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Wan Ahmad Asyraf bin Wan Md Adnan

2nd May 2013

Moderator: Dr Lee Pui Kuan


 Case Example
 Introduction
 Problems Associated with Trauma
 Initial Assessment
◦ Primary and Secondary Survey
 Anaesthetic Consideration & Management
 Take Home Messages
 References
 17 years old boy
 Alleged MVA (unknown mechanism of injury)
◦ Was brought to A&E by ambulance
 Upon arrival to A&E:
◦ Vital signs: BP 130/78, HR 90, SpO2 93%, dscan 7.2
◦ Airway: patient was intubated for airway protection (poor
conscious level), done with MILS
 Given IV fentanyl, IV midzola and IV suxamethonium
◦ Breathing: Equal chest movement, crepitations on right
lung
◦ Circulation: no external haemorrhage, 1st FAST negative
◦ Pupils 3mm bilaterall equal, response to pain stimulus
 Further examinations:
◦ Head: haematoma over occipital region (5cm x 6cm)
with no active bleeding, no ENT bleeding
◦ Chest: no external injuries, equal chest movement,
crepitations on right side
◦ Abdomen: soft, not distended
 rpt FAST -> presence of minimal free fluid over
rectovesical pouch, haematuria on CBD
◦ Pelvis: no external wound
◦ Spine: no obvious deformity
 Investigations
◦ CXR: right lung contusion, no pneumothorax
◦ Pelvic x-ray: no fracture
◦ CT brain
 Mix of EDH and SD at left temporo-parietal regions
(thickness 12mm)
 Right basal ganglia haemorrhage
◦ CT cervical
 No obvious fracture seen
◦ CT abdomen
 Traumatic liver injuries (at least Grade IV) with
haemoperitoneum and active bleeders
 Bibasal lung contusions with haemothorax
 Proceed with operation
◦ Craniectomy + evacuation of blood clot
◦ Exploratory laparotomy + liver packing
◦ Classified as ASA IVE
 Monitoring
◦ NIBP + IABP
◦ ECG
◦ EtCO2
◦ IV access: triple lumen at right femoral, 14G x 2
 Intraoperatively:
◦ Stable haemodynamically, started on noradrenaline
infusion to achieve MAP of 80
◦ Difficulties to maintain oxygenation
 Occasional desaturation to 86-90%
 Higher settings requirement (PIP 22, PEEP 14, FiO2 100%)
 SpO2 maintained mostly around 95%
◦ EBL: 2L
◦ Fluids:
 1 cycle of DIVC, 3 pints whole blood, 2 pints 0.9% saline, 2
pints venofundin
 Postoperatively admitted to ICU for cerebral
protection
 Patient was ventilated on bilevel mode initially in
ICU
◦ Able to wean down to SIMV after 1 day
 Proceed with removal of pacing after 48 hours
◦ Uneventful
 At D4 of admission, developed signs of sepsis
(unknown source)
◦ Started on antibiotics, changed a few times after a few
days
◦ Recovered well afterward in terms of septic parameter
 Extubated on D8 of admission, transferred out to
general ward 2 days later
 Patient stay for another 5 days in general ward
before discharged home
 Trauma is the leading cause of death in
young people worldwide, including Malaysia
 Mainly involved in motor vehicle accidents
 Trimodal Death Distribution (50%, 30%, 20%)
◦ 1st phase: major severe injuries
◦ 2nd phase: treatable life threatening injuries
◦ 3rd phase: infection, multiple organ failure
 The concept of ‘golden hour’
◦ The importance of resuscitation from the arrival of
patient to health care provider
◦ Hence, the development of ATLS: framework for
immediate management for trauma patient
 Multiple injuries (life threatening)
 Compromised airway, breathing and
circulation needing urgent/ongoing
resuscitation
 Limited time for preparation (dealing with life
threatening situation)
 Inadequate history or trauma circumstances
in comatose / restless patient
 Risk of aspiration
◦ Inadequate fasting time
◦ Pregnancy
◦ Pain
 Potential difficult airway
 Co-existing disease
 Coagulopathy
◦ Massive blood loss
◦ On anticoagulant therapy
◦ Dilutional coagulopathy
Primary Secondary Definitive
Resuscitation
Survey Survey Care
Initial Assessment

 Airway with cervical spine control


 Breathing and ventilation
 Circulation and haemorrhage control
 Disability (neurological function)
 Exposure
Initial Assessment: Primary Survey

