Anesthesia for Trauma and Burns - Specific Injuries
Intracranial and Spinal Cord Trauma
Intracranial and Spinal Cord Trauma (see Chapter 25)
Facial Trauma. Considerable force is required to produce facial fractures. Accordingly, these injuries often are associated with other injuries such as intracranial and spinal cord trauma, thoracic injury, myocardial contusion, and intra-abdominal bleeding. Brisk oral or nasal bleeding, broken teeth, vomitus, or tongue or pharyngeal injury may occlude the airway and complicate airway management. Trismus may be associated with these injuries and should be assessed before the induction of anesthesia. Emergency cricothyroidotomy or tracheostomy done under local anesthesia may be lifesaving.
- Maxillary fractures are grouped by the LeFort classification (Fig. 34.1).
- Type I (transverse or horizontal). The body of the maxilla is separated from the base of the skull above the level of the palate and below the level of the zygomatic process.
- Type II (pyramidal). Vertical fractures through the facial aspects of the maxilla extend upward through the nasal and ethmoid bones.
- Type III (craniofacial dysjunction). Fractures extend through the frontozygomatic suture lines bilaterally, across the orbits, and through the base of the nose and the ethmoid region.
- Le Fort and related fractures are frequently associated with skull fractures and cerebrospinal fluid rhinorrhea. Nasotracheal intubation and placement of nasogastric tubes are relatively contraindicated under these circumstances. Elective nasal intubation (or tracheostomy) may be necessary, however, before operative repair. A fiberoptic bronchoscope may be used in these cases to guide endotracheal tube into the trachea.
- In the presence of rhinorrhea, positive-pressure mask ventilation can potentially cause pneumocephalus.
- Mandibular fractures
- Malocclusion, limitation of mandibular movement, loose or missing teeth, sublingual hematoma, and swelling at the fracture site complicate airway management.
- Posterior displacement of the tongue producing airway obstruction is associated with bilateral condylar or parasymphyseal fractures of the mandible. Simple forward traction on the tongue often provides relief.
- Reestablishment of normal occlusion may necessitate intermaxillary fixation, which can also be combined with rigid fixation. Awake nasotracheal intubation is recommended if the nose has not been severely traumatized.
- Ocular trauma usually requires general anesthesia for repair. Special considerations for open-eye injuries are discussed in Chapter 26, section I.C.1.
- Anesthetic management. Most displaced facial fractures require general anesthesia for repair. Although children usually require general anesthesia, many soft tissue injuries can be treated with local anesthesia. Maintenance of a patent airway is the principal concern, and induction may require awake nasotracheal intubation, fiberoptic laryngoscopy, or tracheostomy under local anesthesia.
Neck trauma may cause cervical spine injury, esophageal tears, major vascular injuries, and airway injuries. Airway injuries may present with obstruction, subcutaneous emphysema, hemoptysis, dysphonia, or hypoxemia.
- “Clothesline” injuries occur from direct trauma to the upper airway and can result in separation of the larynx from the trachea or separation between the cricoid cartilage and the first tracheal ring. These injuries do not always present with an open neck wound. Additional injuries include laryngotracheal transection, laryngeal fractures, and vascular injury.
- Blunt injury over the carotid arteries may result in intimal disruption and dissection, even in the absence of initial symptoms. Angiography or ultrasonography may be required to exclude these injuries.
- Initial management of penetrating trauma includes direct compression of involved vessels to control hemorrhage and prevent air embolism.
- Associated thoracic injuries, such as pneumothorax and hemorrhage from injury to the great vessels, may occur with lower neck injuries.
- Anesthetic management
- Securing the airway is the central issue in these patients. A coordinated approach among members of the trauma team is necessary. A surgical airway or direct intubation of an open airway defect can be lifesaving. Anesthesia induction via spontaneous ventilation of a potent inhalational agent can be useful in the presence of airway disruption with the caveat that the patient likely has a full stomach and is a high risk for aspiration. Preparations should be made for fiberoptic intubation, rigid bronchoscopy, and a surgical airway.
- Great vessel injuries in the neck may necessitate lower extremity IV access.
Chest trauma can involve injuries to the trachea or larynx, heart, great vessels, thoracic duct, esophagus, lung, or diaphragm.
