Anesthesia for trauma and shock

Essay

1.What is shock? Mention different types of shock and its management?

Definition

It is a syndrome initiated by decreased blood flow leading to tissues hypoxia

and vital organ dysfunction.

Classification

1. Hypovolemic shock
• Hemorrhagic shock –trauma, gastrointestinal bleed, ruptured aneurysm
etc.
• Non hemorrhagic shock – severe diarrhea, vomiting, burns, peritonitis.
2. Cardiogenic shock

Eg

• Acute myocardial infarction

• Cardiomyopathy
• Pericardial effusion
• Cardiac tamponade
• Valvular diseases
• Pulmonary embolism
• Arrhythmias
• Aortic dissection
3. Distributive shock
• Septic shock
• Anaphylactic shock
• Late stages of hypovolemic shock
4. Mixed causes
• Endocrine causes– myxedema coma, adrenal crisis, thyroid crisis.
• Neurogenic causes – traumatic shock without hypovolemia.

Pathophysiology

Arterial hypotension is common to all forms of shock. Arteries constrict in order

to increase the blood pressure, but this can lead to decreased blood flow to organs and
tissues.
 As a result cellular damage and organ dysfunction can occur .

Organ dysfunction

The major vital organs invariably affected area heart , brain and kidney.

Cerebral blood flow and coronary blood flow are maintained because of
autoregulation until the perfusion pressures are very low.

Cerebral dysfunction

Manifested initially as confusion and slurring of speech.

Cardiac dysfunction

Initially evidenced by arterial hypotension and tachycardia.

Renal dysfunction

Results in renal hypoperfusion and decreased urine output.

Pulmonary system

Pulmonary congestion and pulmonary edema occurs . This results in worsening

hypoxemia and hypercapnea, respiratory failure occurs

Development of adult respiratory distress syndrome.

Liver dysfunction

Hepatic function worsens leading to jaundice and hepatic failure.

GIT

Paralytic ileus, mesenteric ischemia.

Disseminated intravascular coagulation.

Assessment of shock

Hypovolemic shock

Class 1 ( 0–15% loss of blood volume)

• Tachycardia
• No change in blood pressure or respiratory rate
• Delay in capillary refill(>3 seconds)

Class 2( 15–30% loss of blood volume)

 • Tachycardia, tachypnea
• Decrease in pulse pressure
• Cool and clammy skin
• Delayed capillary refill
• Slight anxiety

Class3( 30–40% loss of blood volume)

• Marked tachycardia and tachypnea

• Fall in systolic blood pressure
• Oliguria
• Confusion and agitation

Class4( >40% blood volume loss)

• Marked tachycardia
• ↓↓ Systolic blood pressure
• Narrow pulse pressure

Management of shock

• Primary survey and assessment

• Assessment of airway, breathing and circulation
→Adequacy of respiration must be assessed immediately.
→Agitated and confused patients should be presumed hypoxemic.
→ Look for signs of respiratory distress or hypoxia.
→Hypotension( systolic BP<90mmHg below basal level)
→Heart rate
→Degree of pallor
→Quality of mentation and level of consciousness
→Urine output ( <20ml/hr )
→Metabolic acidosis. ABG ↓ should be sent.

Monitoring

• Electrocardiogram
• Pulse oximeter
• Blood pressure
→Invasive
→Non invasive
• Central venous catheterization
 • Pulmonary artery catheterization
• Capnogram
• Urine output
• Temperature probe
• Arterial blood gas analysis

Lab investigations

• Blood glucose concentration

• Plasma electrolyte concentration
• Hb and packed cell volume
• Blood grouping and cross matching
• Coagulation profile
• Blood urea nitrogen, serum creatinine
Imaging studies
• Chest X ray
• USG abdomen
• Peritoneal lavage

2. Describe in detail about anesthesia for trauma and shock?

Anesthesia for Trauma and Shock:

Trauma and shock require prompt and careful anesthesia management

to ensure optimal patient outcomes. The primary goals of anesthesia in trauma and
shock are:

1. Rapid sequence induction: Quickly secure the airway while minimizing the risk
of aspiration.

2. Hemodynamic stability: Maintain blood pressure and perfusion of vital organs.

3. Pain management: Provide adequate analgesia to reduce pain and stress.

4. Prevention of further injury: Avoid exacerbating existing injuries or causing new

ones.

Pre-Anesthetic Evaluation:

1. Rapid assessment: Quickly evaluate the patient’s airway, breathing, circulation,

disability, and exposure (ABCDE).

2. Vital signs: Monitor vital signs, including blood pressure, heart rate, respiratory
rate, oxygen saturation, and temperature.
 3. Laboratory tests: Review laboratory results, including complete blood count,
electrolytes, and coagulation studies.

