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Anesthesia for Trauma : New Evidence and New Challenges
 9781493909087, 1493909088, 9781493909094, 1493909096

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Table of contents :
Preface
Contents
List of Contributors
1: Initial Assessment and Management of the Trauma Patient
Pre-hospital and Triage
Primary Survey
Airway
Breathing
Circulation
Disability
Exposure/Environment
Reevaluation
Adjuncts to the Primary Survey
Monitoring
Imaging
Laboratory
Tubes
Secondary Survey
History
Physical Exam
Disposition from the Trauma Resuscitation Area
References
2: Airway Management in Trauma
Frequently Encountered Clinical Conditions
Full Stomach
The Agitated Uncooperative Patient
Airway Obstruction
Airway Evaluation in the Trauma Patient
Indications for Emergency Tracheal Intubation
Techniques of Airway Management
Airway Management in Specific Injuries
Head, Open Eye, and Contained Major Vessel Injuries
Cervical Spine Injury
Management of Direct Airway Injuries
Maxillofacial Injuries
Cervical Injuries
Thoracic Airway Injuries
References
3: Physiological Derangement of the Trauma Patient
General Physiological Changes Due to Trauma
Hemorrhage-Related Pathophysiological Changes
Stress-Related Physiological Changes
Pain-Related Physiological Changes
Systemic Inflammatory Response and Sepsis
Stages of the Immunoinflammatory Response to Traumatic Injury
Bacterial Translocation into Blood Circulation and Release of Endotoxin
Cytokine Formation and Release
Bone Marrow Changes
Acute Adrenal Insufficiency After Trauma
Enhanced Nitric Oxide Formation
Endocrine and Metabolism Changes
System-Specific Physiological Changes Due to Trauma
Head Injury
Chest Injury
Cardiac Injury
Abdominal Trauma and Digestive System Changes
Summary
References
4: Blood Transfusion and Coagulation Disorders
Introduction
Control of Hemorrhage
Support of Intravascular Volume
Choice of Fluids
Adjuvant Therapies
Late Resuscitation
Future Research
References
5: General Principles of Intraoperative Management of the Severe Blunt or Polytrauma Patient: The Resuscitative Phase
Case Entry Point
Goals and Objectives of Anesthesia Care for the Severe Trauma Patient in the Operating Room
Preparation
Rapid Infuser
Ultrasound Machine
Underbody Forced Air Warmer
Additional Essential Equipment
Goal-Directed Tests and Therapy for the Trauma Patient
Thromboelastography
Thromboelastometry
PFA-Platelet Function Analyzer
Goal-Directed Ventilation of the Severe Trauma Patient
Intraoperative Fluid Monitoring and Treatment with Pulse Pressure Variation
Monitors
Key Management Concerns in Our Patient
Volume Replacement While Waiting for Blood
Hemoglobin-Based Oxygen Carriers
Blood Pressure Management in Our Patient
Vasopressors in Our Patient
Antimicrobial Therapy in Our Patient
The Anesthesiologist and the Immune System: The New Frontier
Case Summary
References
6: Pain Control in Acute Trauma
Physiological and Psychological Consequences of Acute Pain
Management of Acute Pain in Trauma
Strategies of Pain Management and Guidelines from the WHO
Non-opioid Analgesics
Acetaminophen/Paracetamol
Non-steroidal Anti-inflammatory Drugs
COX-II Selective Inhibitors
Use of NSAIDs
Ketamine
Analgesic Adjuncts
Opioids
Regional Anesthesia in the Trauma Patient
Regional Anesthesia in Thoracic Trauma
Regional Anesthesia for Rib Fractures
Regional Anesthesia for Thoracic Surgery in Trauma
Thoracolumbar Epidurals for Abdominal Surgery in Trauma
Peripheral Nerve Blocks to the Abdomen
PVB for Abdominal Surgery
Transversus Abdominis Plane and Rectus Sheath Blocks
Regional Anesthesia for Trauma to the Extremities
Ultrasound-Guided Versus Nerve Stimulator-Guided Regional Anesthesia
Neuraxial Anesthesia for Lower Extremity Trauma
Single-Shot Peripheral Nerve Blocks Versus Peripheral Nerve Catheters
Regional Anesthesia for the Upper Extremity
Interscalene Brachial Plexus Block
Background and Indications
Risks and Contraindications
