Dr Supriya Gajendragadkar

P.D.Hinduja Hospital & MRC

Mumbai
Physical harm or damage to body due to
acute exchange of mechanical, thermal or
other environmental energy that exceeds the
bodys tolerence
Morbidity
Mortality
Financial burden
Prevention: Helmets, high risk behavior, seat
belts+ airbags, substance abuse
Prehospital
Rapid transport to appropriate facility
Clinical shock if not resuscitated and
reversed within one hour, survivability
drops below 10%
Administering
Anaesthesia
Critical Care
Physician
Pain
Specialist
Pre hospital
Care
Physician
Trauma team
member
ATLS

ABCDE pneumonic

AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE
Verification of adequate airway and acceptable
respiratory mechanics is of primary importance

Hypoxia is the most immediate threat to life

Inability to oxygenate a patient will lead to
permanent brain injury and death within 5 to 10
Minutes

Direct injury to the face, mandible, or neck
Hemorrhage in the nasopharynx, sinuses, mouth, or
upper airway
Diminished consciousness secondary to traumatic
brain injury, intoxications
Aspiration of gastric contents or a foreign body
(e.g., dentures)
Misapplication of an oral airway or endotracheal
tube (esophageal intubation)

Diminished respiratory drive secondary to traumatic
brain injury, shock, intoxication, hypothermia, or
oversedation
Direct injury to the trachea or bronchi
Pneumothorax or hemothorax, pulmonary
contusion
Chest wall injury, Cervical spine injury
Bronchospasm secondary to aspiration / inhalation
of smoke or toxic gas

Assume a cervical spine injury in any
patient with multisystem trauma,
especially with an altered level of
consciousness or a blunt injury above the
clavicle
Trauma patients are always considered to have full
stomach
Ingestion of food or liquids before injury
Swallowed blood from oral or nasal injury
Delayed gastric emptying
Administration of liquid contrast medium

Reasonable to administer nonparticulate antacid
prior to induction
All blunt trauma victims should be assumed to have an
unstable cervical spine until proven otherwise

Direct laryngoscopy causes cervical motion and the potential
to exacerbate spinal cord injury

An uncleared cervical spine mandates In-line Stabilization
(Not Traction)

The front of the cervical collar may be
removed for greater mouth opening
and jaw displacement

Same monitoring standards for airway management in the
emergency department or casualty as in the OR, an
electrocardiogram (ECG), blood pressure, oximetry, and
capnometry.

Modified rapid-sequence approach using Selicks manouvre
by an operator with experience in this practice.

Emergency Awake Fiberoptic Intubation
Requires less manipulation of the neck
Generally very difficult
Airway Secretions
Hemorrhage
Rapid Desaturation
Lack of Patient cooperation
Indirect video laryngoscopy with Bullard laryngoscope
or GlideScope or videolaryngoscope offer the potential
to enjoy the best of both worlds: an anesthetized
patient and minimal cervical motion.

The front of the cervical collar is removed once in-line manual stabilization
of the spine is established to allow cricoid pressure and greater excursion of
the mandible. Generallt 4 operators are required.
Dutton RP: Spinal cord injury. Int Anesthesiol Clin 40:111, 2002
ILMA
LMA C Trach
McGrath
Videolaryngoscope
McCoy blade
Tracheostomy tubes
Cardiac or respiratory arrest
Respiratory insufficiency
Airway protection
The need for deep sedation or analgesia, up to and
including general anesthesia
Transient hyperventilation of patients with space-
occupying intracranial lesions and evidence of
increased intracranial pressure (ICP)
Delivery of a 100% fraction of inspired oxygen (FIO
2
)
to patients with carbon monoxide poisoning
Facilitation of the diagnostic workup in uncooperative
or intoxicated patients

Tracheostomy tubes

If not available:
14 / 16 G Jelco
Emergency airway management algorithm used at the R Adams Cowley Shock Trauma Center
Clinical diagnosis inadequate organ
perfusion & tissue oxygenation
Etiology of Shock
1. Haemorragic
2. Non haemorragic
Cardiogenic shock
Tension pneumothorax
Neurogenic shock
Septic shock
Shock is presumed to result from hemorrhage
until proved otherwise.

