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Anesthesia in trauma part 2

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Title: Anesthesia in trauma part 2


1
Anesthesia in trauma part 2
2
  • Future Developments in Resuscitation
  • improvement in diagnosis and control of bleeding
  • high resolution CT SCAN focused assessment by
    sonography (FAST)in trauma SONOGRAPHY
  • Angiographic embolization
  • topical use during emergency surgery
  • Topical preparations of thrombin and fibrinogen
  • can facilitate immediate clot formation.
  • Fibrin glue
  • oozing surfaces and organs that are difficult to
    suture or cauterize, such as the lung or liver.

3
  • Continuous
  • Future formulations of thrombin and fibrinogen
    will come layered on collagen-based dressings for
    rapid control of large injuries to solid visceral
    organs or the musculoskeletal system.(Iraq and
    Afghanistan)
  • Newer hemostatic which have small hydrophilic
    particle
  • Zeolite and chitosan
  • recombinant (rFVlla)
  • Factor VII in physiologic doses works by
    triggering a thrombin burst on the surface of
    platelets activated by exposed tissue factor
  • Prospective studies
  • Elective open prostatectomy
  • Rapid reverse coagulopathy in patient received
    warfarin
  • Retrospective studies
  • GI bleeding
  • Bleeding after cardiovascular surgery
  • Liver transplantation and intracranial
    hemorrhage

4
  • other anticipated in development in the field of
    resuscitation include
  • Prevention of organ damage or ischemia may be
    possible in future through the administration of
    agents that regular cellular function and humoral
    signaling.
  • Possibilities include manipulation of
    shock-related pathophysiologic alterations such
    as complement and granulocyte activation,
    endothelial activation, leukostasis, and edema
    formation with resultant organ injury.
  • use of oxygen carriers ,antioxidants, nitric
    oxide scavengers, and anti endotoxin compounds.

5
Trauma to the central nervous system
  • CNS trauma accounts for almost half of all trauma
    deaths
  • TBI remains the leading cause of disability in
    children and young adults.
  • )As with hemorrhagic shock( CNS trauma
  • 1-primary injury tissue disrupted by mechanical
    force.(neuronal cell body- axon-vasculture)
  • 2-secondary response body reaction to injury
  • secondary brain injury accounts for much of the
    death and disability after trauma. (aggravated by
    hypoxia, ischemia and inflammatory responses)
  • The initial management of this patients can
    significantly affect the outcome.

6
  • Continues
  • Drugs such as free radical scavengers,
    anti-inflammatory agents, and ion channel
    blockers in animal .
  • Brain injury is classified as mild, moderate,
    severe
  • Mild
  • traumatic brain injury (GCS score of 13 to 15)
    who maintain a stable GCS for 24 h are very
    unlikely to deteriorate further but
    postconcussive effects is common

7
  • Moderate TBI
  • (GCS score of 9 to 12) may be manifested as
    intracranial lesions that require surgical
    evacuation, and early cranial CT is strongly
    indicated.
  • Early intubation and mechanical ventilation
  • close observation because of catastrophic
    consequences of respiratory depression or
    pulmonary aspiration
  • Treatment of secondary brain injury is
    accomplished by early correction and subsequent
    avoidance of hypoxia, prompt fluid resuscitation,
    and management of associated injuries.

8
  • The timing of indicated non cranial surgery in
    this patient is highly controversial.
  • Recent review of surgical timing ..
  • Serial Monitoring of consciousness, motor and
    sensory
  • Invasive ICP monitoring is indicated if
  • Anesthesia longer than 2 hours
  • need for aggressive analgesia
  • prophylaxis against delirium tremens
  • Deterioration of the GCS is an indication for
    urgent repeat cranial CT to establish the need
    for craniotomy or invasive monitoring of ICP.
  • mortality from moderate TBI is low, almost all
    patients will suffer significant long-term
    morbidity.

