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trauma Flashcards

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1
Q

Steps in managing a major trauma

A
  • Team approach with clear leader
  • Handover from ambulance team

- Primary survey
o Catastropic haemorrhage – tourniquets / pelvic binders
o AIRWAY + C spine protection
 Secretions, facial injuries, stridor
 ? intubation
o BREATHING
 Look, listen, feel = bruising, chest wounds, rising and falling
 Air entry + adequate ventilation?
 Surgical emphysema, trachea central
 Saturations, 15L O2 non-rebreathe
o CIRCULATION
 Pulse, BP, cap refil
 Heart sounds – tamponade
 Distended neck veins
 Haemorrhage = On the floor and 4 more
 IV access = bloods, G+S, Xmatch, clotting, VBG
o DISABILITY
 Pupils, GCS, signs of basal skull #
- AMPLE Hx
- Trauma CT scan
- Secondary survey – A to E, detailed systems examinations

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2
Q

what is the AMPLE Hx

A

allergies, medical Hx, PMH, last meal, events

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3
Q

In a major trauma when should the CT scan be performed

A
  • Within 30 minutes = key quality benchmark
  • To achieve – close location to scanner, good coordination by team leader, real time radiology reporting
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4
Q

examples of immediate life threatening injuries

A
  • ATOM FC
    o Airway obstruction – haematoma / swelling
    o Tension pneumothorax
    o Open pneumothorax
    o Massive haemothorax
    o Flail chest
    o Cardiac tamponade
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5
Q

what indicates major trauma?

A
  • Mechanism of injury is significant e.g. ejection from car or death of passenger in same car, motor cycle , fall from height
  • Physiological signs of hypovolaemia = HR and BP
  • Serious injuries = 2 of more long bone #, flail chest, penetrating
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6
Q

How does code red trauma differ

A

< 90mmHg + active bleeding
activate MHP - - 4RBC, 4FFP
get everyone ready

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7
Q

what are the key steps in airway assessment in trauma?

A
  • Airway patency – look, listen, feel
    o vomiting / bleeding / swelling / obstructed
  • Breathing – adequate rate, depth, symmetry
  • GCS
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8
Q

What are the indications to intubate

A

- Airway protection
o GCS < 8
o Risk of obstruction – burns, haematoma, laryngeal / tracheal injury, stridor
o Major facial trauma
o Risk of aspiration / blood
- Ventilation
o Low GCS / resp depression
o Hypoventilation – flail chest / pulmonary contusions
o Controlled CO2 in head injury
**- Other **
o Facilitate scanning of agitated patient
o Need for surgery e.g. damage control surgery
- sedation post arrest care

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9
Q

What precautions should be taken when Intubating in trauma setting

A
  • RSI
  • MILS / cervical collars – Video laryngoscope
  • Fentanyl, Ketamine , rocuronium 1.2mg/kg
    o if unstable 1:1:1 dose i.e. 1mg/kg for all
  • Cricoid – 2 hands to protect C spine
  • use checklists
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10
Q

What are the complications of airway management in trauma

A
  • Aspiration
  • Hypoxia / hypercarbia
  • C spine injury
  • Dental / cords/ soft tissue damage
  • failed intubation

haemodynamic instability - drugs and IPPV

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11
Q

What are the benefits of video laryngoscopy in trauma

A
  • Enhanced visualisation – difficult airway with limited neck movement / MILS
  • Good for training / ODP can see and plan ahead
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12
Q

Explain the challenges of intubating in trauma & how to overcome these challenges?

A
  • MILS
  • Distorted airway anatomy from trauma – bleeding / swelling
  • Obscured view from bleeding / aspiration
  • Already hypoxic / unstable
  • Unfamiliar setting – difficult position with ED bed
  • Less equipment available
  • Time pressure and noisy environment

Overcoming these
- VL
- preparation - careful selection of drug doses , airway equiptment
- clear closed loop communication and airway plan shared
- checklists

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13
Q

What specific airway considerations are there in TBI, facial fractures and major burns

A
  • TBI = avoid hypoxia / hypercarbia to prevent secondary brain injury, use agents to minimise response to laryngoscopy and rise in ICP
  • Facial fractures = potential difficult mask ventilation, early intubation between oedema worsens, nasal intubation contraindicated
  • Major burns = early intubation due to oedema, difficult airway due to swelling, use smaller ET tube / size 8 to fascilate later bronchoscopy
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14
Q

define major haemorrhage

A
  • loss of one blood volume within 24 hours
  • or 50% in under 3 hours
  • haemarrhage at rate of 150ml/min
  • 4units in 1 hour
  • 10units in 24 hrs
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15
Q

classes of haemorrhagic shock?