Performing the Block
Supraclavicular Brachial Plexus Block
Background and Indications
Risks and Contraindications
Performing the Block
Infraclavicular Brachial Plexus Block
Background and Indications
Risks and Contraindications
Performing the Block
Axillary Block
Intercostobrachial and Medial Brachial Cutaneous Nerve Blocks
Background and Indications
Risks and Contraindications
Performing the Block
Regional Anesthesia for the Lower Extremity
Lumbar Plexus Block
Background and Indications
Risks and Contraindications
Performing the Block
Femoral Nerve Block and ``3-in-1 Block´´
Background and Indications
Risks and Contraindications
Procedure
Sciatic and Popliteal Nerve Blocks
Background and Indications
Risks and Contraindications
Procedure
References
7: Chronic Pain in Trauma Patients
Introduction
Evaluation of Chronic Pain After Trauma
Complex Regional Pain Syndrome
Traumatic Brain Injury
Spinal Cord Injury
Phantom Limb Pain
Posttraumatic Abdominal Pain
Vertebral Fracture
Chronic Whiplash Syndrome
References
8: Brain Injuries: Perianesthetic Management
Historical Note
Scope of the Problem
Types of Injury
Skull Fractures
Intracranial Bleeding
Pathophysiology
Diagnosis
Risk Factors
Management of Traumatic Brain Injury
Guidelines
Conclusion
References
9: Anesthesia for Cervical Spinal Cord Injury
Incidence and Causes of Spinal Cord Injury
Classification of Spinal Cord Injury
Management of the Cervical Spinal Cord-Injured Patient
Cervical Spinal Immobilization After Injury
Airway Management in Cervical Spinal Cord Injury
Respiratory Management
Hemodynamic Management
Temperature Management
Thromboembolism
Gastrointestinal System
Steroids in the Treatment of Cervical Spinal Cord Injury and Therapeutic Hypothermia
Timing of Surgery
Surgical Interventions
Complications of Surgery of Relevance to Anesthesiologists
Neurophysiological Monitoring During Cervical Spinal Decompression with Fusion and Instrumentation
Pain Associated with Spinal Cord Injury
Anesthetic Technique Specific to Spinal Cord Injury
References
10: Anesthetic Assessment and Treatment of Facial and Ocular Trauma
Introduction
Epidemiology
Initial and Emergency Room Management
Examination
Airway Management
Associated Injuries
Dental Injuries
Vascular Injuries and Hemorrhage
Intraoperative Management
Submental Intubation
Retromolar Intubation
Airway Fire
Previous Facial Trauma
Vision
Nasal Injuries
Maxillary Injuries
Mandibular
Pediatrics
Pain Management
Regional Anesthesia
References
11: Thoracic and Abdominal Injuries
Thoracic Trauma
Resuscitation Phase
Urgent Thoracotomy
Bleeding
Pulmonary and Airway Injuries
Cardiac Injuries
Blunt Thoracic Aortic Injury
Great Vessel Injuries
Esophageal Injuries
Diaphragmatic Injuries
Delayed Thoracotomy
Thoracic Injuries Requiring Nonsurgical Management
Flail Chest and Pulmonary Contusion
Blunt Cardiac Injury (Myocardial Contusion)
Abdominal Injuries
Thoracoabdominal Trauma
Pelvic Injuries
Damage Control Surgery
Damage Control Resuscitation
References
12: Musculoskeletal Injuries and Microvascular Surgery
Musculoskeletal Injuries
Assessment of Injury
Microsurgery: A History
Microsurgery in Trauma
Anesthesia for Microvascular Surgery
Optimizing the Anesthetic for Flap Success
Hemodynamic Support
Intravascular Volume Status and Blood Viscosity
Intraoperative Hemodynamic Monitoring
Techniques in Microcirculation Perfusion Monitoring
Postoperative Considerations
References
13: Assessment and Physiology of Burns
Epidemiology
Classification of Burns
Chemical Burns
Electrical Burns
Inhalational Burns
Characterizing the Burn
Lund-Browder Chart
Rule of Nines
Palm Method
Cardiovascular and Hemodynamic Changes
Pulmonary Changes
Renal and Electrolyte Changes
Gastrointestinal Changes
Metabolic and Endocrine Changes
Hematologic and Immunologic Changes
Neurologic Changes
References
14: Management of Burns and Anesthetic Implications
Initial Management of Burns
Management of Airway and Inhalational Injuries
