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ANAESTHESIA FOR SURGICAL EMERGENCIES INCLUDING MAJOR TRAUMA
Outline: Assessment of a patient presenting with major trauma • • General assessment: airway, breathing and circulation Systematic assessment
Summary of anaesthetic problems Anaesthesia for the patient with multiple trauma Special problems associated with spinal cord injuries
Acute internal bleeding (especially into the abdomen or chest). foetal distress and open wounds often associated with compound fractures are the kinds of emergencies we are considering. Similarly. a rising intracranial pressure. visceral injury. ASSESSMENT OF THE PATIENT PRESENTING WITH MAJOR TRAUMA General Assessment Before starting a detailed assessment of the underlying injuries. the tongue falling back. blood clots. food. the outcome of the surgical procedure depends on how soon it is done. Circulation: Note the pulse and blood pressure. If the patient is breathing but the breathing is shallow. secretion. bleeding into the neck and severe tenderness over the thyroid cartilage may suggest a ruptured larynx. breathing and circulation. Marked surgical emphysema of the face and neck may suggest a ruptured trachea. intubate and ventilate with 100% oxygen.e. respiration may be assisted with a mask or endotracheal intubation may be required. The airway: Any obstruction of the airway must be detected and corrected. it is essential to make a swift assessment of the patient’s airway. If the patient is not breathing.Awetahagn Abreha INTRODUCTION The term "emergency surgery" implies that the time available to prepare the patient for surgery is limited i. Breathing: The patient may be given oxygen by mask until the general assessment is finished. At a pharyngeal level. This has been dealt with in detail in Chapter 8. dentures and foreign bodies are the usual causes. Insert a 14G or 16G cannula and start an initial infusion with Hartmann's solution followed by a 2 .
Send blood for grouping and cross-matching. Have a range of tubes available. In trauma patients a cervical collar should always be used until clinical and X-ray evidence confirms that there is no cervical cord injury. The airway may be secured by passing an endotracheal tube beyond the tear and inflating the cuff. Bleeding into the airway requires careful suction. as outlined in Neurosurgical anaesthesia in Chapter 22. If this is not possible. or tracheostomy may be needed before anaesthesia is started. Systematic assessment Evidence of intracranial injury: Careful neurological observation is essential. Record the patient’s Glasgow Coma score Spinal cord injury: Acute compression of the spinal cord requires very careful positioning. An awake intubation. especially of the level of consciousness and the size of the pupils.Awetahagn Abreha colloid solution. Facial and neck injuries: Airway obstruction is the major problem. surgical exploration is indicated. If airway obstruction has not been evident in the general assessment but facial and neck injuries make it likely . A smaller tube than usual may be necessary.then an inhalational induction and intubation will be safer than using relaxants. A lateral x-ray of the neck is essential in patients with multiple trauma. If the facilities are available. − Injury to the chest wall may result in a flail chest which 3 . Injuries to the structures of the chest: − Tears to the trachea are associated with subcutaneous emphysema of the face and neck. All precautions must be taken to avoid a rise in intracranial pressure. measure arterial blood gases. This assesses the respiratory and metabolic state of the patient.
If tamponade is severe. Crush injuries of the lower chest may be associated with rupture of the diaphragm. Flail chest occurs when there are multiple fractures of adjacent ribs causing a segment of the chest wall to become free. Direct lung trauma may result in contusion of the lung or rupture of a bronchus.Awetahagn Abreha needs to be treated by intubation and prolonged IPPV or if this is not available some other means of immobilizing the segment. Air in the pleural cavity (pneumothorax) may require under water drainage. An x-ray will confirm the diagnosis. the pericardium should be tapped before the anaesthetic is administered. Cardiac tamponade is associated with a low blood pressure. − − − − 4 . jugular distension and muffled heart sounds. especially on the left. Avoid myocardial depressants. − − Bleeding into the pleural cavity (haemothorax) may require drainage. Widening of the mediastinum seen on x-ray may suggest that the aorta or pulmonary artery has been damaged. See Chapters 27 and 46 for water-seal drains. This segment will move paradoxically with respiration and this movement along with underlying lung contusion will usually result in pain and hypoxia. Local anaesthesia and epidural anaesthesia where available are also used and may avoid the need for artificial ventilation in less severe cases.
