41.

Anesthesia for the Trauma Patient

R1

INITIAL ASSESSMENT
initial assess primary survey secondary
tertiary survey
primary survey CPR A,B,C,D.E
.
trauma resuscitation 2 additional
phase
: control of hemorrhage, definitive repair of
the injury

Primary survey
Airway
cervical spine Fx.
: neck hyperextension
jaw-thrust maneuver
aspiration risk endotracheal
tube tracheotomy
: neck hyperextension excessive axial traction
manual immobilization of the head & neck
(manual-in-line stabilization)
nasal intubation : blind or fiberoptic
( )
midface or basilar skull Fx.

laryngeal trauma
larynx , direct laryngoscopy fiberoptic
bronchoscopy with topical anesthetics
endotracheal tube(6.0) awake intubation

upper airway trauma acute obx. :

tracheotomy, cricothyrotomy, percutaneous,
surgical tracheostomy

Breathing
assisted ventilation
.
bag-valve device intubaion
ventlation
head trauma ICP
hyperventilation

Circulation
A. Hemorrhage
shock : vital organ perfusion
circulatory failure
,
hypovolemia
hemorrhage -> tachycardia, poor capillary
perfusion, decrease in pulse pressure to
hypotension, tachypnea, and dilirium

Hct Hb acute bleeding

ER OR hypotension motality
rate
hemorrhagic shock IV fluid resuscitation
transfusion.
: multiple short(1.5-2 inches), large-bore(1416gauge or 7-8.5F) catheter line
massive hemorrhage cardiovascular integrity
fluid interstitial compartment
intravascular shift cell
anaerobic metabolism ATP ATPdependent Na-K pump dysfunction ->
progressive cellular edema

B. Fluid Therapy
initial fluid therapy abailability
: fully cross-matched whole blood
typing cross-match 45~60
crystalloid solutions , inexpensive
intravascular compartment .
.
colloid solution expensive. but intravascular
volume
warming
(hypothermia acid-base disorders, coagulopathies,
myocardia function )
oxygen-hemoglobin curve left shift
lactate, citrate, anesthetic drug .

Fluid Therapy (2)

sign(BP, pulse pressure, HR)

inadequate organ perfusion aerobic metabolism
lactic acid & metabolic acidosis
hypovolemic shock hypotension IV
fluid .
, coexisting
cardiogenic shock, cardiac arrest
vasopressor .

DISABILITY
:rapid neurological assessment
AVPU SYSTEM
(Awake,Verbal response,Pain stimuli
Unresponsive)

SECONDARY SURVEY
A,B,C

neurologic exam : evaluation of consciousness,
pupuillary sign, motor function, sensory loss
hidden injury

TERTIARY SURVEY
init. resuci., op.injury

ANESTHETIC CONSIDERATIONS
HEAD & SPINAL CORD TRAUMA
brain injury
Glasgow Coma Scale evaluation
head trauma mental status neurologic exam
premedication
cerebral hemorrhage or edema ICP .
intracranial hypertension : fluid restriction, diuretics, barbiturate,
hypocapnea
intubation hypertension or tachycardia iv lidocain fentanyl

head trauma autoregulation arterial
hypertension cerebral edema ICP .
hypotension regional cerebral ischemia
-> cerebral perfusion pressure 60mmHg .

spinal cord injury lesion level

: c-spine injury phrenic nerve(C3-C5) - apnea

intercostal function : pulmonary reserve cough

high thoracic injury sympathetic innervation(T1-T4 )

: bradycardia

spinal shock
: acute high spinal cord injury
sympathetic tone
hypotension, bradycardia, areflexia, and G-I atony
: aggressive fluid therapy.
high-dose corticosteroid therapy with methylprednisolone
(30mg/kg followed by 5.4mg/kg/hour for 23hours)

CHEST TRAUMA
, , cardiogenic shock hypoxia

simple pneumothorax
: hyperresonant to percussion, breathing sound , chest
X-ray lung collapse

4, or 5 intercostal space chest tube insertion

tension pneumothorax
: ipsilateral lung collapse, mediastinuma & trachea
shift

hyperresonant to percussion, ipsilateral abscence of

breathing sound, contralateral tracheal shift, distended neck
vein

14G needle catheter midclavicular line 2nd

intercostal space tension pneumothorax open
pneumothorax
chest tube placement

 - Cardiac tamponade
: life-threatening chest injury
Beck's triad (neck vein distension, hypotension,
muffled heart tone)
pulsus paradoxus(spontaneous inspiraton
10mmHg )
pericardiocentesis : temporary relief
: thoracotomy
- Hemothorax

anesthetic management : cardiac inotropism,

chronotropism, preload maximize-> ketamine
induction agent
: : ischemia EKG , cardiac
enzyme ,

elective surgery heart injury sign

 aortic
transection or dissection, avulsion of subclavian
artery, aortic or mitral valve disruption, traumatic
diaphragmatic hernia, esophageal rupture
Acute respiratory distress synd(ARDS)
: delayed pumlonary complication of trauma
: sepsis, direct thoracic injury, aspiration, head
injury, fat embolism, massive transfuion, oxygen
toxicity
mortality rate 50%

ABDOMINAL TRAUMA
: abdominal X-ray free air, peritoneal lavage blood
aspiration
: exploratory laparotomy
abdomen extravasated blood tamponading effet
hypotension .

bowel distension nitrous oxide
massive abdominal hemorrhage packing
abdominal aorta clamping .
prolonged aortic clamping liver, kidney, intestine ischemic injury
compartment synd. .
injury and fluid resuscitation bowel edema .
tight abdominal closure abdominal compartment synd. renal
and splanchnic ischemia
edema 48-72 open secondary
closure

EXTREMITY TRAUMA
.
fat embolism : pelvic & long bone Fx.
1-3 pul. insufficiency, dysrhythmias,
petechiae, mental deterioration
reimplantation
: isolated injury regional technique
sympathetic innervation pph. blood flow

perfusion
shivering