A

Class 1 = up to 15% (750ml) , no major changes. urine >30ml/hr

class 2= 15-30% (1.5L), postural hypotension, HR 100-120, pulse pressure dropped, RR 20-30. urine 20-30, anxious.

class 3= 30-40% (< 2L), BP dropped, HR 120-140, RR 30-40, urine 5-15ml/hr , confused

class 4= > 40% (>2L) , HR> 140, RR > 35, no urine output, lethargic

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16
Q

List 5 signs of major haemorrhage

A
  • Increased HR
  • Decreased BP
  • Decreased pulse pressure
  • Increased RR
  • Decreased urine output
  • Decreased GCS
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17
Q

Why may some people not show the classical signs / symptoms seen in haemorrhagic shock

A
  • Elderly – blunted physiological response
  • On beta blockers
  • Trauma not purely haemorrhage e.g. neurogenic too
  • Young compensate well with catecholaimes
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18
Q

Give the overall steps in managing haemorrhage in trauma

A
  • Activate massive haemorrhage protocol if severe – request Pack A
  • Tourniquets / pelvic binds
  • 100% O2 15L non rebreathe
  • IV access
  • Blood products – 1:1:1 or 2:1
    o Give pack A - usually RBC and FFP in 1:1
    o If still bleeding, request pack B (usually has cryoprecipitate and platelets too)
  • Prevent lethal triad
    o Remove wet clothing, warm fluids / active warming
    o ROTEM, FFP/platelets, Calcium and TXA
  • Caution with excess fluids
    o Permissive hypotension
  • Equipment = belmont rapid transfuser , cell salvage
  • Damage control surgery / interventional radiology – sometimes without CT scan
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19
Q

what is trauma induced coagulopathy?

A
  • Coagulopathy is seen in trauma due to
    o Dilution of clotting factors with crystalloids / bloods
    o Consumptive coagulopathy
    o Lethal triad – often hypothermic (exposed, cold fluid), acidotic (poor perfusion)
    o Hypothermia and acidosis impair platelet function
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20
Q

What is the lethal triad

A
  • Hypothermia
  • Coagulopathy
  • Acidosis
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21
Q

How is coagulopathy in trauma managed

A
  • give FFP and platelets with blood to avoid dilution - 1:1:1
  • Targeted if possible – use ROTEM/ TEG
  • Calcium
  • TXA 1g IV over 10 mins , within 3 hours
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22
Q

What is the issue with resuscitating with fluids?

A
  • Dilution of clotting factors (similarly with RBC)
  • Exacerbates each element of the lethal triad of hypothermia, coagulopathy and acidosis.
    o Cold fluids – hypothermia
    o Chloride in fluids – acidosis
    o Dilution – coagulopathy
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23
Q

What is permissive hypotension and when is it not advised

A

70mmHg / MAP 50mmHg
prevents high pressure bleed/ clot disruption
limited duration 1 hour

dont use in head injury pts

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24
Q

role of TXA in trauma ?

A

antifibrinolytic - inhibits plasminogen to plasmin (which in turn breaks down fibrin clot)

CRASH 2 trial - improves mortality and doesnt increase thrombotic event. CRASH 3 - also in TBI patients