 Aim: patent airway to maintain adequate


oxygenation
 Beware of airway obstruction features:
◦ Respiratory distress, stridor, cyanosis
 Oxygen therapy
 Assess need for intubation
◦ Upper airway obstruction
◦ Severe lung contusion, with ventilatory compromise
◦ Poor GCS
◦ Airway protection (e.g. Bleeding intraorally)
◦ Impending airway obstruction (e.g. Inhalational injury)
 Manual in-line stabilisation (C-spine protection)
Initial Assessment: Primary Survey

 Establish responsiveness
 Airway assessment: look, listen and feel
 Airway opening and maintenance
◦ Jaw thrust vs head tilt, chin lift
◦ Suction airway adjunct (OPA, NPA)
◦ Definitive: ETT, surgical airway
 Maintenance of ventilation
 Common problems encountered:
◦ Tongue obstruction (fall back)
◦ Secretion
◦ Laryngospasm
Initial Assessment: Primary Survey

 Cervical spine assessment


◦ 2 criteria available
 National Emergency X-Radiography Utilisation Study (NEXUS)
Low Risk Criteria
 Canadian C-spine
◦ CCS is superior than NEXUS criteria in terms of
sensitivity and specificity *
 Difficult in unconscious patient
◦ Need of imaging: cervical x-ray, CT cervical, MRI
 Who to clear?
◦ Radiologist
◦ Anaesthesiologist/Intensivist
◦ Surgeon (Neurosurgery / Orthopaedic)
*IG Stiell et al; The Canadian C-Spine Rule versus the NEXUS
Low Risk Criteria in Patients with Trauma. N Engl J Med,
2003:349:2510-8
Initial Assessment: Primary Survey

 NEXUS Low Risk Criteria


Neurological Deficit

 Canadian C-spine Rule


Spinal tenderness

Altered consciousness

Intoxicated

Distracting
injuries
Initial Assessment: Primary Survey

High Risk Factor


•Age >65
•Dangerous mechanism
•Paraesthesias in Extremities

NO

Low Risk Factor


(for safe assessment of ROM)
•Simple rearend MVA
•Sitting position in A&E
•Ambulatory at any time
•Delayed onset of neck pain
•Absence of midline c-spine
tenderness
YES
ROM
•Able to rotate 45 degree left and right
Initial Assessment: Primary Survey

 Assess breathing efforts


◦ Approach: look, listen, feel
◦ Respiratory rate, breathing pattern, use of
accessory muscles, flail chest
◦ Chest spring, chest expansion
◦ Reduced/absent breath sound
Initial Assessment: Primary Survey

 Life threatening injuries:


◦ Tension pneumothorax
 Reduced chest movement, reduced breath sound
 With respiratory distress, tachycardia, hypotension,
tracheal deviation, distended neck veins
 Mx: needle thoracocentesis, followed by chest tube
◦ Open chest injury
 Occlusive dressing, sealed on 3 sides
◦ Massive haemothorax
 Reduced chest movement, dull percussion note
 With hypoxaemia and hypovolaemia
 Mx: fluid resuscitation + chest drain
Initial Assessment: Primary Survey

 Watch out for signs of shock


◦ Cold peripheries, delayed capillary return, pallor,
low pulse volume, tachycardia, hypotension
◦ Secure external haemorrhage
◦ Large bore IV cannulation + blood investigations
◦ Rule out cardiac tamponade
 Beck’s triad: hypotension, distended neck vein,
muffled heart sound
◦ 1st priority  stop bleeding & replace intravascular
volume
◦ Shock in trauma patient is hypovolaemic in nature,
until proven otherwise
Initial Assessment: Primary Survey

 Classification of hypovolaemic shock


Initial Assessment: Primary Survey

 Pupils for size and reaction to light


 Rapid neurological assessment
◦ Awake
◦ Verbal response
◦ Painful response
◦ Unconscious
Initial Assessment: Primary Survey

 Undress patient for through examination of


other injuries
 Prevent hypothermia
◦ Increased oxygen requirement
◦ Myocardial depression
◦ Altered drug metabolism
Parameter Goal
Blood pressure Systolic 80 mmHg, mean 50-60
mmHg
Heart rate <120 bpm
Oxygenation SaO2 >95%
Urine output >0.5ml/kg/hr
Mental state Obey command
Lactate level <1.6 mmol/L
Base deficit >-5
Haemoglobin >8.0 g/dl
Initial Assessment

