Trauma Special Topics Flashcards
(39 cards)
What is the goal of care for head injury?
To prevent secondary brain damage resulting from intracranial complications that are aggravated by intracranial bleeding, edema, and resultant increased intracranial pressure (ICP).
What are modifiable risk factors for M&M following severe traumatic brain injury?
-Presence of hypotension on admission
-Need for mechanical ventilation
Describe anesthetic management of head injured patients.
Early control of the airway and maintenance of CV Stability.
-GCS < 8 necessitates ETT
-Maintain SpO2 > 90% with normoventilation
-Avoid increases in ICP with intubation
-Nasal intubation/nasogastric tube contraindicated 2o to possible basilar skull fracture
-Gastric tubes should be oral only.
-Hypoxemia and hypotension are associated with increased M&M
-CPP = MAP – ICP (60 - 70 mmHg)
-Support treatment for ICP > 20-25 mmHg: HOB elevation, PCO2 30-35mmHg, intermittent intraventricular drainage CSF
-No anesthesia technique superior (TIVA vs. Inhaled), avoid N2O
-Arterial BP monitoring: maintain SBP > 90 mmHg
-Hyperosmolar therapy with mannitol 0.25-1 g/kg helps control elevated ICP
-Corticosteroids (not shown to improve outcome or reduce ICP)
What are risk factors for Spinal Cord Injury (SCI)?
-10,000 SCIs per year in the US
-80% male with median age 25 years
-MVAs, falls, assaults, diving injuries, and other sports
Outcome after an acute SCI depends on what 3 factors?
1) The severity of the acute injury
2) The prevention of exacerbation of the injury during rescue, transport, and hospitalization
3) The avoidance of hypoxia and systemic hypotension, which can further compromise neural function.
Where do most traumatic SCIs occur?
> 50% occur in cervical region.
-Craniocervical junction (33%): occiput and 1st two vertebrae
-Categorized as complete or incomplete
Most common forms:
-Incomplete tetraplegia (31%)
-Complete paraplegia (25%)
-Complete tetraplegia (20%)
-Incomplete paraplegia (19%)
What is the difference between a complete and incomplete SCI?
Complete: absence of motor, sensory, bowel and bladder function below the level of injury
Incomplete: preservation of some neurologic function
What is the difference between Tetraplegia and Paraplegia?
Tetraplegia, also known as quadriplegia, results in the partial or total loss of use of all four limbs and torso; paraplegia is similar but does not affect the arms.
Cervical SCI should be assumed in what situations?
SCI should be ruled out in ANY trauma!!
Assume Cervical SCI in:
-Any trauma to the head or face
-Unconscious trauma patient
-Complaints of pain in the cervical spine with or without palpation.
What are the 6 conditions that correlate with SCIs?
Paralysis
Pain
Position
Parathesias
Ptosis
Priapism
How do you prevent worsening neurological deficits with SCIs?
-Spinal immobilization should be completed prior to patient movement.
-Stabilization can be accomplished by placing a cervical collar on the patient, splinting, and/or sandbagging the head in neutral alignment.
-The patient should be placed on a long spinal back board before he or she is moved.
How do you evaluate a SCI?
-Xray multiple views, CT scan or MRI
-Must include all 7 cervical vertebrae
-C-7 most common injury site
What indicates that a patient is unable to protect their airway?
-Unconscious or semiconscious
-Absent or diminished gag reflex or cough
-Intraoral or facial injuries with significant edema, bleeding, or both
Require rapid intubation.
SCI above what level leads to apnea and ventilator dependence?
SCI above C3 often leads to apnea, rendered ventilator dependent.
-Diaphragm innervated C 3-5, Intercostal muscles T 2-11
How do you perform airway management with SCI?
-The choice of airway management technique will depend to a great extent on the patient’s injuries, level of cooperation, hemodynamic stability, and ability to protect the airway.
-Succinylcholine is not recommended for intubation of the patient with acute SCI because muscle fasciculation may exacerbate the SCI.
-Use Roc or non-relaxant assisted airway control techniques
-Manual In-Line Stabilization may lead to a less than optimal view, but it is still recommended to minimize the risk of secondary cervical SCI.
Describe anesthetic management of SCI procedures (Stabilization or decompression procedures)
-Early stabilization associated with improved outcomes
-Maintain MAP ~ 90 mmHg for up to 7 days postinjury to optimize spinal cord perfusion
-Document neurologic status before start of anesthesia, intubation, and positioning for surgery - Consider awake intubation
-Airway technique dependent on level of injury, level of cooperation, hemodynamic stability and ability to protect the airway
-Manual In-Line Stabilization recommended
-Induction: Propofol versus Ketamine or Combination
-Avoid N2O (chance of head injury, lung insult, or bowel obstruction in trauma patients)
-Antifibrinolytic agents (TXA)
Why are Propofol and Ketamine preferred for induction in the SCI patient?
Propofol decreases CMRO 2 , CBF and ICP, which makes this drug a preferred agent for hemodynamically stable TBI patients.
Use of ketamine in those patients with a TBI may lead to increased ICP, but it may help avoid hypotension in hypovolemic trauma patients.
What is Tranexamic Acid (TXA)?
Antifibrinolytic agent.
-A lysine analog that inhibits plasminogen activation and has been shown in many studies to be particularly helpful at reducing surgical blood loss.
Why do you avoid Nitrous Oxide in trauma patients?
There is a chance the patient has a head injury, lung insult, or bowel obstruction.
What is the triad of spinal shock?
Hypotension, Bradycardia, and Hypothermia
How does Spinal Shock occur?
-Progressively intensified more cephalad (> T-6)
-Loss of sympathetic tone, vasodilation, peripheral circulation pooling, and decreased venous return (Hypotension)
-Unopposed vagal innervation (Bradycardia)
-Interrupts sympathetic pathways from hypothalamus to peripheral blood vessels, unable to constrict or shiver (Hypothermia)
What is the difference between Spinal and Hemorrhagic Shock?
Patients in spinal shock are hypotensive and bradycardic with warm, pink extremities. In contrast, patients in hemorrhagic shock tend to be hypotensive and tachycardic with cold, clammy skin.
What monitoring should be used for the SCI patient?
Use of invasive monitoring is critical for fluid resuscitation and appropriate intervention with vasoactive drugs.
-An indwelling arterial catheter is mandatory in the acute phase of spinal shock.
-The SCI patient is frequently unable to maintain adequate cardiac filling pressures, consider central venous access.
-However, overaggressive fluid therapy can precipitate pulmonary edema.
-For the maintenance of adequate arterial blood pressure and cord perfusion, pressor therapy may be initiated.
What is Autonomic Dysreflexia?
Sudden activation of sympathetic response secondary to noxious stimuli (Colorectal and bladder distention).
-Persists from several weeks to 6 months post SCI
-~ 98% high para/quadriplegic (SCI above T6) will experience AD following painful injury below level of spinal cord lesion
-Often presents with severe hypertension
-Other life-threatening consequences: seizure, pulmonary edema, MI, acute renal injury, and intracranial hemorrhage
