Anesthetic Management for Multiple Trauma

Surgery

DSTC – BITDEC – BALI

 Epidemiology of Trauma

● Trauma is the leading cause of death in

the first four decades of life in most
developed countries.
● There are more than 5 million trauma-
related deaths each year worldwide.
● 3 patients permanently disabled per death
● Motor vehicle crashes cause over 1 million
deaths per year.
● Injury accounts for 12% of the world’s
burden of disease.
 TRAUMA

Tissue / Organ damage

Symphato – adrenal Pain

Response

Vital Function Disturb. Neuroendocrin-metabolic Psychologic

(A-B-C-D) Response Response
Trauma - Anestesia
ATLS
Airway
Breathing
Physical Gangguan Circulation
trauma Organ vital Disability/Brain
Env. control

Mati
Airway
Gangguan Breathing
Anestesia Organ vital Circulation
(Physiological trauma) Disability/Brain
Env. control

Anestesia is Life Support!

“Just bring them back alive”
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As trauma team, the role of the anesthesiologist in
multiple trauma cases are very complex

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Anesthesiologist’s role in multiple
trauma is to provide

 Life support
– to sustain patient’s life as the most important
priority throughout pre and postoperative period
 Anesthesia
– to enable the surgeon to operate to limit further
damage,
– and if condition permits, to do corrective surgery
 Alleviate suffering
– pain relief
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“Life Support” FIRST!

 The surgeon can operate only if the patient

remains alive throughout  First things first
 We must work systematically to provide
– A = airway  clear and keep it clear
– B = breath  give oxygen, assist breathing
– C = circulation  start infusion to improve blood flow,
stop the bleeding if at all possible
– D = disability  prevention of secondary brain injury
– E = exposure/Environment  caution missed injuries,
prevention hypothermia
LIFE Support Definitive Treatment

Surgery Neuro
Obsgyn
Anesthesiology
& Reanimation

Pulmo
Internal nology
Cardiology
Medicine

Integrated Emergency Medical Service

LIFE Support Definitive Treatment

Surgery
Anesthesiology
& Reanimation
Resuscitation Anesthesia Recovery

Stabilize Surgery Intensive Care

 O2 Airway

Breathing

Hb Hb
Cytosol + +
H H+ H
Circulation
c
III IV
I Q bc1 aa3
DH II Fo
TMPD
FADH ADP ATP
NADH
Substrates Succinate O2 +
H H
+

Matrix
Mitochondrial respiratory chain
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Cegah Hipoksemia
 Hypoxic Hypoxemia :
-FiO2 cukup, awas N2O, CO2
-jangan obstruksi airway
 Respiratoric Hypoxemia : jangan
hipoventilasi,maldistribusi, atelektasis, edema paru,
contusio pulmonum Va/Q mismatch
 Anemic Hypoxemia : Hb cukup
 Stagnant Hypoxemia : jangan syok, hipotensi, gagal
jantung
 Histotoxic Hypoxemia : awas sepsis, overdosis obat
 Demand Hypoxemia : febris, menggigil, gelisah,
meronta
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Airway management

Is tailored to :
 Type of injury
 Nature and degree of airway
compromise
 Patient’s hemodynamic
 Oxygenation and ventilation status
 Level of conciousness (LOC)
All traumatized airway patient should be
considered as potentialy difficult airway
How do I manage the airway of a trauma patient?
● Supplemental oxygen
● Basic techniques
Chin lift, jaw thrust, suctioning
● Basic adjuncts
Oro-naso pharyngeal tube
● Definitive airway
Cuffed tube in the trachea
ETT, Surgical airway
● Difficult airway adjuncts
● Unexpected difficult airway
● Predicted difficult airway
 Airway Management

Caution

Protect the cervical spine during

airway management!
Airway Decision Scheme
Methods for insertion of ETT
1. Awake intubation
– atropin, lidocain, (fentanyl)
2. Awake intubation with sedatives
– atropin, lidocain, sedatives, (fentanyl)
3. Asleep intubation non-apneic
– atropin, lidocain, more sedatives, (general
anesthesia, fentanyl)
4. Asleep intubation apneic
– atropin, lidocain, sedatives, NMBA, (general
anesthesia, fentanyl)

always think : Full Stomach

“What makes you think I am a new
anesthesia student?”
The compromised airway is always challenging

We can not simply follow the algorithm.

