ANESTHESIOLOGY [MONDAY SESSION] AY 21-22

ANESTHETIC CONSIDERATIONS IN TRAUMA

Vanessa Anne C. Gonzalez MD, DPBA, FPSA
5.04
16 JUL 21

TABLE OF CONTENTS ■ Effective life support by improving oxygenation and

I. INITIAL EVALUATION AND RESUSCITATION OF THE reducing hypercarbia in the unresponsive trauma patient
INJURED PATIENT ........................................................................... 1 can be effective in removing the need for endotracheal
A. Overview ............................................................................. 1 intubation.
B. Airway with Cervical Spine Control ..................................... 1 → Presumed cervical spinal cord injury until proven otherwise
C. Breathing ............................................................................ 2 ■ Cervical collar (C-collar) applied prior to transport.
D. Circulation ........................................................................... 2 ■ Traditional soft collars provide NO USEFUL cervical spine
E. Disability ............................................................................. 3 stabilization.
F. Exposure ............................................................................. 3 → Potential for a failed intubation
II. PREOPERATIVE EVALUATION ............................................. 3 ■ Expect a difficult airway with the presence of a C-collar with
A. Preparation ......................................................................... 3
maxillofacial trauma.
B. Patient ................................................................................. 3
● Assessment by establishing verbal contact with the patient
III. INTRAOPERATIVE MONITORING ......................................... 4
IV. INDUCTION AND MAINTENANCE OF ANESTHESIA ........... 4 → Clear phonation by the patient establishes a patent airway.
A. Induction ............................................................................. 4 ● Ascertain patency.
B. Maintenance ....................................................................... 4 → Inspection of foreign bodies, dentures.
V. EXTUBATION .......................................................................... 4 → Is there any facial, mandibular, tracheal, or laryngeal trauma?
● Clinical signs and symptoms of an obstructed airway: | G
MUST KNOW BOOK PREVIOUS TRANS → Apprehensive behavior
G & 4 → Refusal to lie supine
→ Noisy, labored breathing
This trans is heavily lifted from A2021 CC Group 1 trans of the same topic, and → Anxiety
updated with the September 2021 asynchronous lecture of Dr. Gonzales.
→ Suprasternal/intercostal retractions, alar flaring
I. INITIAL EVALUATION AND RESUSCITATION OF THE ● Anesthesiologists must expect a challenging airway, as routine
INJURED PATIENT airway management techniques have likewise been proven
unsuccessful.
● Begins with primary survey ● Assessment of airway with C-spine injury
● Rapid and efficient assessment of vital functions in a multiple → Highly suspicious if patient is obtunded and has above clavicle
injured patient in a systematic way with treatment priorities injuries, is unconscious, and/or has significant head injury.
A. Overview → Maintain immobility during assessment of airway patency.
Primary Survey ■ Should not be flexed, extended, or rotated.
■ Use semi-rigid collar or manual in-line immobilization
● ABCDE Approach and Resuscitation during intubation.
→ Identify and treat conditions that are an immediate threat to life ● Early use of pulse oximetry (Normal: > 95%) to detect
● A rapid assessment for ABCD includes a verbal communication inadequate oxygenations.
with patient
→ Ask his name and mechanism of injury Cervical Spine Injury
→ If response is appropriate, ensure: ● Presumed in any patient complaining of neck pain, any significant
■ Airway is not an immediate threat head injury, neurologic signs and symptoms suggestive of
■ Breathing is not compromised cervical SCI, intoxication, and loss of consciousness.
■ No major decrease in level of consciousness ● Hard collar or non-hospital setting use of sandbags is effective
■ Cerebral perfusion is good for immobilization.
Secondary Survey → Provides near or complete cessation of movement.
● For failed direct laryngoscopy:
● Once resuscitation is underway, and return of normal VS and → Alternative devices for airway management are used.
primary survey are completed, the secondary survey begins ■ Combitube or supraglottic airway device
● AMPLE History and PE (including rectal exam)
→ From head to toe excluding occult injuries Maneuvers to Remove Obstruction
→ Racoon eyes (periorbital hematoma) ● First rule out basal skull fracture prior to inserting a
→ Battle’s ear (retroauricular hematoma) nasopharyngeal airway (NPA)
■ Signifying basilar skull fracture → Epistaxis, rhinorrhea
→ Nasal bone fracture or base of skull fracture ● Jaw thrust
■ If these are present, do not insert NGT or nasopharyngeal ● Assume a full stomach in all trauma patients, so suction in
airway. lateral position (i.e., vomit, blood, foreign body)
● Complete history, laboratory and radiologic studies are done ● Afterwards, supplemental O2 high flow mask 12-15 L/min.
● Repeat GCS Gaining Access to a Difficult Airway
● Diagnostic studies can be repeated
● Jaw Thrust
B. Airway with Cervical Spine Control → While the patient is still using a collar, the anesthesiologist’s
● Important aspects of airway management in the unresponsive assistant places their fingers at the patient’s mandible and
patient: pushes it upwards.
→ The need for basic life support intervention ● Fiberoptic Scope
■ Establishing and maintain a patent airway is priority since → Used by the trained anesthesiologist to visualize the spinal
cerebral hypoxia will lead to irreversible brain injury within cord.
minutes.

