Emergency anaesthesia for suspected major trauma patients in ED

North of Scotland major trauma guidelines

Objectives

Emergency anaesthesia usually occurs as part of the ongoing resuscitation of major trauma patients. The overriding priority in all trauma patients is to provide anaesthetic that maintains haemodynamic stability.

Considerations for the major trauma patient

Prior to Anaesthesia the anaesthetist should:

Arrive before the patient and clarify roles.
Prevent hypothermia – Warmed IV fluids run through.
Check vascular access is working.
Perform the pre intubation checklist
Prepare induction drugs and consider maintenance anaesthesia.

Induction of anaesthesia

RSI is the safest and most effective method to secure the airway.
Induction in the exsanguinating patient can be fatal. Ensure ongoing volume resuscitation during RSI in these patients.
Do not delay induction for arterial or central access in patients in extremis.
Standard induction doses should be reduced and titrated to balance the induction of anaesthesia with haemodynamic changes.
The use of vasopressors in major trauma may be harmful. *
Minimise manipulation of the cervical spine during laryngoscopy using manual in line stabilisation. Direct laryngoscopy rarely causes or worsens cervical spine injury.
Place an orogastric/nasogastric tube as soon as practicable.
Neurogenic shock may be an exception to this.

Maintenance of anaesthesia in the ED

Consider continuous intravenous anaesthesia with propofol.
Provide opioid analgesia in boluses.
Tolerate a MAP >55mmHg in the anaesthetised bleeding patient to facilitate end organ perfusion without exacerbating bleeding.
Patients with a significant brain injury should maintain a SBP >100mmHg unless haemorrhage is the primary pathology.
Administer antibiotics early if indicated.
Employ lung protective ventilation using Vt = 6ml/kg IBW.
Ensure all patient movements and blood/products are communicated to blood bank.
Cross-matched blood and products should follow the patient to their next destination.

Trauma RSI induction protocol

If you have comfort and experience with the following induction protocol, please use. However, use an induction protocol you can administer with confidence.

Trauma RSI

Aim:

Provide strategy for RSI in major trauma patients.
Improve safety for hypovolaemic trauma patients.

Pre-RSI phase

Standard pre-induction preparations/checks
Prepare ketamine 200mg/20mls. Rocuronium 100mg/10mls. Fentanyl 500mcg/10mls
Determine degree/cause of shock + treat.

Euvolaemia (3, 2, 1)

Fentanyl - 3mcg/kg
Ketamine - 2mg/kg
Rocuronium - 1mg/kg

Hypovolaemia (1, 1, 1)

Fentanyl - 1mcg/kg
Ketamine - 1mg/kg
Rocuronium - 1mg/kg

Severe hypovolaemia (1, 1)

Ketamine - 1mg/kg
Rocuronium - 1mg/kg

Peri-arrest (1)

Rocuronium - 1mg/kg

Notes

This document provides a guide to assist with managing induction of anaesthesia in patients with major injury and does not attempt to cover all aspects of trauma patient Mx.

3,2,1

This strategy is aimed at the trauma patient requiring anaesthesia without coexisting hypovolaemia e.g. combative patient with or without head injury, burns patient etc.
Tachycardia/hypertension are not usually an issue post induction if appropriate does of opiate is used.

Post induction

Hypertension post induction should be managed primarily with volume resuscitation plus exclusion of obstructive cause of shock e.g. tension PTX, tamponade.
Ensure adequate anaesthesia post induction and resuscitation/restoration of systemic blood pressure.

Credit: RIE major trauma clinical guidelines

ARI emergency department RSI checklist

ARI emergency department RSI checklist page 1

Tracheal intubation in critically ill adults algorithm

Can’t Intubate, Can’t Oxygenate (CICO) in critically ill adults

DAS / APA Algorithm for failed intubation in Paediatrics

You should not use elective anaesthesia document here!