1. Coordinator:- Dr Roopesh Kumar
Presenter:- Dr ABHISHAKE

2. Introduction:-
 Trauma is the leading cause of death
among people aged 1-38 years but
above 38 are not spared.
 Mortality represents only the tip of the
trauma ICEBERG, it is estimated that, for
each death, three people rendered
permanently disabled.
 The role of the anaesthesiologist in the
majority of institutions is to establish a
secure airway, ensure adequate
ventilation, and provide anaesthesia for
surgery. Added responsibility in modern
scenario are as follows-

3. 1.Prehospital care
2.Emergency
department
Trauma team leader
Trauma team
member
Anaesthesiologist
3.Operating room
Anaestesia
4. Postoperative care
 Intensive care unit
 High-dependency
unit
 Acute pain team
5. Transportation

4.  Anaesthesiologists possess many skills,
which can be used at the scene of an
accident to compliment those of a
paramedic in managing victims of
trauma.
 At accident site, two approach are used:
which one is better, is under the clouds
of conflicts
1. Scoop and run
2. Stay and play

5.  Currently an anaesthesiologist should
attend the scene of an accident as part
of the emergency medical team should
limit initial interventions to securing a
patent airway, ensuring effective
ventilation, controlling external
hemorrhage, and expediting transfer of
the patient to a hospital or trauma
center.
 Only exception to this are those who
have head injuries when, in addition to
above, IV fluids or analgesic may be
required.

6. Prehospital general anaesthesia:-
 General anaesthesia may be required at
accident site as to facilitate extrication or
the amputation of a nonviable limb.
 All immediate life threatening injuries
must be identified first and dealt with
using ABC principles.
 Prior to inducing anaesthesia, all physical
danger to the anaesthesiologist and
patient must have been eliminated as far
as possible, and access to the patient is
maximized.
 Pulse oximetry is the bare minimum
monitoring.

7.  Ketamine is the agent of choice for
prehospital general anaesthesia
preceded by inj. glyco. Concurrent
administration of midazolam prevents
emergence phenomena.
 Ketamine causes tachycardia and an
increase in SBP, secondary to central
sympathetic stimulation and inhibition of
catecholamine uptake. However in
shocked trauma patient, in whom
sympathetic stimulation is already
maximal and exhausted, CO & SBP may
fall as it is direct cardiac depressant.

8.  Other anaesthetic agents are
# Etomidate
# Propofol
 Despite the long list of undesired side
effects, Succinylcholine remained the
agent of choice when muscle
relaxation is required to facilitate
tracheal intubation in emergency
scenario. Now Rocuronium has given
some promising results at the
expense of prolonged block.

9.  In most hospitals, Emergency department
is the first contact between the
anaesthesiologist and trauma patient.
 Time is a crucial factor for a successful
resuscitation of a severely injured patient.
 Ambulance personnel or a doctor at the
scene should communicate directly with
emergency staff which further decide
whether to alert individual specialists or
the trauma team.

10. Resuscitation of patient following trauma
Deaths following trauma shows tri-modal
distribution;
 First peak in deaths is within seconds to
minutes of injury; as a result of major
neurological or vascular injury. This can
only be reduced by PREVENTIVE measures.
 Second peak represents early deaths in
which patient is dying from airway,
breathing or circulatory problems. This
period has been called “THE GOLDEN HOUR”
to emphasize the importance of rapid
timely resuscitation to reduce mortality.
 Third peak of deaths in days to a few weeks
later, as a result sepsis and multiple organ
failure.

11.  The traditional medical practice including
history, examination and investigation is
not appropriate for severely injured patient.
Instead, assessment and resuscitation take
place simultaneously, with the aim being to
identify and treat first the greatest threats
to life.
 Advance Trauma Life Support (ATLS);
although aimed at the single handed
physician working in a rural hospital, the
ATLS protocols can be easily adapted for a
team approach and provide a useful frame
work on which resuscitation efforts in any
environment can be based.

