Trauma Anesthesia

• Golden hour is the critical time where immediate medical or surgical intervention is necessary to prevent death.

Types of Trauma

• Blunt trauma involves direct impact, deceleration, continuous pressure, shearing, rotary forces, or high energy levels.
• Penetrating trauma involves minor punctures to high-velocity projectiles
• Damage factors include the item causing trauma, its velocity and mass, characteristics of tissue, and whether it's a pass-through or retained inside.

Damage Control

• Stage 0 is prehospital and early resuscitation.
• Stage 1 involves lifesaving surgery.
• Stage 2 includes intensive resuscitation.
• Stage 3 is planned reoperation for definitive treatment.

Presentation

• Presentation may include altered mental status, blunted sympathetic tone, and possible drug or alcohol involvement.
• Trauma patients often have full stomachs due to sympathetic response and opioid use.
• Injuries affecting autoregulation, severe hypovolemic shock, hidden injuries, and communicable disease risk are also concerns.

Classes of Blood Loss

• Classified as 1-4
• Replace with blood if patient has lost >1500mL of blood.

Prehospital Care

• Includes assessment, oxygen administration (intubation not always needed), and bleeding control using tourniquets, pressure, or packing.
• Intravenous fluids in prehospital setting is controversial, as crystalloids may dilute blood and clotting factors.

Tourniquet Use

• The best fluid to administer to trauma patients is whole blood.

Assessment

• Primary assessment (ABCDE) identifies and manages life-threatening conditions.
• Secondary assessment involves a head-to-toe evaluation, history, and accident details.

Airway Management

• Assess for foreign bodies and deformities.
• Awake patients may need oxygen to maintain airway.
• If unconscious, establish airway via intubation, cricothyrotomy, or tracheostomy.
• Minimize C-spine movement and consider using the Glidescope.

Intubation Considerations

• Preoxygenate, stabilize C-spine (no head tilt), apply cricoid pressure, administer medications and use video laryngoscopy.

C-Spine Injury

• Occurs in 2-3% of trauma patients and 6-10% of TBI patients.
• Risk factors include neck pain, severe distracting pain, intoxication, LOC, and neurologic symptoms.

Breathing Assessment

• Includes checking chest movement, wounds, flail chest, respiratory effort, auscultation for breath sounds, and tracheal position.

Circulatory Assessment

• Radial pulse indicates SBP>80.
• Femoral pulse indicates SBP>70.
• Carotid pulse indicates SBP>60.

Neurologic Assessment

• Rapid assessment using GCS or AVPU.
• CT scan is done when stable.
• GCS <8 indicates intubation.

Traumatic Brain Injury (TBI)

• Avoid hypotension or hypoxia.
• Increased Intracranial Pressure (ICP) & Hyperthermia are concerns
• Hypotension can cause vasodilation due to cerebral autoregulation.
• Hypertension can cause vasoconstriction due to it.

TBI Hypotension

• Maintain SBP to support CPP >60.
• Measures to decrease ICP.

TBI ICP Management

• Promote venous drainage.
• Maintain MAP >70 and CPP >50-60.
• EVD for CSF drainage

TBI Mannitol Use

• With BBB disruption, mannitol can increase cerebral tissue volume and ICP.
• Hypertonic saline may be a better option in TBI.
• Use anti-seizure meds, hyperventilation, sedation, and decompressive craniotomy.

TBI Hypoxia

• Maintain SpO2 >90%.
• Normocarbia is needed to decrease cerebral edema.

Spinal Cord Injury

• Assess spine and neurologic function.
• CT scan is preferred for c-spine clearance, X-ray if necessary.
• Treat all suspected injuries with full precautions.
• Document clearance by appropriate provider; CRNAs cannot clear patients under spinal cord injury precautions.

Spinal Cord Injury Positioning

• Use C-collar, splints, sandbags, and backboard
• Log roll with documentation.

Hypothermia in Trauma Patients

• Weather-related risks.
• Cut-off clothes for assessment, which makes them even colder
• Maintain room temperature at 30°C (86°F) recommended.
• Use warm fluids, blood, Bair hugger, and thermal blankets.
• 22 degrees C often results in death

Secondary & Tertiary Surveys

• Secondary survey is completed after primary survey and stabilization.
• Tertiary survey identifies injuries missed in primary/secondary surveys and is done within 24 hours; misses 2-50% of injuries.
• FAST exams have increasing popularity to ID injuries.

