The Management of Major Trauma (page 9)

Issue 6 (1996) Article 2: Page 9 of 9

Go to page: 1 2 3 4 5 6 7 8 9

The Management of Major Trauma (Continued)

Unexplained hypoxia in the perioperative period where there is a longbone or pelvic fracture may be due to fat embolism associated with the release of intramedullary fat into the venous circulation from the fracture site. This can occur at any time following fracture, but is more common if surgical fixation is delayed for longer than 8 hours.

The lung injury is characterised by pulmonary capillary leak leading to pulmonary oedema (this occurs in the absence of heart failure and is known as low pressure pulmonary oedema). The X-ray findings are characteristic ( figure 10).

Hypoxaemia is always present and respiratory failure common. The lung injury can be associated with systemic capillary injury (the fat embolus syndrome) comm-only affecting the cerebral circulation, leading to con-fusion and drowsiness. A petechial rash is usually present over the trunk and conjunctiva due to systemic capillary damage. Renal impairment can occur. Treatment of fat embolism involves respiratory support with oxygen therapy and ventilation, and circulatory and renal support if required. When suspected, fat em-bolism should also be treated with 500 mg intravenous methylprednisolone given over 30 minutes. Remember, however, there are other causes of hypoxia in the peri-operative period.

Reversal of anaesthesia and postoperative care: No patient should have their neuromuscular blockade reversed until they have been adequately resuscitated and have a normal blood pressure and pulse rate and adequate urine flow. Following prolonged surgery, and in patients with injury to a number of body systems, particularly head and chest, a period in the recovery room of 24 hours with continuous close observation and availability of an anaesthetist should be considered. Alternatively such patients should be admitted to an intensive care unit where adequate analgesia with intravenous opiates, ventilation, and treatment in response to a change in condition (for example blood loss due to a coagulation defect) can be provided.

Case History: A nine year old girl was admitted to a University Teaching Hospital following a serious car accident in which two people were killed. On primary survey she was dyspnoeic, though her airway was clear. She had absent air entry on the left side of her chest and dullness to percussion. Her trachea was not deviated. She was in hypovolaemic shock with a pulse of 150/minute and unrecordable BP. A distended abdomen was noted as was her depressed conscious level. There was some response to voice but she was making incomprehensible groaning sounds. Both pupils were reacting normally and there was a haematoma on her forehead. Her weight was estimated to be 30kg

Oxygen was immediately given at 8 litres / minute via a face mask and blood taken for crossmatch whilst two intravenous cannulae were inserted. Initially she was given a fluid loading of 10mls/kg body weight (300mls) of saline and then this was repeated using Haemaccel. This improved her blood pressure for only a short time and therefore another 300mls of Haemaccel was administered and then 2 units of uncrossmatched group O negative blood, which were warmed in a basin of water at hand temperature. During this time a surgeon had performed a secondary survey and decided to do an immediated laparotomy where a ruptured spleen was resected. He had also inserted a chest drain on the left side preoperatively and drained a haemo-pneumothorax.

Anaesthesia was induced with ketamine 1.5mg/kg and suxamethonium 1.5mg/kg and maintained with intermittent ketamine and and a muscle relaxant. Two further fluid boluses of Haemaccel were given after which the child stabilised. Postoperatively the child made a good recovery and was discharged home.

Summary

The key to successful trauma management involves prior preparation of the resuscitation room and creation of a trauma team in which the anaesthetist plays a vital role. Once mobilised, the team should be co-ordinated by a leader who should follow a regime based upon a primary survey and resuscitation, a secondary survey once the patient has been stabilised and prompt initiation of definitive treatment. A full history should identify mechanisms of injury. Anaesthesia for the trauma patient must involve a full assessment of the actual and potential injuries with the appreciation that resuscitation is often ongoing and the patient's condition can change dramatically.

This article contained links to the following additional information:

Issue 5 - Intraosseous infusion
Practical procedure - Cricothyrotomy
Practical procedure - Pleural drainage
Practical procedure - Needle pericardiocentesis
Glasgow Coma Scale
Practical procedure- Diagnostic Peritoneal Lavage
Neurological assessment chart