9
  • Severe TBI
  • is classified as a GCS score of 8 or less at the
    time of admission and carries a significant risk
    for mortality.
  • Early, rapid management focused on restoration
    of systemic homeostasis and perfusion -directed
    care of the injured brain will produce the best
    possible outcome in the difficult population

10
  • Airway and Ventilatory Management
  • A single episode of hypoxemia (Pa02 lt60 mm Hg) in
    a patient with severe TBI is associated with a
    near doubling of mortality.
  • Prehospital intubation?
  • In past field intubation.
  • Two retrospective study shown worsened outcome.
  • The patient should be transported as rapidly as
    possible to a facility capable of manger sever
    TBI or to the nearest facility capable of
    intubating the patient and initiating systemic
    resuscitation
  • The main point is systemic oxygenation.
  • The classic teaching of no or low-level positive
    end-expiratory pressure (PEEP) to prevent
    elevated ICP is inappropriate because it may fail
    to correct hypoxemia.
  • With adequate volume resuscitation, PEEP does not
    increase ICP or lower cerebral perfusion pressure
    however, it may actually decrease ICP because of
    improved cerebral oxygenation.

11
  • Hyperventilation therapy (paco2 of 25 mm Hg)is no
    longer recommended as prophylactic treatment.
  • Current guidelines imply a range of 30-35 mmHg
  • hyperventilation to 30 mm Hg only for episodes of
    elevated ICP that can not controlled with
  • Sedatives
  • CSF drainage
  • neuromuscular blockade
  • osmotic agents
  • barbiturate coma
  • Hyperventilation during the first 24 hour is of
    particular concern because of critical
    reductions in perfusion during this timeframe.
  • these recommendations should be taken in context
    and modified In unstable clinical circumstances
    such as expanding mass lesion or signs of
    immediate herniation.
  • 10

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13
  • Circulation
  • The most challenging of all trauma patients are
    those with sever Trauma and coexisting
    hemorrhagic shock.
  • A single episode of hypotension, defined as
    systolic BP less than 90 mmHg, is associated with
    an increase in morbidity and doubled mortality
    after severe TBI.
  • Hypotension together with hypoxia is associated
    with threefold mortality.
  • Systolic BP less than 90 should be avoided with
    a goal MAP greater than 70 mm hg
  • Maintain in euvolemic state
  • Hypertonic salt solution is optimal
  • HCT greater than 30
  • CPP 50-70 mmhg
  • Vasoactive if needed

14
  • Decompressive craniectomy
  • Used to Control Sever elevated ICP prevent
    herniation after stroke
  • Improve mortality and morbidity
  • Decompressive laparatomy
  • If coexisting injuries or vigorous volume
    infusion increase intra abdominal compartment
    pressure more than 20 mmHg
  • increase intra abdominal compartment pressure
    reduce brain drainage.

15
  • Multiple compartment syndrome
  • In patient with sever TBI
  • Fluid therapy or acute lung injury(or both)
    increase intra abdominal pressure and intra
    thoracic pressure and increase ICP.
  • further administration of fluids or increasing
    Ventilatory support to treat lung injury can
    exacerbate this problem.
  • Multiple compartment syndrome
  • Need to open abdomen
  • Hypothermia 33 c (like hyperventilation)
  • Active rewarming in sever TBI??

16
  • Spinal cord injury
  • Occur in 1.5 to 3 all major trauma.
  • Most spinal injuries are found in the lower
    cervical spine, the upper lumbar region
  • SCI at mid thoracic levels Is less common.
  • SCI is commonly accompanied by radiographically
    visible injury to the bony spine and concomitant
    disruption of the muscles, ligaments, and soft
    tissues that support it.
  • clinically significant injury to the cervical
    spinal cord can occur in the absence of visible
    skeletal injury.
  • This phenomenon, known as SCIWORA (spinal cord
    injury without radiographic abnormality), is more
    common in children.
  • Primary injury to the spinal cord sustained at
    the moment of trauma may be exacerbated by a
    number of secondary factors

17
  • Sensory deficit or motor deficit or both.
  • Incomplete deficits may be worse on one side than
    the other and may improve rapidly in the first
    minutes after injury.
  • Complete deficits- representing total disruption
    of the spinal cord at one level are much more
    ominous, with generally little improvement seen
    over time.
  • Cervical spine injuries causing quadriplegia are
    accompanied by significant hypotension because of
    inappropriate vasodilatation and loss of cardiac
    inotropy (neurogenic shock).
  • Functioning of lower cord levels will gradually
    return, with restoration of normal vascular tone.

