CHAPTER 45

ANAESTHESIA FOR SURGICAL

EMERGENCIES
INCLUDING MAJOR TRAUMA

Outline:

Assessment of a patient presenting with major trauma

• General assessment: airway, breathing and circulation

• Systematic assessment

Summary of anaesthetic problems

Anaesthesia for the patient with multiple trauma

Special problems associated with spinal cord injuries

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INTRODUCTION

The term "emergency surgery" implies that the time available to prepare the
patient for surgery is limited i.e. the outcome of the surgical procedure
depends on how soon it is done. Acute internal bleeding (especially into the
abdomen or chest), a rising intracranial pressure, visceral injury, foetal
distress and open wounds often associated with compound fractures are the
kinds of emergencies we are considering.

ASSESSMENT OF THE PATIENT PRESENTING WITH MAJOR

TRAUMA

General Assessment
Before starting a detailed assessment of the underlying injuries, it is
essential to make a swift assessment of the patient’s airway, breathing and
circulation.
The airway: Any obstruction of the airway must be detected and corrected.
This has been dealt with in detail in Chapter 8.
At a pharyngeal level, the tongue falling back, blood clots, secretion, food,
dentures and foreign bodies are the usual causes. Marked surgical
emphysema of the face and neck may suggest a ruptured trachea.
Similarly, bleeding into the neck and severe tenderness over the thyroid
cartilage may suggest a ruptured larynx.
Breathing: The patient may be given oxygen by mask until the general
assessment is finished. If the patient is not breathing, intubate and ventilate
with 100% oxygen. If the patient is breathing but the breathing is shallow,
respiration may be assisted with a mask or endotracheal intubation may be
required.
Circulation: Note the pulse and blood pressure. Insert a 14G or 16G
cannula and start an initial infusion with Hartmann's solution followed by a
colloid solution.
Send blood for grouping and cross-matching.
If the facilities are available, measure arterial blood gases. This assesses the
respiratory and metabolic state of the patient.

Systematic assessment
Evidence of intracranial injury: Careful neurological observation is
essential, especially of the level of consciousness and the size of the pupils.
All precautions must be taken to avoid a rise in intracranial pressure, as
outlined in Neurosurgical anaesthesia in Chapter 22.

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Record the patient’s Glasgow Coma score

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Spinal cord injury: Acute compression of the spinal cord requires very
careful positioning. In trauma patients a cervical collar should always be
used until clinical and X-ray evidence confirms that there is no cervical cord
injury. A lateral x-ray of the neck is essential in patients with multiple
trauma.
Facial and neck injuries: Airway obstruction is the major problem. An
awake intubation, or tracheostomy may be needed before anaesthesia is
started. If airway obstruction has not been evident in the general
assessment but facial and neck injuries make it likely - then an inhalational
induction and intubation will be safer than using relaxants.
Bleeding into the airway requires careful suction.
Have a range of tubes available. A smaller tube than usual may be
necessary.
Injuries to the structures of the chest:
− Tears to the trachea are associated with subcutaneous emphysema
of the face and neck. The airway may be secured by passing an
endotracheal tube beyond the tear and inflating the cuff. If this is
not possible, surgical exploration is indicated.
− Injury to the chest wall may result in a flail chest which needs to be
treated by intubation and prolonged IPPV or if this is not available
some other means of immobilizing the segment. Local anaesthesia
and epidural anaesthesia where available are also used and may
avoid the need for artificial ventilation in less severe cases.
Flail chest occurs when there are multiple fractures of
adjacent ribs causing a segment of the chest wall to become
free. This segment will move paradoxically with respiration
and this movement along with underlying lung contusion will
usually result in pain and hypoxia.
− Bleeding into the pleural cavity (haemothorax) may require
drainage.
− Air in the pleural cavity (pneumothorax) may require under water
drainage. An x-ray will confirm the diagnosis. See Chapters 27
and 46 for water-seal drains.
− Direct lung trauma may result in contusion of the lung or rupture of
a bronchus.
− Widening of the mediastinum seen on x-ray may suggest that the
aorta or pulmonary artery has been damaged.
− Crush injuries of the lower chest may be associated with rupture of
the diaphragm, especially on the left.