Room Preparation for Trauma

• Standardized setups improve safety.

PPE Considerations

• Patients may have thermal, chemical, radiation or biological agents and may need respirators, isolation or chemical showers.

Hemorrhagic Shock

• Common in trauma.
• Bleeding must be stopped.

Classes of Shock

• Hemorrhage leads to Trauma Triad (hypothermia, coagulopathy, acidosis)

Shock Treatment

• Replace volume with fluids or blood.
• Crystalloids are acceptable for minor injuries with no active bleeding and <2L needed.
• Colloids can contribute to pulmonary edema.
• Avoid dextrose solutions because it becomes free water and leads to increased ICP and hyperglycemia.
• Use massive transfusion protocol for severe cases.

Blood Choice & Transfusion

• Best Choice: Fully cross-matched whole blood is ideal
• Type & Screen (5 mins)
• Crossmatch (45 mins)
• PRBC transfusion: NS, Plasmalyte, Normosol (LR controversial)
• Use fluid warmer, filters (170-260 microns)
• RBC = red blood cells
• FFP = coagulation factors
• Platelets = platelets
• Cryoprecipitate = fibrinogen

Platelets

• ABO compatibility is desirable but not required.
• Must be warmed before administration.
• Offsets platelet dysfunction from coagulopathy and massive transfusion
• Each unit of platelets increases platelet count 5-10K.
• Life of transfusion is 1-7 days.

FFP

• Contains all plasma proteins, including clotting factors.
• Ensure it goes through the warmer.

Rapid Infuser Use

• Preferred fluids: LR, Normalyte, Plasmalyte.
• Crystalloids last 20-30 mins in the intravascular space.
• NS is not recommended due to hyperchloremic metabolic acidosis.
• Hypertonic saline increases MAP, decreases swelling, improves regional blood flow.
• Avoid dextrose-containing solutions due to hyperglycemia causing more ischemia and edema.

Coagulopathy in Trauma

• 25% of trauma patients present with coagulopathy.
• "Four horsemen": Dilution, Hypothermia, Acidosis, Hemorrhagic Shock

TXA Administration

• Beneficial in cases with oozing blood (e.g., neck dissection)
• Will not help in massive hemorrhage

Contraindications to Common Anesthetics

• Succinylcholine is avoided 24 hours post burns/ SCI and crush injuries; Fasciculations can cause increased ICP, IOP and displace fractures.
• Nitrous oxide is avoided due to potential air trapping.
• Administer lower dose Propofol, etomidate, narcotics, or midazolam to prevent cardiac collapse.
• Ketamine is avoided in neurotrauma due to increased ICP, but may not have sympathomimetic effects in trauma.

Ketamine

• Sympathetic responses are indirect (similar to ephedrine).
• There will be no response if it catecholamines are depleted
• Histamine producing agents due to decreased BP
• Volatile anesthetics will decrease BP and can increase ICP if >1 MAC

Anesthesia Considerations

• Trauma decreases induction agent requirements (80-90%).
• Cardiac effects of IV anesthetics are more pronounced
• Maintaining CV stability is more important than recall

Maintenance

• Paralyze and maintain MAP >50-60 where possible

Head Injury Management

• Avoid histamine-producing drugs; use BIS.
• Avoid secondary injury (swelling, hypoxia).
• Maintain early airway control and SpO2 >90%.
• Prevent ICP elevation.
• Maintain SBP >90mmHg, ICP <20mmHg, CPP >60mmHg.
• Cushing's triad is usually a late sign that occurs prior to brain herniation.
• Slight elevation of the head can decrease ICP due to increased venous drainage.
• Avoid nasal instrumentation in LeFort II or III.
• Maintain CPP >60mmHg; maintain ICP <20mmHg; maintain euglycemia.

Spinal Cord Injury Management

• Level will determine symptom severity.
• C3,4,5 keeps the diaphragm alive.
• T1-4 are the cardiac accelerator fibers.
• Avoid succs after 24-48 hours post injury because fasciculations can cause more injury.