Anesthetic Techniques:

1. Rapid sequence induction (RSI): Use a combination of sedatives and

neuromuscular blocking agents to quickly secure the airway.

2. General anesthesia: Provide general anesthesia using inhalational or

intravenous agents to maintain unconsciousness and analgesia.

3. Regional anesthesia: Use regional anesthesia techniques, such as spinal or

epidural anesthesia, to provide analgesia and reduce blood pressure.

4. Sedation: Provide sedation using agents like propofol or midazolam to reduce

anxiety and discomfort.

Anesthetic Agents:

1. Etomidate: A short-acting sedative-hypnotic agent that provides rapid sequence

induction.

2. Ketamine: A dissociative anesthetic agent that provides analgesia and sedation.

3. Propofol: A short-acting sedative-hypnotic agent that provides general

anesthesia.

4. Fentanyl: A potent opioid analgesic agent that provides pain relief.

Fluid Management:

1. Crystalloids: Administer crystalloids, such as normal saline or lactated Ringer’s

solution, to maintain fluid balance and blood pressure.

2. Colloids: Use colloids, such as albumin or hetastarch, to maintain blood

pressure and perfusion of vital organs.

3. Blood products: Administer blood products, such as packed red blood cells,
fresh frozen plasma, and platelets, to replace lost blood and clotting factors.

Monitoring:

1. Vital signs: Continuously monitor vital signs, including blood pressure, heart rate,
respiratory rate, oxygen saturation, and temperature.

2. Electrocardiogram (ECG): Monitor the ECG to detect any cardiac arrhythmias or

ischemia.
 3. Arterial blood gas (ABG): Monitor ABG results to assess oxygenation, ventilation,
and acid-base balance.

4. Central venous pressure (CVP): Monitor CVP to assess fluid balance and cardiac
function.

Post-Anesthetic Care:

1. Recovery room: Transfer the patient to the recovery room for close monitoring
and care.

2. Pain management: Provide adequate pain management using opioid analgesics,

non-steroidal anti-inflammatory agents, or regional anesthesia techniques.

3. Fluid management: Continue to manage fluids and electrolytes to maintain fluid

balance and blood pressure.

4. Monitoring: Continuously monitor vital signs, ECG, and ABG results to detect any
complications or changes in the patient’s condition.

3. Resuscitation of trauma patient?

Resuscitation of a Trauma Patient

1. Initial Approach:
• Follow the Advanced Trauma Life Support (ATLS) protocol.
• Rapid assessment and simultaneous interventions.

Primary Survey (ABCDE):

1. A – Airway with cervical spine protection:

• Ensure airway patency (suction, chin lift/jaw thrust).
• Protect cervical spine with collar/manual stabilization.
• Secure airway if compromised (endotracheal intubation or surgical airway).
2. B – Breathing and ventilation:
• Assess chest rise, breath sounds, and oxygen saturation.
• Manage life-threatening thoracic injuries:
• Tension pneumothorax (needle decompression).
• Open pneumothorax (three-sided dressing).
• Flail chest (ventilation support).
• Provide oxygen or mechanical ventilation if necessary.
3. C – Circulation with hemorrhage control:
• Control external bleeding using:
 • Direct pressure, wound packing, or tourniquets.
• Assess for signs of shock (pulse, BP, capillary refill).
• Initiate IV/IO access and fluid resuscitation:
• Warmed crystalloids or balanced blood products (1:1:1 ratio).
• Early use of Tranexamic Acid (TXA) for hemorrhage.
4. D – Disability (Neurological Assessment):
• Use Glasgow Coma Scale (GCS) for rapid evaluation.
• Check for pupil size and reaction.
• Identify signs of brain or spinal cord injury.
5. E – Exposure and environmental control:
• Fully expose the patient to assess injuries.
• Prevent hypothermia using warming blankets and warmed fluids.

Secondary Survey:

• Perform a head-to-toe examination.

• Gather history (AMPLE):

(Allergies, Medications, Past medical history, Last meal, Events leading to

injury.)

• Obtain imaging:

(X-rays, FAST ultrasound, or CT scans as needed.)

Adjuncts to Resuscitation:

• Administer oxygen, analgesia, and antibiotics if necessary.

• Monitor vital signs, urine output, and lab results (lactate, base deficit).
• Consider damage control resuscitation:
• Permissive hypotension for uncontrolled bleeding.
• Early blood product use over large-volume crystalloids.

Resuscitation Strategies

1. Fluid Resuscitation: Administer fluids, such as crystalloids (normal saline or

lactated Ringer’s solution) or colloids (albumin or hetastarch), to maintain blood
pressure and perfusion of vital organs.

2. Blood Transfusion: Transfuse blood products, such as packed red blood cells,
fresh frozen plasma, and platelets, to replace lost blood and clotting factors.
 3. Damage Control Resuscitation: Implement damage control resuscitation
strategies, including permissive hypotension, to minimize bleeding and prevent
further injury.

