Anaesthesia For Trauma Patient

PRESENTERS MATRIC NUMBER

KIISHAAN A/L KRISHNAN 012018100128

MIFTAHUL JANNAH BINTI JOEL KAPALI 012018100024

MUHAMMAD RIDWAN BIN HAIRUSSALEH 012018100030

MUHAMMAD SYUKRI KARIEM BIN MOHD ASRI 012018100136

NUR SHAFIKAH BINTI MUHAMMAD IDRIS 012018100070

NURNADIA BINTI MOHAMMAD AMINULLAH 012018100006

 Outlines
1. Assessment
4. Damage control resuscitation
a. Primary survey – ABCDE approach
a. Permissive hypotension
b. Secondary survey

c. Tertiary survey b. Haemostatic resuscitation

2. Scoring systems c. Damage control surgery

a. Glassgow coma scale 5. Triad of death / lethal triad

b. Injury severity score 6. Massive blood transfusion
3. How to clear the cervical spine (ruling out
cervical injuries) 7. The crystalloids vs colloids controversy : which is

- Canadian C Spine rules, Nexus Criteria better in resuscitation

8. Airway management in trauma patients

9. Cerebral protection & resuscitation

10. Choice of anaesthetic agents in trauma patients

ASSESSMENT BY PRIMARY,SECONDARY AND
TERTIARY SURVEY & SCORING SYSTEMS

KIISHAAN KRISHNAN
(012018100128)
ADVANCED TRAUMA LIFE SUPPORT (ATLS)

● Most widely recognized and practiced protocol for the management of trauma
patients worldwide
● An organized approach to manage patients with acute and severe injury

ATLS PROTOCOL OBJECTIVES

● A standardized approach to all traumatic patient
● A comprehensive assessment and management of patients in emergency situation
● Best utilization of golden hour which lies between life and death after a traumatic
event
ATLS PROTOCOL

TERTIARY
PRIMARY SURVEY
SURVEY SECONDARY
SURVEY
PRIMARY SURVEY: ABCDE APPROACH
A - Airway maintenance and cervical spine protection

B - Breathing

C - Circulation

D - Disability

E - Exposure
A) Airway maintenance and cervical spine protection

ASSESSING AND MANAGING AIRWAY

Signs of patent airway: patient can answer clearly when asked question

Signs of airway compromised: noisy laboured breathing,cyanosis,use of accessory

muscles,paradoxical breathing movement

Causes of airway obstruction:blood,secretions,tissue edema,laryngeal/tracheal

fracture,neck hematoma,reduced pharyngeal tone

Management: head tilt,chin lift,jaw thrust,suction of secretion in mouth,administer oxygen

and endotracheal intubation if needed
ASSESSING AND MANAGING CERVICAL SPINE INJURY

All trauma patients should be presumed to have cervical spine injury especially when complaining
of:

1. Neck pain/significant head injury

2. Neurological signs or symptoms suggestive of cervical spine injury

3. Intoxication/loss of consciousness

Management: cervical spine must be immobilised either by manual in line stabilisation (MILS) or
cervical collar.
B) BREATHING
Assessment of ventilation (Look, listen and feel)
LOOK
Signs of respiratory distress: cyanosis,accessory muscle usage,paradoxical breathing
Chest expansion
LISTEN
Breath sounds (reduced/absent/added sounds), air entry
FEEL
Tracheal position, Chest expansion, Percussion: abnormal dullness/resonance, Tenderness
Immediate Life Threatening MANAGEMENT:
Conditions Every trauma patient should
● Tension pneumothorax receive high flow oxygen(6-
● Massive hemothorax 8L/min) via a mask.
● Cardiac tamponade
● Flail chest
C) CIRCULATION MANAGEMENT
● Identify source of bleeding as internal or
Assessment of circulation is based on: external hemorrhage
● If external hemorrhage,apply direct pressure
● pulse rate to wound or use tourniquet when direct
● pulse volume pressure ineffective
● If internal hemorrhage,imaging like FAST
● blood pressure will be done and proceed with surgical
● signs of peripheral perfusion management
● Establish vascular access,insert 2 large bore
peripheral venous catheter and perform
fluid resuscitation
● Collect and send blood for blood grouping
and crossmatching
D) DISABILITY
Rapid assessment of neurological function

Level 1-AVPU System

● A- alert
● V- verbal responses
● P- pain responses
● U- unresponsiveness

Level 2-Glassgow Coma Scale

E) EXPOSURE

● The patient must be fully exposed and examined so that we can assess the extent of
injury
● Respect the patient’s dignity and minimise heat loss.
SECONDARY SURVEY
Only begin after primary survey completed and all life-threatening injuries have been
dealt with.

