Trauma Anesthesia

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Author:
ariadne9
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270990
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Trauma Anesthesia
Updated:
2014-04-18 13:59:23
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BC Nurse Anesthesia
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trauma
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  1. 4 precepts of trauma anesthesia
    • 1) all are full stomachs
    • 2) partial airway obstruction can progress to complete obstruction
    • 3) all are hypovolemic
    • 4) all have c-spine injury until proven otherwise
  2. Hypotension 2/2 ____ is assumed in trauma pts until proven otherwise
    blood loss
  3. ABCDE of trauma (primary survey)
    • airway
    • breathing
    • circulation
    • disability
    • exposure
  4. Major goals of trauma anesthesia
    preserve: CNS function, adequate gas exchange, circulatory homeostasis
  5. Primary vs. secondary survey
    • primary- lifesaving treatment and rapid initial assessment
    • secondary- repair of injury, control of bleeding
  6. shock s/sx
    • hypotension
    • tachycardia
    • pallor
    • diaphoresis
    • agitation / obtundation
    • prolonged cap refill
    • narrowed pulse pressure
    • diminished urine output
  7. Why might a C1-C2 injury require nasal intubation
    DL may be contraindicated 2/2 fragile neck
  8. Airway techniques for unstable c-spine
    • inline neck stabilization
    • jaw thrust
    • prevent neck extension
  9. How is c-spine injury ruled out?
    • full LOC
    • CT scan
  10. Aspiration prophylaxis is not indicated in trauma pts, T or F?
    • F, trauma pts are always at risk for aspiration
    • use H2 antagonist and / or reglan to raise pH  and decrease volume of gastric contents
    • give 30-60 mins before intubation if possible
  11. How is inline neck stabilization performed?
    • Need 3 people
    • 1- hold head and neck neutral
    • 2- cricoid pressure
    • 3- intubate / DL
  12. 2 indications for emergent trach
    • massive disruption to floor of the mouth
    • disruption to larynx or cervical trachea
  13. Emergency airway algorithm
    • pre-oxygenate
    • cricoid pressure
    • inline neck stabilization
    • MR
    • DL attempt
    • Bougie
    • LMA
    • cricothyroidotomy
    • OR for definitive airway placement
  14. ____ventilation of head trauma pts is performed to ____ ICP
    • Hyper
    • reduce
  15. T or F, the degree of hypotension upon presentation to OR or ER has no relationship with mortality?
    F, directly correlates with mortality rate
  16. IV access for trauma pts
    • 2 large bore IVs (16 g)
    • Upper and lower extremities (dependent on injuries may not reach heart if vascular damage is present)
  17. What does the "D" in the trauma assessment mean?
    • Disability= neuro status
    • GCS
    • LOC
    • Full sensory and motor exam
  18. GCS
    • Assess eye opening (1-4)
    • Assess verbal response (1-5)
    • Assess motor response (1-6)
  19. GCS eye opening
    • 4- spontaneous
    • 3- to voice
    • 2- to pain
    • 1- nada
  20. GCS verbal response
    • 5- alert and conversant
    • 4- confused
    • 3- inappropriate speech
    • 2- incomprehensible sounds
    • 1- nada
  21. GCS motor response
    • 6- obeys commands
    • 5- localizes to painful stimuli
    • 4- withdraws to pain
    • 3- abn flexion (decorticate)
    • 2- abn extension (decerebrate)
    • 1- none
  22. What is involved in "E" in the primary trauma survey?
    • Exposure and secondary survey
    • Remove clothing and assess for occult injuries
    • H+P
    • Need for surgical treatment (immediate or delayed)
    • Potential for systemic infection
  23. T or F, open wounds or fractures do not need to be repaired immediately?
    F
  24. Leading cause of complications and death in trauma pts?
    Sepsis
  25. Cushing's triad
    • late and reliable signs of brain injury
    • precedes herniation
    • HTN
    • altered breathing pattern
    • bradycardia
  26. Mild TBI
    • GCS= 13-15
    • most common
    • 24 hour assessment
    • risk post concussive syndrome
  27. Honeymoon syndrome r/t TBI
    • occurs in elderly due to more compliant cranium
    • delay in s/sx
    • associated with mild TBI
  28. Moderate TBI
    • GCS= 9-12
    • need immediate CT
    • early intervention- intubation, ventilate
    • ? need for ICP monitoring
  29. Severe TBI
    • GCS <= 8
    • high mortality risk
    • rapid airway management
    • early rapid management focused on systemic homeostasis and perfusion of injured brain
