Stabilisasi Respirasi

dan Hemodinamik serta

Pemilihan Anestesi
(Anesthesia for the Trauma patient)
Tatang Bisri
Bag/SMF Anestesiologi & Reanimasi
FK UNPAD/RS Dr. Hasan Sadikin-Bandung
Trauma
USA : 1/3 off all hospital admissions directly
related to trauma.
50% of trauma deaths occurs immediately with
another 30% occurring within a few hours of
injury.
Role of anesthesiologist: primary resuscitator,
providing anesthesia because many trauma
victims require immediate surgery.
Trauma (2)
Remember : drugs abuse, acutely
intoxicated, carriers of hepatitis or HIV.
Assume all multiple trauma patients have
a cervical spine injury, a full stomach and
are hypovolemic.
All patients should have initial stabilization
of the cervical spine before any airway
manipulation.
RAPID OVERVIEW
( Differentiation between stable, unstable and dead or dying patient )
PRIMARY SURVEY
( Evaluation and Concurrent Resuscitation )
1) Airway
2) Breathing
3) Circulation
4) Neurologic Function
5) Examination of undressed patient
( Essential Laboratory and Radiologic Examination )
SECONDARY SURVEY
( Detailed and Systematic Evaluation of Injury to each Anatomic
Region and Resuscitation at any time, if necessary )
Operating Room for
Emergency Surgery
Radiology Suite For Special X-rays
(CT Scan, arteriogram, esophagram)
Observation in ER
Or ICU
Operating Room
Airway
Since hypoxemia an immediate threat to the
trauma patient must focus on the airway.
Assume a cervical spine injury in any patient
with multisystem trauma, especially an altered
level of consciousness or a blunt injury above
the clavicle.
A major trauma patients with unconsciousness
is always considered to be at increased risk for
aspiration airway must be secured ASAP
tracheal intubation / tracheostomy.
Airway..(2)
Neck hyperextension and excessive axial
traction must be avoided .
During mask ventilation and
laryngoscopydemonstrated neck
movement stabilization (sand-bag,
forehead tape, rigid cervical collar ).

Patient may require intubation
The awake patient: awake nasal or
orotracheal intubation, blind nasal
intubation, rapid sequence intubation,
awake tracheostomy.
The combative patient: rapid sequence
induction.
The unconsciousness patient
The intubated patient.
Indication definitive airway:
nasotracheal, orotracheal, surgical airway
Apnea
Inability to maintain a patent airway by other
mean.
Protection from aspiration of blood or vomitus.
Impending or potential compromise of the
airway.
Closed head injury (GCS <8)
Failure to maintain adequate oxygenation by
face mask.
Intubation criteria :
GCS < 8
respiration irreguler
resp rate < 10 or > 40 per minute
tidal volume < 3,5 ml / kg BW
vital capacity < 15 ml / kg BW
PaO2 < 70 mmHg
PaCO2 > 50 mmHg
Sperry RJ et al : Manual of Neuroanesthesia, 1989.
GCS Hemodynamic Hypnotic Urgency Neuromuscular
Stability Blocker
Yes Lidocaine 1,5 mg/kg
3 - 8 Yes Sux 1.0 mg/kg
No
Thiopental 2-3 mg/kg or
Yes propofol 1-2 mg/kg Yes Sux 1.0 mg/kg
9 - 12 + lidocaine 1,5 mg/kg No Vec 1.02 mg/kg
No Etomidate 1-2 mg/kg Yes Sux 1.0 mg/kg
Thiopental 3-4 mg/kg or
Yes propofol 1,5-2,0 mg/kg Yes Sux 1.0 mg/kg
13 - 15 + lidocaine 1,5 mg/kg No Vec 0.02 mg/kg
No Etomidate 1-2 mg/kg Yes Sux 1.0 mg/kg
Lam A.M. : Anaesthetic management of acute head injury, 1995
Table : Suggested Choice for Intubation
Sux = succinylcholine ; Vec = vecuronium ; GCS = Glasgow Coma Scale
Breathing
Most critically ill trauma patients require assisted
or controlled ventilation.
Bag-valve device usually provide adequate
ventilation immediately after intubation and
during transportation.
O2 100%
Ventilation may be compromised by
pneumothorax, flail chest, obstruction of ETT,
direct pulmonary injury.
Indication for mechanical ventilation
in patients with flail chest
Clinical evidence of respiratory failure
RR> 35 breath/min
PaO2 < 60 mmHg
PaCO2 > 55 mmHg
Vital capacity < 15 ml/kg
Clinical evidence of shock
Associated severe head injury with need to
hyperventilate patients lung
Airway obstruction
Significant pre-existing chronic pulmonary
disease.

