Anaesthesia for Trauma Patients

By Dr. H. O. Opere Consultant Anaesthesiologist April 2013

INTRODUCTION
The initial assessment of the trauma patient can be divided into: 1. Primary survey 2. Secondary survey 3. Tertiary survey

PRIMARY SURVEY
The primary survey should take 25 minutes and consists of the ABCDE sequence of trauma: Airway, Breathing, Circulation, Disability, and Exposure.

PRIMARY SURVEY: Airway

Establishing and maintaining an airway is always the first priority. Important signs of obstruction include snoring or gurgling, stridor, and paradoxical chest movements. The presence of a foreign body should be considered in unconscious patients. Advanced airway management (such as endotracheal intubation, cricothyrotomy, or tracheostomy) is indicated if there is apnea, persistent obstruction, severe head injury, maxillofacial trauma, a penetrating neck injury with an expanding hematoma, or major chest injuries.

PRIMARY SURVEY: Airway contd

Cervical spine injury is unlikely in alert patients without neck pain or tenderness. Five criteria increase the risk for potential instability of the cervical spine: 1.Neck pain 2.Severe distracting pain 3.Any neurological signs or symptoms 4.Intoxication 5.Loss of consciousness at the scene.

PRIMARY SURVEY: Airway contd

Laryngeal trauma makes a complicated situation worse. Open injuries may be associated with bleeding from major neck vessels, obstruction from hematoma or edema, subcutaneous emphysema, and cervical spine injuries. Closed laryngeal trauma is less obvious but can present as neck crepitations, hematoma, dysphagia, hemoptysis, or poor phonation.

PRIMARY SURVEY: Breathing

Assessment of ventilation is best accomplished by the look, listen, and feel approach. Look for cyanosis, use of accessory muscles, flail chest, and penetrating or sucking chest injuries. Listen for the presence, absence, or diminution of breath sounds. Feel for subcutaneous emphysema, tracheal shift, and broken ribs.

PRIMARY SURVEY: Circulation

Adequacy of circulation is based on pulse rate, pulse fullness, blood pressure, and signs of peripheral perfusion. Signs of inadequate circulation include tachycardia, weak or unpalpable peripheral pulses, hypotension, and pale, cool, or cyanotic extremities. The first priority in restoring adequate circulation is to stop bleeding. The second priority is to replace intravascular volume.

PRIMARY SURVEY Contd

Disability Evaluation for disability consists of a rapid neurological assessment. Because there is usually no time for a Glasgow Coma Scale, the AVPU system is used: awake, verbal response, painful response, and unresponsive. Exposure The patient should be undressed to allow examination for injuries. In-line immobilization should be used if a neck or spinal cord injury is suspected.

SECONDARY SURVEY
The secondary survey begins only when the ABCs are stabilized. In the secondary survey, the patient is evaluated from head to toe and the indicated studies (eg, radiographs, laboratory tests, invasive diagnostic procedures) are obtained. Head examination includes looking for injuries to the scalp, eyes, and ears. Neurological examination includes the Glasgow Coma Scale and evaluation of motor and sensory functions as well as reflexes.

SECONDARY SURVEY Contd

The chest is auscultated and inspected again for fractures and functional integrity (flail chest). Examination of the abdomen should consist of inspection, auscultation, and palpation. The extremities are examined for fractures, dislocations, and peripheral pulses. A urinary catheter and nasogastric tube are also normally inserted.

SECONDARY SURVEY Contd

Basic laboratory analysis includes a complete blood count (or hematocrit or hemoglobin), electrolytes, glucose, blood urea nitrogen (BUN), and creatinine. Arterial blood gases may also be extremely helpful. A chest X-ray should be obtained in all patients with major trauma. The possibility of cervical spine injury is evaluated by examining all seven vertebrae in a cross-table lateral radiograph and a swimmer's view.

SECONDARY SURVEY Contd

Depending on the injuries and the hemodynamic status of the patient, other imaging techniques (eg, chest computed tomography [CT] or angiography) or diagnostic tests such as diagnostic peritoneal lavage (DPL) may also be indicated.

TERTIARY SURVEY
A tertiary survey is defined as a patient evaluation that identifies and catalogues all injuries after initial resuscitation and operative interventions.

ANAESTHETIC CONSIDERATIONS
General Considerations
Regional anesthesia is inappropriate in hemodynamically unstable patients with lifethreatening injuries. If the patient arrives in the operating room already intubated, correct positioning of the endotracheal tube must be verified. If the patient is not intubated the same principles of airway management described above should be followed in the operating room. If time permits, hypovolemia should be at least partially corrected prior to induction of general anesthesia.

General Considerations contd

Invasive monitoring (direct arterial, central venous, and pulmonary artery pressure monitoring) can be extremely helpful in guiding fluid resuscitation, but insertion of these monitors should not detract from the resuscitation itself. Serial hematocrits (or hemoglobin), arterial blood gas measurement, and serum electrolytes (particularly K+) are invaluable in protracted resuscitations.

Head & Spinal Cord Trauma

Succinylcholine is reportedly safe during the first 48 hrs following the injury but is associated with lifethreatening hyperkalemia afterward.

Chest Trauma Abdominal Trauma Extremity Trauma

The END

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