Trauma Anesthesia

Trauma Anesthesia Indian Medical PG Question 1: Which of the following statements are correct regarding primary survey/management of traumatic head injury patient? I. Ensure adequate oxygenation and circulation II. Exclude hypoglycaemia III. Check for mechanism of injury IV. Check pupil size and response Select the answer using the code given below :

• A. II, III and IV
• B. I, III and IV
• C. I, II and III
• D. I, II and IV (Correct Answer)

Trauma Anesthesia Explanation: ***I, II and IV*** - **Primary survey** in trauma management, including head injury, focuses on immediately life-threatening conditions (Airway, Breathing, Circulation, Disability, Exposure). Ensuring adequate **oxygenation and circulation** (Statement I) is paramount to prevent secondary brain injury. - Exclude **hypoglycemia** (Statement II) is critical because altered mental status due to low blood sugar can mimic head injury and delay appropriate treatment, making it an essential part of the 'D' (disability) assessment. Checking **pupil size and response** (Statement IV) is also part of the 'D' assessment, providing vital information about potential brain stem compromise or intracranial pressure changes. *II, III and IV* - While excluding hypoglycemia and checking pupil response are crucial parts of the primary survey, Statement III, "Check for mechanism of injury," is typically part of the **secondary survey** or initial assessment but not immediately life-saving like ABCD. - The primary survey prioritizes immediate threats to life, and while understanding the mechanism of injury informs subsequent care, it does not directly address a patient's immediate physiologic stability. *I, III and IV* - This option includes checking the mechanism of injury (Statement III) as part of the primary survey, which is generally conducted after the **life-threatening conditions** are addressed. - It omits the critical step of excluding **hypoglycemia** (Statement II), which is an immediate reversible cause of altered mental status that must be ruled out during the primary assessment. *I, II and III* - This option correctly includes ensuring adequate **oxygenation and circulation** (Statement I) and excluding **hypoglycemia** (Statement II) as part of the primary survey. - However, it incorrectly includes checking for the **mechanism of injury** (Statement III) as a primary survey component and omits checking **pupil size and response** (Statement IV), which is an essential part of the 'Disability' assessment in the primary survey for head injury.

Trauma Anesthesia Indian Medical PG Question 2: A 30-year-old road traffic accident victim is being taken up for emergency laparotomy for haemoperitoneum and suspected multiorgan trauma. Which one of the following will be an indication for performing damage control surgery?

• A. Acidosis with pH < 7.32 (Correct Answer)
• B. Blood pressure < 100 mm Hg
• C. Coagulopathy
• D. Hypothermia < 36 °C

Trauma Anesthesia Explanation: ***Acidosis with pH < 7.32*** - This represents **severe metabolic acidosis** and is a specific, measurable component of the **"lethal triad"** (acidosis, hypothermia, coagulopathy) that mandates damage control surgery. - pH < 7.32 (or < 7.2 in some protocols) is a **defined threshold** that indicates severe physiological derangement requiring abbreviated surgery. - Severe acidosis impairs **cardiac contractility**, **enzyme function**, and **coagulation cascade**, making prolonged definitive repair dangerous. - This specific laboratory value provides clear, objective criteria for the surgical decision. *Blood pressure < 100 mm Hg* - While **hypotension** indicates shock and requires aggressive resuscitation, blood pressure < 100 mmHg alone is not a specific criterion for damage control surgery. - Damage control is indicated by the **lethal triad** components, not by blood pressure thresholds alone. - Many trauma patients with BP < 100 mmHg can undergo definitive repair with adequate resuscitation. *Coagulopathy* - **Coagulopathy** is indeed a critical component of the "lethal triad" and a valid indication for damage control surgery. - However, this option lacks **specific laboratory values** (e.g., INR > 1.5, PT > 16-19 seconds, platelets < 50,000) that would make it a definitive, measurable criterion. - In contrast to the specific pH threshold given in option A, "coagulopathy" as stated here is less precise for decision-making. *Hypothermia < 36 °C* - While hypothermia is the third component of the "lethal triad," the typical threshold for damage control surgery is **core temperature < 35°C** (or < 34°C in most trauma protocols). - Hypothermia < 36°C represents only **mild hypothermia** and is not generally considered an absolute indication for abbreviated surgery. - More severe hypothermia (< 34-35°C) would be required to trigger damage control protocols.

Trauma Anesthesia Indian Medical PG Question 3: In trauma transfusion, what is the ratio of RBCs, FFP, and platelets?