Pallor
Diaphoresis
Agitation or Obtundation
Hypotension
Tachycardia
Prolonged Capillary Refill
Diminished Urine Output
Narrow Pulse Pressure

Goal of therapy is restoration of organ perfusion & adequate
tissue oxygenation
Assessment of the circulation
an early phase, during active hemorrhage, and
late phase, which begins when hemostasis is achieved and
continues until normal physiology is restored.
Vascular Access :
Peripheral lines: 2 large bore, short 16G preferred
Central lines
Interosseous route in children <6 years


Maintain
systolic blood pressure at 80 to 100 mm Hg
hematocrit at 25% to 30%
prothrombin time and partial thromboplastin time in normal ranges
platelet count at greater than 50,000 per high-power field
normal serum ionized calcium
core temperature higher than 35C
function of the pulse oximeter
Prevent
an increase in serum lactate
acidosis from worsening
Achieve adequate anesthesia and analgesia

Class I Class II Class III Class IV
Bld loss ml <750 750-1500 1500-2000 >2000
Bld loss %BV <15% 15-30% 30-40% >40%
Pulse <100 >100 >120 >140
BP N N D D
PP N D D D
RR 14-20 20-30 30-40 >35
U/O ml/hr >30 20-30 5-15 Negligible
Mental state Anxious Anxious
Anxious &
confused
Confused &
lethargic
IVF Crystalloids Crystalloids C & Blood C & Blood
Order of Desirability

Large-bore (16g or greater) antecubital vein
Other large-bore peripheral veins
Subclavian vein
Femoral vein
Internal jugular vein (Requires removal of cervical collar
and neck manipulation)
Intraosseous (Tibia or distal end of femur)
Active fluid administration up to 1500 ml/min
Compatible with crystalloid, colloid, RBC, plasma,
washed/salvaged blood (Not platelets)
Reservoir allows for mixing of products
Controlled temperature (38-40C)
Able to pump through multiple IV lines
Fail safe detection system to prevent infusion of air
Accurate recording of volume administered
Portable to travel with patients between units

PRBC vs Whole Blood
Fully crossmatched blood preferable
Type specific or saline crossmatched or quick spin only in life
threatening emergency
If no crossmatching is available, unmatched type sp blood
preferred over type O blood. Rh negative cells are preferred
PRBC administered thru Blood filters: Macropore (160 microns)
Use blood warming devices if possible

Autotransfusion of shed blood
Blood components: FFP, Platelets as guided by the
coagulation tests
Platelet transfusion only if level <50,000
Platelets should be empirically administered in proportion
to RBCs and plasma (1:1:1).
Platelets should not be administered through filters,
warmers, or rapid infusion systems because they will bond
to the inner surfaces of these devices
Noncardiogenic pulmonary oedema resulting from immune
reactivity of certain leukocyte antibodies a few hours after
transfusion.
Signs and symptoms appear 1 to 2 hours after transfusion
and peak within 6 hours.
Hypoxia, fever, dyspnea, and even fluid in the endotracheal
tube may occur.
Therapy
Stop transfusion, fluid restriction, ionotropes
critical care supportive measures.
Most patients recover in 96 hours, although TRALI is 1 of the
top 3 most common causes of transfusion-related deaths.


RCT, penetrating torso trauma, urban center:
n =598
Excluded head injury
Std of care: 2 L crystalloid prehospital vs delayed
resuscitation: no fluid until OR
mortality, LOS + complications in std of care vs.
delayed group
RCT, blunt + penetrating trauma pts w SBP < 90, n =
110; excluded head injury
Gp 1- fluid resusc to SBP 100
Gp 2- fluid resusc to SBP 70
Identical survival: 93% despite ISS in gp 2 [23.9 v
19.5]
Lactate + base deficit cleared to normal in both gps
w similar amounts fluid + blood

Increased blood pressure
Decreased blood viscosity
Decreased hematocrit
Decreased Clotting factors
Greater transfusion requirements
Electrolyte imbalance
Direct immune suppression
Premature reperfusion
Resuscitation during acute hemorrhagic shock is
controversial, but current recommendations are to
maintain deliberate hypotension during active
bleeding by limitation of crystalloid infusion and to
emphasize maintenance of blood composition by
early transfusion of red blood cells, plasma, and
platelets.


Sevoflurane

Etomidate
Increased cardiovascular stability

Ketamine
Direct myocardial depressant
Catecholamine release
Hypertension/Tachycardia

Midazolam
Reduced Awareness
Hypotension

Propofol/Thiopental
Vasodilator, Negative Inotropic effect
May Potentate hypotension/Cardiac Arrest

Succinylcholine
Fastest onset <1 min
Shortest Duration5-10 min
Potassium increase 0.5-1.0mEq/L
Potassium increase >5mEq/L
After 24 hours
Safe in acute airway management
Burn Victims
Muscle Pathology
Direct Trauma
Denervation
Immobilization
Increase intraocular pressure
Increase ICP
Ventilation strategies

