ANESTHESIA

EMERGENCY

MORGAN

MAD
Initial Assessment of the
Trauma Patient
• Airway
• Basic life support: Effective basic life support prevents
hypoxia and hypercapnia from contributing to the
patient’s decreased level of consciousness.
• Cervical spine injury: Assume the presence of cervical
spine injury if the patient is complaining of neck pain or
has significant head injuries, neurologic signs or
symptoms suggestive of cervical spine injury, or
intoxication or loss of consciousness.
Initial Assessment of the
Trauma Patient
• Breathing: Initiate ventilation immediately after
securing the airway. If a patient had multiple
injuries, one should be concerned for possibility of
a pulmonary injury, which could develop into a
tension pneumothorax with the initiation of
mechanical ventilation.
• Circulation: Determine if the patient has a pulse
and a blood pressure. Usually this information has
been previously communicated by prehospital
personnel.
Initial Assessment of the
Trauma Patient
• Neurologic function: Perform a rapid neurologic assessment,
including level of consciousness, pupillary size and reactivity,
lateralizing signs that suggest intra- or extracranial injuries,
and spinal cord assessment. Hypercarbia is often a cause of
depressed level of neurologic responsiveness but also
consider alcohol intoxication, drug effects, hypoglycemia, and
hypoperfusion

• Injury assessment: Fully expose the patient and use caution

because this increases the risk of hypothermia. All fluids
must be warmed, and forced air warmers can be used.
 Hemorrhage and Trauma-Induced Coagulopathy

