Transcript Anethesia for Total Hip and Knee Arthroplasty

Anaesthesia for
Trauma Patients
By Dr. H. O. Opere
Consultant Anaesthesiologist
April 2013
INTRODUCTION
The initial assessment of the
trauma patient can be divided
into:
1. Primary survey
2. Secondary survey
3. Tertiary survey
PRIMARY SURVEY
• The primary survey should take 2–5
minutes and consists of the ABCDE
sequence of trauma: Airway,
Breathing, Circulation, Disability, and
Exposure.
PRIMARY SURVEY: Airway
Establishing and maintaining an airway is always the
first priority.
Important signs of obstruction include snoring or
gurgling, stridor, and paradoxical chest movements.
The presence of a foreign body should be considered
in unconscious patients.
Advanced airway management (such as endotracheal
intubation, cricothyrotomy, or tracheostomy) is
indicated if there is apnea, persistent obstruction,
severe head injury, maxillofacial trauma, a penetrating
neck injury with an expanding hematoma, or major
chest injuries.
PRIMARY SURVEY: Airway cont’d
Cervical spine injury is unlikely in alert
patients without neck pain or tenderness.
Five criteria increase the risk for potential
instability of the cervical spine:
1.Neck pain
2.Severe distracting pain
3.Any neurological signs or symptoms
4.Intoxication
5.Loss of consciousness at the scene.
PRIMARY SURVEY: Airway cont’d
Laryngeal trauma makes a complicated
situation worse. Open injuries may be
associated with bleeding from major neck
vessels, obstruction from hematoma or
edema, subcutaneous emphysema, and
cervical spine injuries.
Closed laryngeal trauma is less obvious but
can present as neck crepitations, hematoma,
dysphagia, hemoptysis, or poor phonation.
PRIMARY SURVEY: Breathing
Assessment of ventilation is best accomplished
by the look, listen, and feel approach.
Look for cyanosis, use of accessory
muscles, flail chest, and penetrating or
sucking chest injuries.
Listen for the presence, absence, or
diminution of breath sounds.
Feel for subcutaneous emphysema, tracheal
shift, and broken ribs.
PRIMARY SURVEY: Circulation
Adequacy of circulation is based on pulse
rate, pulse fullness, blood pressure, and signs
of peripheral perfusion.
Signs of inadequate circulation include
tachycardia, weak or unpalpable peripheral
pulses, hypotension, and pale, cool, or cyanotic
extremities.
The first priority in restoring adequate
circulation is to stop bleeding.
The second priority is to replace intravascular
volume.
PRIMARY SURVEY Cont’d
Disability
Evaluation for disability consists of a rapid
neurological assessment. Because there is
usually no time for a Glasgow Coma Scale, the
AVPU system is used: awake, verbal
response, painful response, and unresponsive.
Exposure
The patient should be undressed to allow
examination for injuries. In-line immobilization
should be used if a neck or spinal cord injury is
suspected.
SECONDARY SURVEY
The secondary survey begins only when the
ABCs are stabilized.
In the secondary survey, the patient is
evaluated from head to toe and the indicated
studies (eg, radiographs, laboratory tests,
invasive diagnostic procedures) are obtained.
Head examination includes looking for injuries
to the scalp, eyes, and ears.
Neurological examination includes the Glasgow
Coma Scale and evaluation of motor and
sensory functions as well as reflexes.
SECONDARY SURVEY Cont’d
The chest is auscultated and inspected again
for fractures and functional integrity (flail chest).
Examination of the abdomen should consist of
inspection, auscultation, and palpation.
The extremities are examined for fractures,
dislocations, and peripheral pulses.
A urinary catheter and nasogastric tube are
also normally inserted.
SECONDARY SURVEY Cont’d
Basic laboratory analysis includes a complete
blood count (or hematocrit or hemoglobin),
electrolytes, glucose, blood urea nitrogen
(BUN), and creatinine.
Arterial blood gases may also be extremely
helpful.
A chest X-ray should be obtained in all patients
with major trauma.
The possibility of cervical spine injury is
evaluated by examining all seven vertebrae in a
cross-table lateral radiograph and a swimmer's
view.
SECONDARY SURVEY Cont’d
Depending on the injuries and the
hemodynamic status of the patient, other
imaging techniques (eg, chest computed
tomography [CT] or angiography) or diagnostic
tests such as diagnostic peritoneal lavage
(DPL) may also be indicated.
TERTIARY SURVEY
A tertiary survey is defined as a patient
evaluation that identifies and catalogues
all injuries after initial resuscitation and
operative interventions.
ANAESTHETIC CONSIDERATIONS
General Considerations
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Regional anesthesia is inappropriate in
hemodynamically unstable patients with lifethreatening
injuries.
If the patient arrives in the operating room already
intubated, correct positioning of the endotracheal
tube must be verified.
If the patient is not intubated the same principles of
airway management described above should be
followed in the operating room. If time permits,
hypovolemia should be at least partially corrected
prior to induction of general anesthesia.
General Considerations cont’d
Invasive monitoring (direct arterial, central
venous, and pulmonary artery pressure
monitoring) can be extremely helpful in
guiding fluid resuscitation, but insertion of
these monitors should not detract from the
resuscitation itself.
Serial hematocrits (or hemoglobin), arterial
blood gas measurement, and serum
electrolytes (particularly K+) are invaluable in
protracted resuscitations.
Head & Spinal Cord Trauma
Succinylcholine is reportedly safe during the
first 48 hrs following the injury but is
associated with lifethreatening
hyperkalemia afterward.
Chest Trauma…
Abdominal Trauma…
Extremity Trauma…
The END
Thank you!