12. The focus of ATLS is the management
of patients with major injuries during
the golden hour and is considered in
four phases:
 Primary survey
 Resuscitation
 Secondary survey
 Definitive care

13. The primary survey and resuscitation
 The primary survey includes ABCDE
1. Airway with control of cervical spine
2. Breathing and ventilation
3. Circulation and hemorrhage control
4. Disability- rapid assessment of
neurological function
5. Exposure with environmental control

14. Airway
 During resuscitation of any severely injured
patient, the initial priorities are to ensure a
clear, secure airway and to maintain adequate
oxygenation.
 If the airway obstructed, immediate basic
maneuvers such as chin lift or jaw thrust
along with suction may temporarily relieve
the obstruction.
 In semiconscious patient, an oropharyngeal
or nasopharyngeal airway may help while
preparing for more definitive management.

15.  Every patient with multiple injuries should
receive a high inspired O2 concentration.
 Pt should always considered full stomach.
 Advanced airway management 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.
 Every patient with significant blunt trauma,
particularly above the clavicles or if
unconscious, should be assumed to have a
cervical spine injury until it is proved
otherwise.

16.  Five criteria that rule out cervical injury
No midline cervical pain or tenderness
No focal neurological deficit
Normally alert
Not intoxicated
No severe distracting pain
 A cervical spine # must be assumed if
any one of these criteria is present, even
if there is no known injury above the
level of the clavicle.

17. Airway obstruction Inadequate ventilation
 Direct injury to face,
mandible or neck
 Hemorrhage in
nasopharynx, sinuses,
mouth or upper airway
 Dimnished consciousness
secondary to TBI,
intoxication or analgesic
medications
 Aspiration of gastric
contents or foreign body
 Misapplication of an oral
airway or endotracheal
tube
 Diminished respiratory
drive secondary to TBI,
shock, intoxication,
hypothermia, or over
sedation
 Direct injury to trachea or
bronchi
 Pneumothorax or
hemothorax
 Chest wall injury
 Aspiration
 Pulmonary contusion
 Cervical spine injury
 Bronchospasm secondary
to inhalation of smoke or
toxic gas

18.  Intubation of the trachea with a cuffed tube
remains the gold standard.
 Technique of intubation may vary from
awake to rapid sequence induction via nasal
or oral route depending upon the skill,
familiarity and expertise of
anaesthesiologist but RSI is most commonly
applied. This consists of:-
1. Manual inline stabilization of cervical spine
2. Pre-oxygenation for 2-3 min
3. Administration of IV anaesthetic agent

19. 4. Application of cricoid pressure by a
separate assistant
5. Admin of rapidly acting NMBA
6. Intubation of trachea
7. Check the position of the tracheal tube
8. Release the cricoid pressure
 MILS unfortunately make direct
laryngoscopy more difficult so some
clinician prefer awake fibro optic intubation
under local anaesthesia in these patients
although the risk of pulmonary aspiration is
there and patient co operation is a must.
 Nasal intubation should not be tried in
patients with midface or basilar skull #.

21.  If intubation of patient proves impossible
and patient can not be ventilated with
face mask, other options should be
considered
1. Laryngeal mask airway
2. Intubating laryngeal mask
3. Needle cricothyroidotomy with 14 G
followed by jet ventilation (80-300 rate,
pressure 400kPa or 3000 mmHg) but
hypercapnia is there
4. Tracheostomy (percutaneous/surgical)

22. Breathing and ventilation
 Assessment of ventilation is best done
by look, listen and feel approach.
1. Look – for cyanosis, use of accessory
ms, flial chest and penetrating and
sucking chest injuries.
2. Listen – for presence, absence or
diminution of breath sounds.
3. Feel – for subcutaneous emphysema,
tracheal shift and broken ribs.