Focus on history and physical examination: elaborate systematic examination of the entire
body to assess any additional injuries

Head to toe evaluation of a trauma patient which includes:

● complete history
● full physical examination
● reassessment of all vital signs.
Complete history can be taken by: AMPLE
A: Allergies
M: Medication
P: Past Illnesses
L: Last meal
E: Events leading to the injury
TERTIARY SURVEY
A repeated complete clinical examination followed by serial assessments ( early+ new
imaging/ lab findings) help recognize missed injuries and related problems

It should be done within 24 hours after admission, and it's aim is to identify injuries that
have been missed previously because sign and symptom were masked initially by other
injuries, drugs, alcohol or altered conscious state
SCORING SYSTEMS
● Glasgow Coma Scale
INJURY SEVERITY SCORE

An anatomical scoring system that provides an overall score for patients with multiple injuries.

Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body
regions: head and neck, face, chest, abdomen, extremities and external (skin).

Only the highest AIS score in each body region is used.

The 3 most severely injured body regions have their score squared and added together to produce the
ISS score.

ISS = 3 highest² of AIS = a² + b² + c²

References
https://trauma.reach.vic.gov.au/guidelines/early-trauma-care/primary-survey#:~:text=The
%20primary%20survey%20is%20the,prevent%20complications%20from%20these%20inj
uries
.

https://resources.wfsahq.org/wp-content/uploads/uia28-Management-of-major-trauma.pdf
 OUTLINES

3. How to clear the cervical spine ?

4. Damage control resuscitation

a. Permissive hypotension
b. Haemostatic resuscitation
c. Damage control surgery

MIFTAHUL JANNAH BINTI JOEL (012018100024)

How to clear the cervical spine ?
- Cervical spine injury usually happened in all trauma patients until proven
otherwise
- Cervical spine clearance defined as confirming the absence of cervical spine
injury
- Important to clear the cervical spine and remove the collar in an
efficient manner
- delayed clearance associated with increased complication
- Cervical spine clearance can be determined by taking a history , physical
examination and radiology study.
HISTORY ( Details of accident )
- Energy of accident
- Higher level of concern when there is a history of high energy trauma as
indicated by
- MVA at > 35 MPH
- fall from > 10 feet
- closed head injuries
- neurological deficit referable to cervical spine
- pelvis and extremity fracture
- Mechanism of accident
- eg. elderly person falls and hits forehead (hyperextension injury)
- eg. patient rear-ended at high speed (hyperextension injury)
- Condition of patient at scene of accident
- general condition
- degree of consciousness
- presence or absence of neurological deficits
- Identify associated conditions and comorbidities
- ankylosing spondylitis (AS)
- diffuse idiopathic skeletal hyperostosis (DISH)
- previous cervical spine fusion (congenital or acquired)
- connective tissue disorders leading to ligamentous laxity
Physical Examination
1st survey
- A, B, C , perform the visual and manual inspection of entire spine (manual inline
traction , seat belt sign (abdominal ecchymosis) )
2nd survey (cervical spine examination)
- remove immobilization collar
- examine face and scalp for evidence of direct trauma
- inspect for angular or rotational deformities in the holding position of the
patient’s head
- palpate posterior cervical spine looking for tenderness along the midline or
paraspinal tissues
- log roll patient to inspect and palpate entire spinal axis
- perform careful neurologic exam
CLINICAL CERVICAL CLEARANCE
- Removal of cervical collar without radiographic studies allowed if
- patient is awake, alert and not intoxicated
- no neck pain, tenderness or neurologic deficits
- no distracting injuries
TREATMENT and COMPLICATIONS
- Non-operative
- Cervical collar
- Indication: initiated at scene of injury until directed examination
performed
- Early active range of motion
- Indications : “whiplash-like” symptoms and cleared from a serious
cervical injury by exam or imaging
- Complications of delayed clearance
- Increased risk of aspiration
- inhibition of respiratory function
- decubitus ulcer in occipital and submandibular area
- increase in intracranial pressure
How to determine either the patient need radiography or
not to rule out the cervical spine injury ?