- Rib fractures are a common feature of major thoracic trauma and mandate assessment for pneumothorax by CXR. First-rib fractures should alert the clinician to the potential for associated internal injuries due to severe forces needed to fracture the first rib. Multiple rib fractures most commonly involve ribs 7 to 10 and often accompany lacerations of the spleen or liver.
- The hypoxemia and respiratory failure that accompany flail chest and other major chest injuries are indicative of underlying pulmonary contusion. IV fluids should be administered judiciously because the injured lung is sensitive to fluid overload.
- The presence of subcutaneous emphysema may indicate the presence of a pneumothorax or laryngeal, tracheobronchial, or esophageal trauma. Pneumothorax and hemothorax may lead to respiratory and cardiovascular collapse. If these conditions are present or highly suspected, chest tubes should be placed before the induction of general anesthesia. Avoid central line insertion (particularly by the subclavian route) on the side opposite an injury because of the potential consequence of bilateral pneumothorax. Avoid the ipsilateral side if a concomitant major venous injury is suspected.
- Traumatic diaphragmatic injury can present as an elevated diaphragm, gastric dilatation, loculated pneumothorax, or subpulmonic hematoma. An upper gastrointestinal contrast study should be considered if the diagnosis is not clear.
- Anesthetic management
- Patients with significant chest injuries almost always require general anesthesia.
- The necessity for mechanical ventilation may extend into the postoperative period.
- Avoid nitrous oxide when a pneumothorax is suspected and a chest tube has not yet been placed. Airway pressures must be closely monitored during positive-pressure ventilation.
- Pulmonary hemorrhage into the main conducting airways calls for isolation of the uninjured side before it is flooded with blood. Double-lumen endotracheal tube placement, mainstem intubation, or endobronchial blockade may be needed to prevent blood from spilling into the noninjured side (see Chapter 22).
- Regional anesthesia (i.e., intercostal nerve blockade, thoracic epidural anesthesia, or paravertebral blocks) may provide analgesia for multiple painful rib fractures. Adequate pain relief can reduce chest wall splinting, regional hypoventilation, and progressive hypoxemia.
Cardiac and Major Vascular Trauma
Cardiac and Major Vascular Trauma
- Blunt cardiac injury can result in myocardial muscle contusion, chamber rupture, valvular disruption, tamponade, or dysrhythmias.
- Cardiac trauma may be associated with a fractured sternum, hemothorax, pericardial tamponade, myocardial dysfunction, valvular dysfunction, and ECG changes (persistent sinus tachycardia, multiple premature ventricular contractions and other dysrhythmias, bundle branch block, nonspecific ST-segment and T-wave changes, and overt ischemia).
- Beck triad of distended neck veins, muffled heart sounds, and hypotension is present in only 30% of patients with pericardial tamponade, and pulsus paradoxus is even less reliable. The diagnostic test of choice is cardiac ultrasound.
- Pericardiocentesis may be used to stabilize the patient until surgical repair can be performed. A subxiphoid pericardial window is ideally performed in the operating room.
- A widened mediastinal profile, lack of clarity of the aortic knob, rightward tracheal shift, or widening of left paraspinal line without associated fracture on the CXR mandate further workup to rule out traumatic aortic injury. Helical CT is the diagnostic test of choice and is more sensitive than is angiography. Potentially salvageable patients with aortic rupture often have an incomplete laceration near the ligamentum arteriosum. An intact adventitial layer or contained hematoma prevents immediate death. An arterial line should be placed in the right arm since the compromised aorta may not transmit a normal pulse distal to the left subclavian and the flow through the left subclavian may be occluded during the course of surgical repair.
- The subclavian artery is subject to injury with hyperextension of the neck and shoulder.
- Anesthetic management
- These patients are often severely hypovolemic and may have compromised cardiac function. Cardiopulmonary bypass may be required for certain repairs.
- Etomidate and ketamine are good choices for induction, but use of the latter must be weighed against its risk in patients with concomitant head injury and those with cocaine abuse.
- Cross-matched type-specific blood or O-negative blood should be available before induction. Inotropic and vasopressor agents should be immediately available to treat severe hypotension.
Peripheral Vascular Trauma
Peripheral Vascular Trauma
- Check peripheral pulses in all extremities during the evaluation of trauma patients. Arteriography can be used to further define injuries.