• A. 1:1:3
• B. 1:1:4
• C. 1:1:1 (Correct Answer)
• D. 1:1:2

Trauma Anesthesia Explanation: ***1:1:1*** - A **1:1:1 ratio** of **Red Blood Cells (RBCs), Fresh Frozen Plasma (FFP), and platelets** is the current recommendation for massive transfusion protocols in trauma. - This ratio aims to mimic whole blood and address the "lethal triad" of acute traumatic coagulopathy: **acidosis, hypothermia, and coagulopathy**. *1:1:3* - This ratio provides proportionally more **platelets** than typically recommended in massive transfusion protocols as compared to FFP and RBCs. - While platelets are crucial for hemostasis, a 1:1:3 ratio might not optimally balance all components for initial trauma resuscitation. *1:1:4* - This ratio implies an even higher proportion of **platelets** relative to RBCs and FFP. - Such a high platelet ratio is generally not the initial target for massive transfusion protocols in trauma, which prioritize balanced component replacement. *1:1:2* - This ratio suggests a slightly higher proportion of **platelets** compared to the standard 1:1:1, but still less than 1:1:3 or 1:1:4. - While closer to the recommended range than other incorrect options, the 1:1:1 ratio is currently considered the ideal balance for comprehensive trauma resuscitation.

Trauma Anesthesia Indian Medical PG Question 4: Best guide for the management of Resuscitation is:

• A. Saturation of Oxygen
• B. CVP
• C. Blood pressure
• D. Urine output (Correct Answer)

Trauma Anesthesia Explanation: ***Urine output*** - **Urine output** is considered the **gold standard** for assessing adequacy of resuscitation as it directly reflects **end-organ perfusion** and **tissue oxygenation**. A target of **0.5-1 mL/kg/hour** indicates adequate renal perfusion and overall circulatory status. - It serves as a reliable **endpoint of resuscitation** in trauma and critical care protocols, providing objective evidence that fluid resuscitation has achieved adequate **tissue perfusion** and **microcirculatory flow**. *Saturation of Oxygen* - While **oxygen saturation** is crucial for ensuring adequate **oxygen delivery** to tissues, it represents only one component of the oxygen delivery equation and doesn't reflect **tissue perfusion** adequacy. - Maintaining normal oxygen saturation does not guarantee adequate **end-organ perfusion** if cardiac output or tissue perfusion is compromised during resuscitation. *CVP* - **Central venous pressure** has poor correlation with actual **intravascular volume status** and **cardiac preload**, making it an unreliable guide for fluid resuscitation. - CVP measurements are influenced by multiple factors including **ventilator settings**, **tricuspid valve function**, and **chest wall compliance**, limiting its utility as a resuscitation endpoint. *Blood pressure* - While **blood pressure** provides immediate feedback on **circulatory status** and is emphasized in current **ACLS** and **ATLS** protocols as an immediate target, it may not accurately reflect **microcirculatory perfusion**. - Blood pressure can be maintained through **vasoconstriction** while **end-organ perfusion** remains inadequate, making it less reliable than urine output for assessing true resuscitation adequacy.

Trauma Anesthesia Indian Medical PG Question 5: A comatose 28-year-old woman sustained a depressed skull fracture in an automobile collision. She has been unconscious for 6 weeks. Her vital signs are stable and she breathes room air. Following her initial decompressive craniotomy, she has returned to the operating room twice due to intracranial bleeding. Select the best method of physiologic monitoring necessary for the patient.

• A. Central venous catheterization
• B. Pulmonary artery catheterization
• C. Intracranial pressure monitoring (Correct Answer)
• D. Blood-gas monitoring

Trauma Anesthesia Explanation: ***Intracranial pressure monitoring*** - This patient has a history of **depressed skull fracture**, **decompressive craniotomy**, and **intracranial bleeding**, all of which significantly increase the risk of elevated **intracranial pressure (ICP)**. - Monitoring ICP is crucial for detecting and managing cerebral edema or hematoma expansion, preventing secondary brain injury in a comatose patient. *Central venous catheterization* - While useful for monitoring **central venous pressure (CVP)** and administering fluids/medications, it does not directly assess cerebral perfusion or intracranial dynamics. - CVP alone is a poor indicator of ICP, and changes in CVP do not reliably reflect changes in cerebral perfusion pressure (CPP). *Pulmonary artery catheterization* - This provides detailed hemodynamic information including **cardiac output**, **pulmonary artery pressure**, and **pulmonary capillary wedge pressure**, primarily for assessing cardiac function and fluid status. - It is overly invasive and unnecessary for a patient with stable vital signs whose primary concern is neurological status. *Blood-gas monitoring* - **Arterial blood gas (ABG)** analysis assesses **oxygenation**, **ventilation**, and **acid-base balance**, which are important for overall patient management. - While important, ABG monitoring does not directly provide information about ICP or cerebral perfusion, which is the most critical parameter in this specific neurological injury scenario.