18
  • Treatment
  • after ABC
  • glucocorticoid steroid bolus, administered to
    any patient with a complete or partial neurologic
    deficit.
  • A bolus dose of 30 mg/kg of methylprednisolone,
    followed by a maintenance infusion of 5.4
    mg/kg/hr, is given if the patient is less than 8
    hours removed from the time of injury.
  • This infusion is continued for 24 hours if
    started within 3 hours of injury
  • for 48 hours if started 3 to 8 hours after
    injury.
  • High dose glucocorticoid therapy demonstrated a
    small, but statistically significant improvement
    in neurologic level after SCI in two large
    multicenter trials.

19
Continued(Treatment)
  • Surgery for cervical lesions
  • Supportive bracing or extension casting for
    lumbar or thoracic fracture.
  • Early intubation for patient with cervical spine
    fracture and quadriplegia(Glidoscope
    fiberoptic before patient agitation)
  • Ventilatory support absolutely required for
    deficit above C4
  • Early intubation is recommended (patient
    cooperation)
  • Patient with levels from C6-C7 may still need
    support
  • Pneumonia is common and recurrent complication
    that necessitate tracheostomy to facilate
    pulmonary toilet

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21
  • Intraoperative management of spinal cord injury
  • Direct laryngoscopy with in-line stabilization is
    appropriate in the emergency setting and in
    unconscious, combative, or hypoxemic patients
    when the status of the spine is not known.
  • In the OR an awake, alert, and cooperative
    patient can be intubated by a number of different
    methods known to produce less displacement of the
    cervical spine and presumably less risk of
    worsening an unstable SCI.
  • A common technique in current clinical practice
    is awake Fiberoptic intubation.
  • nasal route is associated with an increased risk
    of sinusitis in the ICU if the patient is not
    extubated.
  • Oral intubation if patient need mechanically
    ventilation.
  • 20

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23
Orthopedic and soft tissue trauma
  • Lower extremity fractures are the leading cause
    of all trauma admissions.
  • Being familiar with regional anesthesia
  • Fluid balance
  • length of procedures attention to body
    positioning
  • Normothermia
  • preservation of peripheral blood flow
  • early stabilization of long-bon, spine and
    stabular fractures.
  • In one study in femoral fracture ..(2 vs. 38)

24
  • Dislocations of the hip
  • are common after high-energy trauma and are
    frequently accompanied by fracture of the
    acetabulum.
  • significant risk factor for avascular necrosis of
    the femoral head.
  • Reduction typically requires a very deep level
    of sedation and may be facilitated by chemical
    paralysis of the patient.
  • Enough attention to risk of aspiration
  • Whereas the fracture itself can be safely managed
    on a delayed basis ,the dislocation is a medical
    emergency.

25
  • Unlike acetabular fractures, fracture of the
    pelvis ring requires immediate recognition and
    management by the trauma team.
  • Hemorrhage, even exsanguination, is common after
    major pelvic ring fracture and is a leading
    contributor to early death after motor vehicle
    accidents.
  • Bleeding occurs from multiply disrupted venous
    beds in the posterior pelvic bowl.
  • Surgical exploration is usually unrewarding
    because bleeding vessels not accessed.
  • Therapy consists of supportive volume
    resuscitation,
  • external fixation of the unstable pelvis, and
    angiography.
  • In the absence of an orthopedic specialist,
    temporary stabilization and tamponade of some
    pelvic fractures can be accomplished with the use
    of a specially made pelvic binder, the pelvic
    portion of military anti shock trousers, or a bed
    sheet knotted tightly around the bony pelvis.

