Trauma Anesthesia (Nagelhout)

Front 1

The ideal "trauma system" would include what 6 components?

Back 1

1) Triage and in field tx
2) A comm. network
3) Air & ground transport
4) Pt tx within the hospital
5) Ed. of paramedical & public on trauma care and accident prevention.
6) Eval of care

Front 2

T/F: Trauma is the leading cause of death in people <45 and the fifth leading cause of death among all ages in the U.S.

Back 2

TRUE

Front 3

Cell injury is...

Back 3

an alteration in the normal homeostasis that leads to unfavorable consequences for the organism...changes may lead to restoration or cell death.

Front 4

When _____ and ____ are involved, tissue that require high oxygen consumption are more vulnerable to injury and subsequent death.

Back 4

When shock and hypoxia are involved, tissue that require high oxygen consumption are more vulnerable to injury and subsequent death.

Front 5

_____ ______, not ______ _______ are realted to O2 consumption

Back 5

Metabolic rates, not tissue mass are realted to O2 consumption.
Therefore, tissues with the highest metabolic demand are likely to suffer damage and death.

Early intervention, adequate oxygenation & ventilation and perfusion to the trauma patient are vital.

Front 6

What happens to a trauma patient when the body reflexes can no longer compensate for disturbances s.t to tramatic insult?

Back 6

An irreversible condition that eventually leads to death.

Front 7

When trauma leads to hemm. volume depletion s/t blood loss or sequestration of EC fluids in injured tissues, what two autonomic mechanisms react to provide reflex responses to compensate?

Back 7

The low-pressure baroreceptors in the right atrium and the high-pressure baroreceptors in the carotid arteries and aorta.

When circ. volume is reduced, this evokes neurohumoral responses that include secretion of ACTH, ADH and GH via CENTRAL pathways. It includes secretion of EPI, NOREPI, renin and glucagon via peripheral symp. pathways.

Inhibited secretion of insulin.

Front 8

What are some conditions in a trauma patient that preclude the use of certain specific anesthesia agents/techniques?

Back 8

Shock: Most anesth. agents cause dose-related CV depression. Use IV induction agents carefully, incrementally and in small doses. Add VAs slowly as CV status stabilizes. Avoid use of hist. releasing MRs (atracurium) and narcs (MSO4 & codeine) b/c they can aggravate shock.

Head Injury:
-Ketamine ↑ICP
-N2O ↑pneumothorax tension
-SUX causes ↑in ICP that can be detrimental in certain situations of sig ICP elevation.
-Hypervent patient to 30-35 mmHg can drop ICP (but do not do in TBI)
-Hypervent to < or =25mmHg not recc.

Burns, SCI, Crush Injury:
-SUX can cause dangerous ↑in K+ in these patients if given >24 hours post injury.
-Do not use at all in patients with permanent SCI.

Pneumothorax/-cephalus/-peritoneum:
- Avoid N2O as it can accumulate in closed spaces and aggravate these conditions.
- N20 exaggerates the effect of air embolism

MH:
-All potent inhalational agents and SUX are avoided.

Front 9

________ causes activation of nociceptive fibers, leading to release of endogenous opiates, ADH/vasopressin, ACTH, catecholamines and other hormones.

Back 9

Pain causes activation of nociceptive fibers, leading to release of endogenous opiates, ADH/vasopressin, ACTH, catecholamines and other hormones

Front 10

The compensatory mechs that evolve in shock may eventually lead to ______.

Back 10

The compensatory mechs that evolve in shock may eventually lead to death.

Front 11

What are some factors released by injured tissues that affect the fx of OTHER organ systems?

Back 11

Tissue thromboplastin (lead to DIC)
Prostaglandin
Myocardial toxic factor
Endotoxins released for gram-negative bacteria in the gut.

Front 12

On the trauma team, the anesthetist begins assmt and tx of the trauma patient where? What is their primary concern?

Back 12

At door or E.R. or on the helipad.

Their primary concern at that point is managing the airway and ventilation during the initial resuscitation efforts. Once done, we move on to intraop care.

Front 13

How are trauma centers classified and describe those classification categories?

Back 13

Trauma centers in the US are classified as either Level 1, Level 2 or Level 3.

These represent the best possible use of comm. resources.

Level 1 and Level 2: training and research programs are essential components.
Goals include: improved care of injured patient, euc for all personnel involved in trauma care, research in trauma. quality of pt care should be same in most hospitals.

