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Advances in Trauma Anesthesia

Advances in Trauma Anesthesia. Charles E. Smith, MD Professor, Case Western Reserve University Director, Cardiothoracic and Trauma Anesthesia MetroHealth Medical Center Cleveland, Ohio May 2009. Objectives. Approach to injured pt: airway, c-spine clearance

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Advances in Trauma Anesthesia

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  1. Advances in Trauma Anesthesia Charles E. Smith, MD Professor, Case Western Reserve University Director, Cardiothoracic and Trauma Anesthesia MetroHealth Medical Center Cleveland, Ohio May 2009

  2. Objectives • Approach to injured pt: airway, c-spine clearance • Fluids: delayed resuscitation, massive trx, FVIIa • Cardiac + great vessel injuries • TEE +TTE in trauma • Advantages of early fracture repair: femoral, pelvis + acetabulum

  3. Trauma • Leading cause of death, ages 1 - 44 yrs • 60 million injuries annually in USA • 3.6 million require hospitalization • 9 million are disabling: TBI, SCI, ortho, thoracic, abdominal • Costs are staggering: • $100 billion annually • 40% of health care $ ATLS Provider Manual

  4. Eldar Soreide, Trauma Care 2002 Prehospital Rapid transport to appropriate facility Prevention: Helmets, ↓ high risk behavior, seat belts+ airbags, ↓ substance abuse

  5. 1o Survey • Airway + c-spine control • Breathing, O2 sat • Circulation, BP, pulse, stop external bleeding • Disability: Neuro exam • Exposure/ environmental control

  6. LEMON LAW: Ron Walls • Look externally • Evaluate the 3-3-2 rule • Mallampati • Obstruction • Neck mobility National Emergency Airway Course. ATLS Manual 8th ed.

  7. Airway Exam • Thyromental distance • Obvious trauma • Swelling, scarring • Tracheal deviation • Neck extension • Subcutaneous emphysema McIntyre: Can J Anaesth 1987;34:204-13

  8. Airway Management • Usually modified RSI by experienced provider unless difficulty anticipated • Anesthesia + NMB allow for best intubating conditions in trauma especially if uncooperative, hypoxic, head injury • Etomidate + succinylcholine • Propofol + thiopental avoided if hypovolemia or shock. Roc suitable alternative to sux

  9. Drug Assisted Intubations outside the OR Karlin A. Problems in Anesthesia 2001;13:283. MHMC failed intub- 1% ED, OR; 3%- aeromedical

  10. Gum-Elastic Bougie • Insert under epiglottis • Gently advance until clicks or hold up • 2nd operator threads ETT over bougie • May need to rotate bougie 90o • Ideal for Grade III view Nolan: Anaesthesia 1993;48:630; Smith: Am J Anesthesiol 2001;28:98

  11. 2o Survey • Rest of vitals, Physical exam • Xrays: chest, pelvis, + c-spine, • FAST, CT, labs • Done only after 1o survey completed + resuscitation begun

  12. FAST • Perihepatic • Perisplenic • Pelvis • Pericardial Focused Assessment for the Sonographic examination of the Trauma victim

  13. Obtunded Head Injured Pts + C-spine • Reliable P/E cannot be done, therefore immobilize • CT scanning from skull base to T1 (16 row detector) w sagittal + coronal reconstruction • Identifies bony fx, marked prevertebral soft tissue swelling or hematoma, malalignment + abnormal facets • Negative predictive value 98.9% for ligament injury + 100% for unstable c-spine injury Como JJ et al. J Trauma 2007;63:544

  14. Traumatic unilateral jumped facet. Kincaid + Lam. Anesthesia for Spinal Cord Trauma

  15. Obtunded Head Injured Pts • MR advocated to evaluate ligamentous + soft tissue injuries not detected by CT • Disadvantages: cost, restricted availability, transport issues • Dynamic fluoroscopy w flex/ext views: no longer done • Plain c-spine films: no longer routine • EAST practice guidelines in press [Como et al] Como JJ et al. J Trauma 2007;63:544

  16. Risks of Aggressive Volume Resuscitation • ↑ hemorrhage + excessive hemodilution due to ↑ BP, ↓ blood viscosity, ↓ hematocrit, ↓ clotting factor concentration