By using the CANADIAN C-SPINE RULE AND

NEXUS CRITERIA
Canadian C-spine rule VS NEXUS criteria
Canadian C-spine rule
- sensitivity ranged from 0.90 to 1.00 and specificity ranged from 0.01 to 0.77.

NEXUS (National Emergency X-Radiography Utilization Study) criteria

- sensitivity ranged from 0.83 to 1.00 and specificity ranged from 0.02 to 0.46.

One study directly compared the accuracy of these 2 rules using the same cohort and
found that the Canadian C-spine rule had better accuracy.
CANADIAN C-SPINE
RULE
 NEXUS CRITERIA
Midline Cervical Tenderness

● Present if pain is elicited on palpation of the posterior cervical midline from the nuchal ridge to the prominence of the first thoracic
vertebra, or if pain is reported on palpation of any cervical spinous process

Altered mental status

● Glasgow Coma Scale ≤14

● Disorientation to time, place, person or events
● Inability to remember three objects at 5 minutes
● Delayed or inappropriate response to external stimuli

Focal Neurologic Deficit

● Any patient-reported or examiner-elicited neurologic deficit

Evidence of Intoxication

● Recent history reported by the patient or an observer of intoxication or intoxicating ingestion

● Evidence of intoxication on physical examination, such as odour of alcohol, slurred speech, ataxia, dysmetria, or other cerebellar
findings
● Behaviour consistent with intoxication
● Tests of bodily secretions are positive for drugs (including but not limited to alcohol) affecting mental alertness

Painful distracting injury

● Any condition thought by the clinician to be producing pain sufficient to distract the patient from a cervical spine injury. Examples
may include:
a. any long bone fracture
b. a significant visceral injury
c. a large laceration, degloving injury, or crush injury
d. extensive burns
e. any other injury producing acute functional impairment

- If met all the low risk criterias above , radiography must be done
- If not , cervical collar can be removed and radiography is not needed
DAMAGE CONTROL RESUSCITATION
Definition : A systematic approach to the management of the trauma patient with severe
injuries that start in the emergency room and continues through the operating room and
the intensive care unit (ICU)
It involves:
- Permissive hypotension
- Haemostatic resuscitation
- Damage control surgery
DCM aims to maintain circulating volume, control haemorrhage and correct the ‘lethal
triad’ of coagulopathy, acidosis and hypothermia until definitive intervention is
appropriate.
Permissive Hypotension
- Is the practice of restricting fluid resuscitation in trauma patient. Target of BP
being between 50-70mmhg, and never reaching normotension.
- Why never reach normotension?
- Aggresive fluid resuscitation can cause more blood loss.
- Achieving 80mmhg and above can disrupt coagulation process and dislodge
body’s normal natural mechanism of stopping bleeding ( read:blood clots )
- Fluid resuscitation can dilute coagulation factors that help form and stabilise a
clot.
- Hypothermia (if fluids not warmed first) , can aggravate factors if body
temperature drops.
But
- Good to note it is only a temporary measure (<90 minutes)
- Contraindications are patients with preexisting hypertension since they are more
likely to experience hypoperfusion. Patients with IHD , their hearts may not be able
to keep up with increased need of pumping, can lead to myocardial infarction.
- Also CI in cerebrovascular disease and can compromise the renal function.
Haemostatic resuscitation
Is a key component of damage control resuscitation.
- It involves using blood components resembling whole blood
- In ratio 1 : 1 : 1 of RBC : FFP : platelets
- There is 3 aims in haemostatic resuscitation
- maintain circulating volume
- limit ongoing bleeding
- prevent lethal triad of hypothermia , acidosis and acute coagulopathy of trauma.
RATIONALE
- Correct hypothermia
- decreases plate tile responsiveness
- alter fibrinolysis

- Correct Acidosis
- pH strongly affects activity of factors V, VIIa and X
- acidosis inhibits thrombin generation and
- CVS effects of acidosis (pH <7.2) - decreased contractility and CO , vasodilation and hypotension,
bradycardia and increased dysrhythmias

- Treat coagulopathy early and aggressively

- coagulopathy occur early after trauma
- so using higher FFP to PRBC ratios (from 1:1 to 2:3) is associated with improved survivals
Why do they use blood products instead of using the isotonic crystalloid fluid ?
- Large volume of crystalloids can lead to dilutional coagulopathy
- crystalloids have no O2 carrying capacities, so cannot correct the anaerobic
metabolism.
- Need less volume of blood products therefore likely to be less tissue and organ (eg.
lung , small intestine mucosa) oedema and failure (eg. pulmonary oedema ,
abdominal compartment syndrome)
 Damage Control Surgery