Trauma Anesthesia Indian Medical PG Question 6: A patient presented to the emergency department with blunt abdominal trauma. His pulse rate is 150/min, and his BP is 80/50 mm Hg. He is scheduled to undergo an emergency laparotomy. Which of the following is the anesthetic of choice?

• A. Ketamine (Correct Answer)
• B. Thiopentone
• C. Midazolam
• D. Propofol

Trauma Anesthesia Explanation: ***Ketamine*** - **Ketamine** is the anesthetic of choice in this hypotensive patient because it typically causes **sympathomimetic effects**, leading to an increase in heart rate and blood pressure, which is beneficial in **hypovolemic shock**. - It preserves **airway reflexes** and has analgesic properties, making it suitable for patients undergoing emergency procedures with hemodynamic instability due to blunt abdominal trauma. *Thiopentone* - **Thiopentone** is a barbiturate that causes significant **myocardial depression** and **vasodilation**, which would further worsen the patient's existing hypotension and shock. - It can lead to a precipitous drop in blood pressure, making it a poor choice for hemodynamically unstable patients. *Midazolam* - **Midazolam** is a benzodiazepine that can cause **dose-dependent hypotension** due to peripheral vasodilation and myocardial depression, which would exacerbate the patient's shock. - While it provides sedation, it lacks sufficient analgesic properties for surgical anesthesia and is contraindicated in severe hypovolemia. *Propofol* - **Propofol** frequently causes **profound hypotension** due to significant vasodilation and myocardial depression, which would be detrimental in a patient with severe hypovolemic shock. - Its use in this critically ill, hypotensive patient risks further hemodynamic collapse and cardiac arrest.

Trauma Anesthesia Indian Medical PG Question 7: Which of these is the most life-threatening injury that can be identified by assessing the breathing component of the patient?

• A. Blunt cardiac injury
• B. Tension pneumothorax (Correct Answer)
• C. Cervical spine injury
• D. Laryngotracheal injury

Trauma Anesthesia Explanation: ***Tension pneumothorax*** - A tension pneumothorax is a **life-threatening condition** identified during the breathing assessment, as it severely impairs ventilation and causes **hemodynamic instability** by compressing major vessels. - Key signs include absent breath sounds on the affected side, **tracheal deviation**, and **hypotension** due to mediastinal shift. *Blunt cardiac injury* - While serious, blunt cardiac injury is typically identified during the **circulation assessment**, with signs like arrhythmias, hypotension, or cardiac tamponade. - Its direct impact on breathing is less immediate compared to a tension pneumothorax. *Cervical spine injury* - A cervical spine injury can affect breathing if it involves the **phrenic nerve** (C3-C5), leading to respiratory paralysis, but this is assessed during the **disability component** or secondary survey for neurological deficits. - It does not directly cause an acute, life-threatening compromise of lung function discernible primarily through a breathing assessment like a tension pneumothorax. *Laryngotracheal injury* - A laryngotracheal injury primarily affects the **airway component** (A in ABCDE), leading to immediate obstruction or stridor. - While critical, it is distinct from problems with the lungs' ability to expand or perform gas exchange, which are assessed under breathing.

Trauma Anesthesia Indian Medical PG Question 8: Which of the following is not done in the primary survey of trauma?

• A. Intubation
• B. NCCT head (Correct Answer)
• C. ICD drainage
• D. CXR

Trauma Anesthesia Explanation: ***NCCT head*** - A **Non-Contrast CT (NCCT) head** is typically performed during the **secondary survey** once the patient is hemodynamically stable and life-threatening conditions have been addressed. - The primary survey focuses on immediate **life-saving interventions** for airway, breathing, circulation, disability, and exposure. *Intubation* - **Intubation** is a critical intervention during the primary survey, specifically under the **'A' (Airway)** component, to establish and secure a patent airway in a compromised patient. - Failure to establish an airway can rapidly lead to **hypoxia** and death. *ICD drainage* - **Intercostal drain (ICD) drainage** is an urgent intervention in the primary survey, falling under **'B' (Breathing)**, to manage conditions like **tension pneumothorax** or massive hemothorax. - These conditions can severely compromise ventilation and circulation, requiring immediate relief. *CXR* - A **Chest X-ray (CXR)** is a rapid and essential diagnostic tool in the primary survey, also under **'B' (Breathing)**, to identify life-threatening thoracic injuries such as pneumothorax, hemothorax, or mediastinal shift. - It provides quick information crucial for immediate management decisions.