Daily experiences dictate how creativity matters22
 What is the problem ?
 Is the airway clear ?
 What is the risk ?
 How to secure
the airway ?
Time saving is live saving
Do Something !
O2

By Passing Transtracheal Airway

ETT
ETT
Difficult Airway / Mucosal Oedema
 Breathing Management

 Open the airway first → assess the breathing →

adequate or not ? Need assist ventilation and oxygen ?
 Several causes may alter breathing after trauma :
• Pneumothorax - tension
- open
- simple
• Hemothorax
• Flail chest
• Pulmonary contusion
• Diaphragmatic rupture
• Aspiration of blood, gastric contents
• Cardiac tamponade
• Cervical injury
Tension pneumothorax Flail chest
Multiple ribs fracture Pulmonary contusion
Needle thoracentesis and tube thoracentesis
Hemothorax massive

Lung colaps

Gun shot

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Penetrating chest
trauma

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 Circulation management

 Assess for organ perfusion / shock

 Control hemorrhage
 Restore volume
 Re assess patient
 Hemodynamic unstable:
 Surgical resuscitation immediately
 To stop the bleeding

 Hemodynamic stable → further diagnostic

procedures
 Oxygen Delivery

DO2= CO x Hb x SaO2 x 1.38

Freq x Stroke Volume Respiratory gas exchange

(Airway – Breathing)

Preload Contractility Afterload

Fluid Inotropes Vasoactives

therapy
 Blunt abdominal and chest trauma
 Unstable hemodynamic
 Surgical resuscitation immediately

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 Disability

 Basic neurological evaluation

• GCS / AVPU
• Pupillarry response
 Prevention of secondary brain injuries
 GCS < 9
• Intubation
• Adequate ventilation and oxygenation
• PaCO2 = 35 - 40 mmHg
• PaO2 = 90 - 100 mmHg
 CPP = MAP – ICP (CPP + 70 mmHg)
Patient required Asleep intubation apneic
smooth intubation.
Bucking, gagging,
coughing must
be avoided
to prevent
brain herniation.

Adequate dose
of thiopentone
or propofol
and full dose NMBA
+ lidocain +
fentanyl
 Exposure / Environment

 Undressed patient
 Log rolling
 Caution : missed injuries
 Prevention of hypothermia
 Triad of death : - Hypothermia
- Coagulopathy
- Acidosis
 Premedication

 Rarely indicated
Especially patient wirh:
• Hypovolemic / shock
• Head injured
• Decrease LOC
 If needed (with close monitoring vital signs)
 Small closes of opioid
• Morphin 1 – 2 mg/IV
• Fentanyl 25 – 50 mg/IV
 Small doses of sedative
• Midazolam 0,5 – 1 mg/IV
 Induction agents
 Thiopental 3-4 mg/kg; reduce doses in
unstable patients; most commonly used in
trauma
 Ketamine 0.5-1 mg/kg; useful for burn and
hypovolemic patients; avoid with head
injuried
 Etomidate 0.1-0.3 mg/kg; reduce doses
with hypovolemia; ? Myoclonus effects
 Propofol 1-2 mg/kg in stable patients;
reduce doses in hypovolemia
 Muscle relaxants
 Succinylcholine: 1-2 mg/kg; useful for RSI/emergency;
contraindicated burns; spinal cord injury and crush
injuries > 24-48 hours after injury
 May give non depolarizing dose prior to Sux to
inhibit fasciculations (esp. with SCI)
 Nondepolarizers
 Vecuronium 0.1 – 0.2 mg/kg; onset for intubation
2-3 min ; duration 45 – 60 min; good cardiovascular
stability without histamine release.
 Rocuronium 0.6 – 1.0 mg/kg ; onset for intubation
45-60 secs; duration 45 -60 min, usefull for RSI.
 Cisatracurium 0.15 – 0.2 mg/kg ; onset for
intubation 2 – 3 min, duration 45 – 60 min,
degraded by Hoffman elimination.
 Simple anesthesia is effective