See Chapter 52. Guarding or re-bound tenderness may be associated with intra-abdominal bleeding or soiling of the peritoneal cavity from a ruptured bowel. The following may lead to suspicion of an abdominal injury: − − − − Persistent hypotension despite apparently adequate resuscitation. both bony and soft tissue.Awetahagn Abreha Abdominal injuries: Explore any penetrating injuries in relation to the abdomen. spleen or a major blood vessel.danger of regurgitation. Resuscitation: This may involve care of the airway. Orthopaedic injuries: Orthopaedic injuries that constitute an emergency are acute fractures. Increasing size in the abdomen after resuscitation may suggest intra-abdominal bleeding. See Chapter 8. which are described in detail in Chapters 52 and 58 SUMMARY OF ANAESTHETIC PROBLEMS All of the following problems have been discussed in detail elsewhere. See Chapter 22. can be associated with a large but relatively hidden blood loss. Raised intracranial pressure. Full stomach . Hypoxia . See Chapter 8. especially those associated with arterial obstruction and open wounds. Haematuria suggests kidney or renal tract injury. Hypovolaemia/shock. See Chapter 49 5 . artificial ventilation and cardiac compression and treatment of the shocked patient. Orthopaedic injuries. See Chapter 16 for RSI and Chapter 46 Massive blood transfusion. In this situation bleeding may occur from the liver. This is discussed under Anaesthesia for Orthopaedic surgery in Chapter 31.especially due to chest injuries. • • • • • • Airway problems.
• Large volumes of blood will be required. 6 . • Do not use ketamine if there is evidence of a head injury. • A higher concentration of oxygen (50%) than normal may be needed. then induction and intubation under inhalational anaesthesia is safer than using relaxants. Chest and head injuries must always be looked for in patients with multiple trauma. • Spinal anaesthetics are unsafe in hypovolaemic patients whose blood loss cannot be controlled. The problems associated with massive transfusions need careful attention. See Chapter 49 • If there is airway obstruction pre-operatively. • If there is air or blood in the pleural cavity it should be drained before anaesthesia/surgery.16 G cannulae) should be in progress before anaesthesia is commenced. • IPPV may be necessary after surgery. Surgery should be delayed until this has been achieved unless there is uncontrolled bleeding. if not otherwise contraindicated. Two infusions (14 . can be used provided that there has been adequate preoperative fluid resuscitation.Awetahagn Abreha • Fat embolism. an “awake intubation” or a tracheostomy may be necessary before the start of anaesthesia. If there is no airway obstruction but there is a likelihood of obstruction due to facial and neck injuries. If there is no head injury ketamine is an excellent induction drug for the shocked patient. • Whenever possible patients should be normovolaemic. See Chapter 46 ANAESTHESIA FOR THE PATIENT WITH MULTIPLE TRAUMA The subject is dealt with extensively under the subject "Shock" in Chapter 52 but note these points: • Regional anaesthetics.
because of swallowed blood. 7 . SPECIAL PROBLEMS ASSOCIATED WITH SPINAL CORD INJURY • A recent quadriplegic may have an unstable cervical spine and pose intubation problems.Awetahagn Abreha • Every case of major trauma must be treated as having a full stomach. • Psychiatric disturbance is likely. • Muscle spasms may be a problem. • Temperature regulation is interfered with in quadriplegics. delayed gastric emptying time and recent food. It is safe to use within 48 hours of injury but unsafe to use thereafter because of the possibility of a rapid rise in serum potassium. • There is also a tendency to hypertension. This response can persist for up to 1 year. serum electrolytes and acid base status should be monitored if the facilities are available. • Positioning may be difficult. • Suxamethonium can cause severe hyperkalaemia 48 hours after a spinal cord lesion. • Pressure sores are more common. using small doses of drugs and high oxygen concentrations. • Respiratory problems are more common due to intercostal paralysis and partial paralysis of the diaphragm. are used. • The usual principles of light anaesthesia. The increase in serum potassium in these patients may be responsible for cardiac arrhythmias when suxamethonium is given. Even if the patient has sensory loss at the site of the operation they may still need some form of anaesthesia to control the muscle spasm. • Chronic infection and nutritional deficiencies lead to anaemia. • The hourly urine output.
Awetahagn Abreha 8 .