Trauma Anaesthesia

Question 1

What is the Haemorrhage classification 1 - 4

Answer 1

Class 1

• Blood loss without haemodynamic consequence
• < 15%

Class 2

• Blood loss leads to SNS activation (↑HR and DBP)
• 15 -30%

Class 3

• Blood loss leads to ↓ BP (ineffective SNS)
• 30 - 40%
• may prompt damage control procedure

Class 4

• Blood loss leads to unresponsive patient with ↓↓ BP
• > 40%

Question 2

What is adult versus child vs infant blood volume

Answer 2

Adult: 70 ml/kg
Child: 80 ml/kg
Infant: 90 ml/kg

Question 3

Why does coagulopathy occur in trauma

Answer 3

1. Acidosis impairs coagulation

2. Hypoperfusion: endothelium release thrombomodulin and activated protein C to prevent microcirculation thrombosis

Question 4

What is haemostatic resuscitation

Answer 4

RCC:FFP:PLTs(+cryoprecipitate) in a 1:1:1 ratio

Question 5

What should ideally be used during preoperative resuscitation in trauma patients

Answer 5

Damage control resuscitation = Controlled permissive hypotensive haemostatic resuscitation using a 1:1:1 ratio of RCC:FFP:PLT with antifibrinolytic therapy (tranexamic acid)

Ideally use viscoelastic haemostatic assay = Thromboelastography to guide administration of blood components.

Question 6

What is the leading cause of blood transfusion related death

Answer 6

Transfusion associated lung injury (TRALI)

Question 7

Define and describe the score used to determine the likelihood that a patient will require a massive transfusion

Answer 7

The assessment of blood consumption score (ABC score)

1. Penetrating trauma (1 point)
2. SBP < 90 (1 point)
3. HR > 120 (1 point)
4. Positive eFAST (1 point)

2 or more points predicts likely massive transfusion will be required.

Question 8

Describe preoperative preparation for major trauma case

Answer 8

Document possibility of awareness in notes

A - Prep difficult airway trolley
B - Machine check/IMALES/drugs
C - Rapid infusion catheters/large bore catheters/A-line/Adrenalin infusion/FDP’s
D - Consider possibility of C-spine: personal for manual in-line
E - Warm theatre. Warm fluids to 39 deg C.

Question 9

Describe induction technique in a trauma patient

Answer 9

RSI
Etomidate/Ketamine - low dose
Midazolam (amnestic)
Succinylcholine

Volatile - 0.5 MAC

Question 10

What are the principles of damage control surgery

Answer 10

1. Stop haemorrhage
2. Limit gastrointestinal contamination of the abdominal compartment
3. Exclusion of definitive repair of complex injuries
   - eg. staple intestines closed and reconnect later to prevent abdominal compartment contamination
4. Interruption of procedure with packing to catch up with maintaining adequate perfusion
5. Once damage control is complete transfer to ICU for correction of: hypothermia, coagulopathy and acidosis
6. Once these have significantly improved –> definitive surgical repair can proceed.