 The necessities required by multiple trauma

patients are
– analgesia  fentanyl or low dose ketamine
– amnesia  midazolam
– muscle relaxant  if needed
– adequate oxygenation  just O2, no N2O
– stable blood pressure and normovolemia
– no increase in Intracranial Pressure
 Other things may come later
Remember !

Almost all anesthetics are :

 Respiratory depressant
 Cardiovascular depressant
 CNS depressant
 Thermo-regulatory depressant
 Neuroendocrin depressant
 Baroreceptor reflexes depressant

The best anesthesia is minimum anesthesia

 Quick in - quick out (damage control)
 Regional anesthesia if possible
 General anesthesia with special consideration
This man was admitted in severe shock. After 4 litres
of Ringer Lactate, BP remained low and Hb 6 gm/dL.
The surgeon urged us to start anesthesia ……..

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 In the operating room

Liver rupture grade IV

BLOOD & CLOT ± 3500 cc FROM INTRA ABDOMINAL

PRINGLE MANEUVER EVERY 15’  ACTIVE BLEEDING ± 2500 CC
 SHOCK HYPOVOL  CARDIAC AREST  CPR  ROSC
CONTINUOUS OPHYPOTHERMIA , COAGULOPATHY, ACIDOSIS  AS SOON AS
DAMAGE CONTROL & PACKING STOP OP
 Damage Control
Sequence PART III - OR
 pack removal
 definitive repair
PART I - OR
 control hemorrhage

 control contamination
Transfer problems
 intraabdominal packing

 temporary closure PART II - ICU

 core rewarming

 correct coagulopathy

 maximize hemodynamics

Transfer problems  ventilatory support

 injury identification
(tertiary survey)
Reoperation → Pack Removal

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 THINK DAMAGE CONTROL
 Core temperature : < 35 o C
 PH : < 7,2
 Base deficit :
• < -15 mmol/L (<55 years)
• < -6 mmol/L ( >55 years)
 Serum lactate : > 5 mmol/L
 Coagulopathy : PPT – APTT > 50% N
 Length of operation more than 90 minutes
 TRIAD
OF
DEATH

Moore EE Am J Surg,
1996, 172;405
Burch et.al (Surg.Clin.North.Am 1997;77;779-82)
 Batas suhu kritis 32 C
o

 Suhu < 32oC mortalitas 100%

 Suhu antara 36 C - 32 C:
o o

 Window of opportunirty to salvage patient

 Pada laparatomi dicapai dalam 60-90mnt
 Heat loss terutama dari rongga peritonium

yang terbuka
 Tak dapat diimbangi dengan cairan dan

matras hangat
 Segera tutup rongga peritonium/damage
control
WINDOW OF OPPORTUNITY 90 MINUTES
Simulation of heat loss during “damage control”

Operative Profiles
1 hour laparotomy at 21o C
36 90 minutes at 21o C
Core Temperature (C)

90 minutes at 24o C

Therapeutic
32 window

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0 30 60 90 120

Time (hours)
Post Operative

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Post Operative
 Observation of vital functions / organs
 Continue life support (ABCD)
 Continue organ support
 Treatment of hypothermia/rewarming
 Fluid and nutritional support
 Prevention of infection
 Pain relief → multi modal approach
 NSAID ?

 Narcotic IV / peridural

 Local anesthetic

• Peridural

 Psycho therapy and physio therapy

MULTI MODAL
THERAPY

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Always work
as a team!

Success
Thank you for your kind attention!

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