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Anaesthesiology
Anesthesia for Trauma and Burns
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
17 sections · 198 slides
Overview
- Scope of this topic
- Key messages
The Trauma Anesthesiologist
- Role of the anesthesiologist in trauma
- Effect of critical care training on practice
- Checklists in trauma anesthesia
- Trauma-specific cognitive aids
Airway Management
- Rapid sequence induction in trauma
- Gum elastic bougie technique
- Manual in-line stabilisation
- Safety of orotracheal intubation in spinal injury
- Canadian C-Spine Rule
- NEXUS criteria
- Video laryngoscopy versus direct laryngoscopy
- Video laryngoscopy outcomes in trauma
- Video laryngoscopy in intensive care and prehospital settings
- Cochrane conclusion on laryngoscope choice
- Supraglottic airways in trauma
- Cricothyroidotomy
- Outcomes and technique of cricothyroidotomy
- Drugs used in trauma induction
- Common anesthetic medications used during resuscitation
- Common anesthetic medications used during resuscitation (continued)
Pulmonary Management
- Low tidal volume ventilation
- Alveolar recruitment manoeuvres
- Lung protection in the operating room
- Tidal volume versus PEEP for postoperative complications
- Transfusion-associated circulatory overload
- TACO versus TRALI
Cardiovascular Management
- Vasopressors in hemorrhagic shock
- Early vasopressor use and mortality
- Pharmacology of vasopressin
- Animal studies of vasopressin in hemorrhage
- Vasopressin in human traumatic hemorrhagic shock
- The AVERT trial
- Methylene blue for vasoplegia
- Blood flow versus blood pressure
- Hypotensive resuscitation
- Prehospital crystalloid volume and outcome
- Defining hypotension
Neurologic Injury
- Secondary brain injury
- Cerebral perfusion pressure targets
- Decompressive craniectomy
- Steroids in traumatic brain injury
- Hyperosmolar therapy
- Hypertonic saline in children with raised intracranial pressure
- Post-traumatic seizure prophylaxis
- Preventing the second hit after brain injury
Transfusion and Resuscitation
- Massive transfusion definitions
- Origin of ratio-based transfusion
- Outcomes with balanced ratios
- Survivor bias in ratio studies
- Optimal ratio studies and PROPPR
- Prehospital plasma: the PAMPer study
- Freeze-dried plasma products
- Whole blood resuscitation
- Low-titer group O whole blood
- Safety and efficacy evidence for whole blood
- Practical advantages and cautions of whole blood
Pharmacological Adjuncts
- Tranexamic acid: mechanism and CRASH-2
- MATTERs study and patient selection for tranexamic acid
- Fibrinolysis phenotypes in trauma
- Three fibrinolysis states
- CRASH-3 and tranexamic acid in brain injury
- Calcium in massive transfusion
- Calcium on admission before transfusion
- Prothrombin complex concentrate
- Fibrinogen replacement
- Estrogen and desmopressin for platelet dysfunction
- Steroids in critical illness and trauma
- Hydrocortisone trials in trauma
Crystalloids, Bicarbonate and the Kidney
- Crystalloid choice in trauma
- Balanced solutions versus saline
- Sodium bicarbonate in lactic acidosis
- Urine output as a measure of resuscitation
- Rhabdomyolysis and acute kidney injury
- Renal-dose dopamine
- Diuretics and the bicarbonate-mannitol regimen
Measures of Resuscitation
- End-tidal carbon dioxide in shock
- End-tidal carbon dioxide and outcome
- Base deficit
- Base deficit and transfusion need
- Base deficit shock classification
- Stroke volume variability
- Comparing fluid responsiveness measures
- Assessment of Blood Consumption score
- Assessment of blood consumption
Viscoelastic Testing
- Trauma-induced coagulopathy
- Conventional coagulation tests
- Principles of viscoelastic hemostatic assays
- Viscoelastic tracing parameters and matching hemostatic therapy
- Reading a viscoelastic tracing
- Speed of viscoelastic results
- Reducing turnaround of conventional tests
- Detecting abnormal fibrinolysis
- Viscoelastic tracing patterns and recommended treatment
- Interpreting the treatment algorithm figure
- Platelet contribution to clot strength
- Separating fibrinogen from platelet effect
- Evidence for viscoelastic-guided resuscitation
- Interpreting the ITACTIC result
- Limitations of viscoelastic assays
- What viscoelastic assays cannot detect
- Comparing the two testing approaches
- Comparison of conventional coagulation test and viscoelastic hemostatic assays
Point-of-Care Ultrasound
- Point-of-care ultrasound in trauma anesthesia
- The FAST examination
- Probe positions and views of the FAST examination
- Limitations of FAST
- Ultrasound for airway management
- Ultrasound appearance of oesophageal intubation
- The double trachea sign
- Ultrasound for pneumothorax
- Lung ultrasound signs of pneumothorax
- Interpreting the lung ultrasound signs
- Ultrasound for pleural effusion and hemothorax
- Focused cardiac ultrasound
- Transoesophageal echocardiography in trauma
Future Directions
- Extracorporeal membrane oxygenation in severe trauma
- Immunotherapy after injury
- Adenosine, lidocaine and magnesium therapy
- Proposed mechanism of ALM therapy
- Animal evidence for ALM therapy
Pediatric Trauma
- Epidemiology of pediatric trauma
- Why airway priority is higher in children
- Pediatric airway anatomy
- Pediatric respiratory reserve
- Airway technique in children
- Emergency invasive airway in children
- Pediatric cardiovascular reserve
- Blood volume by age
- Vascular access and temperature in children
- Adult strategies not proven in children
Burns
- Global burden of burn injury
- Systemic effects of major burns
- The two phases of burn pathophysiology
- Burn shock phase
- Hypermetabolic phase
- Nutritional implications of the hypermetabolic phase
- Classification of burn depth
- Clinical meaning of burn depth
- Inhalation injury and mortality
- Types of inhalation injury
- Upper airway thermal injury
- Why repeated airway assessment matters in burns
- Lower airway chemical injury
- Consequences of lower airway injury
- Clinical suspicion of inhalation injury
- Physical findings and pitfalls in inhalation injury
- Diagnostic testing for inhalation injury
Summary
- Take-home points: airway and lungs
- Take-home points: circulation and transfusion
- Take-home points: monitoring, children and burns
References
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition