Emergency anaesthesia in the ED

South East Scotland Major Trauma Guidelines
NHS Lothian

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 minimises haemodynamic instability.

Prior to anaesthesia the anaesthetist should:

  1. Arrive before the patient and clarify role
  2. Prevent hypothermia – forced air patient warming device e.g. bair
    hugger and warmed IV line.
  3. Utilise damage control resuscitation and code red protocols when
    indicated (see separate guideline)
  4. Check that vascular access is working.
  5. Perform the pre intubation checklist (please click here)

Induction of anaesthesia

  • RSI is the safest and most effective method to secure the airway.
  • Induction in the exsanguinating patient can be fatal. Provide ongoing volume resuscitation during RSI in these patients
  •  Do not delay induction for arterial or central access in patients inextremis.
  • Standard induction doses should be reduced and titrated to balance the induction of anaesthesia with haemodynamic changes
  • Ketamine is the first line agent for RSI in major trauma patients
  • 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 possible

 Please refer to Induction Protocol.

Patients who require RSI should have this performed within 46 minutes of injury.  

Maintenance of anaesthesia in the ED

  • Provide continuous intravenous anaesthesia with propofol
  • Provide opiod 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 >90mmHg unless haemorrhage is the primary pathology
  • Administer antibiotics early if indicated.
  • Employ lung protective ventilation using Vt = 6ml/kg IBW
  • Ensure all patient movements are communicated to blood bank

Standards

  • Patients who require an RSI should have this performed within 45 minutes of injury.
  • Trauma patients in the OR should maintain a temp >36 degrees Celsius.
  • Induction of anaesthesia should not cause >20% drop in initial blood pressure
  • Antibiotics, when indicated, should be administered within 30 minutes of incision.

Cautious doses of ketamine or midazolam may be used in resus to maintain anaesthesia: Seek PICU advice. 

Airway assessment

Airway assessment
• Anticipate a difficult airway
• Assign roles
• Pre-oxygenate
• Ketamine (0.5mg/kg IV) if combative/uncooperative to facilitate pre-oxygenation
• Manual in line stabilisation (MILS )

Trauma RSI induction protocol

Trauma RSI Induction Protocol

RIE emergency department RSI checklist

Please also refer to RIE Airway Management Guidelines

RSI Checklist table

RSI Checklist Part 2

Tracheal intubation in critically ill adults algorithm

Please also refer to the BJA guidelines on tracheal intubation of critically ill adults in critical care guidelines (click here).

DAS / APA algorithm for failed intubation in paediatrics

Please refer to the DAS / APA Algorithm for failed intubation in paediatrics (click here).

Editorial Information

Last reviewed: 01/09/2021

Next review date: 01/09/2024

Version: 1.0