Anaesthetic management of the Trauma Patient Chapter 23

Pre operative assessment History History C A M E L S Chronic illnesses Allergies and Addiction Medication Events or environment related to injury Last meal

Pre operative examination Clinical Examination Airway Cardiac Vascular Respiratory Abdomen Limbs Tubes Fluids

Pre operative assessment Neurological Examination Neurological Examination A V P U Head Trauma and Spinal cord injury must be excluded GCS Alert Vocal stimuli response Painfull stimuli response Unresponsive

Pre operative Assessment Special investigations Baseline bloods CSPINE CXR Pelvis FBC , UKE , Acid Base , Glucose Airway etc

Principles Anatomical Considerations Physiologic Considerations Head to toe All organ systems Vital organs Physiologic failure leads to homeostatic failure

Principles Monitoring Considerations Xenobiotics Pharmacological Considerations Monitoring Considerations Xenobiotics Recreational Toxins Decreased central volume of distribution versus increased volume of distribution [Free drug]

Anaesthetic Technique Resuscitation Get help A B C D E Airway and CSPINE Breathing Circulation and Coagulation Disability Exposure and environmental control

Airway management and Breathing Chest ETT Burns Cervical Spine injury Bronchoscopy Intercostal drain Mode of Ventilation Expose , auscaltate Intratracheal, size, depth, cuff, reintubation Swelling Bimanual cricoid pressure Secretions , foreign matter Hemo , pneumo , amount , type Lung protective ventilation, vcv versus pcv

Circulation and coagulation Stop Haemorhage Awake shock index Clinical signs of hypovolaemia Venous access CVP, Art 8.5 F Swan Ganz sheath Finger in artery Pulse rate/systolic blood pressure, N=0.5, > 10%, 33%, 50% decrease in CO Class 1 – 4 14 or 16 G X 2 Do not waste time

Circulation and Coagulation Fluids Trauma induced Coagulopathy Crystalloids Colloids Loss Dilution Consumption Hyperfibrinolysis Hypothermia Acidosis

Circulation and Coagulation Haemostatic Resuscitation Ratio of 1:1:1:1 = Whole blood Target Hct 30 Clotting factors Every 6 packed RBC Cryoprecipitate Damage control resuscitation Packed RBC: FFP: Platelet: Fibrinogen RBC FFP Mega unit Platelets Fibrinogen

Disability Neurologic Vascular eyes Central , brain , spinal cord Peripheral nerves

Exposure and environmental control Physical Chemical Biological

Hypothermia Worse outcome Exposed, fluids, casualty, radiology, OR Permissive, induced O2, coagulation, drugs, vasoconstriction, dysrhythmias, infection, dehiscence, Space blanket , warm fluids, bair hugger, fluid warmers, aircon Brain and Spinal cord injuries

Hyperthermia Endogenous versus exogenous Pontine lesions, status epilepticus Drugs – anticholinergics, alcohol, amphetaminoids, cocaine Active cooling Heat stroke

Endpoints of fluid resuscitation Systolic BP 90 Hct 30 No TRIC BE improving Lactate improving Systolic pressure variation

Induction of anaesthesia and airway Resuscitation BIS or Entropy Cardiovascular collapse versus permissive hypotension Aspiration Ketamine versus Etomidate Suxamethonium

Maintenance of anaesthesia Vapour versus ketamine infusion versus opioid infusion Nitrous Oxide Muscle relaxants Analgesia – do not give NSAIDS

Emergence Extubation criteria Stable versus unstable High care versus ICU

Damage control surgery Damage control resus/ Haemostatic resus Life and limb threatening first ICU stabilization Definitive care Lethal triad Hypothermia < 35 Acidosis Ph < 7.2 Clinical Coagulopathy

Occupational health and Hazards Physical Blood Toxins Sharp objects Psychological Counselling