Care of the Unconscious, Multi-trauma Patient

8/3/2019 Care of the Unconscious, Multi-trauma Patient

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The management of the patient with

major trauma requires a multidisciplinary

team effort. Trauma management is based on ATLS

protocols.

Rapid primary survey

Resuscitation of vital functions

Detailed secondary survey

Definitive care


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Rapid primary survey

Recognition & treatment of any immediately

life-threatening complications (ABCDE) Resuscitation of vital functions

Haemorrhage control, intravenous access &

volume resuscitation.

Detailed secondary survey

Recognition of potentially life-threateninginjuries


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The first priority for the anaesthetist when

confronted by a unconscious multi-

trauma victim is to establish patency ofthe airway whilst assuming immobilisation

of the cervical spine ("manual in-line

stabilization" or MILS).

Although unstable cervical spine injury arerelatively uncommon, all patients should beassumed to be at risk until proven otherwise.


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If upper airway obstruction is present the

pharynx is cleared of any debris and the

jaw displaced forward (jaw thrust). Neck tilt & chin lift are avoided as these

manoeuvres could displace an unstablecervical spine.


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If the patient is apnoeic ventilation by maskis started with 100% O2 Good oxygenation & correction of hypercapnia

should be ensured before tracheal intubation isundertaken.

The possibility of cervical spine injury doesnot contraindicate the orotracheal

intubation provided it is performed withcare & in-line immobilisation of the cervicalspine is maintained throughout theprocedure.


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If there are clinical signs suggesting a

pneumothorax or surgical emphysema

and/or flail chest apparent then a chestdrain should be inserted simultaneously

or before mechanical ventilation is

commenced.


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Persistence of hypoxemia after institution ofmechanical ventilation suggests unrecognised pneumothorax,

haemothorax,

pulmonary contusion, or

poor cardiac output due to hypovolaemia,tamponade, etc.

When the airway is under control, ventilationdeemed adequate and any other external

bleeding has been arrested, the next priority isevaluation of the cardiovascular system


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Assessment of

Blood volume status

Pump function


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Patients with major trauma often requireurgent restoration of circulating blood

volume. Two large-gauge (14 gauge) IV cannulae

(preferably attached to warming coils)

Isotonic electrolyte solutions are used for

resuscitation initially 1-2 L of hartmanns solution is given as

rapidly as possible & patients responseassessed.


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If this does not significantly improve

perfusion or arterial blood pressure and

cross-matched blood is not yetavailable, either plasma or a plasma

substitute should be considered.

(Hetastarch, Gelatin)

Up to 1500ml may be given initially; in mostcircumstances this is adequate to restorecirculating blood volume until cross-matched blood is available.


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Warm, stored blood is administered

subsequently to maintain Urine Output,

Arterial Pressure & CVP. As soon as possible a reliable CVP

catheter is inserted.

The right internal jugular is the preferred sight.

Fluid infused through the peripheral IVcannulae to produce a CVP ofapproximately 5-10 mmHg


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If the breach in the circulation is large

then the prime objective of resuscitation

is to maintain cerebral and coronaryperfusion whilst control of the source of

bleeding is accomplished, not to restore

a normal blood pressure.


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The commonest cause of pump failure in major trauma isthe presence of a pneumothorax, but other possibilitiesinclude

Severe myocardial contusion Traumatic pericardial tamponade

Tension pneumothorax causes compression of the

mediastinum (heart & great vessels) and presents with

extreme respiratory distress,

shock,

unilateral air entry,

a shift in the trachea towards the normal side, &

distension of the veins in the neck.

The last sign may not be seen in hypovolaemic shock .


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It may be relieved immediately by insertion of a 14-gauge cannula through the second intercostalspace in the midclavicular line.

This should be followed by a standard chest drainage.

If there is any suspicion of tension pneumothorax,IPPV should not be instituted until decompressionhas been achieved, otherwise mediastinal

compression is increased. Patients with blunt chest trauma and fractured ribs

may develop a tension pneumothorax rapidlywhen positive pressure ventilation is commenced.

consideration should be given toward the prophylacticinsertion of chest drains in such patients.