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 − Cardiac tamponade is associated with a low blood pressure, jugular
distension and muffled heart sounds. If tamponade is severe, the
pericardium should be tapped before the anaesthetic is
administered. Avoid myocardial depressants.
Abdominal injuries: Explore any penetrating injuries in relation to the
abdomen. The following may lead to suspicion of an abdominal injury:
− Persistent hypotension despite apparently adequate resuscitation. In
this situation bleeding may occur from the liver, spleen or a major
blood vessel.
− Increasing size in the abdomen after resuscitation may suggest
intra-abdominal bleeding.
− Guarding or re-bound tenderness may be associated with intra-
abdominal bleeding or soiling of the peritoneal cavity from a
ruptured bowel.
− Haematuria suggests kidney or renal tract injury.
Orthopaedic injuries: Orthopaedic injuries that constitute an emergency are
acute fractures, especially those associated with arterial obstruction and
open wounds.
Orthopaedic injuries, both bony and soft tissue, can be associated with a
large but relatively hidden blood loss.
This is discussed under Anaesthesia for Orthopaedic surgery in Chapter 31.
Resuscitation: This may involve care of the airway, artificial ventilation
and cardiac compression and treatment of the shocked patient, which are
described in detail in Chapters 52 and 58

SUMMARY OF ANAESTHETIC PROBLEMS

All of the following problems have been discussed in detail elsewhere.
• Airway problems. See Chapter 8.
• Hypovolaemia/shock. See Chapter 52.
• Hypoxia - especially due to chest injuries. See Chapter 8.
• Raised intracranial pressure. See Chapter 22.
• Full stomach - danger of regurgitation. See Chapter 16 for RSI and
Chapter 46
• Massive blood transfusion. See Chapter 49
• Fat embolism. See Chapter 46

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ANAESTHESIA FOR THE PATIENT WITH MULTIPLE TRAUMA

The subject is dealt with extensively under the subject "Shock" in Chapter
52 but note these points:
• Regional anaesthetics, if not otherwise contraindicated, can be used
provided that there has been adequate preoperative fluid resuscitation.
Surgery should be delayed until this has been achieved unless there is
uncontrolled bleeding.
• Spinal anaesthetics are unsafe in hypovolaemic patients whose blood
loss cannot be controlled.
• Whenever possible patients should be normovolaemic. Two infusions
(14 - 16 G cannulae) should be in progress before anaesthesia is
commenced.
• A higher concentration of oxygen (50%) than normal may be needed.
• If there is air or blood in the pleural cavity it should be drained before
anaesthesia/surgery. Chest and head injuries must always be looked for
in patients with multiple trauma.
• Do not use ketamine if there is evidence of a head injury. If there is no
head injury ketamine is an excellent induction drug for the shocked
patient.
• IPPV may be necessary after surgery.
• Large volumes of blood will be required. The problems associated
with massive transfusions need careful attention. See Chapter 49
• If there is airway obstruction pre-operatively, an “awake intubation” or
a tracheostomy may be necessary before the start of anaesthesia.
If there is no airway obstruction but there is a likelihood of obstruction
due to facial and neck injuries, then induction and intubation under
inhalational anaesthesia is safer than using relaxants.
• Every case of major trauma must be treated as having a full stomach,
because of swallowed blood, delayed gastric emptying time and recent
food.
• The hourly urine output, serum electrolytes and acid base status should
be monitored if the facilities are available.
• The usual principles of light anaesthesia, using small doses of drugs
and high oxygen concentrations, are used.

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SPECIAL PROBLEMS ASSOCIATED WITH SPINAL CORD
INJURY

• A recent quadriplegic may have an unstable cervical spine and pose

intubation problems.
• Muscle spasms may be a problem. Even if the patient has sensory
loss at the site of the operation they may still need some form of
anaesthesia to control the muscle spasm.
• There is also a tendency to hypertension.
• Temperature regulation is interfered with in quadriplegics.
• Positioning may be difficult.
• Suxamethonium can cause severe hyperkalaemia 48 hours after a
spinal cord lesion. It is safe to use within 48 hours of injury but
unsafe to use thereafter because of the possibility of a rapid rise in
serum potassium. This response can persist for up to 1 year. The
increase in serum potassium in these patients may be responsible for
cardiac arrhythmias when suxamethonium is given.
• Respiratory problems are more common due to intercostal paralysis
and partial paralysis of the diaphragm.
• Chronic infection and nutritional deficiencies lead to anaemia.
• Pressure sores are more common.
• Psychiatric disturbance is likely.

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