Anaesthetic Care of the Unconscious, Multiple Trauma and Burns Patient

Care of the Unconscious;
Multiple Trauma / Burns Patient
Lasonya A. Fletcher
Medical Student, Class of 2015
Anaesthesiology, August 2013
2013 Prepared by Lasonya A. Fletcher
1

Introduction
• Trauma accounts for 10%-15% of all patients hospitalized.
• Trauma is the leading cause of death in Americans from the first to
the thirty-fifth year of age.
• Fifty percent of trauma deaths occur immediately, with another
30% occurring within a few hours of injury (the "golden hour").
• Anaesthesiologists directly affect the survival of trauma victims –
most victims require immediate surgery
• Role of anaesthesiologist: Often that of primary resuscitator, with
provision of anesthesia a secondary activity.
2

Case
Car 1: Two Adults, Male
teenager, female child
Car 2: Two Adults, Male
child
Van: One Adult
Expected injuries?
Appropriate Management?
3

Initial Evaluation
1º Survey
• [2-5 mins.]
• Airway
• Breathing
• Circulation
• Disability
• Exposure
2º Survey
• Head-to-toe Examination
• Relevant Investigations
• Definitive Repair of Injuries
3º Survey
• Repeat Head-to-toe Exam
• Repair remaining/arising injuries
Resuscitation and Assessment
Control of Haemorrhage and
Definitive repair of Injury
2013 Prepared by Lasonya A. Fletcher 4

PRIMARY SURVEY
5

Primary
Survey
Airway and
Cervical Spine
 Establishing and maintaining airway = first priority
 If patient can talk  airway usually clear
 If patient is unconscious  likely require airway and
ventilator assistance
 Signs of obstruction: stertor (snoring), stridor,
gurgling, paradoxical chest movements
 If there is apnoea, persistent obstruction, severe head
injury, maxillofacial trauma, penetrating neck injuries
with an expanding hematoma or major chest injuries 
Advanced airway management is indicated
(endotracheal intubation, cricothyrotomy or
tracheostomy)
1ºA

Primary
Survey
Airway
and Cervical Spine
 Cervical spine injury unlikely in alert patients without
neck injury or tenderness
 Five criteria increase the risk of cervical spine
instability:
1. Neck pain
2. Severe distracting pain
3. Any neurological signs and symptoms
4. Intoxication
5. Loss of consciousness at the scene
A cervical spine fracture must be assumed if any
one of these criteria is present, even if there is no
known injury above the level of the clavicle.
1ºA

Primary
Survey
Airway
and Cervical Spine
 Unconscious patients with major trauma are at risk for
aspiration therefore airway should be secured quickly
with an endotracheal tube or tracheostomy.
 Neck hyperextension and axial traction should be
avoided Use MILS (Manual In-line Stabilization)
 Nasal intubation should be avoided in patients with
mid-face or basilar skull fractures.
1ºA

Primary
Survey
Breathing
Look
Listen
Feel
1ºB

Primary
Survey
Breathing
Look
1ºB
Cyanosis
 Use of accessory muscles
 Flail chest
 Penetrating or sucking chest
injuries.

Primary
Survey
Breathing
Listen
1ºB Presence, absence, or diminution of
breath sounds.

Primary
Survey
Breathing
Feel
1ºB Subcutaneous emphysema
 Tracheal shift
 Broken ribs
The clinician should have a high index of
suspicion for tension pneumothorax and
haemothorax particularly in patients
with respiratory distress.

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.
 First Priority in maintaining adequate circulation: STOP
BLEEDING
 Second priority: Replace intravascular volume
 Cardiac arrest during transport or shortly after arrival at
hospital following penetrating chest injury is an indication
for emergency room thoracotomy
 Pregnant patients at term who are in cardiac arrest or shock
often cannot be resuscitated properly until after the delivery
of the baby.
1ºC

Primary
Survey
Circulation
Haemorrhage
 Obvious sites  identify and control with direct
pressure
 Extremity bleeding  pressure dressings and packs
 Bleeding due to chest trauma (possibly intercostal
arteries) may slow down or stop when the lung has re-
expanded after the insertion of a chest tube.
 Bleeding due intra-abdominal injuries may tamponade
itself, depending on the severity
Pneumatic antishock garments may work to stop bleeding in the
abdomen and lower extremities but are contraindicated in cases of
bleeding above the garment
Tourniquets can cause reperfusion injuries
1ºC

