Trauma Anesthesia Principles

Primary Survey & Resuscitation - Trauma Tango

Systematic ABCDE approach: rapid ID & management of life-threatening injuries. Simultaneous resuscitation. 📌 Airway, Breathing, Circulation, Disability, Exposure.

• Airway & C-Spine:
  • Assess patency, clear. Secure airway (intubate if GCS ≤ 8).
  • C-spine immobilization.
• Breathing & Ventilation:
  • Assess rate, depth. Oxygenation (SpO₂ > 94%).
  • Manage tension pneumothorax, open pneumothorax.
• Circulation & Hemorrhage:
  • Control external bleed. IV access (2 large-bore).
  • Fluids/blood. Permissive hypotension (SBP 80-90 mmHg) if no TBI.
• Disability (Neuro):
  • GCS, pupils.
• Exposure & Environment:
  • Undress fully. Prevent hypothermia (warm blankets/fluids).

⭐ Lethal Triad in trauma: hypothermia, acidosis, coagulopathy. Early, aggressive management is crucial for survival.

Trauma Airway Management - Breath Guardian

• C-spine immobilization: MILS during airway maneuvers.
• Rapid Sequence Intubation (RSI): For unprotected airway.
  • Preoxygenate: 100% O2, 3-5 min.
  • Drugs: Ketamine (1-2 mg/kg IV) / Etomidate (0.2-0.3 mg/kg IV); Succinylcholine (1-1.5 mg/kg IV) / Rocuronium (1.2 mg/kg IV).
• Difficult Airway: LEMON assessment.
  • Backups: SGA, Video Laryngoscopy.
  • Failed: Surgical Cricothyroidotomy.
• "Breath Guardian" - Post-Intubation:
  • Confirm: EtCO2 (gold standard), chest rise.
  • Secure tube.
  • Ventilate: LPS ($V_T$ 6-8 mL/kg IBW, PEEP).
  • Monitor: SpO2, EtCO2. Prevent hypoxia/hypercapnia.

⭐ Ketamine is often favored in hypotensive trauma patients for RSI due to its sympathomimetic properties, maintaining hemodynamic stability.

Hemorrhagic Shock & MTP - Red River Rally

• Hemorrhagic Shock: Blood loss → ↓perfusion.

  • ATLS Classes I-IV guide resuscitation. Key examples:
    • Class III: 30-40% loss, HR >120, BP ↓, UO 5-15ml/hr.
    • Class IV: >40% loss, HR >140, BP markedly ↓, UO negligible.
  • Management: Stop bleed, restore volume, permissive hypotension (SBP 80-90 mmHg pre-control, not TBI).
  • ⚠️ Avoid "Lethal Triad": Hypothermia, Acidosis, Coagulopathy.

• Massive Transfusion Protocol (MTP):

  • Triggered by e.g., >4 units PRBCs in 1 hr.
  • Ratio: 1:1:1 (PRBC:FFP:Platelets). 📌 Mnemonic: "Red River Rally".
  • Goals: Hb >7 g/dL, Plt >50,000/µL, Fibrinogen >1.5-2 g/L, normothermia, normocalcemia.

  ⭐ TXA: 1g IV within 3 hrs of injury, then 1g IV over 8 hrs. Reduces mortality in bleeding trauma.

Anesthetic Management & DCS - Damage Control Dance

• Core Goals: Rapid physiological stabilization & surgical control.
  • Address "Lethal Triad":
    • Hypothermia (<35°C): Aggressive warming (warm fluids, forced air warmers).
    • Acidosis (pH <7.2, BE <-6): Optimize ventilation/perfusion, judicious bicarbonate.
    • Coagulopathy (INR >1.5, PTT >60s, Platelets <50,000): Tranexamic acid (TXA), 1:1:1 PRBC:FFP:Platelets. (📌 "Trauma triad is a bad cascade")
  • Permissive Hypotension: Target SBP 80-90 mmHg (unless TBI: MAP >80 mmHg).
• Anesthetic Choices:
  • Induction: Ketamine (hemodynamically stable), Etomidate (cardio-stable, adrenal suppression risk).
  • Maintenance: Low MAC volatiles (e.g., Sevoflurane <1 MAC) or TIVA. Avoid N₂O.
• Damage Control Surgery (DCS) - "The Dance":
  • Phase 1 (OR): Abbreviated surgery (control hemorrhage/contamination).
  • Phase 2 (ICU): Physiological restoration (correct lethal triad).
  • Phase 3 (OR): Planned re-operation for definitive repair.

  ⭐ Early administration of Tranexamic Acid (TXA) within 3 hours of injury significantly improves survival in bleeding trauma patients.

High‑Yield Points - ⚡ Biggest Takeaways

• Airway management is paramount; assume cervical spine injury until cleared.
• Rapid Sequence Intubation (RSI) is standard for securing the trauma airway.
• Manage hemorrhagic shock with permissive hypotension (SBP 80-90 mmHg) and 1:1:1 balanced transfusion.
• Prioritize Damage Control Resuscitation (DCR) and early Damage Control Surgery (DCS).
• Prevent and treat the lethal triad: hypothermia, acidosis, and coagulopathy.
• Ketamine is preferred for induction in hemodynamically unstable patients.