- Anesthetic management should focus on the recognition of hypovolemia secondary to uncontrolled hemorrhage. Regional anesthetic techniques may be considered in stable patients.
- In stable patients without peritonitis, penetrating abdominal wounds (with the exception of gunshot wounds) are initially evaluated by local wound exploration. If the exploration is equivocal, diagnostic peritoneal lavage, abdominal ultrasound, or an abdominal CT scan may be performed.
- All patients with gunshot wounds of the abdomen are surgically explored.
- With impalement injuries (e.g., stab wounds or falls onto sharp objects), the penetrating object, if still present in the wound, will usually be removed in the operating room after anesthesia has been induced and the patient stabilized. Removal may result in exsanguination.
- Blunt trauma may result in intra-abdominal or retroperitoneal bleeding.
- The spleen is the most frequently injured abdominal organ in blunt trauma. Signs and symptoms include abdominal or referred shoulder pain, abdominal rigidity, a falling hematocrit, or hypotension. Minor splenic hematomas are often managed nonoperatively, but grade IV (active bleeding) and V (shattered/avulsed spleen) injuries require splenectomy.
- The liver frequently fractures with blunt abdominal trauma. Minor injuries are managed nonoperatively unless other injuries mandate laparotomy. Thus, liver injuries that require operation are often complex with large blood loss and high mortality. Manual compression can temporarily control bleeding and allow time for volume resuscitation. Perihepatic packing (“damage control surgery”) with later reexploration is sometimes considered for patients with severe injuries.
- Abdominal compartment syndrome can occur in setting of direct injury as well as after massive fluid resuscitation.
- Abdominal compartment often presents with clinical triad of
- tense, distended abdomen
- respiratory distress or high peak pressure if the patient is intubated and
- oliguria. Hypotension is common because of a decrease in preload by compression of the inferior vena cava. IAP greater than 12 mm Hg is indicative of abdominal hypertension, and IAP 20 to 25 mm Hg warrants immediate decompression.
- Retroperitoneal hematomas and aortic rupture may present with abdominal compartment syndrome. Bowel reperfusion can occur from ischemia, and peritonitis can lead to further tissue edema. Electrolyte disorders, myoglobinuria, and renal failure can occur.
- Surgical decompression may be necessary. These patients are often intravascularly depleted and may become severely hypotensive after decompression due to increase in capacitance of bleeding from uncompressed vasculature. Cross-matched type-specific blood or O-negative blood should be available before induction. Inotropic and vasopressor agents should be immediately available to treat severe hypotension.
- All multiple trauma patients should have a Foley catheter placed. If pelvic or perineal injury has occurred, as evidenced by blood at the urethral meatus, a perineal hematoma, or a high-riding prostate, retrograde urethrography should be performed before urethral catheterization.
- All patients with penetrating abdominal or back injuries and those with significant hematuria after blunt trauma should have a radiographic kidney–ureter–bladder examination and undergo IV pyelography or contrast-enhanced CT.
- Eighty-five percent of renal injuries can be managed nonoperatively, but patients with refractory hypotension should go directly to the operating room for exploration.
- Ureteral laceration is managed by surgical intervention after locating the disruption by retrograde urography.
- Bladder contusions may be treated nonoperatively, but rupture usually requires exploration.
- The inability of the patient to void or clinical signs of injury indicate injury to the urethra. Diagnostic urethrography should precede treatment with suprapubic cystostomy for urinary diversion and control of hemorrhage. Most disruptions can undergo delayed repair.
- All fractures or dislocations that compromise nerve or vascular function may constitute surgical emergencies (e.g., radial nerve injury with humeral shaft fractures and aseptic necrosis of the femoral head with hip dislocation) and must be reduced immediately. It is important to document the neurovascular examination immediately before anesthesia and upon awakening. Regional anesthesia may delay diagnosis of compartment syndrome and is relatively contraindicated if compartment syndrome is anticipated.
- Upper extremity
- Severe depression or hyperabduction of the shoulder girdle can stretch or tear the brachial plexus. Horner syndrome may present with damaged cervical sympathetic chain.
- When the shoulder is struck hard from the side, the medial end of the clavicle may be dislocated upward or retrosternally. Pressure on the trachea in a retrosternal dislocation may cause life-threatening airway compromise.