Burn Resuscitation
Wound Management
Nutritional Supplementation in Burn Patients
Anesthetic Management for the Burn Patient
Sepsis and Multiorgan Failure in the Burn Patient
Rehabilitation After Burns
Pain Control in Burn Patients
Conclusion
References
15: Perioperative Pediatric Anesthesia Trauma Considerations
Introduction
Special Pediatric Anatomical and Physiologic Characteristics
Airway
Circulation
Temperature Regulation
Initial Resuscitation and Primary Survey
A=Airway, B=Breathing
C=Circulation
D=Disability
E=Exposure/Environmental Control
Preoperative Evaluation and Intraoperative Management
Secondary Survey
Equipment
Monitors and Monitoring
Induction Agents
Neuromuscular Blockers
Fluids and Blood Replacement
Postoperative Care of Pediatric Trauma Patients
References
16: Trauma in the Pregnant Patient
Introduction
Types of Trauma
Patterns of Injury
Blunt Injury to the Abdomen
Penetrating Trauma
Pelvic Fracture
Causes of Maternal Trauma
Motor Vehicle Accidents
Falls
Assaults, Homicide, and Suicide
Burns and Electrical Injuries
Poisoning
Maternal and Fetal Outcomes Following Trauma
The Physiology of Pregnancy and Management of the Trauma Patient
Airway Management
Gastrointestinal Changes
Respiratory Changes
Cardiovascular Changes
Coagulation
Field Intervention and Resuscitation
Primary Survey
Fluid Resuscitation
Transfusion
Trauma-Induced Coagulopathy
Antifibrinolytics
Fibrinogen
Prothrombin Complex
Recombinant Factor VIIa
Anti-shock Garments
Secondary Survey
Maternal and Fetal Monitoring
Laboratory Tests
Imaging
Specific Management Issues
Traumatic Brain Injury
Spinal Cord Injuries
Respiratory Failure and Extracorporeal Lung Support
Analgesia
Thromboprophylaxis
Antibiotic and Tetanus Prophylaxis
Pregnancy-Related Management Issues
Fetal Delivery
Cardiac Arrest and Perimortem Cesarean Delivery
Anesthetic Management
Induction and Intubation
Maintenance of Anesthesia
Conclusion
References
17: Anesthesia for the Geriatric Trauma Patient
Background
Etiology of Geriatric Trauma
Physiological Considerations in the Elderly
Cardiovascular
Anesthetic Considerations
Pulmonary
Anesthetic Considerations
Renal
Anesthetic Considerations
Central Nervous System
Anesthetic Considerations
Pharmacologic Considerations
Initial Assessment of the Geriatric Trauma Patient
Triaging
Initial Management
Oxygenation and Ventilation
Cardiovascular Considerations
Temperature Considerations
Monitoring
Anesthetic Concerns for Specific Injuries
Orthopedic Injuries
Head Injuries
Thoracic Injuries
Summary
References
18: Trauma Critical Care
Introduction
Resuscitation and Intraoperative Phase
Damage Control Phase
Subacute Phase
Neurologic Issues
Cardiac Support
Respiratory Support
Renal Support
Infectious Disease and Antibiotic Issues
Nutrition, Electrolytes, and Prophylaxis
Palliative Care and End-of-Life Issues
Conclusion
References
19: Trauma Simulation
Introduction
Brief History of Simulation
What Is Trauma Simulation?
Example of Trauma Simulation Scenario: Penetrating Chest Trauma
Case Description
Learning Objectives
Simulation Environment
Case Narrative
Debriefing
What Is the Evidence?
Drawbacks of Medical Simulation
References
20: Civilian Trauma Systems
Requirements Specifically Related to Anesthesiologists
References
21: Modern Military Trauma
Pre-hospital Treatment
Hospital Treatment
Aeromedical Evacuation
Conclusion
References
22: Disaster Preparedness
Definitions
Victim Characteristics
Event Characteristics
Resource Characteristics
Response Sequence
Table-Top Exercises
References
23: Substance Abuse in Trauma and the Anesthesia Care Provider
Introduction
Trauma in the Intoxicated Patient
Specific Drugs
Alcohol
Cocaine
Methamphetamine
MDMA
Synthetic Cathinones
Synthetic Cannabinoid Receptor Agonists
Chemically Altered Cannabis
Inhaled Volatile Compounds
Heroin and Other Opioids
Identification and Treatment of Withdrawal
Treatment Options and Referral Sources
Conclusion
References
Index