  30. CBF _____ after TBI.
    • decreases
    • vasoreactivity is not always intact
  31. T or F, agents like mannitol are effective in a pt with TBI
    F, since they rely on an intact BBB they may not be effective due to disruption to BBB
  32. Goal PaCO2 for TBI
    35 mmHg
  33. T or F, PaO2 < 60 mmHg is associated with increased mortality in TBI pts?
    T
  34. T or F, hypocapnea has been shown to be helpful with TBI
    F, used only when interventions like barbs, sedatives, CSF drainage, or osmotic agents are ineffective
  35. Goal SBP, MAP, CPP for TBI
    • SBP > 110
    • MAP > 90
    • CPP >70 mmHg
  36. SCI to C3-5
    damage to phrenic nerves and potential apnea
  37. SCI to T1-4
    risk of bradycardia, hypotension, and CV collapse (cardioaccelerator fibers)
  38. Spinal shock
    • Loss of SNS motor tone below the level of injury
    • hypotension, bradycardia, GI atony, areflexia
    • may require aggressive fluid therapy in initial stages
    • possible venous distention in legs
  39. Sympathetic outflow originates from ____
    T1- L2
  40. Succ is safe for SCI pts for _____.
    • the first 48 hours post injury
    • contraindicated after due to risk of hyperkalemia
  41. Common s/sx associated with high cervical injuries
    • Hypotension
    • Bradycardia
    • due to disruption of SNS outflow from T1-L2, result is unopposed vagal tone and VD
  42. Autonomic dysreflexia
    • Associated with injuries above T5
    • Massive HTN, H/A, diaphoresis above the injury
    • Due to stimuli occurring below the injury
  43. When is nasal intubation contraindicated?
    • Basal skull fx
    • Lefort 2 or 3
  44. Considerations r/t facial trauma
    • ability to BMV
    • post-op maxillary fixation and nasal packing may make reintubation impossible
    • trach?
    • c-spine injury?
    • risk partial obstruction leading to complete obstruction
    • deep anesthesia to prevent coughing and moving
    • possible need for pt to remain paralyzed and intubated
  45. Why are facial traumas associated with fevers?
    Potential for bacteremia due to fractures thru paranasal sinuses
  46. Lefort 1
    • body of maxilla is separated from skull base above the palate and below the zygomatic processes
    • transverse
  47. Lefort 2
    • pyramidal
    • vertical fxs thru the maxilla extend up thru nasal and ethmoid bones
  48. Lefort 3
    • craniofacial dysjunction
    • fx extends thru frontozygomatic suture lines bilaterally, across the orbits, thru base of nose and ethmoid region
  49. Mandibular fractures
    associated with posterior tongue displacement causing airway obstruction
  50. Pneumothorax
    air btw parietal and visceral (inner) pleura
  51. Tension pneumo
    • ipsilateral lung collapses and tracheal and mediastinum are displaced to contralateral side
    • air forced into the thorax with inspiration and unable to escape during expiration