Level 3: generally serves communities that do not have resources for a Level 1 or 2 trauma center. Needs agreements for transfer and protocols for the most severely injured.

Front 14

Death from trauma presents in a trimodal distribution...describe this.

Back 14

Inital peak occurs withing seconds or minutes of injury; d/t lacerations of brain, brainstem, Upper SC, aorta or other large vessels. Few of these patients can be saved.

2nd peak occurs within first 2 hours after injury; usually s/t subdural & epidural hematomas, hemopneumothorax, ruptured spleen, liver lac, fractured femur, or multiple injuries assoc w/sig blood loss. Sig # of patients can be saved & these benefit from regionalized trauma care.

Third peak in deaths occurs days to weeks after injury. Usually s/t sepsis and MSOF.

Front 15

Compare and contrast the 3 general categories of injuries:

Back 15

Severe injuries: immediately life-threatening; 5% of injuries but resp for 50% of trauma deaths.

Urgent injuries: not immediately life threatening but may becmoe so or result in sig disability. Accout for 10-15% of all injuries.

Nonurgent injuries: Not imm. life-threatening and do not pose risk of permanent disability.

Front 16

What are some common problems in traum that can cause life-threatining outcomes?

Back 16

Undx'ed & untreated pneumothorax.
Cardiac tamponade.
Cardiac contusion
C-spine injury
Open and Closed head injuries.
Major blood vessel disruption.
Airway disruptions.

Front 17

In some situations, intubation must be done imm'ly; but in most situations intubating conditions improve after ______ and ________.

Back 17

In some situations, intubation must be done imm'ly; but in most situations intubating conditions improve after _fluid resuscitation_ and _general stabilization_.

Front 18

T/F: Rapid control of airway and ventilation with O2 is critical for traumatic shock resuscitation.

Back 18

TRUE: ventilation with O2 via mask should start at scene in the field.

Front 19

If pt can maintain spontaneous ventilation, what is done first?

Back 19

Radiography of c-spine before intubation to detect possible C-spine injuries.

ABGs are done imm'ly after patient arrives for guidance of subsequent airway interventions. Put patient on a KNOWN FiO2 before ABG so adequacy of O2 exchange can be eval'ed more accurately

Front 20

What are some preop anesthetic considerations & prep for trauma patients?

Back 20

Get phone/radio report from field providers.
Prep anesthesia machine & ventilator plus drugs and supplies.
Prep standart ett equip + alternative airway interventions.
Have std. monitoring equipment & supplies, plus RAPID TRANSFUSION equipment for blood and fluids.
Use proper PPEs.
Eval patient at earliest feasible time after arrival of patient
Get info on pt to ascertain current and past hx of trauma, surgeries, med condx, current meds, allergic reactions, prev anesthesia hx, current mech of injury.
Evaluate airway & vent for adequacy of presenting status and need for immediate or delayed interventins.
Evaluate airway to determine anticipated relative difficulty and plan for primary and possible secondary measures for securing airway.
Do GCS and Trauma Severity score at time of arrival.
IV access with 2 or more large bore IVs and initiate use of fluid warmer ASAP.
Obtain venous and arterial blood samples for typing and XM...and other blood tests/ABGs.
Have proper crystalloids, colloids and blood comp available for use.
Formulate anesthesia plan for patient.
Provide airway and anesthesia suport prn for diagnostic procedures.
Exercise care during transport of trauma patient within the trauma facility to protect the spine, ensure adequate ventilation, maintain homeostasis, manitain fluid infusion and maintain drug therapies.

Front 21

What are some common problems in trauma that can cause Life-threatening outcomes?

Back 21

Undiagnosed & untreated pneumothorax.
Cardiac tamponade
Cardiac contusion
C-spine injury
Open & closed head injuries
Major blood vessel disruptions.
Airway disruptions

Front 22

What is the major concern at scene of a trauma?

Back 22

Securing patient's airway - may be intubated on scene.

If patient has adequate resp exchange, intubate at trauma center after patient is stabilized.

Also, control bleeding points and initiate fluid resuscitation at scene.

Front 23

Prompt appropriate tx within the first ___ _______ after a severe tramatic injury often determines whether a patient will survive

Back 23

Prompt appropriate tx within the first 60 _minutes_ after a severe tramatic injury often determines whether a patient will survive.

It is called the Golden Hour.

Front 24

For a patient in hemorrhagic shock; if the effects of shock are not sufficiently corrected in the first _____ ___ ______ minutes the mortality rate ____ substantially.