1g should be given ASAP and within 3 hours . then 1g over 8 hours

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25
what are the benefits of rapid transfusion devices?
QUICK - multiple hanging bags, minimal time switching, plus rapid flow WARMS FILTER AIR TRAP - less riks of air embolus than manual pressure
26
give lab values that indicate need for product transfusion other than RBC
platelets < 50 or < 100 in TBI Fibrinogen < 1.5 (2 in obs) FFP if INR > 1.5 Calcium < 1.1 mM
27
list immune complications of massive blood transfusion
- ABO incompatibility and haemolytic reaction - Delayed haemolytic transfusion reaction – minor Ab e.g. Kidd / rhesus - Febrile non haemolytic transfusion reaction – reaction to donor leucocyte antigens (now leukocyte deplete blood used) - Allergy / anaphylaxis - TRALI – donor leukocytes reacting with HLA in recipient
28
List 4 non immune complications of massive blood transfusion
* TACO * electrolyte disturbance - K+ * acid base - citrate from prep/ lactic acid from RBC * infections * iron overloa * hypothermia * air embolism * dilutional coag
29
What electrolyte abnormalities are common in transfusion
- Hyperkalaemia – target should be to keep below 5.8 - Hypocalcaemia – consumptive and citrate in blood binds to Ca
30
what is the diamond of death
- Hypothermia, coagulopathy , acidosis , hypocalcaemia
31
What is the recommendation on using vasopressors in haemorrhage?
- Avoid until adequately filled with blood / volume - If hypotension persists after haemostasis and euvolaemia then may be useful but also rule out o Blunt cardiac injury , cardiac tamponade, high spinal cord injury, SIRS response
32
what is damage control resusitation?
life saving approach in trauma focussing on - controlling bleed- tourniquet / pelvic binders - preventing coagulopathy - lethal triad - accepting permissive hypotension - prioritising surgical control of bleed e.g. damage control surgery
33
What indicates the patient may benefit from damage control resuscitation
- hypotensive unresponsive to resuscitation - serum lactate > 2.5 / Base deficit < -6 - abnormal coagulation e.g. INR despite resuscitation - positive fast scan - inability to obtain haemostasis
34
what is damage control surgery
- surgery to achieve rapid physiological stabilisation rather than complete anatomical repair - usually, short procedure to manage bleed - then patient undergoes period of resuscitation and stabilisation in ICU - later returns for definitive surgery
35
what are the aims of damage control surgery
- control haemorrhage - control bowel content - reperfusion of vital organs
36
What key considerations when anaesthetising a trauma patient for damage control surgery
- very unstable – minimal induction agents, use fentanyl, ketamine, roc - arterial line shouldn’t delay surgery - have arms out and someone assigned to this - someone allocated to checking blood - regular ABG / ROTEMs - depth of anaesthesia monitoring can be useful to limit sevo used. - Close communication with blood bank
37
What factors influence the decision to admit a trauma patient to ITU
- Age - Pre – hospital unconsciousness - SBP < 90 - Acidosis - Coagulopathy e.g. INR >1.4
38
How are trauma patients managed in ITU
- Full Hx and examination – assessing for other injuries - Monitor for re bleeding o Serial trends in Hb, lactate, BE, BP/HR - Optimising physiology and preventing organ failure o Correct trauma induced coagulopathy o Manage multisystem complications o Continue resuscitation - Preparing for return to theatre for definitive management - Early family discussions
39
How is injury severity graded in trauma
- Injury severity scores – ISS – retrospectively graded once injuries are known - The 3 most severely body regions are scored on there severity e.g. score of 1 for superficial injuries up to 6 which is incompatible with life. - The 3 scores are squared and added - 1 to 75 - Score of > 15 = major trauma
40
What are the causes of acute respiratory failure in trauma patients?
- Chest trauma – contusions, flail chest - Pneumonia - ARDS
41
What are the ventilation strategies in trauma, when may these not be advised
- Lung protective ventilation – 6ml/kg, PEEP titrated to FiO2, permissive hypercapnoea - Not in TBI / Spinal cord injury = here ventilation titrated for PaCO2 4.5-5kpa
42
When might a palliative approach to trauma be more appropriate
- Catastrophic injury e.g. cerebral herniation - Disabling injury with poor quality of life – high spinal cord injury - Severe frailty / comorbid - Metastatic disease / existing terminal illness
43
How is VTE risk managed in trauma patients
- Delay LMWH until bleeding and coagulation controlled - Resume as soon as safe as trauma patients at increased risk - Can use mechanical measures in the meantime
44
How does blunt cardiac injury present and how is it recognised
- Chest pain, ECG changes, haemodynamic instability - TOE, continuous ECG and troponins
45
When are prophylactic antibiotics indicated in trauma patients
- Penetrating brain / chest injuries - Open fractures - Abdominal trauma post laparotomy - Not for basal skull #
46
What are the benefits of early nutritional support in trauma patients
- Shown to improve outcomes - Reduced sepsis rates - Reduced gut mucosal atrophy and support gut flora – enteral - Limits stress response - Should start nutrition within 72 hours of injury
47
What are the signs of a basal skull #
rhinorrhoea ottorhoea battle sign - bruising behind ear (haemotympanum) panda eyes - brusing under both eyes
48
what is a flail chest?
3 or more continigous ribs fractured in 2 or more places resulting in a segment of chest being separated from the rest of the chest wall - 3 or more contiguous ribs broken in 2 or more places resulting in a floating segment - Results in difficult ventilation due to abnormal chest wall dynamics, V:Q mismatch / hypoxia
49
What is a pneumothorax?
- Presence of air in pleural cavity
50
Potential causes of pneumothorax
- Trauma – rib fractures - Spontaneous – lung disease , tall males , smoker, marfans - Iatrogenic – barotrauma , central line,
51
Landmarks for needle decompression of tension pneumothorax
