RSI /emergency
CI (after 24hrs) in:- Burn, SCI and crush injury

Vecuronium: 0.28 mg/kg high dose:

Cardiovascular stability
No histamine release

onset in 80 secs;

duration 75-90 min

Rocuronium: 1.2 mg/kg high dose:

Histamine release
On set 45-60 secs;

duration 67 minutes
ANALGESICS
Opioid analgesics are an important
component of trauma anesthesia practice,
not only for critically injured patients who
require immediate anesthesia induction
Fentanyl- 0.001- 0.003 mg/kg

Sulfentanyl : 0.1-0.5 ug/kg

Morphine: 0.05-0.1mg/kg

Regional anesthesia- blocks

 MAINTENANCE
O2/air/Forane(isoflorane)mixture
Avoid N2O if any question of :
pneumothorax,
pnuemocephalus,

pneumomediastinum,

bowel injury

Fentanyl 1-10 mcg/kg/hr

Monitor fluids and administer carefully

Prepare to give blood products if necessary

EMERGENCE
Normal extubation criteria
Remain intubated for:
Hemodynamically unstable,
Elderly with rib and long bone fractures,
Those who have received massive fluid and blood
resuscitation,
Severe burns, and
Those with coagulopathies
 POSTOPERATIVE PAIN MANAGEMENT
Long-acting opioids:-
morphine
hydromorphone,

methadone,

oxycodone,
Epidural infusions
Intercostal blocks
 REGIONAL ANESTHESIA

It can be an important adjunct to the total

anesthetic management of the trauma
patient, especially for its ability to reduce
inflammatory triggers from the site of injury
Epidural anesthesia reduce systemic stress
from surgery, but it must be used especially
carefully in trauma patients
Peripheral nerve blocks will reduce the need
for systemic opioids in the postoperative
phase and in many instances allow earlier
extubation of the trauma patient with painful
injuries
POSTOPERATIVE MANAGEMENT
Monitored and labs followed closely
Correct acid-base imbalances and electrolyte

disturbances
Long-acting opioids
Epidural infusions
Intercostal blocks
Complications:
Hypothermia, atelectasis, V/Q mismatch,
coagulopathy
 Helping patients is our life
work and life is now!!!

THANK YOU!!!