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● Adequate circulation is required for oxygenation to the brain and

other vital organs.
● Blood loss is the most common cause of shock in trauma
patients.
● This is evaluated by assessing:
→ Level of responsiveness (mnemonic: AVPU)
■ Alert
■ Respond to Verbal stimuli
■ Respond to Painful stimuli
■ Unresponsive to any stimuli
→ Obvious hemorrhage
Figure 1. (L-R): Jaw thrust and Fiberoptic Scope.
→ Skin color
● Indications for cricothyroidotomy or tracheostomy: | G → Pulse (presence, quality, and rate)
→ Severely distorted facial or upper airway anatomy ● Compressible hemorrhage in an extremity with vascular injury
→ Impediment to adequate mask ventilation → Hemorrhage, NOT limb ischemia or function, is the most
→ Hemorrhaging into the airway pressing threat to life and, thus, must be controlled at the
earliest time.
C. Breathing
→ Warrants use of tourniquet
● Adequate oxygenation and ventilation must be assured. ● Once presence of circulation is confirmed, a quick assessment of
→ All injured patients should receive supplemental O2. neurologic function is done:
→ Pulse oximeter > 95% SAO2 → Entertain other possible causes of a depressed neurologic
● In multiple-injury patients, maintain a high level of suspicion for function:
pulmonary injury. ■ Alcohol drug intoxication
→ Tension pneumothorax ■ Effects of illicit or prescribed meds
■ Intervention: 14-gauge needle inserted at the 2nd ICS MCL ■ Hypoglycemia
followed by a larger thoracotomy tube in MAL ■ Hypoperfused brain or SCI
→ Open pneumothorax ● Understanding this classification promotes more effective
→ Flail chest communication between surgeons and anesthesiologists,
● Trauma patients are presumed to have full stomachs ensuring a common understanding.
→ Risk of pulmonary aspiration of gastric contents
→ Intervention: Sellick’s Maneuver | G Resuscitation
■ Application of cricoid pressure during assisted ventilation ● Estimated blood volume: | G
■ Contraindications: → Adult: 70 mL/kg
- Suspected airway injury (especially injuries at the → Children: 80 mL/kg
cricotracheal junction) → Infants 90 mL/kg
- Foreign body at the level of the cricoid (either within the Table 1. Hemorrhage Classifications
esophagus or the trachea) Class
- Active vomiting present I ● Unchanged BP, HR
- Awake patient < 15% of ● No hemodynamic consequences
○ Intubation or light sedation can be done in awake circulating ● IVF resuscitation not required for controlled
patients blood volume and minor surgery
Sniffing Position and Head Tilt-Chin Lift ● Prompts sympathetic response
● In patients without cervical spinal cord injury ● Normal capillary refill time (< 2 seconds)
● These maneuvers align the oral, pharyngeal, and tracheal axes, II ● ‹ diastolic pressure d/t vasoconstriction, and
which brings into view the vocal cords during laryngoscopy. HR to maintain CO
< 15-30%
● A pillow underneath the patient’s head and upper back in that ● IVF/colloids may be given rapidly, or
the tragus is aligned with the sternal angle of Louis ● Blood transfusion – required for continuous
→ This also facilitates viewing of vocal cords. bleeding
● Consistently hypotensive and tachycardic
with ensuing metabolic acidosis
● Insufficient compensatory mechanisms of
III vasoconstriction and tachycardia for
maintaining perfusion and meeting metabolic
30-40% demands of the body.
● Blood transfusion is a must to restore tissue
perfusion and provide O2 to tissues.
● Damage Control Procedure or Surgery (DCS)
Figure 2. Sniffing position. (Left) Step-by-step in placing the patient in sniffing ● Patient unresponsive with profound
position; (Right) Final position. hypotension
D. Circulation ● Rapid control of bleeding
IV ● Aggressive blood-based resuscitation
● Primary survey involves signs of BP and pulse are sought. (Damage Control Resuscitation)
→ Absence of a pulse following trauma is associated with dismal 40% lost ● Trauma-induced coagulopathy
chance of survival. → Independent risk factor for death
● Initial management in a trauma patient in cardiac arrest: | G → 25% of major trauma: high likelihood of
→ Emergent ultrasound of chest and abdomen death
■ Focuses on an empty heart
■ Indicated for any trauma patient arriving in cardiac arrest
■ (+) Massive blood collections in chest or abdomen
→ Prompt bilateral needle decompression
→ Rapid fluid bolus: IVF 500 – 1L fluid bolus in a pulseless
victim of penetrating trauma
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G | Damage Control Procedure/Survey (DCS) F. Exposure