26
  • Continued
  • Open fracture should be pulse- lavaged and
    debrided as soon as possible even on bed side if
    patient is unstable
  • Advantages and disadvantages of GA and RA
  • Intraoperative TEE has shown that most patient
    undergoing long-bone fracture manipulation
    experience microembolism of fat and marrow.
  • some Lung dysfunction in almost always patients
    has range from minor laboratory abnormalities to
    full-blown fat embolism.(FES) 3-10.
  • Coexist lung disease and multiple long bone
    fractures have additional risk for FES
  • Signs hypoxia-mental status changes-petechia
    rash-tachycardia
  • Failure to awaken after G.A
  • FES should be considered if

27
  • Diagnosis in the operatory room is based on
    clinical findings after ruling out other causes
    of hypoxia
  • fat globules in Urine are not diagnostic but
    lung infiltration on CXR confirm the presence of
    injury
  • Treatment
  • Early recognition
  • Administration of oxygen
  • Judgious of fluid management
  • A change in orthopedic procedure may be indicated
    such as converting intra medullary nailing of the
    femur to external fixation

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30
Acute compartment syndrome
  • Increased pressure within a limited space
    compromise the circulation and function of the
    tissue within that space.
  • With orthopedic trauma the most common cause of
    compartment syndrome is edema secondary to muscle
    injury and associated hematoma formation.
  • Also occur as result of
  • Reperfusion injury
  • Burns
  • drug over dose
  • prolonged limb compression
  • The most common fracture associated with C.S is
    tibia shaft and forearm.

31
Risk factors for development of compartmant
syndrome
  • Orthopedic
  • Fracture and operative repair
  • Vascular
  • Reperfusion injury
  • Hemorrhage with hematoma formation
  • Ischemia from arterial and venous injury
  • Soft tissue
  • Crush injury
  • Burns
  • Prolonged compressing
  • Iatrogenic
  • Casts and circular dressing
  • Use of pneumatic anti shock garments
  • Intraosseous fluid replacement in infant and
    child
  • Extravasation from venous or arteies puncture
    site
  • Miscellaneous
  • Snakebite

32
  • Classic triad of compartment syndrome
  • The 5p
  • Pulslessness
  • Pallor
  • Paralysis
  • Parasthesia
  • Pain
  • Presences of these finding associated with
    established syndrome and Fasciotomy has poor out
    come.
  • the early presence of pain out of proportion to
    the injury can be the first clinical indication
    of compartment syndrome .

33
  • Treatment
  • Fasciotomy is indicated when
  • compartment pressure approaches 20-30 mmhg below
    diastolic pressure in any patient with worsening
    clinical condition.
  • major soft tissue injury
  • history of 4-6 hours of total ischemia of an
    extremity.
  • Prophylactic Fasciotomy may be indicated
  • in patient with warm ischemic time in excess of
    4-6 hours
  • ligation of the major veins in the popliteal
    region or distal part of the thigh
  • crush injury.

34
  • Crush syndrome
  • Crush syndrome is the general manifestation of
    crush injury caused by continuous prolonged
    pressure on one or more extremities in patients
    who have been trapped in one position for an
    extended period
  • myoglobinuria, which can lead to acute renal
    failure and electrolyte disturbances.
  • The most critical treatment consists of
    crystalloid fluid resuscitation a total body
    fluid deficit of 15 L may occur in sever
    rhabdomyolysis.
  • Osmotic diuresis with mannitol and alkalization
    of urine with sodium bicarbonate is
    controversial.
  • The preferred therapy for renal failure secondary
    to rhabdomyolysis continuous renal replacement
    therapy.

35
Soft tissue trauma
  • May be jeopardized by
  • Avulsion at the time of injury
  • Ischemia from elevated compartment pressure
  • bacterial infection
  • All dead or devitalized tissue must be
  • debrided
  • wound irrigated
  • to reduce the load of bacteria contaminants.
  • When muscle or fascia involvement is significant
    at 1-3-day interval debridment needed.
  • Vacuum dressing for large soft tissue wounds
  • When serial debridement establish viable tissue
    at all margins closure can be made.
  • Closure
  • Split thickness graft
  • Free tissue transfer

36
Anesthesia
  • Vacuum dressing can be made at the bed side with
    light sedation or anesthesia
  • Need for repeated surgery is an important
    consideration for the anesthetic technique
  • Anesthesia for free tissue transfer is protracted
  • Keeping the patient warm, euvolemic and
    comfortable and maintain HCT in rheological
    favorable range of 25-30
  • Every effort should be made to facilate perfusion
    Of the graft vessels.
  • Use of epidural anesthesia and analgesia is
    controversial
  • 1-Vasodilatory effect
  • 2-Steal phenomenon (limit flow in denervated
    tissue)
  • Amputation is occasionally necessary for Massive
    crush injury (strong emotional)
  • Regional anesthesia limit development of phantom
    limb pain
  • GA is better accept.