Short notes

1.Rapid sequence intubation?

Rapid Sequence Intubation (RSI):

Rapid Sequence Intubation (RSI) is a medical procedure used to quickly

and safely intubate a patient’s airway. RSI is typically performed in emergency situations,
such as trauma, cardiac arrest, or severe respiratory distress.

Indications for RSI:

1. Respiratory failure: Inability to breathe or ventilate adequately.

2. Cardiac arrest: Need for immediate airway management during cardiac arrest.

3. Trauma: Severe trauma, including head injury, neck injury, or multiple injuries.

4. Seizures: Status epilepticus or severe seizures requiring airway protection.

5. Overdose: Overdose with respiratory depression.

Preparation for RSI:

1. Pre-oxygenation: Provide 100% oxygen for 3-5 minutes to denitrogenate the

lungs.

2. Monitoring: Establish monitoring, including electrocardiogram (ECG), blood

pressure, and oxygen saturation.

3. Airway equipment: Prepare airway equipment, including a laryngoscope,

endotracheal tube, and stylet.

4. Medications: Prepare medications, including sedatives, neuromuscular blocking

agents, and anti-sialogogues.

Medications Used in RSI:

1. Sedatives: Etomidate, midazolam, or propofol to induce sedation and amnesia.

2. Neuromuscular blocking agents: Succinylcholine or rocuronium to induce

muscle relaxation and facilitate intubation.
 3. Anti-sialogogues: Glycopyrrolate or atropine to reduce salivation and prevent
bradycardia.

Steps of RSI:

1. Pre-oxygenation: Provide 100% oxygen for 3-5 minutes.

2. Administration of sedatives and neuromuscular blocking agents: Administer

sedatives and neuromuscular blocking agents simultaneously.

3. Laryngoscopy: Perform laryngoscopy to visualize the vocal cords and glottis.

4. Intubation: Pass the endotracheal tube through the vocal cords and into the
trachea.

5. Verification: Verify correct placement of the endotracheal tube using

capnography, auscultation, and visualization.

Complications of RSI:

1. Hypoxia

2. Bradycardia

3. Hypotension

4. Dental or airway trauma

5. Aspiration

Post-Intubation Care:

1. Ventilator management_:

2. Sedation and analgesia

3. Monitoring

4. Weaning and extubation

Short answers

1.Resuscitation in trauma and shock?

Resuscitation in Trauma and Shock

1. Primary Survey (ABCDE):

• A: Ensure airway patency and cervical spine protection.
 • B: Assess breathing, manage pneumothorax or hemothorax, and provide
oxygen.
• C: Control hemorrhage, establish IV/IO access, and start fluid or blood
resuscitation.
• D: Perform neurological assessment using GCS and check pupils.
• E: Fully expose patient to identify injuries and prevent hypothermia.
2. Shock Management:
• Identify type of shock (e.g., hemorrhagic, obstructive).
• Control bleeding and use blood products (1:1:1 ratio for hemorrhagic shock).
• Administer Tranexamic Acid (TXA) if indicated.
• Use permissive hypotension until bleeding is controlled.
3. Secondary Survey:
• Conduct a head-to-toe examination.
• Obtain imaging (X-rays, FAST, CT) as needed.
• Plan for definitive treatment (e.g., surgery).
4. Adjuncts:
• Monitor vitals, urine output, and labs.
• Prevent complications like hypothermia or acidosis.

2.Preoperative investigation for shock?

The essential preoperative investigations for a patient in shock are:

1. Complete Blood Count (CBC): To assess for anemia, thrombocytopenia, and

leukocytosis.
2. Electrolyte Panel: To evaluate for electrolyte imbalances, such as hyponatremia,
hyperkalemia, or hypocalcemia.
3. Coagulation Studies: To assess for coagulopathy, including prothrombin time (PT),
partial thromboplastin time (PTT), and international normalized ratio (INR).
4. Arterial Blood Gas (ABG): To evaluate oxygenation, ventilation, and acid-base
status.
5. Electrocardiogram (ECG): To assess for cardiac arrhythmias, ischemia, or other
cardiac abnormalities.

3.Resuscitation in polytrauma?

The initial resuscitation priorities in a polytrauma patient are:

1. Airway management: Establish a patent airway and protect the cervical spine.
2. Breathing support: Provide oxygen therapy and mechanical ventilation as needed
to maintain adequate oxygenation and ventilation.
3. Circulatory support: Control bleeding and administer fluids and blood products as
needed to maintain perfusion of vital organs.
4. Disability assessment: Evaluate neurological function, assessing for signs of head
injury, spinal cord injury, or other neurological deficits.
5. Exposure and environmental control: Expose the patient to assess for other
injuries, remove clothing, and apply warm blankets to prevent hypothermia.