23. Common cause of impaired ventilation in
trauma patient
 Gastric dilatation- pass oro/nasogastric
tube
 Pneumothorax- insert a chest drain
 Hemothorax- insert a chest drain
 Ruptured diaphragm- surgical
intervention
 Pulmonary hemorrhage- endoscopy,
consider double lumen tube if unilateral
 Broncho-pleural fistula- double lumen
tube

24.  Three major chest injuries need to be
excluded:-
1. Tension pneumothorax:- respiratory
distress with reduced chest movement,
reduced breath sounds, a hyper
resonant percussion note on affected
side, hypotension and tachy, neck vein
distension, and tracheal shift to
opposite side
Mx- immediate decompression with 14 G
cannula inserted in 2nd ICS in MCL on
affected side. Once IV access has been
obtained, a large chest drain,36FG
inserted in 5th ICS in ant. axillary line
and connected to underwater seal drain.

25. 2. Open pneumothorax:- followed by large
hole in chest, air will preferentially enter
the pleural cavity via the defect.
Mx- Defect should be covered and chest
drain inserted to prevent the risk of a
tension pneumothorax developing.
3. Flial chest:- it is an indication of severe
chest injury with multiple ribs #. Hypoxia is
often worsened by underlying pulmonary
contusion or hemothorax may requiring
intubation and mechanical ventilation.
Paradoxical chest movement is
characterstic of this but not present
always.
Mx: Intubation with IPPV

26.  Hemothorax:- massive when > 1500 ml
blood in hemithorax, result in reduced
chest movement, a dull percussion note,
hypoxemia and hypovolemia.
Mx- once volume replacement is
commenced, a chest drain is placed,
 Cardiac tamponade:- Beck’s triad including
distended neck vein, hypotension and
muffled heart sound
Mx- Pericardiocentasis should be performed.

27.  Most critically ill patients require assisted, if
not controlled ventilation. AMBU usually
provide adequate ventilation immediately
after intubation and during period of patient
transport

28.  Coma- Glasgow coma scale≤8
 Loss of protective airway reflexes
 Hemorrhage into the airway
 Ventilatory insufficiency
PaO2<60 mmHg
PaCO2>45mmHg
 Seizures
 Combative patients requiring investigations
 General anaesthesia
 Cardiac arrest

29. Circulation
 Adequacy of circulation is based on pulse
rate, pulse fullness, blood pressure and sign
of peripheral perfusion.
 Symptoms and sign of shock
◦ Diaphoresis
◦ Agitation or Obtundation
◦ Hypotension
◦ Tachycardia
◦ Prolonged Capillary Refill
◦ Diminished Urine Output
◦ Narrow Pulse Pressure

30.  The first priority in restoring adequate
circulation is to stop bleeding followed by
replacement of intravascular volume
secondarily.
 Until prove otherwise, assume shock as the
result of hypovolemia secondary to
hemorrhage.
 Hypotension in these patients should be
aggressively treated with IV fluids and
blood products, not vasopressors, unless
there is profound hypotension that is
unresponsive to fluid therapy, coexisting
cardiogenic shock, or cardiac arrest.

31. Pathophysiology Clinical Manifestation
Mild(<20%
of blood
volume lost)
Decreased peripheral
perfusion only of organ
able to withstand
prolonged ischemia
(skin, fat, muscle, and
bone)
Pt complaint of feeling
cold
Postural hypotension and
tachycardia
Cool, pale, and moist skin
Concentrated urine
Moderate(2
0-40% of
blood
volume lost)
Decreased central
perfusion of organs able
to tolerate only brief
ischemia(kidney, liver)
Metabolic acidosis
present
Thirst
Supine hypotension and
tachycardia(variable)
Oligouria and anuria
Severe(>40
% of blood
volume lost)
Decreased perfusion of
heart and brain
Severe metabolic
acidosis
Respiratory acidosis
possibly present
Agitation, confusion, or
obtundation
Supine hypotension and
tachycardia invariabaly
present
Rapid, deep respiration

32. Class I Class II Class III Class IV
Blood loss (ml) ≤750 750-1500 1500-2000 >2000
% blood loss ≤15 15-30 30-40 >40
Heart rate
(bpm)
<100 >100 >120 >140
SBP N N D D
Pulse pressure N or I D D D
Capillary refill N I I I
Resp rate/ min 14-20 20-30 30-40 <35
Urine output
(ml/hr)
>30 20-30 5-15 Negligible
Mental status Slightly
anxious
Mildly
anxious
Anxious
and
confused
Confused and
lethargic
Fluid
replacement
crystalloi
d
Crystalloid
and blood
Crystalloid
and blood
Crystalloid, and
blood

33.  Cardiac temponade
Tachycardia, dilated neck vein, muffled heart
sound
Pericardiocentesis
 Myocardial contusion
Tachycardia, cardiac dysrhythmias
Crystalloid, vasodilators, inotropes
 Pneumothorax or hemothorax
Tachycardia, dilated neck veins, absent breath
sounds, dyspnea, subcutaneous emphysema
Chest tube

34.  Spinal cord injury
Hypotension without tachycardia, narrow
pulse pressure, vasoconstriction
Crystalloids, vasopressor, inotropes
 Sepsis
Develops after a few hrs after colon injury
present as modest tachycardia, wide pulse
pressure and fever
Antibiotics, crystalloids, inotropes

35.  Multiple large bore, 14-16 G cannula
are placed in whichever vein are easily
accessible. As placement of central
line is time consuming and associated
with life threatening complications,
peripheral lines are usually sufficient
for initial resuscitation.

36. Fluid therapy
 For the majority of hypovolemic patients in
emergency department the initial choice is
less important than availability, speed and
adequacy of replacement.
 Fully cross matched whole blood is ideal
but cross matching take a min of 45-60
min. O-negative blood can be used in case
of extreme emergency.
 Crystalloid solutions are easily available and
inexpensive. RL and NS are commonly used
fluids. Dextrose containing fluid should be
avoided in TBI & in the absence of
documented hypoglycemia

37.  Colloids are far expansive but they are more
efficient in rapidly restoring IV volume.
Combination of both gives best results.
Albumin is usually selected over dextran or
hetastarch because of fear of inducing
coagulopathy.
 Whichever fluid is chosen, it must be warmed
prior to administration. Rapid-infusion
systems are available for this purpose.
 The ATLS curriculum advocates rapid infusion
of up to 2 L of warmed isotonic crystalloid
solution in any hypotensive patient with the
goal of restoring normal blood pressure.

38. Risks associated with aggressive volume
replacement during early resuscitation
 Increased blood pressure
 Decreased blood viscosity
 Decreased hematocrit
 Decreased clotting factor concentration
 Greater transfusion requirement
 Disruption of electrolyte balance
 Direct immune suppression
 Premature reperfusion
 Increased risk of hypothermia

39.  The aggressive fluid admin is often
result in transient rise in BP, followed by
increased bleeding, another episode of
hypotension and need for more volume
administration.
 ATLS manual categorized these patient
as “TRANSIENT RESPONDERS”
 Resuscitation of these pts should be
considered in two phases:-
1. Early, while active bleeding is still
ongoing.
2. Late, once all hemorrhage is controlled

40.  Maintain SBP at 80-100 mmHg
 Maintain hematocrit at 25-30%
 Maintain the PT & PTT in normal ranges
 Maintain the platelet count at >50000/ HPF
 Maintain normal serum ionized calcium
 Maintain core temp higher than 35 C
 Maintain function of the pulse oximeter
 Prevent an increase in serum lactate
 prevent acidosis from worsening
 Achieve adequate anaesthesia and analgesia

41.  Maintain SBP>100mmHg
 Maintain hematocrit above individual transfusion
thresold
 Normalize coagulation status
 Normalize electrolyte balance
 Normalize body temperature
 Restore normal urine output
 Maximize CO by invasive or noninvasive means
 Reverse systemic acidosis
 Document decrease in lactate to normal range

42. Prevention of hypothermia in seriously injured
patients during surgery
 Use of forced air-warming device
 Use of heat and moisture exchanger(HME)
b/w anaesthetic gases and breathing system
 Cover all body surfaces except surgical site
including the head
 Maintain the operating room temprature as
warm as possible
 Warm all fluid, both IV and those used for
lavage by the surgeons
 Place the patient on a warming blanket

43.  The amount of fluid administered is based on
improvement of clinical signs, particularly BP,
HR and pulse pressure. Central venous
pressure and urinary output also provide
indication of restoration of vital organ
perfusion.