Primary
Survey
Circulation
 The trauma patient may be in shock – most
commonly hypovolemic shock
 Physiological responses: tachycardia, poor
capillary perfusion, and a decrease in pulse
pressure, hypotension, tachypnea, and
delirium.
 The mainstay of therapy of hemorrhagic shock
is intravenous fluid resuscitation and
transfusion
 Multiple short (1.5–2 in), large-bore (14–16 gauge
or 7–8.5F) catheters are placed in easily accessible
veins.
 Central lines may be useful but are time-consuming
and introduce possible life-threatening
complications
1ºC

Primary
Survey
Circulation
FluidTherapy
 Choice of fluid initially is usually based on
availability
 Fully cross-matched blood ideal  time-
consuming to obtain
 Type-specific blood is appropriate but may
cause minor antibody reactions
 Uncrossed O-neg packed RBC’s should be
reserved for life-threatening losses that cannot
be replaced by other fluids
1ºC

Primary
Survey
Circulation
FluidTherapy
 Crystalloid solns  readily available and
inexpensive
 Resuscitation requires large quantities of
crystalloids
 Lactated Ringer's soln is less likely to cause
hyperchloremic acidosis than is normal saline
 Dextrose-containing solns may exacerbate ischemic
brain damage
 In the presence of cerebral edema, hypertonic solns
(3% or 7.5% saline) are effective for volume
resuscitation
1ºC

Primary
Survey
Circulation
FluidTherapy
 Colloids  more expensive than crystalloids
but more effective in rapidly restoring
intravascular volume
 Albumin is usually selected over dextran or
hetastarch due to the fear of inducing a
coagulopathy
Whichever fluid is chosen  must be warmed prior to
administration.
Hypothermia worsens acid-base disorders,
coagulopathy and myocardial dysfunction. It also shifts
the oxygen-hemoglobin curve to the left and decreases
the metabolism of lactate, citrate and some anesthetic
drugs
*MonitorVital Signs!! (Blood pressure, pulse pressure and
heart rate)
1ºC

Primary
Survey
Circulation
FluidTherapy
 CentralVenous pressure and urinary output 
indications of restoration of vital organ
perfusion
 Inadequate organ perfusion interferes with
aerobic metabolism produces lactic acid and
metabolic acidosis
 Hypotension in patients with hypovolemic
shock should be aggressively treated with IV
fluids and blood products NOT vasopressors
unless there is profound hypotension
unresponsive to fluid therapy
 Shock refractory to aggressive fluid therapy
may be due to uncontrolled haemorrhage that
exceed the rate of transfusion
1ºC

Primary
Survey
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
 unresponsive.
1ºD

Primary
Survey
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.
1ºE

SECONDARY SURVEY
22

Secondary
Survey
 Begins once the ABC’s have been stabilized
 Patient evaluated from head to toe and the
indicated studies carried out
 Basic laboratory investigations include:
 complete blood count
 Electrolytes
 Glucose
 Blood urea nitrogen (BUN)
 Creatinine
 Arterial blood gases
 Chest X-ray
 Cross-table lateral and swimmer’s view
 Skull, pelvic and long bones
 Focused assessment with sonography (FAST)
 CT Chest
 Peritoneal lavage
2º

Secondary
Survey
Head-toe-Assessment: Main Points
 Head: injuries to scalp, eyes and ears
 Neuro: Glasgow Coma Scale, evaluation of sensory and
motor function
 Chest: auscultate and inspecte again for fractures
and functional integrity
 Diminished breath sounds  may indicate a
pneumothorax
 Distant heart sounds  may indicate pericardial
tamponade
 Abdomen: inspection, auscultation, and palpation.
 Extremities: examine for fractures, dislocations,
and peripheral pulses
 A urinary catheter and nasogastric tube are also
normally inserted
2º

Secondary
Survey
2º Eye Opening
• Spontaneous (4)
• To verbal
command (3)
• To pain (2)
• None (1)
BestVerbal
Response
• Oriented
conversation (5)
• Disoriented
conversation (4)
• Inappropriate
words (3)
• Incomprehensible
words (2)
• Incomprehensible
sounds (2)
• None (1)
Best Motor
Response
• Obeys verbal
command (6)
• Localizes painful
stimuli (5)
• Flexion withdrawal
from painful
stimuli (4)
• Decorticate
response to painful
stimuli (3)
• Decerebrate
response to painful
stimuli (2)
• None (1)
Glasgow Coma Scale

