Anaesthesia for the Trauma patient:
Outline:
1. Initial resuscitation
2. The Lethal Triad
3. Damage Control Resuscitation
4. The Anaesthetic for the Trauma Patient: Pre-op, Intra-op, Post-op
The management of the trauma patient may require a multidisciplinary team:
- Trauma surgeon
- Orthopaedic Surgeon
- Neurosurgeon
- Plastic Surgeon
- Vascular Surgeon
- Radiologist
- Laboratory technician
- Blood bank technician
- Intensivist and
- Anaesthetist who will continue the resuscitation already in progress.
The anaesthetist is also expected to triage patients scheduled for emergency
operations during a:
- busy weekend call,
- massive casualty incident,
- natural disaster,
deciding the order in which procedures should be performed and determining
which procedures should be postponed until the patient is more stable.
1. Initial Resuscitation:
In South Africa, ATLS (Advanced Trauma Life Support) principles are followed.
Primary Survey: Life threatening injuries are identified and resuscitation is begun.
- Airway and C-spine protection
- Breathing and Ventilation: look especially for injuries that may impair
ventilation eg. tension pneumothorax, flail chest with pulmonary contusion,
massive haemothorax.
- Circulation with haemorrhage Control: external bleeding should be
controlled by direct pressure. Occult bleeding may be from the chest,
abdomen, pelvis and long bones.
- Disability: ?neurologic status – assess the patient's level of
consciousness (GCS), pupil size and reaction, lateralizing signs, and
spinal cord injury level.
- Exposure/Environmental control: completely undress the patient to
adequately assess the entire patient, but avoid hypothermia.
This is followed by a Secondary Survey: which involves an elaborate systemic
examination and diagnostic investigations.
, 2. The Lethal Triad of Trauma
The lethal triad of trauma, as the name suggests, results in an increased
mortality, and should thus be avoided and treated without delay.
- Hypothermia:
• Definition: Core temperature <35C
• Usually results from exposure at the scene, on examination and
intraoperatively eg. laparotomy with loops of bowel exposed, infusion of
cold resuscitation fluid and blood.
• Hypothermia prolongs coagulation affecting the enzymatic reactions and
platelet function
- Coagulopathy of Trauma:
• Is an independent risk factor for death.
• Mechanism: During hypoperfusion the endothelium releases:
o Thrombomodulin which binds Thrombin, this complex activates
Protein C and it also prevents Fibrinogin → Fibrin
o Protein C inhibits: factor V, factor VIII and Plasminogen activator
inhibitor (PAI inhibits fibrinolysis, therefore Protein C causes
fibrinolysis)
• Crystalloid and Colloid resuscitation contributes to coagulopathy by
dilution of coagulation factors.
- Acidosis:
• Occurs due to tissue hypoperfusion during hypovolaemic shock with
metabolic acidosis and lactate production.
• Acidosis also prolongs coagulation affecting the enzymatic reactions.
3. Damage Control Resuscitation: It is a strategy that combines:
- Permissive Hypotension:
• Aggressive fluid resuscitation → transient ↑BP → “pop the clot”
phenomena → haemorrhage → subsequent deterioration → further fluid
administration → leading to the “bloody vicious cycle”
• The goal is a SBP 80-100mmHg, limiting fluid administration until
haemorrhage has been controlled.
• Accept a limited period of suboptimal end-organ perfusion.
• Contraindicated in severe head injury where maintenance of cerebral
perfusion pressure is essential.
- Haemostatic Resuscitation:
• Blood and blood products are administered preemptively to address a
presumed coagulopathy.
• Limited crystalloids and synthetic colloids administration.
• Current evidence justifies the use of Fresh frozen plasma (FFP): Red
blood cells (RBC): Platelets in a ratio of 1:1:1. In South Africa, the mega
units of pooled platelets used, contain the platelets pooled from 6 donors,
therefore they should be transfused for every 4-6 units of FFP and RBC’s
administered.
• Tranexamic Acid (anti-fibrinolytic) beneficial if administered within 3 hours
of injury.