Back 24

For a patient in hemorrhagic shock; if the effects of shock are not sufficiently corrected in the first _60_ to _90_ minutes the mortality rate _rises_ substantially.

As more time elapses between the moment a trauma patient develops hemorrhagic shock and the beginning of resuscitation, the rate of survival decreases.

The highest rate of mortality occurs at Approximately 60 minutes.

Front 25

Monitoring _______ enable early diagnosis of acute respiratory distress syndrome and a previously undiagnosed pneumothorax or other forms of pulonary dysfx.

Back 25

Monitoring _oxygenation_ enable early diagnosis of acute respiratory distress syndrome and a previously undiagnosed pneumothorax or other forms of pulonary dysfx.

Front 26

Rapid control of airway & ventilation with O2 is critical for traumatic shock resuscitation. Intubation conditions generally_______ after initial fluid resusc & general stabilization.

Back 26

Rapid control of airway & ventilation with O2 is critical for traumatic shock resuscitation. Intubation conditions generally_improve_ after initial fluid resusc & general stabilization.

Front 27

____ ____ ____ values are obtained immediately after patient arrives and are use to guide subsequent airway interventions.

Back 27

Arterial blood gas values are obtained immediately after patient arrives and are use to guide subsequent airway interventions.

Front 28

Why does placing a patient on a know FiO2 help prior to pulling an ABG?

Back 28

B/C the adequacy of O2 exchange is more reliably evaluated.

Front 29

What are some preop anesthesia considerations and Preps for trauma patients?

Back 29

Get an initial telephone/radio report on patient.

Preop anesthesia machine, ventilator, drugs and supplies.

Prep standard ET intubation as well as alternative airway interventions.

Have proper monitoring equipment & supplies in addition to RAPID INFUSION SUPPLIES for blood and fluids.

Use PPEs and Universal Precautions.

Eval patient at earlist feasible point after arrival of patient to trauma facility (at entrance or helipad).

Get appropriate info from patient at earliest possible time to ascertain current and past hx of trama, surgeries, med condx, current meds, allergic rexn, previous anesthesia experiences and current mechanism of injury.

Evaluate airway and ventilation for adequacy of presenting status and need for immediate or delayed interventions.

Eval airway to determine anticipated relative difficulty and plan for primary and possible secondary maneuvers for securing the airway.

Determine GCS and Trauma Severity score at time of arrival.

Get IV access with two or more large bore catheters, and initiate use of fluid warmer ASAP.

Obtain venous and art blood samples for typing and XM, CBC, electrolyte levels, blood glucose levels, coag profiles, toxicology screen and ABG.

Have appropriate crystalloids, colloids and blood components for use.

Formulate plan for anesthesia

Provide airway and anesthesia support prn for dx-tic procedures.

Exercise care durign transport of trauma patient within the trauma facility to protect spine, ensure adequate ventilation, maintian hemostasis, maintain fluid infusion and maintain drug therapies.

Front 30

What are some factors considered in securing the airway of the trauma patient?

Back 30

Severity of deterioration of ventilation and oxygenation.

Need for rapid assmt and intervnetion in a ltd. time.

Full stomach

Hemorrhagic shock and/or CV instability.

Influence of alcohol and/or drugs.

Burns/inhalational injuries.

head injury and/or obtunded or combative patient.

Maxillofacial and larygneal injuries.

Neck injuries and/or C-spine injuries.

Chest injuries to lungs, major airways, heart, great vessels

Penetrating eye injuries.

Near-drowning.

Anatomic distortion.

Existing medical problems.

Prior medication administration.

Front 31

For what type of patients is nasal intubation appropriate? Inappropriate?

Back 31

awake nasal (or oral) intubation can be attempted in cooperative patients who are adequately oxygenated and hemodynamically stable

Nasal intubation is contraindicated in head injured patients who may hae cribiform plate injureis b/c of potention for ett to enter brain vault.

Front 32

When is a chest tube inserted in presence of pneumothorax r/t intubation?

Back 32

Placement of a chest tube in the presence of a pneumothorax is completed before, or simultaneously with intubatoin in order to avoid acceleration of size of pneumothorax with the potential development of mediastinal shift and hemodynamic compromise.

Front 33

Who benefits from oral intubations?

Back 33

Head-injured patients with suspected basilar skull fx (raccoon eyes, Battle sign, cerebrospinal fluid from nose or ears) benefit from oral intubations to avoid penetration of the cribiform plate and subsequent entry of foreign material into the brain through fracture sight.