  17. Bickell et al: NEJM 1994;331:1005 • RCT, penetrating torso trauma, urban center: n =598 • Excluded head injury • Std of care: 2 L crystalloid prehospital vs delayed resuscitation: no fluid until OR • ­ mortality, LOS + complications in std of care vs. delayed group

  18. Dutton et al J Trauma 2002;52:1141 • RCT, blunt + penetrating trauma pts w SBP < 90, n = 110; excluded head injury • Gp 1- fluid resusc to SBP 100 • Gp 2- fluid resusc to SBP 70 • Identical survival: 93% despite  ISS in gp 2 [23.9 v 19.5] • Lactate + base deficit cleared to normal in both gps w similar amounts fluid + blood

  19. Goals for Early Resuscitation • Systolic BP 80-100 mmHg unless head or SCI • Hematocrit 25-30% • PT, PTT, INR in normal range • Platelet count > 50,000 • Normal ionized calcium • Prevent acidosis from worsening • Core temp > 36 C

  20. Room temp > 28 oC Soreide + Smith. Hypothermia in Trauma. In: Trauma Anesthesia, Cambridge University, 2008

  21. Acute Coagulopathy of Trauma (ACoTS) Hess et al. J Trauma 2008

  22. Brohi et al. J Trauma 2003;54:1127 • Retrospective review 1088 trauma pts • Average ISS 20 • 24% had PT > 18 s or PTT > 60 s on arrival • Dose- dependent prolongation of clotting times w hypoperfusion • Activation of anticoagulant + fibrinolytic pathways: thrombomodulin- protein C

  23. Coagulopathy Initiated by Hypoperfusion Brohi et al. Ann Surg 2007;245:812

  24. Acute Coagulopathy of Trauma Studies Brohi et al. Curr Opin Crit Care 2007;13:680

  25. Implications • Early administration of FFP • Damage control surgery to minimize acidosis + hypothermia • Massive transfusion protocols, hemostatic resusc Hess et al. JOT 2008. Hoyt et al. JOT 2008; 65:755. Soeride + Smith. Hypothermia in Trauma, 2008

  26. Hemostatic Resuscitation: Civilian • 16 Level 1 trauma centers, n= 1574. Retrospective • 467 received massive transfusion [ >10 u / 24 h] • Excluded pts who died within 30 min arrival • Hypothesis: ↑ plasma + platelet to RBC ratio improves survival after shock Holcomb et al. Ann Surg 2008;248:447

  27. Patient Information. Holcomb et al. 2008 • Mean age 39, 76% men, 65% blunt injury Holcomb et al. Ann Surg 2008;248:447

  28. Results • High plasma + high platelet to RBC ratios associated w • ↓ truncal hemorrhage • ↓ ICU, vent days + LOS • ↑ survival Holcomb et al. Ann Surg 2008;248:447

  29. 24 h Survival Holcomb et al. Ann Surg 2008;248:447

  30. MHMC Massive Transfusion Protocol • 1st pack: 4 O neg RBC + 2 AB plasma • 2nd pack: 6 RBC + 4 plasma. Type specific • 3rd + all subsequent MTP packs: 6 RBC, 4 plasma, 6 platelets, rFVIIa 1.2 mg Activated by Surgeon, Emerg, Anesthesiologist

  31. Factor VIIa Use in Trauma 1999: Approved for bleeding pts with hemophilia A or B + inhibitors to FVIII or IX 2001: Martinowitz: case series of 7 pts Currently: Multiple anecdotal reports + descriptive studies w off label use. Cost of drug offset by ↓ trx RBC + FFP [Stein D et al. Injury 2008;39:1054]

  32. Dutton et al. J Trauma 2004;57:709 • 81 coagulopathic trauma pts • Coagulopathy reversed in 75% w 1.2 mg dose • PT 17→ 10.6 s w ↓ RBC + FFP over 24 h • 43.5% survived to discharge • Thromboembolic events in 12 pts (15%) • Conclusion: consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy

  33. Bufford et al. J Trauma 2005;59:8 • RCT of blunt + penetrating trauma. Multicenter • Inclusion: severe trauma + need for 6 RBC u w/in 4 hr admission, n = 301 • Randomized to 3 successive doses rFVIIa: 200, 100 + 100 ug/kg vs placebo. 2nd + 3rd dose given 1 + 3 h after 1rst dose • Exclusion: cardiac arrest before VIIa, GSW to head, GCS <8, BD >15, pH <7, injury > 12 h before randomization