Outline:
1. Initial resuscitation
2. The Lethal Triad
3. Damage Control Resuscitation
4. The Anaesthetic for the Trauma Patient: Pre-op, Intra-op, Post-op
The management of the trauma patient may require a multidisciplinary team:
- Trauma surgeon
- Orthopaedic Surgeon
- Neurosurgeon
- Plastic Surgeon
- Vascular Surgeon
- Radiologist
- Laboratory technician
- Blood bank technician
- Intensivist and
- Anaesthetist who will continue the resuscitation already in progress.
The anaesthetist is also expected to triage patients scheduled for emergency
operations during a:
- busy weekend call,
- massive casualty incident,
- natural disaster,
deciding the order in which procedures should be performed and determining
which procedures should be postponed until the patient is more stable.
1. Initial Resuscitation:
In South Africa, ATLS (Advanced Trauma Life Support) principles are followed.
Primary Survey: Life threatening injuries are identified and resuscitation is begun.
- Airway and C-spine protection
- Breathing and Ventilation: look especially for injuries that may impair
ventilation eg. tension pneumothorax, flail chest with pulmonary contusion,
massive haemothorax.
- Circulation with haemorrhage Control: external bleeding should be
controlled by direct pressure. Occult bleeding may be from the chest,
abdomen, pelvis and long bones.
- Disability: ?neurologic status – assess the patient's level of
consciousness (GCS), pupil size and reaction, lateralizing signs, and
spinal cord injury level.
- Exposure/Environmental control: completely undress the patient to
adequately assess the entire patient, but avoid hypothermia.
This is followed by a Secondary Survey: which involves an elaborate systemic
examination and diagnostic investigations.
, 2. The Lethal Triad of Trauma
The lethal triad of trauma, as the name suggests, results in an increased
mortality, and should thus be avoided and treated without delay.
- Hypothermia:
• Definition: Core temperature <35C
• Usually results from exposure at the scene, on examination and
intraoperatively eg. laparotomy with loops of bowel exposed, infusion of
cold resuscitation fluid and blood.
• Hypothermia prolongs coagulation affecting the enzymatic reactions and
platelet function
- Coagulopathy of Trauma:
• Is an independent risk factor for death.
• Mechanism: During hypoperfusion the endothelium releases:
o Thrombomodulin which binds Thrombin, this complex activates
Protein C and it also prevents Fibrinogin → Fibrin
o Protein C inhibits: factor V, factor VIII and Plasminogen activator
inhibitor (PAI inhibits fibrinolysis, therefore Protein C causes
fibrinolysis)
• Crystalloid and Colloid resuscitation contributes to coagulopathy by
dilution of coagulation factors.
- Acidosis:
• Occurs due to tissue hypoperfusion during hypovolaemic shock with
metabolic acidosis and lactate production.
• Acidosis also prolongs coagulation affecting the enzymatic reactions.
3. Damage Control Resuscitation: It is a strategy that combines:
- Permissive Hypotension:
• Aggressive fluid resuscitation → transient ↑BP → “pop the clot”
phenomena → haemorrhage → subsequent deterioration → further fluid
administration → leading to the “bloody vicious cycle”
• The goal is a SBP 80-100mmHg, limiting fluid administration until
haemorrhage has been controlled.
• Accept a limited period of suboptimal end-organ perfusion.
• Contraindicated in severe head injury where maintenance of cerebral
perfusion pressure is essential.
- Haemostatic Resuscitation:
• Blood and blood products are administered preemptively to address a
presumed coagulopathy.
• Limited crystalloids and synthetic colloids administration.
• Current evidence justifies the use of Fresh frozen plasma (FFP): Red
blood cells (RBC): Platelets in a ratio of 1:1:1. In South Africa, the mega
units of pooled platelets used, contain the platelets pooled from 6 donors,
therefore they should be transfused for every 4-6 units of FFP and RBC’s
administered.
• Tranexamic Acid (anti-fibrinolytic) beneficial if administered within 3 hours
of injury.