TERTIARY SURVEY
26

Tertiary
Survey
 Tertiary Survey defined as a patient evaluation
that identifies and catalogues all injuries after
initial resuscitation and operative
interventions.
 Typically occurs within 24 h of injuries.
 Delayed evaluation normally results in a more
awake patient who is able to fully communicate
all complaints, more detailed information on
the mechanism of injury, and a detailed
examination of the medical record to
determine preexisting comorbidities.
3º

Tertiary
Survey
 The tertiary survey occurs prior to discharge to
reassess and confirm known injuries and
identify occult ones.
 Includes another "head-to-toe examination"
and a review of all laboratory and imaging
studies.
 Missed injuries can include extremity and pelvic
fractures, spinal cord and head injuries, and
abdominal and peripheral nerve injuries
3º

General Considerations
Head and Spinal Trauma
Chest Trauma
Abdominal Trauma
Extremity Trauma
29

If a patient arrives in the operating theatre already
intubated, correct positioning of the endotracheal tube
must be verified
Patients with suspected head trauma  hyperventilate to
decrease intracranial pressure
Ventilation may be compromised by pneumothorax, flail
chest, obstruction of endotracheal tube or direct
pulmonary injury

If a patient is not intubated then proper airway
management principles should be followed.
Where possible, hypovolemia should be at least partially
corrected prior to induction.
Fluid resuscitation and transfusion should continue
throughout induction and maintenance of anaesthesia.
Commonly used induction agents for trauma patients
include ketamine and etomidate

A 'rapid sequence
induction' is used
when a patient
requires general
anaesthesia who
has been identified
as having risk
factors for gastric
aspiration.

Technique for Rapid Sequence Induction
1. Prepare for General Anaesthesia
2. Turn on pharyngeal suction apparatus
3. Have patient breath 100% O2
4. Position head in ‘sniffing’ position
5. Consider patient’s size, age and state of health to determine ideal
dose of induction agent. Give dose + 1mg/kg succinylcholine in
quick succession.
6. As soon as the patient has lost consciousness, apply pressure to
cricoid cartilage (Sellick’s manoeuver)
7. Reconfirm posture and intubate trachea at onset of paralysis
8. Inflate cuff of endotracheal tube before releasing cricoid pressure
9. Check position of ET tube, make adjustments and secure in place2013 Prepared by Lasonya A. Fletcher 33

Any trauma victim with altered consciousness must be
considered to have a brain injury
The level of consciousness is assessed by serial Glasgow
Coma Scale evaluations
Injuries requiring immediate surgical intervention:
epidural hematoma, acute subdural hematoma, some
penetrating brain injuries and depressed skull fractures.
 Injuries managed conservatively: basilar skull fracture and
intracerebral hematoma.

 Basilar skull fractures are often associated
 “Raccoon eyes"
 Battle's sign
 CSF rhinorrhea
 Other signs of brain damage include restlessness, convulsions, and
cranial nerve dysfunction
 The classic Cushing triad (hypertension, bradycardia, and respiratory
disturbances) is a late and unreliable sign that usually just precedes
brain herniation
 Patients suspected of sustaining head trauma should not receive any
premedication that will alter their mental status or neurological
examination

Brain injuries  intracranial pressure from cerebral
haemorrhage and edema
Controlled by
 fluid restriction (except in hypovolemic shock)
 diuretics [0.5g/kg mannitol]
 Barbiturates
 Deliberate hypocapnia [PaCo2 of 28-32 mm Hg]
*Hypertension or tachycardia during intubation can be
attenuated with intravenous lidocaine or fentanyl.

The degree of physiological derangement following spinal
cord injury is proportional to the level of the lesion.
Lesions of the cervical spine may involve the phrenic nerves
(C3–C5) and cause apnea.
Loss of intercostal function limits pulmonary reserve and the
ability to cough.
High thoracic injuries will eliminate sympathetic innervation of
the heart (T1–T4), leading to bradycardia.
Acute high spinal cord injury can cause spinal shock, a
condition characterized by loss of sympathetic tone in the
capacitance and resistance vessels below the level of the
lesion, resulting in hypotension, bradycardia, areflexia, and
gastrointestinal atony2013 Prepared by Lasonya A. Fletcher 37

Succinylcholine is reportedly safe during
the first 48 h following the injury but is
associated with life-threatening
hyperkalemia afterward.
Short-term high-dose corticosteroid
therapy with methylprednisolone (30
mg/kg followed by 5.4 mg/kg/h for 23h)
improves the neurological outcome of
patients with spinal cord trauma.