It involves limited surgical interventions to control haemorrhage and minimize

contamination until the patient has sufficient physiological reserve to undergo definitive
interventions
RATIONALE
- management of the metabolic derangement of ongoing bleeding supersedes the need
for definitive surgery
- abbreviated operations that control haemorrhage and contain spillage from the
alimentary and urogenital tracts
- able to do a rapid transfer to ICU for correction of acidosis, coagulopathy and
hypothermia (ongoing haemostatic resuscitation)
BENEFITS
- maintain normothermia
- less coagulopathy
- improve survival
REFERENCES
- https://www.orthobullets.com/spine/2012/cervical-spine-trauma-evaluation
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3494329/#:~:text=For%20the%20Ca
nadian%20C%2Dspine,ranged%20from%200.02%20to%200.46
.
- https://www.racgp.org.au/afp/2012/april/cervical-spine
- https://litfl.com/damage-control-resuscitation/
 Triad of Death/Lethal Triad,
Massive Blood Transfusion &
Crystalloids vs Colloids Controversy
MUHAMMAD SYUKRI KARIEM BIN MOHD ASRI
012018100136

MUHAMMAD RIDWAN BIN HAIRUSSALEH

012018100030
Triad of Death /
Lethal Triad
Triad of Death / Lethal Triad
 Hypothermia

Complications
Defined as core body temperature less than 35˚C

Hypothermia in trauma patient may result from:

● Patient net heat loss
● external exposure
● open body cavities
● cold fluid administration during
resuscitation
 Acidosis
Defined as arterial pH < 7.35

Results from lactate overproduction from ischaemic tissues through anaerobic

metabolism

Acute blood loss As perfusion worsens,

Impair oxygen delivery the lactic acid rapidly
& stimulate accumulates in
Tissue hypoperfusion
anaerobic metabolism tissues causing body
Peripheral producing lactic acid pH to drop leading to
vasoconstriction metabolic acidosis
 Coagulopathy
Temperature dependent In trauma-induced
enzymatic reactions in Resuscitation with crystalloids & coagulopathy, binding of
coagulation cascade become colloids thrombin and thrombomodulin
ineffective due to hypothermia lead to activation of protein C

Lead to reduced thrombin

Dilution of the coagulation
Platelets dysfunctions production by inhibit cofactor
factors as well platelets
factor V and VII

Coagulopathy
Massive Blood
Transfusion
 Massive Blood Transfusion

Defined by replacement of the whole blood volume within 24 hours, or 50% of the
blood volume in three hours.

Can occurs in settings such as, ruptured aortic aneurysms, severe trauma, surgery
and obstetrics complications

The main goals is to:

○ Early recognition of blood loss
○ Tissue perfusion & oxygenation maintenance
○ Blood volume & haemoglobin restorations
○ Arrest the bleeding with early surgical or radiological intervention
○ Usage of blood component therapy to correct the coagulopathy.
ABC Scoring System for Massive Transfusion

Score ≥ 2 is 75% sensitive and 85% specific for

predicting massive transfusion
 Trauma Associated Severe Haemorrhage (TASH) Score

● Suggestive for trauma patient to receive

blood through massive transfusion protocol
● Consider activating MTP if TASH score
more than 16
 Massive Transfusion Investigation & Monitoring
Parameters Aim Values
● Should be measured early Temperature ≥ 35 ℃
and frequently 30
minutes to 1 hour; or Acid base status pH ＞ 7.2, base excess < -6, lactate < 4 mmol/L
after blood component
transfusion Ionised calcium ＞ 1.1 mmol/L

Haemoglobin (Hb) Should not be used alone as transfusion trigger;

and, should be interpreted in context with
haemodynamic status, organ & tissue perfusion

Platelets ≥ 50,000/cc

PT/APTT ≤ 1.5x of normal

Fibrinogen ≥ 1.0 g/L

 Massive Transfusion Complications
● Due to fluid shift from the intravascular compartment that
DILUTIONAL leads to dilution of the coagulation factors during
THROMBOCYTOPENIA hemorrhagic shock
● Will further accentuated when the lost blood is replaced
with coagulation factor deficient fluids.

