Trauma Anaesthesia

Objectives

To outline the expected conduct of an Anaesthetic in the operational environment

Scope

What preparation should be done prior to casualty arrival?

What equipment might be needed for an RSI in different locations (e.g. Pre-Hospital, Resus bay, Operating table)?

What drugs might be used during an RSI in different situations?

What different communication tools can be used before and during damage control resuscitation/surgery?

What different strategies can be used for specific clinical problems?

Audience

Anaesthetists

Peri-operative Practitioners

Emergency Medicine Physicians

Emergency Department Nurses 

Initial Assessment & Management

Before the Casualty Arrives

Assess Pre-Hospital Information
  • Number and Severity of casualties?
  • Airway at risk or already secured?
  • Likely to need Massive Transfusion
Prepare Anaesthetic Team
  • Brief anaesthetic assistants
  • Check availability of 2nd anaesthetist
  • Determine need to split team between casualties
Prepare Anaesthetic Equipment
  • Airway equipment and ventilator
  • Anaesthetic drugs
  • Large bore central venous access

Initial Resuscitation in the Emergency Department

Catastrophic Haemorrhage

If external control of ongoing catastrophic bleeding impossible, all efforts should be directed at immediate surgical control of bleeding.

This may require induction of anaesthesia in an unstable patient with drug doses, ventilation and fluids adjusted accordingly.

Airway

Assess and treat, with rapid sequence induction if indicated (see RSI Guideline).

Breathing

In severe hypovolaemic shock, aim to minimise intrathoracic pressure during ventilation with low respiratory rate (e.g. 6 breaths/min) and zero PEEP.

Circulation

Gain large bore central venous access if indicated.

Analgesia

Manage acute pain in accordance with guidelines.

Anaesthesia

Maintain anaesthesia with an IV agent ready for transfer to Operating theatre (or CT where available).

Next Steps

Provide guidance to Team Leader to decide:

  • Immediate surgery or CT scan first?
  • RSI prior to transfer?
  • If surgery, which body cavity first?

Advanced Assessment & Management

Rapid Sequence Induction in the Emergency Department

Indications

Indications for RSI in ED include:

  • Inadequate airway or Ventilation
  • Low GCS or agitation due to head injury
  • Humanitarian - uncontrollable pain
RSI in uncontrolled intra-abdominal (or other cavity) bleeding may be more appropriate on the operating table, immediately prior to surgery

Equipment and Team

Equipment should include:

  • Self-inflating bag and mask
  • 2 sizes of working laryngoscope
  • Appropriately sized ETT (+ 1 size below)
  • Suction
  • Bougie
  • End-tidal CO2 monitor
  • Catheter mount and HMEF
  • Syringe and tube tie/tape
  • Failed/Difficult airway equipment
  • Oropharyngeal airway
  • LMA
  • Video Laryngoscope
  • Plan D equipment (Size 6 ETT/No 10 Scapel/Bougie)

Team should include (+potential actions):

  • Experienced Anaesthetic assistant
  • 2nd clinician to give drugs and monitor cardiovascular changes
  • Rapid infusion team (where appropriate)
  • Team leader (who has been made aware prior to RSI)
  • Team ready for immediate chest decompression (thoracostomy) due to tension pneumothorax

C-Spine Precautions

  • Remove or open C-Collar/remove blocks and use manual in-line stabilisation (MILS) for RSI
  • Use a bougie routinely when using MILS

Drugs

In major trauma these drugs are routinely used:

  • Fentanyl
    • 1-2μg/kg at induction
  • Ketamine
    • 1-2mg/kg as induction agent to preserve cardiac output
  • Rocuronium
    • 1mg/kg
      • Alternative, Suxamethonium
        • 1.5mg/kg
        • Caution in hyperkalaemia, spinal cord injury > 10 days, burns >24 hrs
  • Midazolam
    • 0.02-0.05mg/kg at induction
    • 0.02mg/kg in titrated boluses
Avoid vasopressors in hypovolaemia due to trauma. Manage hypotension with blood products/fluids, titrated to BP.
In the critically injured, lower doses of the drugs mentioned above may be required.