- Dislocation of the glenohumeral joint can cause axillary nerve injury.
- Fractures of the humeral shaft, especially the middle or distal part, are frequently associated with radial nerve injury.
- Neurovascular compromise of the forearm can occur with fracture or dislocation of the elbow. Peripheral ischemia is often complicated by edema of the anterior compartment with risk for nerve and muscle necrosis. Fasciotomy may be indicated.
- Median nerve compression is possible with fractures at the wrist or with carpal dislocation and may require division of the transverse carpal ligament.
- Patients who have sustained pelvic injuries can be divided into three major categories:
- Exsanguinating hemorrhage from external bleeding in open fractures or from retroperitoneal hematoma in closed fractures (0.5% to 1.0%). These patients almost always present with severe hypotension or cardiac arrest and rarely respond to resuscitative measures.
- Hemodynamically stable with a relatively uncomplicated course (75%). Urgent or elective surgery for repair of bony and ligamentous pelvic disruptions may be required.
- An intermediate group in critical condition with various degrees of overall injury, hemorrhage, and hemodynamic instability (25%).
- Initial management for these injuries may include the application of a compressive binder for “open-book” fractures, pelvic angiography (with or without therapeutic embolization to control hemorrhage), and external pelvic fixation.
- Pelvic fractures without major disruption, such as type I anterior posterior compression (APC) injury or type I lateral compression injury, can be treated with bed rest and delayed open reduction and internal fixation (ORIF). More complex injuries such as APC II (widened sacroiliac joint with hemorrhagic and vascular consequences) require acute external fixation with delayed conversion to internal fixation, acute ORIF, or arterial embolization.
- Fat embolism can occur with pelvic and major long-bone fractures (see Chapter 19).
- Crush injuries may be associated with myoglobinuria. Aggressive and early hydration may help prevent acute renal failure.
- Lower extremity
- Fractures of the tibia and fibula, the most common major skeletal injuries, can be associated with neurovascular trauma and attendant compartment syndrome.
- With a fracture of the femur, blood loss can be much greater than is evident from superficial inspection.
- Hip fractures are common in the elderly, whose clinical picture is often dominated by other complicating medical illnesses. Traction is used initially for pain relief, but most fractures require ORIF to ensure adequate healing and function and to avoid the complications of prolonged immobilization.
- Regional, general anesthesia, and combined techniques can be considered for patients with isolated lower-extremity injuries.
- Extremity reimplantation
- Indications. In general, these procedures are performed on the upper extremities and only in patients who are otherwise stable. An amputated arm, hand, or digit will not be reimplanted if it has sustained a severe crush injury or has been raggedly torn from major nerves and blood vessels. Reimplantations may be extremely lengthy procedures, occasionally in excess of 24 hours.
- Anesthetic management
- General anesthesia is usually chosen because of the long duration of these procedures. A combined technique will reduce anesthetic requirements and provide for postoperative analgesia (especially with catheter placements, rather than single-dose brachial plexus blocks). Regional anesthesia may improve blood flow via the induced sympathectomy.
- During general anesthesia, the head and pressure points must be evaluated every 1 to 2 hours to avoid pressure-induced injury (e.g., scalp ulceration and hair loss). Low-pressure mattresses and padded sponge blocks should be used to minimize pressure on susceptible peripheral nerves (e.g., ulnar, sciatic, peroneal, or sural). The endotracheal tube cuff pressure should be periodically assessed because nitrous oxide will diffuse into the cuff and increase the pressure on the tracheal mucosa.
- Patients should be kept warm and adequately hydrated. Avoid hyperventilation or the use of vasoconstrictors.
- Consider invasive hemodynamic monitoring for optimization of the perfusion pressure and for prolonged cases. If a noninvasive blood pressure cuff is used, it should be rotated among multiple sites. The need for anticoagulation is determined intraoperatively.
- Blood loss can be vastly underestimated. Blood samples should be sent periodically to assess hemoglobin levels.
Rosen P, Baker FJ, Barkin RM, et al., eds. Emergency Medicine: Concepts and Clinical Practice. 2nd ed. St. Louis: Mosby; 1988.)
Anesthesia for Trauma and Burns - Specific Injuries
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