IPPV in the OR and ICU
Familiarity with weaning modes
NIPPV
CPAP post extubation

Invasive monitoring
Interpretation of Arterial Blood gases
Correction of electrolyte abnormalities
Eye Opening Response Motor Response
4=Spontaneous 6=Follows Commands
3=To Speech 5=Localizes to Pain
2=To Pain 4=Withdraws from Pain
1=None 3=Abnormal Flexion
(Decorticate Posturing)
Verbal Response 2=Abnormal Extension
5=Oriented to Name (Decerebrate Posturing)
4=Confused 1-None
3=Inappropriate Speech
2=Incomprehensible Sounds
1=None

Anesthetic Management
Avoidance of Hypoxemia
Intubation
Airway protection
Controlled Hyperventilation
Uncooperative/Combative Patient
GCS < 8
Control Hemodynamics
Avoid Hypotension
Fluid Administration
Vasopressors
Arterial Line

Management of Cerebral Circulation
Hyperventilation
PaCO2 at 35 mmHg
PaCO2 at 30 mmHg for episodes of elevated ICP
Mannitol
0.5-1g/kg
Barbiturate



Temperature
Avoid Severe Hypothermia
Do not warm aggressively
Hyperthermia increases CMRO2
Position Therapy
Elevation of Patients Head
Facilitate venous drainage
Lower ICP
Improved Ventilation/Perfusion

Epidural analgesia
pain relief
Prevent hypoxemia,
hypoventilation, the need
for tracheal intubation
Endotracheal intubation
unable to oxygenate or
ventilate
require protection of the
airway.
Flail chest
Fractured ribs
Haemothorax
Needle decompression
2
nd
intercostal space
ICD in 5
th
ICS
Precordial/Epigastric Wounds

Hypotension
Suspect Cardiac Injury
Airway Control Central Venous Lines
Volume Expansion Tube Thoracostomy
Hemodymanic Instability Hemodymanic Stability
Operating Capability In E.R.
Yes
No
Immediate TRT Relief of
Tamponade Cardiorrhaphy
Pericardiocentesis Intrapericardial
Catheter Constinous Aspiration
Operating Room Transfer
Subxiphoid Pericardial Window
Diagnosis Confirmed
Operating Room Transfer Definitive Casrdiorrhaphy
Control of Other Injuries Closure of Incision
Occurs in 80% multiple
trauma pts
Incidence ortho trauma =
2x thoracic 4x
abdominal
Team approach
Hemorrhage and shock
Compartment syndrome requires urgent fasciotomy.
Open injuries have very high risk of infections and
sepsis.
Crush injury muscle injury secondary to ischemia
causes myoglobinuria and may lead to acute renal
failure. Treatment includes crystalloid resuscitation,
osmotic dieresis, alkalization of urine, hemofiltration.

Restore perfusion + limb alignment
Debride open wounds
Repair traumatic amputations
Relieve compartment syndrome
Repair vascular + nerve injury
Treat pain

Thoracic Epidural analgesia for fractured ribs,
flail chest
Lumbar epidural for abdominal trauma /
fractures of the lower limbs
Regional nerve blocks
Femoral nerve block for knee joint injury
Brachial plexus blocks
IV Patient controlled analgesia (PCA)
Goals of analgesia, is provision of adequate medication to
facilitate physical therapy without so sedating the patient
that participation is impossible.

Careful titration of analgesics ideally in ICU.
Counselling
Early mobilization.
Neuropathic pain should be recognized and treated
accordingly.
Regional analgesia provided through an epidural or brachial
catheter preferred it will spare the use of systemic narcotics
and facilitate early mobilization.

Fat particles are identified in the pulmonary arteries in 90%
of patients with skeletal trauma.
Occurs 1224 hours after injury or with surgical manipulation
of long-bone fractures.
Delayed stabilization of long-bone or pelvic fractures and
surgical internal fixation of long-bone fractures with
intramedullary reaming.

Petechial rash, altered mental status, and respiratory
insufficiency. Minor nonspecific signs include tachypnea,
tachycardia, hypoxia, hypercapnea, and infiltrates on chest
radiography.
Treatment of FES is supportive, preventing FES and
maintaining a high index of suspicion for FES is critical.

Advantages

Allows continued assessment of mental status
Increased vascular flow
Avoidance of airway instrumentation
Improved postoperative mental status
Decreased blood loss
Decreased incidence of deep venous thrombosis
Improved postoperative analgesia
Better pulmonary toilet
Earlier mobilization
Disadvantages


Peripheral nerve function difficult to assess
Patient refusal common
Requirement for sedation
Hemodynamic instability with placement
Longer time to achieve anesthesia
Not suitable for multiple body regions
May wear off before procedure(s) conclude


Advantages
Speed of onset
Durationcan be maintained as long as needed
Allows multiple procedures for multiple injuries
Greater patient acceptance
Allows positive-pressure ventilation

Disadvantages
Impairment of global neurologic examination
Requirement for airway instrumentation
Hemodynamic management more complex
Increased potential for barotrauma


Thank you