Trauma Anesthesia Indian Medical PG Question 9: A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. Airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be

• A. Laparoscopy
• B. Insertion of abdominal drain followed by laparotomy
• C. Exploratory Laparotomy under general anesthesia (Correct Answer)
• D. FAST

Trauma Anesthesia Explanation: ***Exploratory Laparotomy under general anesthesia*** - The presence of **peritonitis** and **shock** following abdominal injury indicates a **life-threatening intra-abdominal injury** requiring immediate surgical intervention. - An **exploratory laparotomy** allows for direct visualization, control of hemorrhage, repair of organ damage, and addressing the source of peritonitis. *Laparoscopy* - While minimally invasive, laparoscopy is often **contraindicated in hemodynamically unstable patients** or those with diffuse peritonitis due to the risk of exacerbating shock and limited access. - It is also generally **more time-consuming** than a laparotomy in acute trauma settings, delaying definitive treatment. *Insertion of abdominal drain followed by laparotomy* - **Insertion of an abdominal drain** in the context of peritonitis and shock is insufficient and inappropriate as a primary measure. - A drain cannot address active bleeding, repair visceral perforation, or adequately decontaminate the peritoneal cavity, thus **delaying definitive surgical treatment**. *FAST* - **Focused Assessment with Sonography for Trauma (FAST)** is a diagnostic tool used to detect free fluid (blood) in the abdomen or pericardium. - While useful for initial assessment, a **positive FAST scan in an unstable patient** with peritonitis necessitates immediate surgical intervention, not further diagnostic delay.

Trauma Anesthesia Indian Medical PG Question 10: A patient is admitted following a road traffic accident. He has sustained significant blunt injury to his head, chest and abdomen and has a Glasgow Coma Scale score of 8/15. His saturations are poor at 89% on 15 L of oxygen a rebreathing mask. You note bruising around both eyes and blood-stained fluid issuing from his left ear, which forms concentric circles when dripped on a white sheet. You wish to support his airway to improve oxygenation. The first choice of airway adjunct would be

• A. Nasopharyngeal tube
• B. Intubation
• C. Laryngeal mask
• D. Oropharyngeal airway (Correct Answer)

Trauma Anesthesia Explanation: ***Oropharyngeal airway*** - An **oropharyngeal airway (OPA)** is the most appropriate initial airway adjunct in a patient with a **depressed GCS (8/15)** and poor oxygenation, as it helps to relieve **upper airway obstruction** caused by the tongue falling back. - Given the potential for a **basal skull fracture** (bruising around eyes, blood-stained fluid from ear forming concentric circles), a **nasopharyngeal airway (NPA)** is contraindicated due to the risk of intracranial insertion. *Nasopharyngeal tube* - A **nasopharyngeal airway (NPA)** is contraindicated in this patient due to signs suggestive of a **basal skull fracture**, which include **raccoon eyes (periorbital bruising)** and **Battle's sign (bruising behind the ear)**, as well as the **halo sign (concentric circles of blood and CSF)** from the ear. - Inserting an NPA in such a scenario risks inadvertently entering the **cranial cavity**, leading to further neurological damage or infection. *Intubation* - While **intubation** may eventually be necessary given the patient's low GCS and poor oxygenation, it is not the *first choice* of airway adjunct. - The immediate priority is to establish a **patent airway** quickly and safely, which an OPA can achieve while preparations for definitive intubation are made. *Laryngeal mask* - A **laryngeal mask airway (LMA)** could be considered for airway management, but it is typically a more advanced adjunct than an OPA. - Its insertion requires a certain level of skill and might be more time-consuming than an OPA, which is crucial in an emergency setting.

Trauma Anesthesia Flashcard 1 of 4

Question: Target MAP in patients of polytrauma on vasopressor therapy is _____ mmHg

Answer: 65

Trauma Anesthesia Flashcard 2 of 4

Question: Incidence of coagulopathy in massive transfusion can be minimized by infusing _____, platelets, and RBCs in a 1:1:1 ratio

Answer: fresh frozen plasma

Trauma Anesthesia Flashcard 3 of 4

Question: Minimizing _____ based resuscitation is a part of balanced resuscitation (damage control resuscitation)

Answer: crystalloid

Trauma Anesthesia Flashcard 4 of 4

Question: Patients with polytrauma can be shifted in _____ position to prevent aspiration

Answer: prone