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Trauma : Anesthetic Issues

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R2 Hong SK. Preoperative Evaluation (1) History. Mental ... NPO time : m/c full stomach. Preoperative Evaluation (2) Physical Examination. Ask deep breathing ... – PowerPoint PPT presentation

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Title: Trauma : Anesthetic Issues


1
Trauma Anesthetic Issues
  • R2 Hong SK

2
Preoperative Evaluation (1)
  • History
  • Mental status
  • Glasgow Coma Scale
  • Trauma Scale
  • NPO time m/c full stomach

3
Preoperative Evaluation (2)
  • Physical Examination
  • Ask deep breathing
  • Palpate radial pulse
  • Orthostatic testing
  • Neck injury check
  • Early bladder catheterization
  • Chest trauma check

4
Laboratory Studies
  • First procedure
  • lateral cervical spine C1, C7, body
  • AP CXR
  • Blood Hgb
  • ECG
  • Second
  • Routine Lab

5
Preparation
  • Operaing room warming
  • Supply cart
  • Large-bore (14G or 16G) cannula
  • Transtracheal jet ventilation
  • central line set
  • Premedication
  • Sedative analgesics
  • Antacid Tx
  • Cimetidine MX 30 60 min before induction

6
Monitoring
  • ECG lead II V5 , continuous ST analysis
  • Sphygmomanometer
  • Core temperature
  • Urinary catheterization
  • A-line
  • CVP, PAC, ICP

7
Airway Management (1)
  • Cervical spine intact check
  • Pulmonary aspiration risk high
  • Sellicks maneuver

8
Airway Management (2)
  • Caution
  • Poor ventilation or oxygenation
  • decreased or changing mental status
  • airway obstruction sign stridor, snoring
  • airway burn soot in nares,
  • singed nasal hairs
  • Shock
  • combativeness

9
Airway Management (3)
  • Breathe 100 O2
  • at least 2 min before intubation
  • Mask holding with Sellicks maneuver
  • Orotracheal intubation fail
  • -gt transtracheal jet ventilation buy time
  • -gt emergency cricothyroidotomy

10
Induction and Maintenance of Anesthesia (1)
11
Induction and Maintenance of Anesthesia (2)
  • Succynylcholine CIx
  • Severe burn or crush injury gt 24 hr
  • s-K level increase
  • denervating dis. major stroke,
  • Multiple Sclerosis
  • serious intra-abdominal infection
  • myotonic dystrophy

12
Induction and Maintenance of Anesthesia (3)
  • Regional anesthesia
  • no hypovolemic or Hrr
  • no coagulopathy
  • alert cooperative patient

13
Fluid Management (1)
  • Crystalloid solution component

14
Fluid Management (2)
  • Resuscitation fluid choice
  • Crystalloid
  • blood oxygen-carrying capacity restore
  • coagulation status normalization
  • Volume loss calculation
  • acute blood loss
  • tissue loss during surgery 4 8 mg/kg/hr
  • crystalloid replacement 2 3 times of blood
    loss
  • anesthetic increase intravascular capacity
  • Lasix in the RR is preferable to CPR in the OR

15
Fluid Management (3)
  • Colloid replacement
  • Blood products, high molecular wt dextran
  • Albumin, hetastarch solution
  • positive side
  • intra vascular longer -gt less edema
  • increase cardiac output
  • negative side
  • Allergic or immune reaction
  • Electrolytic imbalances
  • Toxic effect citrate toxicity, nephro toxicity,
    crossmatch problems, coagulopathy

16
Coagulopathies (1)
  • M/C dilutional thrombocytopenia
  • -gt later deficiency of fibronogen or other
    coagulation factor
  • Cause transfusion lost blood with anything
    other than whole blood
  • Dx PLT lt 70,000 abnormal bleeding
  • Tx replacement

17
Coagulopathies (2)
  • DIC or consumption coagulopathy (1)
  • Cause
  • Rapid consumption PLT, fibrinogen,
  • Factor V VIII
  • triggered by phospholipid
  • (PLT Factor III or tTP)
  • Dx
  • PLT fibrinogen(lt 150 mg.dl/L) decrease,
  • fibrin-spirit product (), aPTT aNL

18
Coagulopathies (3)
  • DIC or consumption coagulopathy (2)
  • Tx
  • 1. underlying dis.
  • 2. replacement PC, FFP,cryoprecipitate
  • Goal
  • 1. PLT gt 100,000
  • 2. normal aPTT
  • 3. fibrinogen gt 200 mg/dL

19
Hypothermia (1)
  • Advantage
  • metabolic rate decrease
  • oxygen demand decrease
  • blood flow shifting
  • Disadvantage
  • cardiac problem sinus bradycardia, AF,
  • prolong PR QT interval, widen QRS
  • -gt nodal rhythm, frequent PVC, AV block, VF
  • 2. hypoxic pul. Vasoconstriction attenuation
  • 3. plasma volume decrease
  • 4. PLT dysfunction thrombycytopenia -gt DIC

20
Hypothermia (2)
  • Prevention
  • OR warming
  • warmed humidified respiratory gase
  • IV replacement
  • irrigation fluid warming (37?)
  • Air-filled patient warmer
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