Trauma Anesthesia Video:

In this video, Dr. Doreen Yee answers questions related to providing anesthesic services in trauma.

Transcript of the video:

Dr. Yee: Hello, my name is Doreen Yee and I’m a staff anesthesiologist at Sunnybrook Health Sciences Centre. For the last number of years, I’ve also been one of the trauma team leaders at Sunnybrook which is, as some of you may know, one of the major trauma centres in Canada.

Question 1: What are some difficulties you can encounter when trying to establish an airway on a trauma patient?

Dr. Yee: In a trauma patient, the airway has more challenges than a regular airway. This is for a number of reasons. First, it is because it is an emergency situation so you don’t have as much time to prepare your equipment and your approach. So, you need to be prepared quickly and think on your feet. Secondly, most trauma patients have a full stomach and are at higher risk of regurgitation and aspiration at any time during their stay in the trauma room. The other things that are often involved are drug intoxications, including alcohol. As well as head injury, which makes them less able to protect their airway. Finally, there may be trauma and injuries to the airway itself, which adds new challenges to securing the definitive airway.

Question 2: What are some of the airway adjuncts you can use when there is a difficult airway?

Dr. Yee: One of the best adjuncts is an educated assistant, I might have to say. Other than that, there are different kinds of equipment we can use in a trauma patient. Besides a regular laryngoscope there is also a glidescope, there are also bougies and styletted tubes and so forth that one can use. Most trauma rooms will have what we call a difficult airway cart which should contain most of this equipment. Oftentimes when we’re unable to intubate we may have to resort to getting help and extra equipment and in the meantime oxygenating the patient with the regular bag mask, laryngeal mark or regular oral airway.

Question 3: How does sedation differ in the management of a trauma patient?

Dr. Yee: Many of the drugs we use for analgesia, as well as sedation, do cause a decrease in your blood pressure. In trauma patients who may be hypovolemic, these drugs may further cause a drop in blood pressure. So, one has to really balance how much sedation and pain medication is required in the patient. You have to understand their volume status before you give them anything. I think the best advice is to start slowly to see how the patient reacts. Unfortunately, sometimes if a patient is truly in hypovolemic shock, we can’t afford to give them too much sedation or pain medication or it just might drop the pressure to the point of difficult resuscitation.

Question 4: What are some of the signs that a trauma patient has sustained a head injury?

Dr. Yee: Head injuries are unfortunately very common in trauma. One of the signs is an altered level of consciousness. People can range from being combative and confused to sometimes very subtly changed, where you don’t see too much at all until you do the CT scan. On the other end of the spectrum are patients who show up in a COMA where it is very obvious they have a head injury. The best thing for head injuries is to maintain cerebral perfusion pressure. Usually that means maintaining an adequate blood pressure so blood can get to the brain. Unfortunately, just by examination alone it is hard to tell exactly if the patient has increased intracranial pressure. Other signs could include late signs such as a blown pupil or people who are posturing in different ways which are indicative of head injuries. These things are hard to tell until we do the CT scan to see how severe the injury is. The best thing we can do as anesthesiologists is to maintain the cerebral perfusion pressure, as well as oxygenation to optimize the chances of oxygen getting to the brain.

Question 5: What is the Glasgow Coma Scale and how is it used to evaluate patients in a trauma?

Dr. Yee: The Glasgow Coma Scale, shortened to GCS, is a scale out of 15 points that was developed in Glasgow Scotland by a neurosurgeon. It depends on three different domains of a patient. The first one being eye opening, second being verbal response and the third being motor response. Out of the score of 15 it allows people to get an idea of what level or how severe the head injury may be. So, one can communicate, and people can tell how deep of a coma a patient is in. That is how it is used to evaluate trauma patients. We look at that all the time, at their eye opening, verbal and motor response out of a score of 15.

Question 6: What types of shock do patients present with in the trauma bay?

Dr. Yee: Of all the different kinds of shock, hypovolemic, or hemorrhagic shock is certainly the most common type of shock. A little bit less common, but still not uncommon is obstructive shock, where patients may have a tension pneumothorax or cardiac tamponade. Other types of shock are less common such as cardiogenic shock or anaphylactic shock but they are still possible. People with spinal cord injuries can also present with a neurogenic shock where they become vasodilated and lose all their tone. This is probably the third most common after hypovolemic and obstructive shock. There are different ways of identifying these types of shock. Usually you start with blood pressure monitoring, and we can also look at their perfusion and colour which can give us an idea of what type of shock they have. Patients with hemorrhagic shock usually also have a lactic acidosis where their pH is low because they are not getting enough blood to their periphery and their cells go into anaerobic metabolism.

Question 7: Why do some patients become coagulopathic and how can we minimize this risk?

Dr. Yee: Trauma patients become coagulopathic because frequently their tissue injury sets off a cascade which in addition to bleeding, causes fibrinolysis. For that reason, to minimize this risk, the faster you can replace their blood losses and stop their bleeding the better off you are at stopping this cascade of coagulopathy. As well, it has been shown in a fairly large study that antifibrinolytic drugs such as tranexamic acid can help with these patients. Part of our routine is to give a gram of TXA or tranexamic acid, followed by a second gram to minimize the fibrinolysis. Again, as in all kinds of hemorrhagic shock the number one goal is to stop the bleeding and a close second is to replace the blood they have lost.

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