- 2nd intercostal mid clav line, above rib
52
Landmarks for chest drain insertion in pneumothorax
- lateral border of Pectoralis major - anterior border Lattisimus dorsi - Apex of axilla - Line at 5th intercostal space - in line with nipple
53
Early and late complications of a chest drain
- Early – bleeding, malposition and fails to drain, pulmonary lacerations , injury to liver / spleen/ heart , pain - Medium – infection, re-expansion pulmonary oedema , subcutaneous emphysema - Late – infection, persistent air leak (bronchopleural fistula), blocked , chronic pain
54
canadian C spine rule
a clinical tool to help clinicians decide if trauma patients require C spine imaging 1. presence of high risk factors -- > 65yrs, dangerous mechanism, parasthesia - any present scan 2. low risk factors - simple mechanism, sitting in ED, delayed neck pain, no C spine tenderness if no high risk and presence of low risk then assess next step 3. neck rotation - able - no scan, not able - scan.
55
what group of patients are more likely to have a spinal cord injury that does not show radiological abnormalities ?
children still will have clinical signs of injury e.g, motor sensory, priapism etc
56
what is the difference between a trauma unit and major trauma centre?
- Trauma unit = hospital equipped for immediate resuscitation and stabilisation but lacking tertiary level services e.g. neurosurgery / cardiothoracics - - Major trauma centre = specialist tertiary level services to deal with major trauma
57
What non technical skills are important in trauma
leadership clear closed loop communication - Quiet during handover / primary surgery - clearly assigned roles
58
What are the roles of the anaesthetist in trauma?
- Responsible for assessment and management of the airway and ventilation. o Administers oxygen; performs suction; inserts airway adjuncts o endotracheal intubation (RSI). - Maintains cervical spine immobilisation and controls the log roll. - GCS and pupils - May help with IV access
59
how would you assess a burns patient?
- Treat as major trauma – A to E + C spine, immediate life threatening injuries first - Burns assessment o Airway o % coverage – lund and browder chart / Wallace rule of 9s o Appearance – wet / dry, blistering , red / white - Focused Hx o Mechanism – in enclosed space? o Time o AMPLE - Secondary survey
60
What is the Wallace rule of 9
- Estimated total % body surface area affected - Adults = head = 9%, arms 9% each, legs 18% each, chest 18%, back 18% , perineum 1% - Child = head 18%, arms 9% each, legs 13.5% each, chest and back 18% , perineum 1%
61
How are burns classified
- By origin = thermal, electrical, chemical - By thickness = o superficial epidermal burn  Epidermis only – red, painful, dry, no blisters o Superficial dermal / partial thicknes  Epidermis and upper dermis  Pink , blistered, painful o Deep dermal / partial thickness  Epidermis and lower dermis  Dry, blotchy, red, painful o Full thickness  Through epidermis and dermis to subcut tissue  White, painless, no blisters or bleeding, dry, waxy
62
What would you include in your airway assessment of a burns patient
- Direct burns to face - Singeing of eyebrows and lashes - Swelling of the face, lips and tongue or oropharynx - Coughing - Wheeze / stridor - Soot in nose, mouth or sputum - Saturations ?
63
How would you manage the airway of a burns patient
- 100% O2 non rebreathe - Full assessment - Intubate if indicated o Use a full length tube / uncut – facial swelling likely to occur o Size 8 – facilitate bronchoscopy o Tape not tie – facial oedema
64
What are the indications for intubation in a burns patient?
- Airway involvement – swelling, stridor, full thickness neck burn - Low GCS – unconscious - Hypoventilation / respiratory distress – hypoxia / hypercarbia - Severe CO poisoning
65
How would you approach fluid management in burns patients?
- Parkland formula – for anyone with > 15% BSA burn - 4ml x kg x % S.A - Give first half in 8 hours, second half in 16 hours - Use hartmans / plasmalyte - Urinary catheter and guide IV fluids by urine output
66
When can oral fluids be used in burns
- < 15% BSA burn
67
Give reasons why additional fluids to the parkland formula might be required…
- Blood loss due to other injuries - Blood / evaporate loss due to debridement - Inhalation injury - Electric burns - SIRS response and further fluid shifts - Maintenance if no oral intake
68
Give approaches to monitoring the effectiveness of fluid rehydration in burns patients
- Urine output >0.5-1ml/kg/hr - Serum lactate - Haematocrit - Cardiac output monitoring or stroke volume variation monitoring
69
What is the criteria for referring to a burns service
> 2% children/ 3% adults - involving hands / feet / genitalia - all full thickness burns - All circumferential burn – deep burn that completely encircles a body part e.g. Limb – risk of vascular compromise / compartment syndrome / ischaemia - electrical / chemical / cold burns - any suspicion of NAI - not healed in 2 weeks
70
how is a burns patient managed on critical care
- Likely to lead to a massive inflammatory response - A o Remain intubated for airway protection and ventilation - B o Lung protective ventilation o Regular pulmonary toileting and bronch lavage in airway burns - C: o Invasive monitoring o Maintain good volume and pressure – fluids / pressors - D: o Sedated - E: o High risk of infection – microbiological surveillance , regular dressing changes o Monitor electrolytes closely o Ulcer prophylaxis o DVT prophylaxis o Enteral nutrition via NGT – reduces bacterial translocation and infection
71
What are the indications for surgery in burns patients
* full thickness circumferential burns * full thickness chest burns requiring escharotomy to improve ventilation * fasciotomy for compartment syndrome in unburned limbs due to fluid accumulation * burn wound debridement
72
What is escharotomy
- Surgical procedure through not compliant full thickness burn tissue - To relieve compression on o Vessels of limbs o Chest wall = prevent restriction of chest wall movement which may impair ventilation
73