● Hypothermia or hypoperfusion due to massive blood loss

can lead to citrate toxicity due to decrease rate of citrate
CITRATE TOXICITY – metabolism.
HYPOCALCEMIA ● Unmetabolized citrate can bind with ionized calcium
leading fall in concentration of calcium in plasma. This can
lead to myocardial depression.

● Usually associated with patients who have underlying renal

HYPERKALEMIA insufficiency or renal failure or severe tissue injury
● Transient hyperkalemia is much more common when rates
of blood transfusion exceed 100 to 150 mL/min
 Massive Transfusion Protocol (MTP)

● Process of management of blood Consider activating MTP for:

transfusion requirements in major
bleeding episodes, assisting the ● Patient who require greater than 3 units
interactions of the treating clinicians and of blood in one hour (or anticipated)
the blood bank and ensuring judicious use ● Patient who loss more than 50% blood
of blood and blood components volume within 3 hours
● If heart rate/ systolic blood pressure
>1.4 (shock index)
● Patient who meet the ABC scoring (2/4)
Crystalloids vs Colloids
Controversy: Which
better in resuscitation?
 CRYSTALLOIDS
● It is aqueous solutions of ions (salts) with or without glucose that help in increase
intravascular volume.
● Initial resuscitation fluid in hemorrhagic and septic shock, burn, head injury, and patients
undergoing plasmapheresis and hepatic resection.
● For primary loss of water: hypotonic solution (maintenance-type solutions).
● For both water and electrolytes loss: isotonic electrolyte solution (replacement-type
solutions).
● Glucose provided to maintain tonicity, prevent ketosis and hypoglycemia.
 TYPES OF CRYSTALLOIDS
● Lactated Ringer’s solution. (commonly ● Normal saline(isotonic) - hypochloremic
used) metabolic alkalosis and for diluting packed
○ Although slightly hypotonic, it has red blood cells prior to transfusion
least effect on extracellular fluid ● Five percent dextrose in water (D5W)
composition and become a solution ○ replacement of pure water deficits and
if large volumes are necessary. as a maintenance fluid for patients on
○ Converted to bicarbonate in liver. sodium restriction
○ isotonic
● Hypertonic 3% saline - for severe
symptomatic hyponatremia
 COLLOIDS

● May be included in resuscitation efforts following initial administration of

crystalloids solutions.
● Indications: fluid resuscitation in severe intravascular fluid deficits prior for blood
transfusion, severe hypoalbuminemia, large protein losses(burn).
● Many clinicians use colloid in conjunction with crystalloids when fluid replacement
> 3-4L
● Colloid should prepared in normal saline and thus can cause hyperchloremic
metabolic acidosis.
● Blood derived colloids include albumin and plasma protein fraction.
● Synthetic colloids include dextrose starches and gelatins.
 Crystalloids vs Colloids
● Fluid therapy should be based on the specific needs of each individual patient.
● Colloids are in most situations to be preferred when the main indication is to increase
intravascular volume.
● Albumin may be contraindicated in case of suspected increased capillary
permeability due to SIRS.
● Crystalloids are needed for correction of extravascular fluid derangements.
● In conclusion, fluid resuscitation with either crystalloids or colloids must be
individualized.
REFERENCES
● Morgan & Mikhail’s Clinical Anesthesiology 5th Edition
● https://www.ncbi.nlm.nih.gov/books/NBK499929
● https://www.slideshare.net/zorzisandro/trauma-lethal-triad
● https://persysmedical.com/blog/hypothermia-prevention/trauma-triad-of-death/
AIRWAY MANAGEMENT IN
TRAUMA PATIENT
Nurnadia Mohammad Aminullah
012018100006
 OUTLINES
● Introduction
● Difficult airway algorithm
● Indications of Emergency Airway Managememnt
● Approach to the airway
- Assessment of difficulty
- Special clinical considerations
A. Injury to the airway
B. Traumatic brain injury
C. Cervical spine injury
D. Chest trauma
E. Shock
● References
Important areas of trauma care for anaesthesiologist

● Initial resuscitation

● Airway management

● Induction of general anaesthesia

● Management of acute and massive bleeding

Introduction
● Trauma to the face and neck can cause airway compromise (life-threatening situation)