Citation preview

Corey S. Scher Editor

Anesthesia for Trauma New Evidence and New Challenges

123

Anesthesia for Trauma

.

Corey S. Scher Editor

Anesthesia for Trauma New Evidence and New Challenges

Editor Corey S. Scher Bellevue Hospital Center New York University New York, NY, USA

ISBN 978-1-4939-0908-7 ISBN 978-1-4939-0909-4 (eBook) DOI 10.1007/978-1-4939-0909-4 Springer New York Heidelberg Dordrecht London Library of Congress Control Number: 2014944317 # Springer Science+Business Media New York 2014 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Preface

I keep time through a conglomeration of the media, the music industry, and film. My first exposure to trauma was through the nightly telecasts of the war in Viet Nam by the partnership of Chet Huntley and David Brinkley of NBC news. Walter Cronkite was a legend at the same time period and represented CBS. Both were responsible for the graphic images of the war; Night night after night, for years, I was mesmerized by the images of the wounded and dead. The film industry joined in, taking advantage of the politics of the war and the staggering number of the injured and dead to make Apocalypse Now, Born on the fourth of July, Platoon, Good Morning Viet Nam, and so on. Although these were just films, their closeness to reality put the trauma patients in my face. With the music and festival of Woodstock, I have never been able to turn back. Trauma was again brought front and center as the seed of medical school was planted in my mind. Trauma was clearly a specialized field of medicine. Like many fields of medicine, there is little consensus on what to do with the trauma patient. In our recent history, other causes of trauma such as 9/11, Hurricane Katrina, the Haitian Earthquake, and the Tsunamis of Thailand and Japan have challenged trauma providers. Each one of these disasters presented trauma providers new sets of problems never seen before. The ongoing and complex conflicts in the Middle East (The Hurt Locker, The Lone Survivor, Argo, and Zero Dark Thirty) brought explosive devices, rocket-propelled grenades, and suicide bombers that created injuries we have never seen and challenged us to the highest level in terms of prevention and treatment. Readers in professional fields look at textbooks seeking recipes to handle defined medical or legal problems. The initial intent of this book was to offer recipes to the anesthesiologist for each type of trauma. As all authors describe in this book, no two traumas are alike, most traumas include multiple sites that change the rules for one site. From a clinical research perspective, it is almost impossible to find a cohort of patients that match one another. Simply stated, a consensus of practice is offered in each chapter, but the scientific evidence may not be strong. The massive transfusion protocol in Dr. Dutton’s chapter is well subscribed to by clinicians throughout the country with questionable evidence. We break trauma down into anatomical parts and try to offer consensus. The book starts off with one of the most important topics: assessment of the v

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trauma patient. Dr. Wilson’s systematic examination of the patient and gathering of data is the standard approach to the trauma patient (Advanced Trauma Life Support). Dr. Dutton’s chapter on blood and blood products is in alignment with the recommendations of American Society of Anesthesiologists. That said, many trauma centers have not adopted these recommendations for complex reasons. My chapter offers a consensus on how to take care of the multitrauma patient. The evidence is strong but goes against the grain of an approach that dates back to the Civil War (Lincoln 2013). There will be many naysayers who will keep to the current paradigm they practice from. Simply stated, trauma providers may not buy into what is now new evidence. At every national anesthesia meeting, exhibitors demonstrate the latest difficult airway device. Dr. Capan has an international reputation for airway management. This is an area of enormous research and development in devices that deal with the difficult and traumatized airway. It is conceivable that the conventional laryngoscope’s life span can now be measured. Dr. Capan fills in any possible deficit in the understanding of the challenging airway in his chapter keeping in mind new ways to assess the bad airway with new devices. It is difficult to separate the traumatized airway from cervical spine injuries. Dr. Abramowicz, a national expert on neuroanesthesia, links the two while Dr. Frost, a well-known name in the field of anesthesia and brain science, covers the brain and the spinal cord. It would be unusual if an airway trauma did not include the brain and the spinal cord. Dr. Frost offers the newest evidence on the brain, a subject that seems to be waxing and waning each year. Dr. Wang wrote two crucial chapters on burns. Many level I trauma centers may not take care of severely burned patients. The criteria for a hospital to have a burn center are different from a level I trauma center. It is not unusual that trauma centers do not provide burn skills; I have read it several times to gain another skill that I am missing in my trauma repertoire. It is the largest topic as it makes up what is missing in the anesthesiologist’s literature. There are several chapters, which I call foundation chapters for clinicians, that describe the physiological changes in the body with severe trauma. Dr. Liu et al. have written a comprehensive piece on the physiological derangement of the trauma patient. In his chapter on trauma simulation, civilian trauma systems, Dr. Choi has presented the emerging world of simulation for the clinician so that critical advanced trauma life support steps are not missed during the assessment and initial treatment. There are three patient populations that get special attention: the pediatric trauma (Dr. Fox), the pregnant (Dr. Fedson-Hack) trauma patient, and the complex geriatric patient, whose number increases (Dr. Alrayshi). In all the three chapters, we see a long stream of patients flowing into the trauma bay. The endless lineup of these three groups of patients makes these chapters a vital and wonderful welcome to this book. The persistent Middle East wars have exposed anesthesiologists to blast injuries from suicide bombers, rocket-propelled grenades, and a wide array