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38
  • Head and neck surgery
  • Except zone II most repair of head and neck
    trauma will occur in sub acute phase after
    complete resuscitation and diagnostic studies
  • Nasotracheal intubation for mandible and
    maxillary fracture
  • Switch oral to nasal?
  • Oral tube secured behind the second molar (to
    allow dental occlusion)
  • Tracheostomy
  • surgery lead to significant soft tissue swelling
    after operation thus
  • Needs several days of intubation and sedation
    until sufficient venous drainage has occurred to
    allow safe extubation.
  • Air leak when the endotracheal tube cuff is
    deflated

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40
Chest Injuries-Rib Fractures
  • Are the most common injury from blunt chest
    trauma.
  • The fracture itself generally requires no
    specific treatment and will heal spontaneously
    over a period of several weeks.
  • Therapy is directed at minimizing pulmonary
    complications secondary to these fractures
  • Pain
  • atelectasis
  • hypoxemia
  • Pneumonia
  • elderly (older than 55 years).
  • Elderly patients have twice the mortality and
    thoracic morbidity.
  • Epidural anesthesia should be liberally used
  • in patients with severe pain
  • elderly
  • patients with preexisting compromised pulmonary
    function.
  • Some data support a decrease in morbidity and
    mortality in the elderly by 6 when epidural
    anesthesia is used.
  • And decreased Hypoxia ,hypoventilation ,tracheal
    intubation and mechanical ventilation decreased.

41
  • Continued
  • Fracture of multiple neighboring ribs will result
    in flail chest syndrome, characterized by
    paradoxical chest wall motion during spontaneous
    ventilation.
  • ventilation and positive pressure for internal
    chest stabilization, and endotracheal intubation
    should be reserved for those who meet the usual
    criteria.
  • Patients who are not initially intubated should
    be closely observed in the ICU for signs of
    worsening respiratory function.
  • Increasing numbers of reports have described the
    use of noninvasive positive-pressure ventilation
    (NIPPV) for lung injury caused by trauma.
  • NIPPV is associated with
  • fewer cases of pneumonia
  • which may lead to fewer tracheostomies
  • therefore decreased ICU length of stay.

42
  • Continued
  • Concomitant pulmonary injury ,specially lung
    contusion is commonly associated with flail
    chest.
  • Pulmonary contusion lead to shunting, this
    syndrome may progress rapidly in hours to days.
  • Clear CXR doesn't exclude possibility of the
    contusion
  • Treatment of hypoxemia
  • High degree of suspicion along with a continues
    search for missed injuries.
  • Early and aggressive implementation of lung
    protective strategy is crucial in the treatment
    of patients with significant pulmonary contusion
    to minimize progression to ARDS or concomitant
    ventilator associated lung injury .

43
  • Chest Injuries-Cardiac Injury
  • Blunt cardiac injury is a rare and poorly
    understood phenomenon
  • Bruising or edema of the myocardium is
    functionally indistinguishable from IHD
  • Blunt cardiac injury can be safely excluded if
  • patient is hemodynamically stable
  • ECG does not demonstrate
  • conduction disturbances
  • or tachyarrhythmias
  • new tachyarrhythmia
  • conduction disturbance
  • unexplained hypotension
  • (other causes should be ruled out)

44
  • Continues
  • Treatment
  • blunt cardiac injury should be managed as
    ischemic cardiac injury
  • Completion of resuscitation
  • Careful control of fluid volume
  • Administration of coronary vasodilator
  • Monitoring and symptomatic treatment of rhythm
    disturbance
  • Anticoagulant with aspirin and heparin?(approached
    on case by case)
  • Cardiology consultation patient might benefit
    from coronary angiography followed by angioplasty
    or stenting of stenotic vessels

45
  • Continues
  • Penetrating cardiac trauma and blunt trauma
    causing rupture of one or more chambers (usually
    the atria)
  • Patients who do not die immediately of free
    exsanguination into the thoracic cavity will have
    pericardial tamponade and can be extremely
    unstable in the first minutes after admission.
  • Relief of tamponade
  • Cardiopulmonary bypass may be required.

