Chapter 39: Anesthesia for Trauma & Emergency Surgery

Key Concepts

• All trauma patients should be presumed to have a full stomach and thereby be at increased risk of pulmonary aspiration.

• Cervical spine injury is presumed in any trauma patient presenting with neck pain or any suggestion of neurologic injury as well as those with loss of consciousness, significant head injury and/or intoxication.

• In the patient with blunt or penetrating injury, providers should maintain a high level of suspicion for pulmonary injury that could evolve into a tension pneumothorax when mechanical ventilation is initiated. No trauma patient should die without having potential tension pneumothorax relieved.

• In up to 25% of trauma patients, trauma-induced coagulopathy (TIC) is present shortly after injury and before any resuscitative efforts have been initiated.

• Balanced administration of red blood cell, fresh frozen plasma, and platelet units (1:1:1) is termed damage control resuscitation (DCR). Administering blood products in equal ratios early in resuscitation has become an accepted approach for preventing or correcting TIC.

• Transfusion-associated circulatory overload (TACO) is the greatest risk to trauma patients from DCR. The incidence of transfusion-related acute lung injury (TRALI) has decreased markedly with restriction of plasma and platelet donation to donors who are male, or who are female and who have either never been pregnant or who have been tested and found to be anti-HLA negative.

• Damage control surgery is a surgical intervention intended to stop hemorrhage and limit gastrointestinal contamination of the abdominal compartment in severely injured and bleeding patients. An emergent exploratory laparotomy is performed in a start–stop fashion, attempting to discover and control bleeding injuries, while affording the anesthesia provider opportunities for resuscitation and preventing prolonged hypotension and hypothermia between surgical interventions.

• Any trauma patient with an altered level of consciousness must be considered to have a traumatic brain injury (TBI) until proven otherwise. Presence or suspicion of TBI mandates attention to maintaining cerebral perfusion pressure and oxygenation during all aspects of care. The most reliable clinical assessment tool in determining the significance of TBI in a nonsedated, nonparalyzed patient is the Glasgow Coma Scale. Acute subdural hematoma is the most common brain injury warranting emergency neurosurgical intervention and is associated with the highest mortality.

• Systemic hypotension (systolic blood pressures <90 mm Hg), hypoxia (PaO₂ <60 mm Hg), hypercapnia (PaCO₂ >50 mm Hg), and hyperthermia (temperature >38.0°C) have a negative impact on morbidity and mortality following head injuries, likely because of their contributions to increasing cerebral edema and intracranial pressure (ICP).

• Current Brain Trauma Foundation guidelines recommend maintaining cerebral perfusion pressure between 50 and 70 mm Hg and ICP at less than 20 mm Hg for patients with severe head injury.

• Maintaining supranormal mean arterial blood pressure to help ensure adequate spinal cord perfusion in areas of otherwise reduced blood flow due to cord compression or vascular compromise is likely to be of more benefit than steroid administration.

• Major burns (a second- or third-degree burn involving ≥20% total body surface area [TBSA]) induce a unique hemodynamic response. Cardiac output declines abruptly by up to 50% ...