Chest Trauma may severely compromise
the function of the heart or lungs,
leading to cardiogenic shock or hypoxia
 Simple Pneumothorax
 Tension Pneumothorax
 Multiple rib fractures
 Hemomediastinum
 Pulmonary Contusion
 Cardiac Tamponade
 Anaesthetic Mx: maximize cardiac
inotropism, chronotropism and preload
 Ketamine is a favored induction agent

Chest Trauma may also result in
 Myocardial contusion
 Aortic transection or aortic dissection
 Avulsion of the left subclavian artery
 Aortic or mitral valve disruption
 Traumatic diaphragmatic herniation
 Esophageal rupture.
Acute respiratory distress syndrome
(ARDS) is usually a delayed pulmonary
complication of trauma that has
multiple causes: sepsis, direct thoracic
injury, aspiration, head injury, fat
embolism, massive transfusion, and
oxygen toxicity.2013 Prepared by Lasonya A. Fletcher 40

Patients involved in major trauma should
be considered to have an abdominal injury
until proved otherwise
Abdominal trauma is usually divided into
penetrating (eg, gunshot or stabbing) and
non-penetrating (eg, deceleration, crush, or
compression injuries).
Penetrating abdominal injuries are usually
obvious with entry marks on the abdomen
or lower chest. The most commonly injured
organ is the liver. Patients tend to fall into
three subgroups: (1) pulseless, (2)
hemodynamically unstable, and (3) stable.

Pulseless and hemodynamically unstable
patients (those who fail to maintain a
systolic blood pressure of 80–90 mm Hg
with 1–2 L of fluid resuscitation) should be
rushed for immediate laparotomy.
Stable patients with clinical signs of
peritonitis or evisceration should also
undergo laparotomy as soon as possible
Hemodynamically stable patients with
penetrating injuries who do not have
clinical peritonitis require close evaluation
to avoid unnecessary laparotomy2013 Prepared by Lasonya A. Fletcher 42

Profound hypotension may follow opening of the abdomen as
the tamponading effect of extravasated blood (and bowel
distention) is lost..
Nitrous oxide is avoided to prevent worsening of bowel
distention.
A nasogastric tube (if not already present) will help prevent
gastric dilation but should be placed orally if a cribriform plate
fracture is suspected.
Massive abdominal hemorrhage may require packing of bleeding
areas and/or clamping of the abdominal aorta until bleeding
sites are identified and the resuscitation can catch up with the
blood loss.2013 Prepared by Lasonya A. Fletcher 43

 Extremity injuries can be life-threatening because of associated
vascular injuries and secondary infectious complications.
 Fat emboli are associated with pelvic and long-bone fractures and
may cause pulmonary insufficiency, dysrhythmias, skin petechiae,
and mental deterioration within 1–3 days after the traumatic event
 Compartment syndrome can occur following large hematomas, crush
injuries, fractures and amputation injuries
 If the injury is isolated, a regional technique (eg, brachial or
interscalene plexus block) is often recommended to increase
peripheral blood flow by interrupting sympathetic innervation.
 During general anesthesia, the patient should be kept warm, and
emergence shivering must be avoided to maximize perfusion.

CASE
• A 43-YEAR-OLD MAN WHO SUFFERED A MAJOR
THERMAL BURN 7 DAYS PREVIOUSLY IS SCHEDULED
FOR EXCISION AND GRAFTING UNDER GENERAL
ANESTHESIA
2013 PREPARED BY LASONYA A.
FLETCHER
46

CLASSIFICATION OF BURNS
From Bailey and Love’s Short Practice of Surgery
th
• Burn injuries are described according to the percentage of
body surface area involved and the depth of the skin
destroyed.
• Survival is influenced by the percentage surface area
involved and the age of the patient.
• The rule of nines divides the body's surface area into areas
of 9% or multiples of 9%
• The surface area of one side of the patient's hand represents
1% of total body surface area.
• First-degree burns are limited to the epithelium, second-
degree burns extend into the dermis, and third-degree burns
destroy the entire skin thickness
FLETCHER
47