Describe the anaesthetic considerations of a burns patient having surgery
- Difficult IV access - Difficult monitoring e.g. arterial line and placing ECG stickers o May need to place skin staples instead of electrodes o Tongue / nose clips can be used in place of finger pulse ox - Chest burns may make ventilation difficult - Suxamethonium contraindicated 24hours after - May need blood products – oozing and long surgery - Analgesia is challenging
74
complications of burns
early - dehydration / fluid loss/ AKI - electrolyte disturbance Intermediate - ARDS - infection + sepsis - DIC - gastric ulcer - DVT late: -cosmetic - ventilation issues - restrictive lung pathology, chest wall and fibrotic lung - PTSD - chornic pain
75
mechanisms of inhalation injury
direct thermal injury to upper airways - nasal and oropharyngeal mucosa , stridor / wheeze indirect to lower airways - particulate matter enters lower airways and is hot, inflammation and mucus plugging. wheeze, SoB, hypoxia Noxious gas poisoning - CO and cyanide
76
Signs and symptoms of inhalation injury
upper airway - oedema, cough, stridor, pain , voice change lower airway - wheeze, low sats, dypnoea Noxious gas - headache, N&V, low GCS,
77
What factors in someone’s history would indicate inhalation injury
fire in enclosed space Hx of flames / smoke death of someone in same fire loss of consciousness at scene
78
What investigations are useful in the assessment of inhalation injury
CXR fibreoptic laryngoscopy / FNE - oedema, erythema, ulceration Carboxyhaemaglobin ABG - PaO2 , lactic acidosis VBG - AV difference in O2 decreaased
79
Management of inhalation injury
100% oxygen intubate ventilate - lung protective ventilation bronchoscopy and washout nebulised heparin , 20% N-acetylcysteine, salbutamol chest physio
80
what are the signs of severe CO poisoning?
N&V , headache , weak/dizziness, seizures, low GCS
81
how is CO poisoning managed?
high flow O2 continue FiO2 at 1 may require hyperbaric (but not recommended in inhalation injust)
82
specific treatment for hydrogen cyanide poisoning
Hydroxycobalamin - binds to cyanide to form not toxic product (also sodium thiosulphate can be used)
83
Explain how burns injurie influence use of succinylcholine
- Avoid from 24 hours to 1 yr after injury - Fetal type upregulated, hyperkalaemia, arrhythmias
84
what are the functions of the skin?
- Epidermis o Innate immunity / barrier function o Prevention of fluid loss o Melanocytes – skin pigmentation o Sensory function – light touch and pain - Dermis o Thermoregulation – dermal vascular plexus , piloerection, sweat glands
85
2 approaches to reduce heat loss in theatre during debridement procedures
- Minimise patient exposure - Maintain theatre temp 28-33 degrees - IV fluid warmers - Forced air warmers - Use HME filter
86
Give an approach to reducing blood loss during debridement surgery
- Use of limb tourniquets - Use of topical adrenaline - ROTEM / ABG and correction
87
what is drowning
respiratory impairment due to submersion or immersion in water
88
How can drowning be classified
- Fatal vs non-fatal drowning - By status at scene o Class 1 = no inhalation of water o Class 2 = inhaled water but adequate ventilation o Class 3 = evidence of inhalation and inadequate ventilation o Class 4 = absent ventilation and circulation
89
describe pathophysiology of drowning...
initially water submersion causes breath holding. may get laryngospasm from fluid on oropharynx eventually CO2 rises and triggers ventilation inhalation of water - chemicals triggers bronchospasm - water washes surfactant - collapse alveoli - fresh water - damages alveoli - leaky - salty water - osmosis and draws water in CVS - catecholamine release initially - SIRS response - hypotension / SIRS hypothermia
90
What is the diving reflex seen in young children
- Bradycardia and vasoconstriction as a result of cold water stimulation - Stimulates trigeminal nerve and vagal nerve - Maxes brain and heart perfusion and minimises O2 consumption
91
What is meant by dry drowning
- Drowning without fluid aspiration – may be due to death by trauma or arrhythmia prior to drowning
92
What are the factors influencing neurological injury after drowning
- Age - Co-existing CVS or resp disease - Water temperature - Submersion time - Presence of diving reflex
93
outline the management of a drowning victim
- Attempt resuscitation in all patients - A to E o A: 15L O2 , C spine protection, RSI / intubate o B: Lung protective , avoid permissive hypercapnia to improve neurological injury, consider ECMO o C: ionotropes / vasopressors, arterial line, warmed IV fluids, continuous cardiac monitoring o D: neuroprotection, sedation/ paralysis, o WARMING Hypothermic patients –  Remove wet clothes, insulate with blankets, forced air warmers, warmed IV fluids, body cavity lavage (fill bladder with warm fluid o Correct electrolytes - Consider other injuries
94
List specific investigations relevant to the assessment of a patient who has suffered from nonfatal drowning
- Core body temperature – guides rewarming - ABG – degree of hypoxia to target O2 therapy - Venous blood – o electrolytes – AKI can develop o DIC may occur o Toxicology - 12 lead ECG o Arrhythmias due to hypothermia / hypoxia o Or as underlying cause of drowning - CXR o ARDS identification - Trauma imaging o CT head / C spine
95
What are the issues seen with electrical injury
- Burns – o through direct contact to electricity source o Damages tissue beneath the skin – not always apparent from external appearance o May ignite e.g. clothes set on fire causing further burns - Arrhythmias - Rhabdomyolysis - Compartment syndrome - SIRS response
96
Which factors determine the extent of external injury
- Voltage - Current – AC more dangerous - Resistance to flow – certain tissues have low resistance e.g. skin and fat o Thick skin high impedance, wet skin, low impedance - Duration of contact
97
What clinical effects are seen at different currents?
1-3mA = tingling 5mA = pain 15mA = muscle spasms 30mA = cant let go 50mA = respiratory arrest/ asphyxia 100mA = VF, burns
98
what is meant by microshock?