46
  • Chest Injuries-Pulmonary
  • Injuries to the lung parenchyma producing a
    Pneumothorax
  • Can be managed by tube thoracostomy.
  • Bleeding from the low-pressure pulmonary
    circulation is usually self-limited.
  • Thoracostomy
  • evidence of mediastinal injury
  • chest tube output exceeds 1500 mL in the first
    hours
  • tracheal or bronchial injury and massive air leak
  • hemodynamically unstable with evident thoracic
    pathology.

47
  • Continued
  • Hemorrhage necessitating surgery may be from
    injured intercostal or internal mammary arteries
    as well as from the lung parenchyma.
  • Although double-lumen endotracheal intubation is
    desirable during urgent thoracotomy, such
    intubation should not be the initial approach .
  • Rapid-sequence intubation with a large-caliber
    (at least 8.0-mm internal diameter) conventional
    endotracheal tube will permit diagnostic
    bronchoscopy and will protect the patient from
    aspiration until passage of a gastric tube can
    reduce stomach contents.
  • The change to a double lumen tube can then be
    done under controlled conditions, that is, in the
    presence of adequate oxygenation, anesthesia, and
    muscle relaxation.

48
  • continued
  • Tolerance of single-lung ventilation is variable
    in the trauma population
  • chest trauma requiring pneumonectomy has
    historically resulted in mortality approaching
    100.
  • Intraoperative deaths are the result of
  • uncontrollable hemorrhage
  • acute right ventricular failure
  • air embolism.
  • Blunt thoracic trauma requiring pneumonectomy is
    often associated with abdominal and pelvic
    trauma.
  • Volume replacement must be judicious
  • Treat right ventricular failure and pulmonary
    hypertension

49
  • Tracheobronchial injury
  • can result from either blunt force or penetrating
    trauma (more promptly diagnosed).
  • Blunt trauma most commonly results in an injury
    to the Tracheobronchial tree within 2.5 cm of the
    carina and may initially be unrecognized.
  • The presence of
  • subcutaneous emphysema
  • pneumomediastinum
  • Pneumopericardium
  • Pneumoperitoneum
  • Despite helical CT scan and bronchoscopy small
    injury never be delineated.
  • Complete and incomplete tracheobronchial injury

50
  • Chest Injuries-Traumatic Aortic Injury
  • Traumatic aortic injury must be ruled out in
    high-energy injury
  • fall motorcyclet accident
  • Aortic injury occurs most commonly just distal to
    the left subclavian artery
  • Diagnosis
  • CXR (screen) followed by
  • Definitive Angiography
  • CT
  • TEE
  • Surgical or endovascular repair is indicated for
    most patients with traumatic aortic injury
    because of high risk for rupture in the hours and
    days after injury.
  • Various techniques have been described for it
    ,with the best result the reports recently
    attributed to partial bypass techniques .
  • Reports of selective nonoperative management of
    high-risk patients with traumatic aortic injury
    have appeared in the recent literature.
  • ß blockade to minimize the cardiac rate-pressure
    product.
  • Endovascular repair.

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53
  • Trauma and Pregnancy
  • Trauma to pregnant patients is associated with a
    high risk of
  • spontaneous abortion
  • preterm labor
  • premature delivery
  • Early consultation with an obstetrician both for
    immediate management and for long-term follow-up.
  • The best treatment of the developing fetus
    consists of rapid and complete resuscitation of
    the mother.
  • The best guarantee of a healthy infant is a well
    mother.
  • Trauma patients in the first trimester of
    gestation may not realize that they are pregnant
    for this reason, human chorionic
    gonadotropin(HCG) testing is part of the initial
    laboratory studies for any injured woman of
    childbearing age.

54
  • Serious trauma occurring during the period of
    fetal organogenesis
  • 1-hemorrhagic shock
  • 2- radiation to the pelvis
  • 3- medications
  • may induce birth defects or miscarriage
  • Indicated radiologic tests should not be
    deferred, but shielding of the pelvis should be
    provided whenever possible.
  • Trauma occurring in the second or third trimester
    of pregnancy necessitates early ultrasonographic
    examination to determine fetal age, size, and
    viability.