RSI in Hypovolaemia

  • Where practical, significant hypovolaemia should be corrected prior to RSI to avoid arrest on induction (due to the IPPV and anaesthetic drugs).
  • Ensure adequate IV/IO access with rapid infusions of warmed fluids/blood products as indicated.
  • Aim for normal BP if haemorrhage is controlled.
  • Aim for radial pulse if uncontrolled bleeding.
  • Carefully titrate fentanyl and ketamine to control/agitation prior to RSI if required.
If Immediate intubation is required (e.g. compromised airway), ventilation with reduced respiratory rate (e.g. 6 breaths/min) and zero PEEP will limit the cardiovascular effects of IPPV.
Vasopressors may be indicated in this situation to counteract the cardiovascular effects of the induction agents.

 

In the Operating Room

Positioning on Arrival in the Operating Room

The default patient position is Supine with both arms abducted on boards.

Apply forced air warmer/under warmer, and commence warming ASAP.

Don't attempt an arterial line until a strong radial pulse is palpable.

Handover from the Trauma Team Leader

Hanover begins when the patient is properly positioned and established on the anaesthetic machine. Information should include:

  • List of injuries
  • Treatments given so far
  • Transfusion running totals
  • Outstanding issues/tasks/medications
  • Provisional plans

Maintenance of Anaesthesia

During hypovolaemic shock, titrate fentanyl and volatile/TCI anaesthetic agents carefully.

When bleeding is controlled, carefully titrate in further analgesia (e.g. consider fentanyl up to 15μg/kg) to reduce sympathetic tone, prevent excessive vasoconstriction and permit further volume resuscitation with blood products.

Haemostatic Resuscitation

Before surgical control of haemorrhage:

After surgical control of haemorrhage:

  • Take handover of transfusion from the Emergence Department
  • Beware over-transfusion and hyperkalaemia
  • Move to a tailored transfusion guided by physiology, viscoelastic testing and BMS lab tests

Remember:

  • Warm aggressively to achieve normothermia
  • Frequently check patient electrolytes as at risk of ↑K+ or ↓Ca2+ 
Do not treat hypovolaemic shock with vasopressors
Do not replace acute blood loss with Crystalloid/Colloid

Communication and Teamworking

Maintain effective 2-way communication with Surgery, Radiology, Critical Care and the Deployed Medical Director (if present)

Ensure surgeons are aware of:

  • Current physiological status
  • Coagulopathy on viscoelastic/lab testing
  • Plans for onward transfer, time constraints and resource limitations

Ensure passage of information from surgeons, especially:

  • Tourniquets, vascular clamps or endovascular occlusive devices being released or applied
  • Difficult surgical control of haemorrhage
  • Surgical evidence of coagulopathy

[Where available] Check CT scan reports for:

  • Radiological C-Spine clearances
  • Other injuries found not identified during primary survey
Remember the Deployed Medical Director for:
- Activation of the Emergency Donor Panel
- Requests for transfer out of the facility
- Difficult futility decisions
- Resolution in areas of disagreement

Preparing for Post-operative Care

  • Agree next destination (e.g. Critical Care, Aeromed or CT [where available])
  • Ensure effective post-operative analgesia, including systemic analgesics and regional anaesthesia
  • Handover to the receiving team

Paediatric Considerations

Anticipated Difficult Airway

Unanticipated Difficult Airway

Anaesthesia for Traumatic Brain Injury

Early Recognition of Traumatic Brain Injury

History Clinical Observations
  • Nine Liner/AT-MIST information
  • Loss of consciousness at any time
  • Altered mental status
  • History of seizure
  • Exposure to blast (particularly if enclosed space)
  • Any injury above clavicles
  • External head wounds
  • Decreased GCS
  • Unequal pupils
  • Focal neurology 
  • Headache/nausea/vomiting
  • Seizure activity
[Where available] An Urgent CT head scan should be performed in  patients with suggestion of moderate to severe traumatic brain injury (GCS < 13)

Prevention of Secondary Brain Injury

Maintain Airway patency and cervical spine stabilisation

  • If intubation is performed, careful titration of induction agents will be required (e.g. Propofol) to prevent precipitous decreased in mean ABP. 
  • Ketamine may be a suitable alternative in hypovolaemic polytrauma patients with suspected brain injury

Maintain PaO2 > 13kPa

Maintain PaCO2 between 4.5 - 5.0 kPa

  • Hyperventilation in the acute phase is not recommended.
  • In the presence of brain herniation stigmata, short term hyperventilation to a PaCO2 < 4.0 kPa may be utilised, but only to facilitate other procedures (e.g. transfer to CT)

Maintain MAP > 80mmHg in adults

  • Cerebral perfusion requires an adequate mean ABP. 
  • Haemostatic resuscitation will mitigate the effect of hypovolaemic shock.
  • Viscoelastic testing is important as coagulopathy is found in 1/3 of severely head injured patients.