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In the unconscious patient, the tracheamay be intubated after administration of

a paralysing dose of succinylcholine. After intubation, the lungs are ventilated

at the lowest peak airway pressureconsistent with an acceptable tidal

volume. Pancuronium or rocuronium is given in

small incremental doses of 1 or 5 mg,respectively, to maintain relaxation.


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Monitoring Blood may be sampled from the arterial line to

monitor changes in the acid-base state,

haemoglobin concentration, coagulation, &electrolyte concentrations.

Requirement for further colloid replacement may beassessed from CVP measurement and urine output.

When surgical bleeding has been controlled,

the patients cardiovascular status shouldimprove, but if hypotension persists despiteadequate fluid administration, other causes ofhaemorrhage should be sought.


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It is important that the anaesthetist monitors thepatient regularly during prolonged anaesthesia toexclude these latent complications of trauma.


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If an amount greater than 50% of the patients blood volumeis replaced rapidly, the transfusion is deemed massive.

E.g. 5 units of blood in a 70 kg adult.

Features of stored blood pH: 6.6 7.2

Serum [K+] : 5-25 mmol/L

Temperature: 4 60C.

Citrate as anticoagulant

> 5 days storage time insignificant amounts of 2,3 DPG.

>24 hours storage time no functional platelets, Factors V& VIII 10% of normal & factor IX 20% of normal.

Debris; effete cells clumped together with platelets


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Citrate is removed by metabolic conversion inthe liver forming mostly HCO3

-

Transfused cells act as K+ sink; mopping up

excess K+ quickly. The post transfusion alkalosis (resulting from

citrate metabolism) may contribute tohypokalaemia in the post transfusion period.

If the transfused blood is warmed to body

temperature before transfusion & a 20 micronfilter used to remove unwanted cellular debris,the commonest problem is acute haemostaticfailure.


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Transfusion of bank blood in quantitiesapproaching the patients blood volume

causes a dilutional thrombocytopenia &some degree of clotting factordeficiency, both of which affecthaemostasis adversely.

These abnormality may be detected bya platelet count, PT, aPTT, reflectingdisorders of extrinsic & intrinsic systems asa result of dilutional loss of factor V & VIII.


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Treatment should be directed at

correcting the dilutional coagulation

change and consists of Fresh frozen plasma (at least 1 unit for every

4 units of blood)

Platelet concentrate for severe

thrombocytopenia (Plt count < 30 X 109/L ) ormilder in patients with intracranial injury.


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Request of these expensive bloodproducts should be made early as

there is often delay in obtainingthem & it is better, if possible, toprevent the development of

coagulation failure and theresulting bleeding tendency.


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Although diffuse pathological bleedingmay be secondary to dilutional effects, it is

also a manifestation of tissue hypoperfusiondue to shock & inadequate or delayedresuscitation.

Clinically, this microvascular bleeding produces

oozing from the mucosae, raw surfaces andpuncture sites & may increase the extent of softtissue & pulmonary contusions.

It is difficult to treat and this underscores theimportance of rapid and adequate resuscitation


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The rapid and effective restoration of anadequate circulating blood volume iscrucial in the management of majorhaemorrhage, as mortality increases withincreasing duration & severity of shock.

Inadequate volume replacement is themost common complication of

haemorrhagic shock The importance of prevention of

hypothermia during massive transfusioncannot be overstated.


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Hypothermia causes Platelet dysfunction

Reduced metabolism of citrate & lactate

Increased tendency to cardiac arrhythmias

Which may result in A bleeding diathesis

Hypocalcaemia Metabolic acidaemia

Cardiac arrest


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Core temperature should be measuredcontinuously during massive transfusion andevery effort must be made to prevent heatloss.

Thermally insulating plastic drapes can beused to cover the patient, who should beplaced on a heated ripple mattress

Efficient systems for heating stored blood &allowing rapid infusion should be available However all fluids should be warmed to body

temperature if possible.


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Documents

Care of the Unconscious, Multi-trauma Patient