● The American Society of Anaesthesiologist (ASA) algorithm for the management

of difficult airways in trauma patients can be used
● However, some modifications have been made to adapt it to unstable trauma patients,
where reawakening of the patient is not an option because the need for emergency
Difficult Airway Algorithm
 Approach to the Airway
1. Assessment of difficulty
2. Special clinical considerations
A. Injury to the airway
B. Traumatic brain injury
C. Cervical spine injury
D. Chest trauma
E. Shock
 1. Assessment of Difficulty
● Difficult airway:
1. Difficult laryngoscopy
2. Difficult BMV
3. Difficult EGD
4. Difficult cricothyrotomy

Methods of Airway Assessment

 Difficult laryngoscopy: LEMON Difficult BMV: MOANS
M Mask seal/ male sex/ Mallampati
Look Injury, incisors, large tongue, beard

Evaluate 3-3-2 finger breadth measurement O Obesity/obstruction

Inter incisor - Floor of mandible - Thyroid
to mandible

A Age > 55 years

Mallampati Score ≥ 3

N No teeth
Obstructio Any condition causing obstruction
n

S Stiff / snoring
Neck Limited neck mobility

Difficult EGD: RODS Difficult Cricothyrotomy: SMART

R Restricted mouth opening S Surgery (recent/remote)

M Mass
O Obstruction / obesity

A Access / Anatomy
D Disrupted / Distorted airway
R Radiation (and other deformity or scarring)
S Stiff
T Tumor
 2. Special Clinical Considerations
A. Injury to the airway

● Direct airway injury may be the result of:

- Oral & maxillofacial trauma
- Blunt or penetrating anterior neck trauma
- Smoke inhalation

● Patients with signs of significant airway compromise: The urgency for

intubating and risk of using neuromuscular blockade are high

● Modest symptoms: More time to plan and execute the airway intervention

● Delay of management is not advisable

 2. Special Clinical Considerations
B. Traumatic Brain Injury

● Any trauma patient with altered level of consciousness must be considered to

have a traumatic brain injury (TBI) until proven otherwise
● Assessment tool: Glasgow coma scale (GSC)
● When neurologic status is altered, neurologic examination is important before
intubation is undertaken
● In severe TBI, prevention of secondary injury, that is, minimizing the
magnitude and duration of hypoxia or hypotension is important
● Secondary injury is the term applied when the insult to the injured brain is
worsened by hypoxia, hypotension or both
 2. Special Clinical Considerations
C. Cervical Spine Injury
● Any blunt trauma patients are assumed to have cervical spine injury until proven
otherwise
● In line immobilisation of the cervical spine is very important to be maintained at all
times (esp laryngoscopy and intubation)
● Four providers are required to intubate

Nurse 1: Hold the neck, and Intubating physician: Hold the Nurse 2: Maintain the Physician 2: Administer
provide in-line cervical mask, perform laryngoscopy, cricoid pressure the anaesthetic
stabilisation intubation and ventilation medications
● Once the airway has been secured, the neck immobilisation devices should be
returned in position
● To prove cervical spinal injury: a lateral radiograph is needed before
intubation (unless in urgent airway management)

● To maximize success when intubating:

- Perform gentle intubation, using a video laryngoscope
- In-line cervical stabilisation by second provider
- BURP maneuver (to improve visualisation of the glottis during DL without
compromising spine stabilisation)
- Jaw thrust
- Cricoid pressure (sellick’s maneuver)
Manual in-line immobilization
Jaw thrust Cricoid pressure (Sellick’s
maneuver)

BURP maneuver
 2.Special Clinical Considerations
D. Chest Trauma

● Blunt and penetrating chest trauma

● Pneumothorax, hemothorax, flail chest, pulmonary contusion, open chest

wounds all impair ventilation and oxygenation

● Preoxygenation may be difficult or impossible

● Rapid desaturation following paralysis is the rule

 2. Special Clinical Considerations
E. Shock
● Shock in multiple injured patient: haemorrhagic or non-haemorrhagic

● Non-hemorrhagic: tension pneumothorax, pericardial tamponade, myocardial

contusion, spinal shock

● To identify the causes:

- Targeted physical examination
- Selective bedside testing (chest x-ray, pelvic x-ray, and e-FAST)

● As the causes of the shock are elucidated and addressed, airway

management decisions must consider the erosion of hemodynamic reserve in
these patients
 REFERENCES
● Manual of Emergency Airway Management 4th Edition by M.D. Walls, Ron M.,
M.D. Murphy, Michael F.
● Morgan and Mikhail's Clinical Anesthesiology, 6th edition 6th Edition by John Butterworth,
David Mackey, John Wasnick
● Anaesthesia for trauma patients by Ortega-Gonzalez M.
● Lecture notes on clinical anaesthesia / Carl L. Gwinnutt.—2nd ed
ANAESTHESIA IN
TRAUMA PATIENT