Manage Intracranial Pressure (ICP)

 

Consideration

Action

Physical Methods

Free flow in cerebral venous return

Tape ETT tubes

Ensure correct sizing of cervical collar

30° head up (if injury pattern permits)

Pharmacology

 

Adequate triad of anaesthesia osmotherapy with CT evidence of raised intracranial pressure

OR

evidence of brain herniation syndromes

Ensure adequate anaesthesia and paralysis

10% Mannitol

  • 0.25-1.0gKg-1 to maintain serum osmolarity <320mOsm L-1 

OR

5% NaCl

  • 1 - 2mls Kg-1
  • Beware hyperchloraemia

Surgical

 Extra-axial collection with increased ICP Surgical Evacuation

Maintain Haemoglobin at 100gL-1

Control Temperature

Normothermia should be maintained as there is no evidence to support the routine use of hypothermia in TBI.

Pyrexia should be avoided.

Aim for Blood Glucose < 10mmol L-1

Regular monitoring and insulin sliding scale if required.

Anaesthesia for Thoracotomy

Airway Management

Follow conventional <c>ABC with standard RSI anaesthetic and controlled ventilation with single lumen endotracheal tube.

Do not attempt to insert a double lumen endotracheal tube (DLT).

Manage air leaks surgically as necessary.

Intraoperative Air Leak   Intraoperative Hypoxaemia

Detection:

  • See it
  • hear it
  • Machine detected

 

Communicate problem to surgeon:

  • How severe is it?
  • What is the implication?
  • What can be done?
 Ventilate with 100% O2

Check it is not a circuit leak

 

 Check SpO2 reflects poor gas exchange, not hypoperfusion

Vigilance:

Leak will vary in magnitude with surgical manipulation

 

 Increase PEEP to +5cm H2O and check effect on operating conditions

If large leak, ask the surgeon to compress hole, or clamp bronchus

If practical, advance ETT into left main bronchus for right sided leaks (ask surgeon to compress right main bronchus)

 

 Check ETT position and suck out any secretions

 

 

 Accept SpO2 <90%

 

 

 Suggest clamping pulmonary artery of injured lung

 

 

 Hand ventilate sympathetic to surgical activity

Anaesthesia for Myocardial Laceration Repair

Patient positioning

Move operating table to aid surgical exposure and temporarily increase pre-load

  • Use rotation and Trendelenburg to minimise retraction/rotation of heart
  • Access to the lateral LV will require rotation with patient right side down with 20-30° head down
  • Be prepared to pause ventilation to aid surgical access

Communicate with Surgeon

  • Ensure pericardium is opened maximally 
  • Ensure sutures are used to elevate the pericardium (not swabs)
Surgical manipulation may lead to hypotension or loss of cardiac output with transient arrhythmia.
Stop or reduced manipulation and allow restoration of output

Inotropes and Rate Control

  • Aim for HR 60 - 75 and accept transient hypotension to allow surgical repair.
  • Consider Esmolol or Neostigmine to slow heart rate (or Adenosine for temporary arrest)
  • Avoid inotropes and/or accept lower BP post repair

Postoperative care after pulmonary or branchial injury

Principles of Postoperative care include:

  • Avoid positive pressure ventilation
  • Excellent analgesia is key
  • Involve physiotherapy early
  • Avoid over-transfusion and over-hydration

Anticipated Difficult Airway

Unanticipated Difficult Airway

Next review date: 02/04/2025

Author(s): CGO Pj Lead.

Approved By: DCA Anaesthetics

Reviewer name(s): CGO Pj Lead, DCA Emergency Medicine.

Related resources

DAS Intubation Guidelines (2015)

Evidence method

Consensus Guideline