shock
First step: recognized its present. Shock is
inadequate organ perfusion and tissue
oxygenation (tachycardia, peripheral
vasoconstriction cool)
Second step: identify the probable cause of the
shock.
Hemorrhagic shock
Non hemorrhagic shock (cardiogenic,
tension pneumothorax, neurogenic,
septic)
Cause of hypotension in the initial
phase of trauma
Hemorrhage or extensive tissue injury
Tachycardia, narrow pulse pressure, peripheral
vasoconstriction.
Th/: Crystalloid solution initially and transfuse if
2000 ml in 15 minutes does not improve BP.
Cardiac tamponade
Tachycardia, dilated neck veins, muffed heart
sound.
Th/: Pericardiocentesis
Cause of hypotension in the initial
phase of trauma
Myocardial contusion
Tachycardia, cardiac dysrythmias
Th/: Crystalloid , vasodilators, inotropes
Pneumothorax or hemothorax
Tachycardia, dilated neck veins, absent breath
sound, dyspnoe, subcutaneus emphysema
Th/: Chest tube
Cause of hypotension in the initial
phase of trauma
Spinal cord injury
hypotension without tachycardia, narrow pulse
pressure or vasoconstriction.
Th/: Crystalloid , vasopressor, inotropes.
Sepsis
Depelops typically a few hour after colon injury
(in normovolemic patients manifest as modest
tachycardia, wide pulse pressure, fever)
Th/: Antibiotics, crystalloid, inotropes.
Clinical classification of shock
Blood volume loss Clinical manifestations
Mild (<20%) Patient complain of feeling cold,
postural hypotension and tachycardia,
cool, pale, moist skin, collapsed neck
veins, concentrated urine
Moderate (20-40%) Thirst, supine hypotension and
tachycardia. Oligouria and anuria
Severe (>40%) Agitation, confusion, or obtundation.
Supine hypotension and tachycardia.
Rapid and deep respiration
ATLS classification of hemorrhagic shock
Class I Class II Clas III Class IV
Blood loss (ml)
Blood loss (% of BV)
Heart rate
SBP
Pulse pressure
Capillary refill test
Resp rate
Urine output
Mental status

Fluid replacement
Up to 750
Up to 15%
<100
Normal
Normal or
Normal
14-20
>30
Slightly
anxious
Crystalloid
750-1000
15-30%
>100
Normal
Decreased
Positive
20-30
20-30
Mildly anxious

Crystalloid
1500-2000
20-40%
>120
Decreased
Decreased
Positive
30-40
5-25
Anxious and
confused
Crystalloid
and blood
>2000
>40%
>140
Decreased
Decreased
Positive
<35
Negligible
Confused
andlethargic
Crystalloid
and blood
Circulation & Fluid resuscitation
The mainstay of therapy : intravenous fluid
resuscitation
Insert catheter veins : short and large.
Central line : time consuming, possibility of
the life threatening complications.
Not give vasopressor (except: cardiogenic
shock, cardiac arrest) or bicarbonate
Circulation & Fluid resuscitation
Hypovolemia should be corrected before
induction of anesthesia.
RL less likely to cause hyperchloremic acidosis
than normal saline
In traumatic brain injury avoid RL (RL is
hypoosmoler solution , 273 mOsm/lt, NaCl 303
mOsm/lt).
Dextrose containing solution may exacerbate
ischemic brain damage and should be avoided
in the absence of hypoglycemia.
Circulation & Fluid resuscitation
Hypertonic solution
Colloid
Fluid must be warmed prior to administration.
Hypothermia worsens acid-base disorders,
coagulopathies and myocardial function, shift
oxygen-hemoglobin curve to the left, decrease
metabolism lactate, citrate, some anesthetic
drugs
ANESTHESIA
GENERAL
Intravenous
Inhalation
Intramuscular
LOCAL
Topical
Infiltration
Peripheral
nerve block
Spinal
Epidural
Caudal
IVRA
COMBINATION
Spinal +
propofol
Caudal
+Inhalation
New trend in GA
Low-flow Anesthesia Low-cost
Anesthesia
VIMA (Volatile Induction and
Maintenance of Anesthesia)
Fast-Track Anesthesia
Single-breath induction (Rapid induction)
SAFE (Short Acting Fast Emergence)
Choice of anesthesia
In unstable patient base of anesthesia is muscle
relaxant, with general anesthetic agent titrated in
an effort to give amnesia. MAP 50-60 mmHg
Patient with mild to moderate degree of
hypovolemia, decrease dose 30-50%
Agitated and uncooperative patient may require
a rapid sequence induction of anesthesia
followed by laryngoscopy-intubation.

Anesthetic agent
Ketamine indirectly stimulate cardiac function in
normal patient can display cardiodepresant
properties in shock patients.
Avoid N2O : limited oxygen concentration, when
pneumothorax is suspected . Drugs that tend to
lower BP must be avoid
The rate of rise of alveolar concentration of
inhalation anesthetics is greater. Effect of
intravenous anesthetic are exaggerated.
Variable Halothane Enflurane Isoflurane Sevoflurane

BP
Vascular resistance
Cardiac output
Cardiac contraction
CVP
Heart rate
Sensitization of the
heart to epinephrine


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0
Cardiovascular effect of volatile inhalation
anesthetics at 1-1,5 MAC
0 = no change (<10%)
= 10-20% decrease
= 20-40% decrease
= increase
Management of anesthesia
Clear airway
Control ventilation
Avoid increase/decrease of BP
Avoid increase of cerebral vein pressure
Avoid drugs & technique of anesthesia increase ICP.

Nancye Edwards : Principles and Practice of Neuro
anaesthesia,1991
Conclusions:
In perioperative period : concept of ATLS
choice of anesthesia
Terimakasih
Tatang Bisri
Bandung, 2004
Approximate PaO2 versus SpO2
PaO2 SpO2
27 mmHg 50%
30 mmHg 60%
60 mmHg 90%
90 mmHg 100%