NUR SHAFIKAH BINTI MUHAMMAD IDRIS

(012018100070)
 OUTLINE:
CEREBRAL CHOICE OF
INTRODUCTION TO ANAESTHETICS AGENT
PROTECTION AND
CEREBRAL ISCHEMIA IN TRAUMA PATIENTS
RESUSCITATION
 Brain ischemia
Def: a condition that occurs when there isn't enough blood flow to the brain to meet metabolic demand

Type:

a) Global ischemia : Global ischemia is characterized by a complete cessation of CBF (eg : cardiac arrest )
b) Focal ischemia : characterized by a region of dense ischemia (the so called “core ”) that is surrounded by
a larger variable zone that is less ischemic (the penumbra)
 Pathophysiology of cerebral ischemia
Interruption in cerebral perfusion, metabolite substrate and severe hypoxemia effect functional impairment of
brain and clearance of toxic metabolites

During ischemia, intracellular potassium ↓, intracellular sodium ↑, intracellular calcium ↑ d/t

failure of ATP-dependent pumps

Sustained ↑ in intracellular calcium initiate structural damage to neurons.

Free fatty acid concentration leads to formation of prostaglandin and

leukotrienes which responsible for cellular injury

Reperfusion to ischemic tissue cause tissue damage d/t

formation of oxygen derived free radicals.
CEREBRAL BLOOD FLOW METABOLISM
● Most of cerebral oxygen consumption (60%) is used in generating adenosine triphosphate (ATP) to
support neuronal electrical activity
● CBF varies with metabolic activity.
● The cerebral metabolic rate (CMR) is usually expressed in terms of oxygen consumption (CMRO2)
● Total CBF average 50ml/100 g/min
○ CBF is altered
- 20–25 mL/100 g/min - cerebral impairment
- 15 and 20 mL/100 g/min - flat (isoelectric) EEG
- 10 mL/100 g/min - irreversible brain damage.
 Extrinsic mechanisms
Regulation of CBF
● Respiratory Gas tensions
- CBF is directly proportional to PaCO2
between tensions of 20 and 80 mm Hg
- Only marked changes in PaO2 alter CBF
Intrinsic mechanisms ● Temperature
- CBF changes 5–7% per 1°C change in
● Cerebral perfusion pressure (CPP) temperature
● Auto regulation ● Viscosity
- A decrease in hematocrit decreases viscosity
and can improve CBF
- a reduction in hematocrit also decreases the
oxygen-carrying capacity and thus can
potentially impair oxygen delivery
● Autonomic influences
- Intense sympathetic stimulation induces
marked vasoconstriction in these vessels, which
can limit CBF.
 CEREBRAL PERFUSION PRESSURE AUTOREGULATION

- CPP is the difference between mean arterial - The brain normally tolerates wide swings in blood
pressure (MAP) and intracranial pressure (ICP) MAP pressure with little change in blood flow
– ICP (or CVP) = CPP.
-Changes in MAP will lead to transient changes in
- CPP is normally 80–100 mm Hg CBF

- Moderate to severe increases in ICP (> 30 mm Hg) - Normal MAP - 60 and 160 mm Hg
can significantly compromise CPP and CBF
- Beyond these limits, blood flow becomes pressure
dependent

- Pressures above 150–160 mm Hg can disrupt the

blood–brain barrier and may result in cerebral edema
and hemorrhage
 CEREBRAL PROTECTION AND RESUSCITATION
CEREBRAL PROTECTION : CEREBRAL RESUSCITATION

- Methods attempt to reduce the effects of - Therapeutic interventions after an ischemic

event
cerebral ischaemia and damage , in order to
- Treatment of ischemia and reducing neuronal
improve neurological outcomes injury.
- Prevention of cerebral neuronal damage
NON-PHARMACOLOGICAL TREATMENT
● Maintain normothermia
● Therapeutic Hypothermia
● Avoidance of hyperglycemia
● Prevention of
- Hypotension
- Hypoxia
- Hypercapnia
● Hemodilution
● Prevent from increased ICP
● Correction of acidosis and electrolyte imbalance
CHOICES OF ANAESTHETIC AGENTS IN TRAUMA
PATIENT
Medication for initial management