 Detailed examination (head-to-toe) after


primary survey is completed and vital signs
are relatively stable
 Complete anatomical evaluation
◦ Head
◦ Chest
◦ Abdomen
◦ Pelvis
◦ Spine
◦ Extremities
 History: AMPLE
Initial Assessment: Secondary Survey

 Assess conscious level according to GCS


 Scalp: lacerations, haematoma, depressed
skull fractures
 Signs of basal skull fracture
◦ Racoon eye, bruising over mastoid process,
otorrhoea & rhinorrhoea
 Presence of maxillofacial injury
 Imaging: CT scan
Initial Assessment: Secondary Survey

 Rule out lethal conditions


◦ Pulmonary contusion
 Hypoxaemia (reduced PaO2/FiO2 ratio)
 CXR: patchy infiltrates
◦ Cardiac contusion
 Cardiac arrhythmia, ST changes on ECG
◦ Tracheobronchial disruption
 Hoarseness, SC emphysema, palpable fracture crepitus
◦ Diaphragmatic rupture
 Diminished breath sounds, chest and abdominal pain,
respiratory distress
◦ Eosophageal rupture
◦ Aortic rupture
Initial Assessment: Secondary Survey

 Examine for laceration, bruising, distension,


tenderness
 Imaging modalities
◦ Ultrasound, CT scan
Initial Assessment: Secondary Survey

 Difficult to diagnose
 Suspicious in patient who is pale and
hypotensive with no obvious source of
bleeding
 Imaging modalities: pelvic x-ray
Initial Assessment: Secondary Survey

 Assume cervical injury until excluded


 Quick neurological assessment of upper and
lower limbs
 Imaging: cervical x-rays
 Log roll: examination of whole spinal length
Initial Assessment: Secondary Survey

 Examine all limbs for any fractures or any


damages towards nerve, tendon, blood vessel
 Exclude compartment syndrome in closed
fractures
 Thorough preoperative evaluation and
resuscitations
 Blood samples including GXM
 Type of anaesthesia
◦ General anaesthesia
◦ Regional anaesthesia
◦ Peripheral nerve block
Anaesthetic Considerations

 Identify potential airway problems


◦ Rapid sequence induction with cricoid pressure
 Minimise risk of aspiration
◦ If anticipate difficult airway, may consider other
modalities
 Awake fibre optic
 Inhalational induction
 Surgical airway
◦ MILS for cervical spine protection
 Preoxygenation with 100% over 3-5 minutes
 Choice of IV induction agent
◦ Thiopentone and propofol (head injury patient)
◦ Ketamine (in hypotensive patient)
◦ Etomidate
Anaesthetic Considerations

 Muscle relaxant
◦ Use suxamethonium unless contraindicated
◦ Alternative: rocuronium
 Maintenance
◦ Avoid nitrous oxide in hypotension, hypovolaemic,
hypoxia
 Fluid resuscitation
◦ Secure large bore IV line prior to starting operation
◦ Blood products readily available when needed
◦ Volume status must be continuously assessed
throughout and after operation
Anaesthetic Considerations

 Monitoring
◦ ECG
◦ NIBP or IABP in critical patient
◦ SpO2
◦ End tidal CO2
◦ Temperature
◦ Urine output
◦ CVP
 Consider intra-op investigation
◦ E.g. ABG may help with resuscitation process
Anaesthetic Considerations

 Reversal in usual manner at the end of


surgery
◦ Decision for extubation depends on the condition
of patient
 Consider ICU admission post operative
◦ Severe head injury for cerebral protection
◦ Severe chest injury
◦ Polytrauma
◦ Unstable haemodynamic status
◦ Massive blood loss
 Systematic patient
assessment
◦ Primary survey
◦ Secondary survey
 Rapid sequence intubation
◦ Reduce risk of aspiration
 Continuous
haemodynamic
assessment of patient
intraoperatively
 C Y Lee; Manual of Anaesthesia. McGraw-Hill
Education (2008).
 G E Morgan, M S Mikhail, M J Murray; Clinical
Anaesthesiology (4th Edition). Lange Medical
Books (2006)
 K G Allman, I H Wilson; Oxford Handbook of
Anaesthesia (3rd Edition). Oxford Medical
Publications (2012)