Chapter 39. Anesthesia for Trauma & Emergency Surgery

Brian P. McGlinch, MD

All trauma patients should be presumed to have “full” stomachs and an increased risk for pulmonary aspiration of gastric contents.
Cervical spine injury is presumed in any trauma patient complaining of neck pain, or with any significant head injury, neurological signs or symptoms suggestive of cervical spine injury, or intoxication or loss of consciousness.
In the multiple-injury patient, providers should maintain a high level of suspicion for pulmonary injury that could evolve into a tension pneumothorax when mechanical ventilation is initiated.
In up to 25% of major trauma patients, trauma-induced coagulopathy is present shortly after injury and before any resuscitative efforts have been initiated.
Administering blood products in equal ratios early in resuscitation has become an accepted approach to correction of trauma-induced coagulopathy. This balanced approach to transfusion, 1:1:1 (red blood cell:fresh frozen plasma:platelet), is termed damage control resuscitation.
Noninfectious transfusion reactions are now the leading complication of transfusion and represent a more than 10-fold greater risk than blood-borne infection. Transfusion-related acute lung injury is the leading cause of transfusion-related death.
The assessment of blood consumption (ABC) score is an attempt to predict which patients are likely to require a massive transfusion protocol. The ABC score assigns 1 point for the presence of each of four possible variables: (1) penetrating injury; (2) systolic blood pressure less than 90 mmHg; (3) heart rate greater than 120 beats per minute; and (4) positive results of a focused assessment with sonography for trauma evaluation. Patients with ABC scores of 2 or higher are likely to require massive transfusion.
Any trauma patient with altered level of consciousness must be considered to have a traumatic brain injury (TBI) until proven otherwise. 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 condition warranting emergency neurosurgery and is associated with the highest mortality.
Systemic hypotension (systolic blood pressures <90 mm Hg), hypoxemia (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 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 pressures to assure spinal cord perfusion in areas of 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 by up to 50% within 30 minutes in response to massive vasoconstriction, inducing a state of normovolemic hypoperfusion (burn shock).
In contrast to fluid management for blunt and penetrating trauma, which discourages use of crystalloid fluids, burn fluid resuscitation emphasizes the use of crystalloids, particularly ...