44. Disability
A rapid assessment of neurological function
 Level 1- AVPU system
A- Alert
V- Verbal response
P- Painful response
U- Unresponsive
 Level 2- Glasgow Coma Scale
Score ≤8 Deep coma, severe head injury, poor
outcome
Score 9-12 Conscious patient with moderate injury
Score 13-15 Mild injury

45.  Eye-Opening Response
 4 = Spontaneous
 3 = To speech
 2 = To pain
 1 = None
 Verbal Response
 5 = Oriented to name
 4 = Confused
 3 = Inappropriate speech
 2 = Incomprehensible sounds
 1 = None
 Motor Response
 6 = Follows commands
 5 = Localizes to painful stimuli
 4 = Withdraws from painful stimuli
 3 = Abnormal flexion (decorticate posturing)
 2 = Abnormal extension (decerebrate posturing)
 1 = None

46.  There is usually no time for Glasgow
Coma Scale, the AVPU system alone
may used in hurry. But if time permit,
GCS should be done as it is reliable,
reproducible and dynamic
measurement, the trend in the
conscious level is more important than
one static reading.

47. Exposure
 The patient should be undressed to
allow examination of entire body
surface for injuries. In-line
immobilization should be used if a
neck or spinal cord injury is
suspected.

48. The objective of secondary survey are:-
 Examine the patient
Head to toe
Front to back
 Obtain a complete medical history in regard of-
Allergies
Medications
Past medical history
Last food or fluid
Events of the incident and environment
 Obtain all clinical, laboratory, and radiological
information
 Formulate a management plan

49.  The secondary survey begins only when ABCs
are stabilized and patient is evaluated from
head to toe and the indicated studies ie
radiographs, laboratory tests, invasive
diagnostic procedures, are obtained.
 Head examination includes looking for injury
to the scalp, eyes and ears. Neurological
examination includes GCS and evaluation of
motor and sensory function as well as
reflexes.
 Chest is auscultated and inspected again for
#s and function integrity. A normal initial
examination does not exclude the posiblity of
flial chest, pneumothorax, hemothorax or
cardiac temponade

50.  Abdominal examination is done under the
heads of inspection, auscultation and
palpation.
 Extremities should be examined for #s,
dislocation and peripheral pulses.
 A urinary catheter and nasogastric tube are
also inserted.
 Basic laboratory analysis includes CBC,
electrlyte, glucose, BUN and creatinine. ABG
may extremely helpful. X-ray chest and cross
table lateral radiograph and a swimmer’s view
are must.
 .

51.  FAST scan: Focused assessment with
sonography for trauma scan is a rapid,
bedside, ultrasound examination performed
to identify intraperitoneal hemorrhage or
pericardial tamponade
 FAST scan examine four area for free fluid
1. Prehepatic/ hepatorenal space
2. Perisplenic space
3. Pelvis
4. Pericardium
 CT, angioraphy or DPL may also be indicated
if any doubt persists.

52. Tertiary trauma survey TTS
 B/w 2-50% traumatic injuries may be missed
in primary and secondary surveys so some
centre advocate a tertiary survey.
 It occurs prior to discharge to reassess and
confirm known injuries and identify occult
one.
 Includes complete head to toe examination
and careful observation of all laboratory and
radiological examinations.