● Emergent Laparotomy for Intraabdominal Hemorrhage ● The patient should be completely undressed and exposed.
→ Identification and control of injured vessels and solid organs → Ensures that no injuries are missed
→ Intended to stop hemorrhage and limit gastrointestinal
● Re-covered with warm blankets afterwards to limit the risk of
contamination of abdominal compartment hypothermia.
→ Inspection of injuries potentially addressed by interventional
radiology II. PREOPERATIVE EVALUATION
→ Planned reoperation once patient is more stable. ● A hemodynamically unstable, non-responding patient would be
G | Hemostatic Resuscitation rushed to the OR so no time for detailed pre-op or laboratory
● Standard trauma infusion protocol in the military setting investigations can be taken.
adopted by trauma civilian centers ● A rapid pre-anesthetic evaluation begins with AMPLE history:
● Early resuscitation to correct trauma-induced coat → Allergies
● 1:1:1 ratio (RBC: FFP: platelet) → Medications currently used
● Approach to transfusion or DCS → Past illnesses/Pregnancy
Assessment of Blood Consumption Score (ABC) → Last meal
● Attempts to predict which patients are likely to require massive → Events/Environment related to the injury
transfusion protocol (MTP) ● Mechanism of Injury
● Assess 1 point for each of the following: → Has a big impact on the pattern of injury (i.e., blunt,
→ Heart rate > 120 bpm penetrating; thermal, chemical, or radiation)
→ Systolic BP < 90 mmHg → If the patient is unable to give information, then get from the
→ FAST-positive companion or family.
→ Penetrating mechanism ● All radiologic investigations and labs are reviewed when
available.
● A score of > 2 is predictive of massive transfusion.
● Informed Consent
E. Disability → Especially in cases where blood transfusion is required.
● Rapid assessment of the patient’s neurologic status is necessary → Advise that intraoperative awareness can occur.
upon arrival in the emergency department. A. Preparation
→ This should include the patient’s conscious state and
● The anesthesiologist must prepare the following:
neurological signs. → Warming of operating room
→ Assessed using: → IV fluid warmers and rapid infusion devices available
■ Glasgow Coma Scale (GCS)
→ Variety of airway equipment prepared
■ Pupil size and reaction
→ Possibility of a difficult intubation
■ Lateralizing signs ■ Possibility of aspiration
● Glasgow Coma Scale
■ C-collar in place
■ Alternative airway devices ready
■ Robust suction equipment
→ Existing peripheral lines good for blood transfusion
under pressure.
■ A central line should be prepared if necessary.
■ Subclavian vein for central access in profoundly
hypotensive patients.
■ Intraosseous access
- Uses small bone drill in the proximal tibia, humerus or
femur (long bones) providing direct access to venous
complexes through the bone marrow.
- Use of this access requires that the proximal and distal
areas to the insertion site are intact; otherwise, fluid will
extravasate to the path of least resistance.
→ Availability of ultrasound
B. Patient
● Patient transfer precautions
→ Protect the spine during transfers from stretcher to operating
table (use patslides or safeslides)
→ Chest tubes are clamped during patient transport (collecting
chamber kept well below the level of the chest) to prevent the
fluid from being sucked into the pleural cavity.
■ Remove once the patient has been shifted to the OR table.
● Airway Control
→ After transfer, verify correct position & level of the
endotracheal tube (possibility of dislodgement during
transport).
Figure 3. Glasgow Coma Scale.
→ Maximum score: 15
■ Indicates optimal level of consciousness
→ Minimum score: 3
■ Signifies deep coma
→ GCS < 8
■ Sign that the patient may have reduced airway reflexes,
making them unable to protect their airways.
■ Under these circumstances, a definitive airway is required.
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III. INTRAOPERATIVE MONITORING