Preface

Preface

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of explosive devices. The medical corps of our armed services have outfitted our soldiers with Kevlar vests, and a medical pack that soldiers wear. Dr. Field’s chapter on trauma on the military might be the most compelling in the book as new treatments for severe trauma to the arms and legs are discussed. Dr. Boldt’s chapter on microvascular surgery on extremities and wound from war complement Dr. Field’s work. These all tie in well with the 2013 Boston Marathon attack when two pressure cookers exploded and killed 3 and wounded over 260 civilians. These events resulted in multiple amputations and leg-sparing operations. From terrorist blast injuries to motor vehicle accidents to bar fights, facial trauma is almost always involved. Dr. Clebone’s comprehensive chapter on facial trauma breaks down a very complex topic into a systematic mode of making a comprehensive diagnosis and its invariable relationship to airway trauma. The chapter moves the anesthesiologist to securing the airway in manners not usually performed, which makes this chapter essential for all members of the trauma team. Most of our penetrating trauma patients either are inebriated or test positive for an illicit substance like cocaine and heroin. Prescription pain killers, benzodiazepines and countless other possible substances. Dr. Bryson’s chapter on substance abuse is enlightening as the initial assessment is masked by these substances. There is a strong link between trauma and this chapter is eye-opening to the clinician. The anesthesiologist must consider the patient as abusing substances until the toxicology screen comes back. Treating for withdrawal must also be considered. The chapter is the most comprehensive I have seen on the subject. There is rarely a night that a national news station is not reporting on trauma whether from conflict or by accident. Dr. Kaye, a popular name in pain management, addresses pain in his superbly written chapter. There are recipes in his chapter that are evidence based and can be followed. Dr. Roccaforte ties many of the themes of the book together with Civilian Trauma Systems, Disaster Management and Critical, How do we organize if another large-scale attack hits the United States. How are resources distributed and what is new in critical care for these patients? The title of the book restates one of the oldest themes in medicine. New evidence asks the clinician to step away from concepts ingrained in their practice and change it. Often, change is made, and new evidence turns out to be false. The reader of this book is asked to step back and consider those clinical changes that may improve their practice. The more the clinicians change their practice, the more likely that the evidence has staying power. New York, NY

Corey S. Scher

ThiS is a FM Blank Page

Contents

1

Initial Assessment and Management of the Trauma Patient Chad T. Wilson and Anna Clebone

1

2

Airway Management in Trauma . . . . . . . . . . . . . . . . . . . . Levon M. Capan and Sanford M. Miller

15

3

Physiological Derangement of the Trauma Patient . . . . . . Henry Liu, Hong Yan, Seth Christian, Santiago Gomez, Frank Rosinia, Mingbing Chen, Juan Tan, Charles J. Fox, and Alan David Kaye

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4

Blood Transfusion and Coagulation Disorders . . . . . . . . . L. Yvette Fouche´-Weber and Richard P. Dutton

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5

General Principles of Intraoperative Management of the Severe Blunt or Polytrauma Patient: The Resuscitative Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corey S. Scher, Inca Chui, and Sanford M. Miller

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6

Pain Control in Acute Trauma . . . . . . . . . . . . . . . . . . . . . 107 Christopher K. Merritt, Orlando J. Salinas, and Alan David Kaye

7

Chronic Pain in Trauma Patients . . . . . . . . . . . . . . . . . . . Lindsay R. Higgins, Whitney K. Braddy, Michael S. Higgins, and Alan David Kaye

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8

Brain Injuries: Perianesthetic Management . . . . . . . . . . . Elizabeth A.M. Frost