small amount of current but in close contact with tissue e.g. myocardium enough to cause cardiac dysfunction 10uA = safe 100uA = VF
99
what is the current of mains UK electricity
230V RMS , 50Hz
100
outline the innervation of the hip
lumbrosacral plexus anterior capsule = femoral nerve, obturator and accessory obturator nerve posterior capsule = sciatic nerve, nerve to quadradus and superior and inferior gluteal nerves skin overlying the hip = lateral cutaneous nerve of thigh and iliohypogastric
101
what regional anaesthetic options are available for patients having hip surgery ...
spinal / epidural paravertebral erector spinae plane block Pericapsular nerve group (PENG) quadratus lumborum block femoral nerve fascia iliaca compartment block 3 in 1 block
102
What are the benefits of using regional anaesthesia in hip surgery?
- Reduced perioperative pain - Reduces need for systemic opioids and their adverse effects - Early mobilisation – DVT / pneumonias - Reduced hospital stays - Better positioning for imaging / spinal
103
borders of fascia iliaca compartment
superior = inferior surface fascia iliaca inferior = iliacus and psoas muscle lateral = attachment of ilacus to iliac crest medial = attachment of psoas to lumbar verebral
104
What nerves are blocked in a fascia iliaca block?
- Lateral cutaneous nerve of the thigh - Femoral nerve - Obturator nerve
105
Why is the fascia iliaca block insufficient alone in NOF surgery
- Posterior hip capsule supplied by sciatic plexus
106
What are the advantages of a fascia iliaca compartment block
- Safe – due to injection site remote from major vessel - Can be performed via landmark or USS - More complete block as covers lateral cutaneous nerve – incisional pain - Reduces opioids / improves post op pain
107
Give 2 anatomical approaches to performing USS guided fascia iliaca blocks
infrainguinal suprainguinal
108
State specific complications of the fascia iliaca compartment block
- Local injury o Femoral artery / vein puncture – pseudoaneurysm / haematoma o Femoral nerve damage – quadriceps weakness o Supra-inguinal technique – risk of bladder / peritoneal puncture - Vascular injection / LAST
109
What are the indications for a fasia iliaca compartment block
- Pre op pain management – to facilitate Xrays / patient comfort - - Intra op = multi model analgesia, opioid sparing - Mostly for hip surgery
110
Describe the infra inguinal USS guided fasia iliaca compartment
- AABGI, access, sterile, prep stop block - Supine - Probe transverse to inguinal crease - In plane approach - Lateral to femoral nerve – pierce through fascia iliaca - 40ml - high volume compartment block
111
How would you perform the landmark approach of a fascia iliaca compartment block
- Pubic turbercle and ASIS found - Lateral 1/3 junction , 1cm caudal (below) this - Check for femoral pulse to make sure not near - Blunt needle – 2 pops = fascia lata and then fascia iliaca
112
Where is the femoral nerve found
- Lateral to the artery in the inguinal crease - NAV = nerve lateral
113
what is the PENG block
pericapsular nerve group block new regional technique - motor sparing gets articular branches of femoral and obturator nerve to give good analgesia found between psoas tendon and ilium
114
What are the advantages of the PENG block
- Motor sparing – hence earlier mobilisation and discharge – good for day case THR - - Reduced opioids use vs fascia iliaca and femoral nerve block
115
What are the limitations of the PENG block
- Does not provide incisional skin cover (lat cutaneous nerve of thigh) - New technique – less established
116
What are the contraindications of regional methods for hip operations
- Patient refusal - LA allergy - Coagulopathy - Infection at site of injection
117
What position is patient in for a PENG block and where is USS placed
supine USS at ASIS - Pivot probe towards pubic symphysis – look for iliopubic eminence - Needle between psoas and ileum
118
How much LA volume for a PENG block
15-20ml
119
What other motor sparing blocks exist for hip surgery
PENG block quadratus lumborum erector spinae plane block iliopsoas plane block
120
Which block can help with posterior capsule pain
- Posterior pericapsular deep gluteal block
121
What is secondary joint arthroplasty?
- secondary arhtoplasty procedures are carried out when the primary one needs revision e.g. infection, recurrent dislocation and/or loosening
122
Differences between primary and secondary joint arthroplasty?
- Secondary is o more complex o longer duration - spinal may not be suitable o associated with increased intra op blood loss o associated with increased post op pain – multimodel , PCA
123
List specific pre op considerations in an 80yr old undergoing revision hip surgery for an deep joint infection
- Adequate treatment of infection / resuscitation – fluids , Abx, microbiology input - Anaemia – identified and optimised - Post op care plan - Dietician input and assessment - Physiotherapy post op planned - AMT – delirium is common in this age group - Assessment and optimisation of other comorbidities
124
What are the risks of delirium in a patient undergoing hip surgery ? how can they be minimised by your anaesthetic plan
* hypotension - good MAP >80mmHg, vasopressors, arterial line * good pain management - multimodel * multimodel antiemetics * minimise depth - BIS * avoid certain drugs - cholinergics e.g. glyco > atropine , benzos / long acting opioids
125
what blood loss prevention strategies are used in hip surgery?
- Good starting Hb - Cell salvage - TXA - Correct coagulopathy – reverse medications - Avoid hypothermia , acidosis - Correct Ca to keep >1mM
126
What is the usual Hb level does NICE recommend transfusion
- Below 70 g/L or 80 if underlying cardiac disease
127
What is the Hb threshold for elderly NOF patients pre op?
- 90 g/L and 100g /L if IHD
128
What is bone cement implantation syndrome
- Complication of any surgery involving cement - As a result of cement entering the circulation and resulting in a SIRS or embolic phenomena - results in varying levels of hypoxaemia and hypotension
129
how can bone cement syndrome be classified?
