advTrauma09May - Advances in Trauma Anesthesia Charles E....

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Advances in Trauma Anesthesia Charles E. Smith, MD Professor, Case Western Reserve University Director, Cardiothoracic and Trauma Anesthesia MetroHealth Medical Center Cleveland, Ohio May 2009
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Objectives Approach to injured pt: airway, c-spine clearance Fluids: delayed resuscitation, massive trx, FVIIa Cardiac + great vessel injuries TEE +TTE in trauma Advantages of early fracture repair: femoral, pelvis + acetabulum
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ATLS Provider Manual Trauma Leading cause of death, ages 1 - 44 yrs 60 million injuries annually in USA 3.6 million require hospitalization 9 million are disabling: TBI, SCI, ortho, thoracic, abdominal Costs are staggering: $100 billion annually 40% of health care $
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Prevention: Helmets, ↓ high risk behavior, seat belts+ airbags, ↓ substance abuse Eldar Soreide, Trauma Care 2002 Prehospital Rapid transport to appropriate facility
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1 o Survey Airway + c-spine control • Breathing, O 2 sat Circulation, BP, pulse, stop external bleeding Disability: Neuro exam Exposure/ environmental control
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LEMON LAW: Ron Walls L ook externally E valuate the 3-3-2 rule M allampati O bstruction N eck mobility National Emergency Airway Course. ATLS Manual 8 th ed.
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Airway Exam Thyromental distance Obvious trauma Swelling, scarring Tracheal deviation Neck extension Subcutaneous emphysema McIntyre: Can J Anaesth 1987;34:204-13
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Airway Management Usually modified RSI by experienced provider unless difficulty anticipated Anesthesia + NMB allow for best intubating conditions in trauma especially if uncooperative, hypoxic, head injury Etomidate + succinylcholine Propofol + thiopental avoided if hypovolemia or shock. Roc suitable alternative to sux
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Drug Assisted Intubations outside the OR Karlin A. Problems in Anesthesia 2001;13:283. MHMC failed intub- 1% ED, OR; 3%- aeromedical Author/Yr # Patients Problems Talucci 1988 260 No hemodynamic or neuro complications Stene, 1991 >3000 None noted Rotondo, 1993 204 No difference from OR Karlin, 2001 647 No difference from OR
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Nolan: Anaesthesia 1993;48:630; Smith: Am J Anesthesiol 2001;28: Gum-Elastic Bougie Insert under epiglottis Gently advance until clicks or hold up 2nd operator threads ETT over bougie May need to rotate bougie 90 o Ideal for Grade III view
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2 o Survey Rest of vitals, Physical exam Xrays: chest, pelvis, + c-spine, FAST, CT, labs Done only after 1 o survey completed + resuscitation begun
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FAST Focused Assessment for the Sonographic examination of the Trauma victim 1. Perihepatic 2. Perisplenic 3. Pelvis 4. Pericardial
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Obtunded Head Injured Pts + C-spine Reliable P/E cannot be done, therefore immobilize CT scanning from skull base to T1 (16 row detector) w sagittal + coronal reconstruction Identifies bony fx, marked prevertebral soft tissue swelling or hematoma, malalignment + abnormal facets Negative predictive value 98.9% for ligament injury + 100% for unstable c-spine injury Como JJ et al. J Trauma 2007;63:544
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Kincaid + Lam. Anesthesia for Spinal Cord Trauma
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advTrauma09May - Advances in Trauma Anesthesia Charles E....

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