● Prepare the standard monitors to be hooked to the patients to
be able to do the intraoperative monitoring.
→ Pulse oximeter, ECG, ETCO2, noninvasive blood pressure
device, HR, RR, and temperature.
■ ECG monitoring: dysrhythmias and ST segment changes
should be monitored
■ ETCO2 esp. if patient will undergo GA and intubation
■ Arterial line if the patient has co-morbids (cardiac problems)
● Adjuncts to primary survey and resuscitation.
Urinary Catheter
● Urine output
→ Sensitive indicator of adequacy of resuscitation Figure 4. Sellick’s Maneuver. Patient is unconscious and sedated.
→ Reflects patients’ volumes status and renal perfusion
● Contraindications to transurethral catheter insertion: B. Maintenance
→ Presence of blood at the urethral meatus ● Inhalational anesthetics titrated as tolerated in hemodynamically
→ Presence of perineal ecchymosis unstable patients.
→ High-riding prostate ● Avoid the use of histamine-releasing neuromuscular blockers
Insertion of nasogastric tube (NGT) (e.g., atracurium, mivacurium) which can attenuate hypotension.
● Nitrous oxide is avoided in:
● To decompress the stomach, decrease risk of aspiration, and to → Pneumothorax
assess concealed GI bleeding → Bowel injury
Invasive Monitors → Pneumomediastinum
● Necessary when it guides titration of vasopressors ● Immediate availability of blood
● Inserted after induction → Should be warm and ready to transfuse.
● Invasive arterial BP, CVP ● There should be rapid infusion of blood products
→ IV calcium given for its replacement
Laboratories
● Expect the possible use of vasopressors to maintain the BP.
● Serial Hgb, Hct, ABG, and serum electrolytes
● Monitored to guide resuscitation V. EXTUBATION
Blood Viscoelastic Tests ● Fulfillment of criteria for extubation:
● Thromboelastography (TEG) → Mental status
● Give an accurate assessment of coagulopathy → Resolution of intoxication
→ Conscious and obeys commands
IV. INDUCTION AND MAINTENANCE OF ANESTHESIA → Non-combative
→ Adequate pain relief
A. Induction ● Airway anatomy and reflexes:
● IV induction agents given in small, incremental doses (titrated) → Intact cough and gag reflex
→ ‹ effect of IV anesthetic agents in hypovolemia ■ Ensures ability to protect own airway from aspiration
● Ketamine: ideal inducing agent in hypovolemic patients | G → Absence of excessive airway edema or compromise
→ Rapidly acting, non-barbiturate general anesthetic ● Respiratory mechanics
→ ‹ HR, BP, and CO, mediated primarily through the sympathetic → Adequate TV and RR
nervous system ● Systemic stability
● Important to recognize that the unstable trauma patient will → Adequately resuscitated
tolerate significantly less IV anesthetic agents for induction and → Low chance for return to the OR
maintenance of anesthesia than in normal circumstances. → Normothermia without signs of sepsis
Airway Access during Induction G | Summary: Definitive Trauma Interventions
● Presence of a surgeon during anesthetic induction for surgical ● Outside the operating room:
access to airway. → Initial history and PE
→ Necessitated for performing urgent cricothyroidotomy or tube → Emergency procedures such as intubation
thoracostomy for tension pneumothorax, which may develop → Labs and radiological studies must be done.
after initiation of positive pressure ventilation. → Resuscitative measures
● Patients received by the anesthesiologist with a non-definitive → Surgical interventions (cricothyroidectomy)
airway must be converted into definitive airway prior to surgery. G | Critical Initial Issues Impacting Anesthetic Management
→ Non-definitive airway examples: laryngeal mask airway (LMA) ● Adequacy of airway and vascular access
or combined esophageal and endotracheal tube (Combitube) ● Ability of the patient to tolerate anesthesia
→ May have been inserted to oxygenate the patient in an ● Prevention of hypothermia
emergent situation. ● Access to blood bank supplies
→ If there is a difficult airway situation (i.e., can’t intubate, can’t
ventilate), do surgical airway control (emergency END OF TRANSCRIPT
cricothyroidotomy)
REFERENCES
Rapid-Sequence Induction
Gonzalez, V.A.C., (2021), Anesthetic concerns: Management of Trauma Patients
● Practiced in securing the airway. [PowerPoint Presentation]. Manila, Philippines: Faculty of Medicine and
→ Reiteration: trauma patients are presumed to have “full Surgery, University of Santo Tomas, ANESTHESIOLOGY
stomachs” – increased risk of aspiration of gastric contents.
→ Sellick’s maneuver is done by applying cricoid pressure to
occlude the esophagus by compressing it against the cervical
vertebral body, therefore reducing the risk of aspiration.
● If a patient has comorbidities, it is helpful for the anesthesiologist
to insert an arterial line.