PULMONARY PATHOPHYSIOLOGY
ASSOCIATED WITH MAJOR BURN INJURIES
• Direct inhalational injury is usually limited to upper airway edema that can lead to life-
threatening airway obstruction.
• Lower airways can also be subjected to direct thermal insult (eg, steam) or can be injured by
exposure to smoke and toxic products of combustion.
• Deactivation of surfactant can lead to atelectasis and pulmonary shunting.
• Permeability can be increased throughout the entire microvascular system contribute to the
development of pulmonary edema and acute respiratory distress syndrome.
• Circumferential burns of the thorax may decrease chest wall compliance and further increase
peak inspiratory pressures
• . Carbon monoxide inhalation shifts the oxygen–hemoglobin curve to the left (interfering with
the unloading of oxygen at tissues) and decreases oxyhemoglobin saturation.
FLETCHER
48

CARDIOVASCULAR EFFECTS ASSOCIATED
WITH BURN INJURIES
• Increases in permeability at the site of injury and throughout the microvasculature cause
a tremendous shift of fluid from the plasma volume to the interstitial space.
• Hematocrit may rise as a result of the contraction of intravascular volume.
• Cardiac output declines as a result of the contraction of plasma volume and a circulating
myocardial depressant factor.
• If volume replacement does not provide an adequate diuresis (1 ml/kg/h), inotropic
support with dopamine may be beneficial.
FLETCHER
49

ELECTROLYTE DERANGEMENTS FOUND IN
BURN PATIENTS
• Hyperkalemia from tissue destruction may complicate management during the acute
resuscitation phase. Later, renal wasting and gastric losses may result in hypokalemia
• Topical antibiotic therapy may also cause electrolyte imbalances
• Electrical burns are associated with such severe muscle cell damage that myoglobinuria
can lead to renal failure.
FLETCHER
50

MONITORS THAT WOULD BE USEFUL DURING
THIS EXCISION AND GRAFTING PROCEDURE
• At least two large-bore intravenous lines, an arterial line, and often a central venous catheter
or pulmonary artery catheter are indicated.
• A central triple-lumen catheter can be helpful in patients with difficult intravenous access. A
noninvasive blood pressure unit should be used as a backup to the arterial line, which may
malfunction if the patient is frequently repositioned.
• Electrocardiograph skin electrodes will not stick to burned areas, and they interfere with
chest wall excision. As an alternative, needle electrodes are often sutured in place.
• Hypothermia can be minimized by using warming blankets and heat lamps, increasing
operating room temperature, humidifying inspired gases, and warming intravenous fluids.
FLETCHER
51

SPECIAL INTUBATION CONSIDERATIONS IN
THESE PATIENTS
• Burn victims with inhalational injury will often be intubated prior to surgery.
• Indications for early intubation include hypoxia not correctable with a face mask, upper
airway edema that may progress to obstruction, or the presence of copious secretions.
• Impending airway obstruction or severe facial contractures call for an awake fiberoptic
intubation.
• Tracheostomies have been associated with increased morbidity in burn patients because
of pulmonary sepsis.
FLETCHER
52

HOW DOES A BURN INJURY AFFECT THE
PHARMACOLOGY OF ANESTHETIC DRUGS?
• Succinylcholine is contraindicated in burn patients after the first 24 h. Its administration has
caused cardiac arrest because of dramatic increases in serum potassium levels.
• Burn patients require higher than normal doses of non-depolarizing muscle relaxants. This
resistance is due to altered protein binding and an increased number of extra-junctional
acetylcholine receptors, which bind non-depolarizing drug without causing a neuromuscular
effect.
• Volatile anesthetics will exacerbate myocardial depression but are useful after the acute
phase.
• Because of the potential for serious dysrhythmias, halothane is best avoided if epinephrine-
soaked bandages are being used to decrease blood loss
FLETCHER
53

REFERENCES
• G. Edward Morgan, Jr., Maged S. Mikhail, Michael J. Murray Clinical Anaesthesia 4th ed. 2007 The
Mcgraw-Hill Companies. Chap 41
• Sullivan, Pat Anaesthesia for Medical Students 1999 Department of Anaesthesia, Ottawa Civic Hospital
• Barash, P Handbook of Clinical Anaesthesia 6th ed. 2009 Lippincott Williams and Wilkins pp 460-478
• Gwinutt, C Lecture Notes: Clinical Anaesthesia 2nd ed. 2004 Blackwell Publishing
• Williams, N et al. Bailey and Love’s Short Practice of Surgery 25th ed. 2008. Edward Arnold
Publishers. Pp 271-394
• Bickley, L Bates’ Guide to Physical Examination and History Taking 10th ed. 2009. Lippincott Williams
and Wilkins

THE END
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Anaesthetic Care of the Unconscious, Multiple Trauma and Burns Patient

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