1. Anaesthetic management of the Trauma Patient
Chapter 23

2. 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

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

4. 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

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

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

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

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

9. 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

10. 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

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

12. 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

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

14. Exposure and environmental control
Physical
Chemical
Biological

15. 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

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

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

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

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

20. Emergence Extubation criteria Stable versus unstable
High care versus ICU

21. 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

22. Occupational health and Hazards
Physical
Blood
Toxins
Sharp objects
Psychological
Counselling