53.  Regional anaesthesia is usually impractical
and inappropriate in hemodynamically
unstable patients with life threatening
injuries.
 In hemodynamically stable patient specially
#s and injuries to extremities,regional
anaesthesia can be a choice.

54. Regional anaesthesia for trauma
Advantages Disadvantages
Allows continued assessment of
mental status
Peripheral nerve function difficult
to assess
Increased vascular flow Patient refusal common
Avoidance of airway
instrumentation
Requirement for sedation
Improved postoperative mental
status
Hemodynamic instability with
placement
Decreased blood loss Longer time to achieve anaesthesia
Decreased incidence of DVT Not suitable for multiple body
lesion
Improved post operative
analgesia
May wear off before procedures
conclude
Better pulmonary toilet
Earlier mobilization

55.  If patient arrives in the operating room
already intubated, correct position of
endotracheal tube must be verified.
 If the patient is not intubated the same
principle as described before should be
followed. If time permits, hypovolemia should
be partially corrected prior to induction.
 Commonly used induction agents for trauma
patients include ketamine and etomidate.
Dose of propofol are greatly reduced (80-
90%) in patient with major trauma.

56. General anaesthesia for trauma
Advantages Disadvantages
Speed of onset Impairment of global
neurological examination
Duration can be
maintained as long as
needed
Requirement for airway
instrumentation
Allows multiple
procedures for multiple
injuries
Hemodynamic
management more
complex
Greater patient
acceptance
Increased potential for
barotrauma
Allows positive pressure
ventilation

57. Severely injured patients requiring anaesthesia
and intubation can be divided into three gps:-
1. Those with severely hypotensive (SBP<80
mmHg), with ongoing resuscitation and are
severely neurologically obtunded. Induction
agent are not usually required, but NMBA is
used to facilitate tracheal intubation.
2. Those who are hypotensive (SBP 80-100
mmHg),hemodynamically unstable or
inadequately resuscitated. A reduce dose of
IV induction agent is used. A NMBA is used
for intubation.

58. 3. Patients with isolated head injury, with sign
of raised ICT. Normal dose of an inducing
agent, NMBA and analgesic are administered.
Induction may also be preceded by IV bolus
of lignocaine.
 Maintenance of anaesthesia in unstable
patients may consist use of muscle relaxants
with general anaesthetic titrated as tolerated
in an effort to provide at least amnesia.
Small doses of ketamine, propofol along
with <0.5 MAC of volatile anaesthetic are
used.
 Histamine releasing NMBA like atracurium
and mivacurium better be avoided as they
may lead to hypotension.

59.  The rate of rise of alveolar conc of
inhalational anaesthetic is greater in shock
because of lower CO & increased ventilation.
So higher alveolar anaestheic partial pressure
lead to higher arterial partial pressurer and
greater myocardial depression.
 The effect of IV anaesthetic are exaggerated
as they are injected into a smaller
intravascular volume
 The key of safe anaesthetic management of
shock patients is to administer small
incremental doses of which ever agents are
selected.

60. Criteria for operating room or Postanaestesia
Care Unit Extubation of trauma patient
 Mental status
Resolution of intoxication
Able to follow commands
Noncombative
Pain adequqtely controlled
 Airway anatomy and
reflexes
Appropriate cough and gag
Ability to protect the
airway from aspiration
No excessive airway edema
or instability
 Respiratory mechanics
Adequate tidal volume
and respiratory rate
Normal motor strength
Required FiO2 is <0.5
 Systemic stability
Adequately resuscitated
Small likelihood of
urgent return to the
operating room
Normothermia, without
signs of sepsis

61.  TRIAGE
 The sorting of and allocation of treatment to the
patients and especially battle and disaster victims
according to a system of priorities designed to
maximise the number of survivors
 Divison of patients for priority of care, usually
into three groups
 1. those who will not survive even with treatment
 2. those who will survive even without tretment
 3. those whose survival depends on treatment
 If triage is applied, treatment of the patients
requiring it is not delayed by useless or
unnecessarily treatment of those in other groups.