- Agitation, pain and seizure may potentially contribute to elevation in intracranial pressure (ICP),
BP and body temperature Analgesia, sedative and anticonvulsant are administered to treat
these conditions
- Diuretic may be used to control raised ICP.
- Intravenous (IV) fluid is administered to restore and maintain the systemic and cerebral perfusion.
Analgesia & used in patients with severe head injury who are intubated and ventilated
sedatives - commonly administered in adults with head injury for one or more of the following indications:
➔ to induce anxiolysis
➔ to control pain
➔ to facilitate mechanical ventilation
➔ to improve ICP

- In mild to moderate head injury:

● analgesia : used to control pain
● short-acting sedative agents : offered in titrated dose to control agitation/ restlessness

Anticonvulsant ● phenytoin is the first line treatment in convulsant

● IV prophylactic Phenytoin administered within 8 hours of head injury

Diuretics ● Mannitol is widely used in the control of raised ICP following brain injury.
(mannitol) ● Diuretics should not be used in hypotensive patients.

Intravenous (IV) • Restoration and maintenance of the systemic and cerebral perfusion
fluid • Isotonic crystalloid is the preferred choice of intravenous fluid in head injury.
 Pharmacological therapy : inhalation agents
1. Volatile anaesthetics - Desflurane, Halothane , Isoflurane
Cerebral Metabolic Rate ● Isoflurane produce maximal depression in cerebral metabolic rate
(CMR)

Cerebral Blood Flow (CBF) • Anaesthetics dilate cerebral vessels and impair autoregulation
• Halothane has greatest effect on cerebral blood flow

Cerebrospinal fluid Dynamic • Formation and absorption of CSF.

• eg: Isoflurane - facilitates absorption

Intracranial Pressure (ICP) • Immediate change in cerebral blood flow

• Delayed alteration on CSF dynamics
• isoflurane and sevoflurane is the drug of choice in patients with reduce
intracranial compliance

2. Nitric Oxide
• Influenced by other agents or changes in carbon dioxide tension.
• When combined with intravenous agents, nitrous oxide has minimal effects on CBF, CMR, and ICP
• Adding this agent to a volatile anesthetic can further increase CBF. When given alone, nitrous oxide causes mild cerebral
vasodilation and can potentially increase ICP
 Pharmacological therapy : Intravenous agents
AGENTS MECHANISM OF ACTION

1. INDUCTION AGENTS

Barbiturates • Hypnosis • Reduction in cerebral blood flow

• Depression in cerebral metabolic rate • Reduction in Anticonvulsant activity

Opioids • Minimal effect on cerebral metabolic rate, cerebral blood flow and ICP
• MORPHINE – slow CNS penetration and prolonged sedative effects

Etomidate • Decrease cerebral metabolic rate, cerebral BF and ICP

• Limited effect on brainstem
• Decrease production & enhance absorption of CSF

Propofol • It has significant anticonvulsant activity.

• Short half-life
• Used as maintenance of anaesthesia in patient with intracranial hypertension

Benzodiazepines • Reduce cerebral metabolic rate and cerebral blood flow

• Midazolam – is drug of choice d/t its short half-life

Ketamine • Only drug – dilates cerebral vessels and increase blood flow
 AGENTS MECHANISM OF ACTION

2. ANAESTHETIC ADJUNCT

IV Lidocaine • Decrease cerebral metabolic rate, cerebral blood flow and ICP
• Neuroprotective effect

Droperidol • Reduces cerebral BF

• Cause prolonged sedation

3. VASOPRESSORS
- With normal autoregulation and intact BBB, vasopressors increase cerebral BF

4. VASODILATORS
- Induce cerebral vasodilation and increase CBF in a dose-related relationship
REFERENCES :
1.CPG Early Management of Head Injury in Adults
2.Morgan & Mikhail’s Clinical Anaesthesiology, 5 th Edition
3.http://aiimsnets.org/NeurosurgeryEducation/GeneralNeurosurgery/Cerebral%20Protection_new/Ce
rebral%20Protection.pdf
4.https://www.slideshare.net/RASHIDAMABUELHASSAN/brain-resuscitation-29411171
5.https://www.slideshare.net/kumarhot48/mechanisms-of-cerebral-injury
6.https://www.slideshare.net/anaest_husm/neuromonitoring-and-cerebral-protection-strategies-15114
553
7.https://www.scribd.com/document/410030043/Anaesthesia-for-Trauma-Patients