Chapter 217. Trauma Anesthesia

Polytrauma: several lesions, of which at least one is a vital risk.

Perform immediate triage: assess severity of trauma

Ensure availability of needed teams/imaging for adequate management (neurosurgery, CT surgery, vascular surgery, orthopedics, CT, MRI, etc.)

Multidisciplinary approach, importance of having a team leader

Concurrent therapy (ABC) and diagnosis (H&P, imaging studies)

Time is of the essence (first hour = golden hour)

Triage

Stabilization/workup on arrival

Airway, breathing

Circulation/heme

Neurological

After initial workup/stabilization

Secondary treatment round, depending on lesions identified

Severity criteria (Vittel, 2002): any of these require transfer to trauma center (except patient factors, which are evaluated on a case-by-case fashion):

• Vital signs:
  • GCS <13
  • SBP <90 mm Hg
  • SpO2 <90%
• High-energy trauma:
  • Ejection from vehicle
  • Another person died in the same vehicle
  • Fall >6 m (about 20 ft)
  • Patient thrown or crushed
  • No helmet/seatbelt
  • Blast
• Lesion itself:
  • Penetrating trauma of head, neck, thorax, etc
  • Limb amputation or ischemia
  • Pelvis fracture
  • Severe burn and/or smoke inhalation
• Management:
  • Need for mechanical ventilation
  • Fluid resuscitation >1,000 mL and/or pressors and/or military antishock trousers (MAST)
• Patient:
  • Age >65
  • CHF, CAD, respiratory insufficiency
  • Pregnancy (especially second and third trimesters)
  • Bleeding diathesis or anticoagulants

Major mortality criteria:

• SpO2 <80% or unobtainable (76% mortality)
• SBP <65 mm Hg (65% mortality)
• GCS = 3 (62% mortality)

• Document basic information:
  • NIBP, HR, SpO2, EtCO2 if intubated, temperature
  • GCS, pupil size and reactivity, moving lower extremities; full neuro exam before any sedative given
  • Finger stick for blood glucose, point-of-care Hct
• At least two large-bore IVs
• Consider CVL and/or A-line; prefer femoral access unless abdominal trauma or B/L LE trauma; insert both lines side-by-side; use 5 Fr arterial catheter (can be used for arteriogram); draw labs when inserting lines:
  • Chem 7, CBC, coags, LFTs, troponin, alcohol/drugs, β-HCG (if female), ABO-Rh for blood bank
• Give tetanus booster shot
• If open fracture, start Abx, for example, cefazolin 2 g IV, and then 1 g q8 hours (if allergy, clindamycin 600 mg IV, and then 600 mg q6–8 hours); add 5 mg/kg per day of gentamycin if Gustilo grade III open fracture (crushed tissue and contamination, with or without vascular compromise)
• Consider analgesia; however, no sedation without intubation
• Portable CXR and pelvic AP film (if pelvic Fx, do not insert Foley)
• Focused Assessment with Sonography in Trauma (FAST: rule out intraperitoneal fluid) and thoracic U/S to r/o hemothorax and/or pneumothorax
• B/L transcranial Doppler if available: Vd on MCA <20 cm/s, pulsatility index >1.2 suggest increased ICP
• Consider OGT to avoid further aspiration of gastric contents/blood (no NGT until skull base fracture ruled out)

• Do not blindly trust ETT in situ; check position and B/L ...