- Grade 1 – moderate hypoxaemia < 94% or mild hypotension (systolic < 20% drop) - Grade 2 – severe hypoxaemia < 88% or hypotension >40% drop or loss of consciousness - Grade 3 – cardiovascular collapse requiring CPR
130
how is bone cement syndrome prevented?
anaesthetic -keep well hydrated - good BP - closed loop communication - vigillance surgeon - avoid excess pressure - wash and dry femoral canal - only use cement if needed
131
What are the risk factors for developing bone cement implantation syndrome?
- Patient factors o ASA 3 or 4, age, male o Pre-existing cardiac disease OR pulmonary HTN o Osteoporosis , diuretic treatment - Surgical o Pathological fracture o Intertrochanteric fracture o Long term arthroplasty
132
signs of bone cement syndrome?
- Hypoxia - Drop in EtCO2 - Hypotension
133
What are the different surgical options available for a NOF
- Dynamic hip screw - extracapsular # - Cannulated hip screw - Hemiarthroplasty - intracapsular #, elderly - Intramedullary nail - THR
134
What are the general principles of preparing patients for NOF surgery pre op
- Usually comorbid and elderly – some optimisation but also balance against risk of waiting - Hb and electrolytes – quickly corrected - Frailty assessment - AMT – cognitive assessment - Analgesia – regional e.g. fascia iliaca compartment block
135
List the pharmacological best practice elements of analgesia in NOF patients
- Regular paraceramol - Regional anaesthesia - Limit use of opioids – careful - Avoid NSAIDs - (IV dexamethasone for THR but avoid in elderly NOF due to delirium)
136
What are the common pre operative issues found in NOF patients
- Anaemia - Hb target 90g/L or 100g/L if IHD - Delirium – issues around consent/ capacity , best interest decision - Co-morbidity – significant CVS disease - Anti platelets / anticoagulation therapy - New murmur finding – don’t delay surgery for an ECHO
137
How urgently should a NOF be operated on
within 36 hours
138
What anaesthetic technique would you choose for NOF patients
spinal or GA - depends on surgical and patient factors avoid hypotension - MAP < 80 for 10 mins - associated with increased mortality, post op cognitive dyfunction and risk of bone cement minimise post op cognitive dys - avoid dexamethasone, benzos, excess opioids - use BIS regional anasthesia alongside GA / spinal - improved post op mobilisation
139
What are the principles of post op care of NOF patients
MDT care- ortho geris, surgeon, OT/ PT appropriate location 4ATS physio within 24 hrs standard NOF pathways
140
What care bundles are related to NOF / targets ?
- Surgery within 36 hours - Geriatrician review within 72 hours - Pre op AMT (abbreviated mental test) - Post op 4ATS (4 As test) - Post op physio within 24 hours - Nutrition assessment , falls assessment, bone protection assessment
141
complications of the lateral position in hip surgery?
A- dislogement / endobronch, macroglossia from poor drainage B - reduced FRC C - loss of IV D - Eyes , common peroneal nerve, saphenous nerve , radial nerve E - necrosis to folded ear
142
What are the potential causes of falls in elderly NOF patients how may they effect anaesthetic
poor coordination - previous stroke poor eye sight arthritis syncope - CVS , infection , arrhtythmia, aortic stenosis , hypoglycaemia
143
Reasons for delaying surgery in NOF
- Electrolyte disturbance - Hb < 90 g/L - Severe sepsis - Uncontrolled diabetes / DKA - Reversible coagulopathy - Tachyarrhythmia - > 120
144
List the patient factors that increase 30 day mortality in hip fractures
- Advanced Age - Males - ASA grade / 2 or more active comorbidities - Dementia - Anaemia - Institutional living
145
How is apixaban managed in those with hip fractures awaiting surgery
- Only need to wait 24 hours since last dose for spinal anaesthesia (normally 48hours however risk vs benefit) – assuming normal renal function
146
How is warfarin managed in those with hip fractures awaiting surgery
if low risk reason - stop and check INR consider vit k recheck in 4-6 hrs INR < 1.5 for spinal or < 1.8 for GA
147
What are the barriers to next day mobility after NOF
- Delirium - Pain - - Urinary retention - - Hypotension - Constipation / diarrhoea - Anaemia
148
Discuss benefits of ERAS in THR
reduced hospital stay reduced cost improved patient experience reduced complications - DVT / pneumonia lower mortality
149
advantages of day case THR
- Reduces NHS bed use and thus risk of cancellation - Helps address long waiting times - Patient satisfaction
150
how would you prepare someone pre op for a THR
MDT smoking cessation weight management alcohol cessation prehabilitation programme anaemia - iron oral / IV (carb loading drink )
151
What are the advantages of neuroaxial techniques in THR
- Overall fewer complications, less surgical stress and improved outcomes - E.g. less pneumonia, AKI, DVT, PE, MI / stroke risk
152
What is one disadvantage of neuroaxial techniques
increased risk of urinary retention
153
Pros and cons of dexamethasone in THR?
- Analgesia - prolongs length of spinal - Anti emetic - Overall reduces length of stay
154
How would you alter your regional anaesthetic technique to aid day case surgery
* avoid femoral / fascia iliaca- motor block * motor sparing techniques: PENG, lumbar erector spinae plane block, quadratus lumborum block * local infiltration * multimodal analgesia - minimal opioids
155
How does the surgical approach to a THR affect the anaesthetic
**- Posterior approach / lateral approach ** o Lateral decubitus position – risk of peroneal nerve injury and brachial plexus o Limited airway access o Reduced FRC o Post op pain can be challenging **- Anterior approach ** o Supine – easier airway access o Less blood loss than posterior approach o Better post op pain **- Robotic assisted THA** o Improved long term outcomes of the hip o However prolonged op time – hypothermia, spinal not suitable, pressure areas o Potentially reduced post op pain as less soft tissue damage
156
What pharmacological agents are required in THR at induction
teicoplanin + gentamicin TXA 1g (ondansetron/ dex )
157
What are the risks and precautions taken for discharging patients on opioids