  52. Pneumo tx
    CT 4 or 5th IC space
  53. T or F, N20 is typically contraindicated in chest trauma cases
    T
  54. Flail chest
    • Segment of thoracic cage is separated from rest of chest wall
    • defined as at least 2 ribs / rib segment
    • unable to help expand lung volume
  55. T or F, a large amount of blood can accumulate in the abd before s/sx appear?
    T
  56. Major risks associated with abd trauma
    risk of sepsis from bacterial leakage
  57. Why can opening of the abdomen be associated with hypotension
    due to loss of tamponade
  58. Is an NGT ok to use with lefort fractures?
    No, OGT is acceptable however
  59. Is N20 acceptable to use with abd trauma?
    No
  60. Risk of lyte disturbance from massive transfusion
    • hyperkalemia (high K concentration in PRBCs)
    • hypocalcemia (citrate is used as an anti-coagulant, acts by chelating ionized Ca)
  61. Horner's syndrome
    • can occur with ISB, shoulder trauma
    • s/sx= ptosis (eyelid droop), miosis (pupil constriction)
  62. Fat embolism
    • associated with trauma to long bones or pelvis
    • may cause pulm insufficiency, dysrythmias, petecchiae, mental deterioration 
    • s/sx may occur 1-3 days after the event
  63. Anesthetic management for ortho trauma
    • GA preferred (length of case and HD control)
    • Avoid hyperventilation and use of VC (pts already max VC- limit already decreased perfusion to periphery)
  64. 1st degree burn
    epithelium only
  65. 2nd degree burn
    extends to dermis
  66. 3rd degree burn
    • full thickness
    • insensate
    • destroys nerve endings
  67. Rule of 9's: adult
    • each LE= 9%
    • both UE= 9%
    • trunk front= 18%
    • trunk back= 18%
    • head= 4%
  68. Rule of 9's: pedi
    • trunk front= 18%
    • trunk back= 18%
    • head= 18%
    • each LE= 14%
    • each UE= 9%
  69. Burn pts and use of succ
    • May be ok immediately post burn
    • Pts have proliferation of muscle Ach receptors
    • After 12-24 hours may have prolonged succ duration and hyperkalemia
  70. Burn pts and use of NDMR
    • rx to NDMR (proliferation of Ach receptors)
    • may require 3-5 x the usual dose
  71. Fluid replacement in burn injury
    • Mainly with crystalloid
    • Parkland or Brooke formula
    • 1/2 of calculated amount is given over 1st 8 hours, remainder given over next 16 hours
    • this is in addition to the pt's maintenance fluid requirements
  72. Parkland formula
    4 ml of LR / kg  / % TBSA burned = 24 hour fluid replacement (not including maintenance)
  73. Brooke formula
    • 1.5 ml of crystalloid / kg / % TBSA 
    • +
    • 2L of D5W
  74. Immune system and burn pts
    Suppressed for weeks to months
  75. Opioid and caloric requirements for burn pts
    • may be massively increased
    • hyper metabolic state for 3-5 days post injury
  76. patho of hemorrhagic shock
    • hypotension leads to VC and catecholamine release
    • blunt is shunted to major organs
    • hormones like RAAS, vasopressin, ADH, growth hormone, glucagon, epi, NE, and cortisol are released
  77. what is no- reflow phenomena?
    • VC of periphery occurs to shunt blood to major organs
    • these areas become anoxic and leak out free radicals and other cell damaging products
    • this causes cell wall and endothelial dysfunction
    • this further reduces flow to the periphery
    • more toxins are produced
  78. What areas suffer decreased perfusion with hemorrhagic shock to preserve perfusion to vital organs?
    Kidney, skin, skeletal muscle, splanchnic circulation
  79. What pts are especially at risk for inability to resuscitate from hemorrhagic shock?
    Eldery pts, pts with cardiac history
  80. The body is able to compensate for up to ___% of blood loss
    35
  81. Early and late resuscitation from hemorrhagic shock
    • early- pt still actively hemorrhaging, complex and greater risk of causing ongoing hypo perfusion
    • late- once hemorrhage controlled, maintain adequate O2 delivery
  82. BP control for resuscitation from hemorrhagic shock
    in what pts is this inappropriate for?
    • lower than normal SBP, 80-100 mmHg
    • inappropriate for pts who have cardiac dz, elderly, SCI, or TBI
  83. Goals for early resuscitation from hemorrhagic shock
    • Normal PT and PTT
    • Hct- 25-30%
    • SBP 80-100 mmHg
    • Plt > 50K
    • Normal ionized Ca (remember it's a clotting factor)
    • T > 35
    • Prevent increase in serum lactate
  84. What risks are associated with aggressive fluid administration during resuscitation?
    • Increased BP
    • Decreased blood viscosity
    • Decreased Hct
    • Decreased clotting factor concentration
    • Greater transfusion requirement
    • Lyte disturbances
    • Immune suppression
    • Increased risk hypothermia
  85. T or F, hypertonic saline may be beneficial to TBI pts?
    T
  86. Hct of 1u PRBCs
    60-70%
  87. Risks associated with massive PRBC transfusion
    • hypothermia
    • hypocalcemia
    • hyperkalemia
    • citrate toxicity
    • coagulopathy
  88. T or F, Plts should be warmed and given via a pump
    F
  89. Goals of late resuscitation from hemorrhagic shock
    • SBP > 100 mmHg
    • Hct > pt transfusion threshold
    • Normalize coags and lytes
    • Normalize body temp
    • Restore normal UO
    • Maximize CO
    • Reverse systemic acidosis
    • Lactate decreased to normal

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