55
  • continuous
  • Preterm labor is very common
  • ß-agonists or magnesium
  • Delivery should be delayed as long as the fetus
    is not an unacceptable metabolic stress on the
    mother
  • Delivery by cesarean section is indicated
  • mother is in extremis
  • uterus itself is hemorrhaging
  • gravid uterus is impairing surgical control of
    abdominal or pelvic hemorrhage.
  • in Placental abruption Emergency cesarean section
    is indicated.

56
  • Continuous
  • The Kleihauer-Betke blood test can be used to
    determine whether fetal blood has leaked into the
    maternal circulation ( is a blood test used to
    measure the amount of fetal hemoglobin
    transferred from a fetus to a mother's
    bloodstream.)
  • if the test is positive, anti-Rh0 immune globulin
    administration is recommended for any Rh-negative
    mother carrying an Rh-positive fetus.
  • Supine hypotension syndrome

57
  • Elderly Trauma Patients
  • markedly more serious outcome in elderly than in
    younger victims.
  • Decreased cardiopulmonary reserves lead to a
    higher incidence of
  • postoperative mechanical ventilation
  • much greater risk for MOSF
  • Greater care must be taken with intra operative
    positioning to avoid pressure injuries.
  • A higher hematocrit with tighter control of
    administered fluid .
  • Post-traumatic myocardial dysfunction is a
    significant risk, particularly if the heart rate
    is elevated secondary to
  • blood loss
  • Pain
  • anxiety.
  • TEE or PAC to guide fluid therapy
  • prophylaxis against DVT

58
Pain management
  • pain management challenges
  • multiple sites of injury
  • protracted episodes of care
  • complicating psychological and emotional issues
  • and frequently, previous or ongoing substance
    abuse.
  • As with pain management practice in other
    disease trauma patients are frequently under
    treated which can be a significant source of
    dissatisfaction.

59
  • Continued
  • Individual patients will have widely variant
    requirements for pain medications, so induction
    of analgesia must be carefully titrated
  • Early or even preemptive treatment of pain has
    been shown to greatly reduce analgesic
    requirements over time.
  • Rapidly acting intravenous agents administered in
    small doses under pain relief is achieved is
    recommended.
  • This allows the practitioner to determine the
    patients basal requirement before starting long
    acting medications or patient control analgesia.

60
  • Continued
  • Hypotension developing in response to the
    appropriate administration of analgesics should
    lead to an investigation for occult hemorrhage or
    hypovolemia.
  • The need for analgesic medication and the
    duration of analgesic therapy will be minimized
    analgesic if a comprehensive emotional support
    system is available to the patient.
  • The availability of counselors religious,
    financial, or legal who can help patient or
    family.
  • The anesthesiologist should refer the patient to
    counseling services as needed and should be alert
    to the potential for post-traumatic stress
    disorder in any traumatized patient.

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  • Adventages of pain control
  • Early mobilization
  • Decrease pulmonary complication
  • venous thrombosis
  • decubitus ulcer
  • 60

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  • Neuropathic pain
  • Arises where there is direct injury to a major
    sensory nerve and is common after
  • spinal cord trauma
  • traumatic amputation
  • major crush injury
  • is characterized by
  • Burning
  • intermittent electrical shocks
  • Dysesthesia
  • in the affected dermatome distribution.
  • it responds poorly to the analgesics used for
    somatic pain.
  • This diagnosis should be considered whenever pain
    control is poor or the patient has arising
    requirement for medications unexplained by the
    anatomic injuries.

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  • First-line therapy for neuropathic pain
  • Gabapentin ( an antiepileptic drug with very
    strong specificity for this problem)
  • Gabapentin therapy is typically initiated at a
    dose of 200 mg three times daily with daily
    titration upward to a maximum of 2 to 3 g/day.
  • If neuropathic pain persists, selective regional
    anesthesia or analgesia may be indicated in an
    effort to "break the cycle" of spinal cord
    receptor recruitment.

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