  34. Results of Bufford et al. J Trauma 2005 • 2.6 u ↓ in RBC trx requirement (blunt gp, P=0.02) • ↓ need for massive trx (blunt gp: 14 vs 33%) • Trend toward ↓ MOF, ARDS + death • No diff in AEs, vent days, ICU days • Trend toward ↓ RBC trx requirement (penetrating gp, P =0.10) http://www.trauma.org/archive/resus/FactorVIIa.html

  35. Concerns with rFVIIa • Microvascular thrombosis • 431 events reported to FDA 1999-2004 • Stroke, MI, PE, other arterial + venous thromboembolism, clotted devices. • Incidence AE < 1% • Dosing not well established. Usually give 4.8 mg [1 vial]. Repeat x 1 or 2 if needed • Lower doses [1.2 mg, 90 ug/kg] effective w ↓ risk • Ongoing trials + case registry http://www.trauma.org/archive/resus/FactorVIIa.html

  36. Concerns with Blood in Trauma • Each unit of blood product biologically active + ↑ risk of infections + ARDS • [Chaiwat et al. Anesthesiology 2009;110:351, n=14,070 pts, NSCOT database, retrospective] • Older blood assoc w ↑ infection, LOS, MOSF + death [Weinberg et al. J Trauma 2008;65:279]

  37. Storage Days of pRBCs, MHMC Kroll A. et al. N=385 trauma pts requiring surgery w/in 24 h admission @ MHMC, 2003-4

  38. Stab wound to LV. Ketamine-sux induction. Adenosine 6-12 mg boluses to allow surgeon time to suture. Lim et al. Ann Thorac Surg 2001;71:1714

  39. Penetrating Cardiac Injuries • GSW: usually die • Stab: usually present with tamponade • Dx: history, Becks’s triad, JVD,  BP, pulsus, echo • JVD- may be absent if hypovolemic Tx: Surgical repair. May need adenosine + bypass

  40. Royse C+ Royse A. Ultrasound in trauma. In: Trauma Anesthesia. Cambridge Univ, 2008

  41. Pericardial Effusion + Tamponade • Pericardial pressure > cardiac chamber pressure • RV or LV diastolic collapse • RA or LA systolic collapse • Plethora of IVC (> 2.5 cm) • ↑ tricuspid E w inspiration (+ ↓ mitral E)

  42. Pericardial Effusion Large, loculated hemopericardium w RA collapse

  43. TG SAX: LV Fractional Area Diastole FAC: (EDA-ESA)/EDA *100 Normal: > 50% Hypovolemia: EDA < 8 cm2 Normal: EDA 8-14 Dilated: EDA >14 Systole

  44. Transthoracic Echo [TTE] • TTE easiest + least invasive way to image cardiac structures + great vessels • Harmonics + contrast: improved TTE exam • TTE still suboptimal in many pts due to obesity, chest tubes, dressings + PPV [Vignon et al, Chest 1994;106:1829]

  45. TEE • TEE has improved sensitivity + specificity • Valvular pathology • Interatrial shunt • Endocarditis • Prosthetic valve dysfunction • Aortic dissection, rupture • LAA pathology • Cardiac source of emboli • TEE is semi-invasive

  46. Median sternotomy Lt anterior thoracotomy Pericardiocentesis not usually done. Aydin et al. Cardiac and great vessel trauma. In: Trauma Anesthesia, Cambridge Univ. 2008

  47. Blunt Cardiac Trauma • New segmental WMA • ↓ RV +/or LV function • Laceration of valvular annuli • Ruptured chordae • Pericardial effusion

  48. BCI + Myocardial Contusion A+B: small, localized C: Extensive. May need milrinone, epi, norepi, vasopressin to maintain CPP + RV fct. Delay non-cardiac surgery 24-48 h

  49. Thoracic Aorta Trauma • 2nd most common cause of death [8000 deaths/yr, USA] • Majority (80-85%) die at scene • Etiology: MVAs, falls, crush, pedestrian struck, airplane crash • Mechanism: deceleration, osseous pinch

  50. Descending Thoracic Aorta Injury Ped vs. car. Sax view of DA 5 cm distal to arch

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