Thoracic Trauma Management

• Anticipate severe respiratory compromise.
• Rib fractures involve more fractures = more serious complications, and higher the rib fracture = greater the trauma.
• Pediatric rib fractures are more serious due to pliable ribs that are difficult to break.

Pneumothorax

• Tension pneumothorax occurs when air enters the pleural cavity with inspiration but cannot escape with expiration.
• Causes decreased compliance and hypoxemia.
• Signs and symptoms include diminished or absent unilateral breath sounds, tracheal deviation, hemodynamic collapse, distended neck veins, and hyper-resonant breath sounds.
• Treatment includes needle decompression in the 2nd intercostal space (above the 3rd rib) midclavicular line, then chest tube insertion.

Flail Chest

• Caused by three or more ribs being fractured in two or more places.
• Results in structural instability of the thorax.
• On inspiration, the rib cage moves outward, and the flail segment moves inward.
• On expiration, the rib cage moves inward, and the flail segment moves outward.
• This movement pattern is known as paradoxical movement of the chest wall.

Lung Contusion

• Associated with lung contusion.
• Lung contusion is also associated with pulmonary edema

Cardiac Tamponade

• Results in cardiogenic shock.
• Beck's triad = hypotension, JVD, muffled heart sounds
• Treat with pericardiocentesis or a pericardial window
• Medically treat with dopamine due to alpha 1 and beta 1 activity before definitive intervention

Pulmonary Contusion

• Caused by blunt chest trauma.
• It is a Major source of post-trauma morbidity & mortality.
• Can lead to Parenchymal hematoma and edema formation.
• Decreased lung compliance, increased airway pressure, and impaired gas exchange.
• Increased FIO2 use.
• Use PEEP to reduce alveolar edema.
• Optimize fluids to avoid further edema.

Cardiac Contusion

• ST elevation and increased cardiac enzymes.
• The right ventricle is the most commonly injured.
• Possible dysrhythmias
• Wall motion abnormalities on echocardiogram

Aortic Dissection

• Screen all patients for abdominal trauma using the FAST Exam.
• Blunt abdominal injury = leading cause of morbidity & mortality in trauma.
• Penetrating or blunt trauma can cause massive bleeding and organ damage.
• Exploratory laparotomy is often required.
• Spleen = most commonly injured organ.
• Opening the abdomen may cause profound hypotension.
• May require aortic clamping to control bleeding.
• FAST exam is used to identify free fluid (i.e., blood) in peritoneal, pericardial, and pleural spaces.

Extremity Trauma

• Can lead to pulmonary embolism (fat, marrow, bone fragments, clots, foreign bodies).
• A femur fracture is most common for fat emboli.
• Rhabdomyolysis → Risk for Acute Kidney Injury (AKI)

Compartment Syndrome

• Surgical emergency (fasciotomy required)
• Causes: Hematoma, crush injuries, amputations
• Diagnosed when compartment pressures > 45 mmHg.
• Major vessel damage possible.

Burns

• Third-leading cause of accidental death.
• 50% of adults <45 years old survive 75% BSA burns.
• High-risk groups: Very young, very old, careless individuals.

Types of Burns

• Thermal (heat).
• Chemical.
• Electrical.
• Inhalational.
• Know Parkland formula and BSA calculation for the exam.

Urine Output Monitoring in Burns

• Adults: 0.5-1 mL/kg/hr.
• Pediatrics: 1-1.5 mL/kg/hr.
• Monitor bladder pressures for >30% BSA burns (risk for high intra-abdominal pressures).

Initial Burn Management

• History: Mechanism and timing of injury.

Airway Burn Treatment

• 100% humidified O2 for CO poisoning.
• Assess for inhalation burns & airway edema → Early intubation
• Begin IV access with large-bore catheters for fluid resuscitation.
• Use Parkland formula.
• Administer pain control with opioids.
• Assess total BSA burned and calculate fluids.
• Labs: Carboxyhemoglobin, ABG.
• Burns patients are unstable.

Intubation in Burns

• Propofol fluid resuscitated cases
• Use Etomidate/Ketamine if not
• Avoid giving Succinylcholine due to risk of hyperkalemia