• Classes of Hemorrhage
• Class I: Volume that can be lost without hemodynamic consequence; represents
less than 15% of the circulating blood volume
• Class II: Loss of volume that prompts a sympathetic response to maintain
perfusion; represents 15% to 30% of the circulating blood volume. The diastolic
blood pressure will increase because of vasoconstriction, and the heart rate will
increase to maintain cardiac output. Intravenous (IV) fluids are usually indicated, and
transfusions may be needed if the bleeding continues.
• Class III: Consistently results in decreased blood pressure; represents 30% to 40%
of the circulating blood volume. Vasoconstriction and tachycardia are not enough to
maintain perfusion. A metabolic acidosis develops, and hypovolemic/hemorrhagic
shock develops. Blood transfusions are necessary to maintain oxygenation and tissue
perfusion.
• Class IV: Life-threatening hemorrhage; more than 40% of the circulating blood
volume is lost. The patient will be unresponsive and severely hypotensive. Rapid
control of bleeding and blood-based resuscitation will be required to prevent death.
It is common that these patients will develop a coagulopathy after their injury,require
massive blood transfusion, and have a high likelihood of dying.
Hemorrhage and Trauma-Induced Coagulopathy
• Trauma-induced coagulopathy: Common after major
trauma; it is thought that global tissue hypoperfusion
plays an important role.
• During hypoperfusion, the endothelium releases
thrombomodulin and activated protein C to prevent
microcirculation thrombosis. Thrombomodulin binds
thrombin, thereby preventing thrombin from cleaving
fibrinogen to fibrin. The thrombomodulin–thrombin
complex activates protein C, which then inhibits the
extrinsic coagulation pathway through effects on cofactors
V and VIII. Activated protein C also inhibits plasminogen
activator inhibitor-1 proteins, increasing tissue
plasminogen activator, resulting in hyperfibrinolysis.
Hemorrhage and Trauma-
Induced Coagulopathy
• Tranexamic acid: Trauma-induced coagulopathy is
not solely related to impaired clot function.
Fibrinolysis is an equally important component as a
result of plasmin activity on existing clot.
Tranexamic acid administration has been associated
with decreased bleeding during cardiac and
orthopedic surgeries, presumably because of its
antifibrinolytic properties. Studies suggest that
there is a significantly reduced risk of death from
hemorrhage when it is initiated.
Hemostatic Resuscitation
• 1:1:1 ratio: Giving blood products in a 1:1:1 ratio (red
blood cells [RBCs]: fresh-frozen plasma [FFP]: platelet)
early in resuscitation is the accepted approach to
trauma resuscitation and is termed damage control
resuscitation.
• RBCs improve oxygen delivery to tissues, and FFP
provides clotting factors V and VIII along with
fibrinogen.
• Platelets and cryoprecipitate are likely not necessary in
the initial phase of resuscitation because platelet and
fibrinogen levels are normal in early coagulopathy.
Platelets may be beneficial if the resuscitation is
prolonged or if a recalcitrant coagulopathy is noted.
Hemostatic Resuscitation
• Massive transfusion protocols (MTPs): MTPs, rather than
crystalloid-based resuscitation, improve survival from trauma,
reduce total blood product utilization in the first 24 hours after
injury, reduce acute infectious complications such as severe
sepsis, septic shock, and ventilator-associated pneumonia, and
decreases postresuscitation organ dysfunction
• To predict which patients are likely to require the MTP, the
Assessment of Blood Consumption (ABC) score was developed,
which scores 1 point for each of the following variables: (1)
penetrating injury, (2) systolic blood pressure below 90 mm
Hg, (3) heart rate above 120 beats/min, and (4) positive results
of a focused assessment with sonography for trauma (FAST)
evaluation.
• Patients with scores above 2 are more likely to require massive
transfusion.
Anesthetic Issues in Trauma
• General considerations: Keep the operating room
(OR) warm and use IV fluid warmers and rapid
infusion devices. Presume that all patients have full
stomachs and are at high risk for aspiration.
• Intravenous access: Usually established before
arrival to the OR. If the lines are confirmed to be
intravascular and are of a large caliber (16 or 14
gauge), a central line is usually not needed.
However, if patients arrive hypotensive and
hypovolemic, this can make placing a peripheral IV
access very difficult, and one should consider
placing a central venous access
Anesthetic Issues in Trauma
• Induction of anesthesia: Propofol may be a poor
drug of choice for induction in trauma patients with
severe injuries because it can cause hypotension.
Etomidate preserves sympathetic tone, which
makes it slightly safer than propofol. Ketamine is
also an option (10 mg IV every 30 seconds until the
patient becomes unresponsive)
Traumatic Brain Injury Case
• Methods to Lower ICP
1. Hyperventilation: Cerebral blood flow is related to
arterial carbon dioxide concentration in a dose-
dependent relationship. When arterial carbon
dioxide levels decrease, cerebral vasoconstriction
occurs, lowering the ICP, and as the levels rise,
vasodilation occurs and may increase ICP. Note that
hyperventilation in the setting of hypotension can
increase the risk of neurologic ischemia.
Traumatic Brain Injury Case
• Methods to Lower ICP
2. Osmotic diuretic therapy: IV mannitol (0.25–1.0
g/kg) draws intravascular volume into the vascular
system to decrease brain edema and subsequently
reduce ICP. Serum osmolarity and electrolytes
(especially potassium) must be monitored because
this therapy induces diuresis
Spinal Cord Injury
• Cervical spine injury: Lateral radiograph of the cervical
spine detects 85% to 90% of significant cervical spine
abnormalities.
• Injuries above C2 are associated with apnea and death
• Lesions of C3 to C5 affect phrenic nerve function and
impair diaphragmatic breathing.
• Neurogenic shock can occur in patients with high spinal
• Injuries because of loss of sympathetic tone. Profound
bradycardia 24 to 48 hours after a high thoracic lesion may
be a result of compromised cardioaccelerator function,
which is located in the T1 to T4 region
Burn Injuries
• Classification of Burns
• First-degree burns do not penetrate the epidermis; fluid
resuscitation is not necessary, and the areas involved should not
be included when calculating fluid replacement when more
significant burns are also present.
• Second-degree burns are partial-thickness injuries that
penetrate the epidermis, extend into the dermis, and are
associated with blistering.
• Third-degree burns penetrate the full thickness of the dermis.
Nerves, blood vessels, lymphatic channels, and other deep
structures may be injured. This creates a severe wound that is
insensate; however, the surrounding tissue may be painful.
Burn Injuries
• Fluid resuscitation: Crystalloid fluids are encouraged
(especially lactated Ringer solution), as opposed to
colloid solutions, hypertonic saline, or blood.
• The Parkland formula recommends 4 mL/kg/% total
body surface area (TBSA) burned to be given in the
first 24 hours (with half given in the first 8 hours and
the rest over the following 16 hours).
• The Modified Brooke protocol recommends 2
mL/kg/%TBSA.
• The “rule of nines” is used to calculate the TBSA.
Burn Injuries
• Patients have an inability to regulate body
temperature and must be kept warm.
• Urgent airway management may be indicated by
the presence of a hoarse voice, dyspnea, tachypnea,
or altered level of consciousness.
• Succinylcholine can cause lethal elevations in
potassium after the first 48 hours.