only 1 week course clear instructions of dosing and tapering plan long acting preferred verbal and written info = driving safety, use of other sedatives, short term use
158
When is hip joint denervation used
- Chronic pain - Inoperable hip fractures - Advanced OA
159
What are the methods of hip joint denervation
- Radiofrequency ablation - Chemical neurolysis - Cryoablation
160
what position is shoulder surgery mostly done in?
Beach chair
161
what are the complications of beach chair position?
**venous pooling - hypotension and cerebral hypoperfusion** brachial plexus injury cervical S pine injury / ischaemia
162
What are the advantages of awake shoulder surgery ?
- Able to spot changes to neurology from hypoperfusion quicker – also less risk because less hypotension than GA - Less PONV - Less airway complications / respiratory from intubating - Quicker recovery - Efficiency and discharge
163
Which block is usually used for shoulder surgery
interscalene
164
If conducting surgery awake – what should be checked before starting surgery
- Block adequacy - Anxiolysis – sedation level adequate - Comfort of patient /position
165
What is the Bezold Jarisch reflex
triad of hypotension, hypoapnoea and brady low preload (venous pooling) triggers heart to slow (parasympathetic) to give more time to fill
166
Surgical options for shoulder replacmenet
- Anatomical – articulation remains anatomical – humerus sits in glenoid - Reverse anatomy = socket formed by the humerus instead.
167
Neuraxial guidelines and anticoagulatants/ antiplatelets
- Apixaban – 24 to 48 hrs - Rivaroxaban = 48hrs - Dabigatran = 48-96hr - Warfarin = INR >1.4 - Prophylactic LMWH = 12 hours - Treatment dose = 24 hours - Unfractionated = 4 hours - NSAIDS / aspirin – no precautions - Clopidogrel and prasugrel = 7 days , can give 6 hours after - Ticagrelor = 5 days , 6 hours after - GLIIb/IIIa = 8 hours before , 6 hours after - Dipyrimadole = no precuations before, 6 hours after
168
What is an intravenous regional anaesthetic?
- Form of regional where a limb is isolated using a tourniquet - Local anaesthetic is injected = BIER block - Can be used for short procedures on upper limb e.g. carpal tunnel or fracture reduction
169
What are the advantages and disadvantages of a BIER block?
- Advantages – avoids a GA , cheap, rapid recovery, bloodless field - Disadvantages – limited time, no post op analgesia, potential LAST, risk of compartment syndrome
170
What are the contraindications of a BIER block / use of tourniquet
- Absolute = raynauds, AV fistula , patient refusal (LA allergy – biers only) - - Relative = HTN >200mmHg, sickle cell , local infection , morbid obesity (unreliable tourniquet)
171
How is a BIERS block performed?
- AABGI, IV intralipid, IV access, prep stop block - Inflate proximal tourniquet around upper limb to > systolic BP - LA injected – procaine is safest 30-50ml 0.5% - After 10 mins , distal tourniquet is inflated over insensate skin and proximal one is deflated - Cuff deflated after 45 mins
172
Why is procaine used for BIER blocks , what are the disadvantages of this
- Amide LA with toxic dose of 6m/kg – it has a longer duration than lidocaine but less toxic than bupivacaine - Risk of methemoglobinemia
173
What are the categories of patient transfer
- Clinical vs non-clinical (capacity related) - Intra / inter/ international - By road / air - Level of patient care = 0,1, 2,3 o Level 2 = doctor and nurse o Level 3 = anaesthetist and nurse
174
What are the problems with aerotransfers
- Gas filled spaces expand with altitude = pneumothorax, cuff of ET tube – check pressure - Partial pressure decreases – O2 requirements increase – if likely to be an issue, intubate before take off - Ambient temp drops = warming devices
175
How much O2 is safe for transfer?
- Double the calculated dose = safety margin - The ventilator also uses / wastes a certain L/ min
176
What is a major incidence
- Any occurrence presenting serious threat to health of the community - Likely to involve disruption of usual services – police, fire, ambulance
177
What are the components of a major incidence plan?
- Major components include major incidence stand by , consolidation phase, recovery phase and restoration to normality - - Major incidence stand by o ED = call additional staff to hospital , discharge patients from minors , set up triage station out of ED, set up teams of 1 doctor 1 nurse for incoming casualities o Critical care – step down o Wards – discharge and prepare for ITU step downs o Theatre – cancel electives , additional staff - Consolidation phase – casualties arrive - Recovery phase – treatment of casualties completed, reschedule operations - Restoration to normalities – may take weeks – debrief and psychological support
178
How are paitents prioritised at triage
- P1 = code red = immediate intervention needed - P2 = yellow = urgent care in 2-4 hours - P3 = green = medical treatment needed but safely delayed - P4 = black = dead or dying
179
what are the risks of a crush injury
- Reperfusion injury - Hypotension due to loss of fluid from crush - Compartment syndrome - Rhabdomyolysis and AKI
180
Locations for interosseous access
- Tibial = anteromedial distal to tuberosity - Femoral in children – distal femur - Humerus – adults only - Sternum – adults
181
Complications of interosseous access
- Fracture - Infection - Fat embolus
182
Contraindications to interosseous access
- Infection overlying skin - Osteogenesis imperfecta - Prosthetic limb
183
How does fat embolus syndrome present
- Respiratory signs - Neurological abnormalities - Petechial rash - All within 1 -3 days of initial insult
184
What is the pathophysiology of fat embolus syndrome
- Mechanical – blockage - Biochemical – SIRS response and microvascular compromise
185
Diagnosis of fat embolism syndrome
GURD criteria major - hypoxaemia , pulmonary oedema, rash, neuro (lethargy, confused) minor: - tachy, pyrexia, renal, retinal, haem (drop in plts) need 4 minor and 1 major
186
how is Fat embolus syndrome minimised?
- Early recognition - Avoid intermedullary fixation - Early surgery
FINAL
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