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9

Anesthesia for Cervical Spinal Cord Injury . . . . . . . . . . . Apolonia E. Abramowicz and Maria Bustillo

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10

Anesthetic Assessment and Treatment of Facial and Ocular Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anna Clebone

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11

Thoracic and Abdominal Injuries . . . . . . . . . . . . . . . . . . . Levon M. Capan and Sanford M. Miller

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12

Musculoskeletal Injuries and Microvascular Surgery . . . . David W. Boldt and Zarah D. Antongiorgi

253

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x

Contents

13

Assessment and Physiology of Burns . . . . . . . . . . . . . . . . . Cynthia Wang

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14

Management of Burns and Anesthetic Implications . . . . . Cynthia Wang

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15

Perioperative Pediatric Anesthesia Trauma Considerations Charles J. Fox, Alan David Kaye, Jacob C. Hummel,

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and Moises Sidransky 16

Trauma in the Pregnant Patient . . . . . . . . . . . . . . . . . . . . Anjali K. Fedson Hack

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17

Anesthesia for the Geriatric Trauma Patient . . . . . . . . . . Walid Alrayashi

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18

Trauma Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . J. David Roccaforte

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19

Trauma Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lynn Choi and Corey S. Scher

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20

Civilian Trauma Systems . . . . . . . . . . . . . . . . . . . . . . . . . J. David Roccaforte

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21

Modern Military Trauma . . . . . . . . . . . . . . . . . . . . . . . . . Aaron M. Fields

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22

Disaster Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . J. David Roccaforte

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23

Substance Abuse in Trauma and the Anesthesia Care Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethan O. Bryson

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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List of Contributors

Apolonia E. Abramowicz, M.D. Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA Walid Alrayashi, M.D. Department of Anesthesiology, New York University Medical Center, New York, NY, USA Zarah D. Antongiorgi, M.D. Department of Anesthesiology, UCLA David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA David W. Boldt, M.D., M.S. Department of Anesthesiology and Critical Care, UCLA David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA Whitney K. Braddy, M.D. Department of Anesthesiology, Tulane University Medical Center, New Orleans, LA, USA Ethan O. Bryson, M.D. Department of Anesthesiology and Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA Maria Bustillo, M.D. Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA Levon M. Capan, M.D. Department of Anesthesiology, New York University School of Medicine, Bellevue Hospital Center, New York, NY, USA Mingbing Chen, M.D., Ph.D. Department of Anesthesiology, Wuhan Tongji Hospital, Wuhan, China Lynn Choi, M.D. Department of Anesthesiology, Bellevue Hospital— NYU, New York, NY, USA Seth Christian, M.D. Department of Anesthesiology, Tulane University Medical Center, New Orleans, LA, USA Inca Chui, M.D. Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA xi

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Anna Clebone, M.D. Department of Anesthesiology and Perioperative Medicine, Case Western Reserve University, University Hospitals, Cleveland, OH, USA Richard P. Dutton, M.D., M.B.A. Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA Aaron M. Fields, M.D. Department of Surgery, Tripler Army Medical Center, Honolulu, HI, USA L. Yvette Fouche´-Weber, M.D. Department of Anesthesiology, University of Maryland Shock Trauma Center, Baltimore, MD, USA Charles J. Fox, M.D. Department of Anesthesiology, LSV–Health– Shreveport, Shreveport, LA, USA Elizabeth A. M. Frost, M.B., Ch.B., D.R.C.O.G. Department of Anesthesiology, Icahn Medical Center at Mount Sinai, New York, NY, USA Santiago Gomez, M.D. Department of Anesthesiology, Tulane University Medical Center, New Orleans, LA, USA Anjali K. Fedson Hack, M.D., Ph.D. New York, NY, USA Lindsay R. Higgins, M.D., M.P.H., B.S. Department of Anesthesiology, Tulane University, New Orleans, LA, USA Michael S. Higgins, D.D.S. Department of Anesthesiology, University of Illinois Medical Center, Chicago, IL, USA Jacob C. Hummel, M.D., M.S.B.S. Department of Anesthesiology, Tulane Hospital, New Orleans, LA, USA Alan David Kaye, M.D., Ph.D., D.A.B.A., D.A.B.P.M., D.A.B.I.P.P. Department of Anesthesiology, LSU School of Medicine T6M5, New Orleans, LA, USA Henry Liu, M.D. Department of Anesthesiology, Tulane University Medical Center, New Orleans, LA, USA Christopher K. Merritt, M.D. Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA Sanford M. Miller, M.D. Department of Anesthesiology, Bellevue Hospital Center, New York, NY, USA J. David Roccaforte, M.D. Department of Anesthesiology, New York University, Bellevue Hospital, New York, NY, USA Frank Rosinia, M.D. Department of Anesthesiology, Tulane University Medical Center, New Orleans, LA, USA Orlando J. Salinas, M.D. Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA

List of Contributors

List of Contributors

xiii

Corey S. Scher, M.D. Department of Anesthesiology, NYU/Bellevue Hospital Center, New York, NY, USA Moises Sidransky, M.D. Department of Anesthesiology, LSU HSC New Orleans, New Orleans, LA, USA Juan Tan, M.D., Ph.D. Department of Anesthesiology, Wuhan Tongji Hospital, Wuhan, China Cynthia Wang, M.D. Department of Anesthesiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA Chad T. Wilson, M.D., M.P.H. Department of Surgery, New York University School of Medicine, New York, NY, USA Hong Yan, M.D. Department of Anesthesiology, Wuhan Central Hospital, Wuhan, China

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Initial Assessment and Management of the Trauma Patient Chad T. Wilson and Anna Clebone

On arrival to the hospital, the injured patient requires immediate attention. Severely injured patients often have dramatic presentations, and chaos is apt to ensue among providers if they are not well prepared. A rational and predefined plan for diagnosing and treating the trauma patient is necessary. The standard approach of performing a full history and physical exam, ordering tests, and then providing treatment is not appropriate, as some patients will have succumbed to their injuries during that time. Instead, the initial assessment and management of the trauma patient needs to be expedient, highly ordered, and prioritized to rapidly and reliably diagnose and treat the most immediately life-threatening problems, but also evaluate for occult injuries that could cause major morbidity and mortality if not identified early. The Advanced Trauma Life Support (ATLS) training program was developed to provide uniformity in the assessment and management of trauma patients. ATLS was first utilized to teach trauma management to rural doctors in the late C.T. Wilson, M.D., M.P.H. (*) Department of Surgery, New York University School of Medicine, 550 First Avenue, NBV 15s5, New York, NY 10016, USA e-mail: [email protected] A. Clebone, M.D. Department of Anesthesiology and Perioperative Medicine, Case Western Reserve University, University Hospitals, 11100 Euclid Avenue, LKS 5007, Cleveland, OH 44106, USA e-mail: [email protected]

1970s [1]. The program was adopted nationally by the American College of Surgeons Committee on Trauma (ACSCOT) in 1980 and has since been taught worldwide and updated to reflect the latest evidence in trauma care [2]. ATLS, now in its 9th edition, is taught to surgeons, emergency medicine physicians, anesthesiologists, nurses, and advanced care providers. This chapter largely reviews the approach taught in ATLS (now in it’s 9th edition) [3].

Pre-hospital and Triage In many communities, information is provided by emergency medical personnel about a trauma patient prior to arrival to the hospital. Prehospital notification allows team members to be alerted, including the trauma surgeon, anesthesiologist, nursing team, and radiology and operating room staff. A team meeting can be held, and preparation can be tailored to specific information provided about a patient. For example, pre-hospital notification regarding a patient with a gunshot wound to the chest and labored breathing would prompt the team to prepare and open a chest tube insertion kit. Finally, pre-hospital notification allows the trauma team to put on personal protective equipment (gloves, gowns, and masks) before the patient arrives. A combative patient can expose providers to substantial amounts of bodily fluids, and the incidence of blood-borne

C.S. Scher (ed.), Anesthesia for Trauma, DOI 10.1007/978-1-4939-0909-4_1, # Springer Science+Business Media New York 2014

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Table 1.1 Example of tiered trauma team activation criteria for trauma patient triage Level 1

Level 2

Level 3

Physiologic criteria: • Impending respiratory failure or intubated • Systolic blood pressure  90 mmHg – Systolic blood pressure  20 mmHg below age appropriate blood pressure in pediatric patients (age < 15 years) • GCS < 10 • HR > 120 Anatomic criteria: • All penetrating injuries to the head, neck, torso, or extremities proximal to the elbows or knees (excluding minor lacerations) • Any penetrating injury with hemodynamic instability • Any extremity amputation proximal to the wrist or ankle • Crushed, mangled, degloved, or pulseless extremity • Pelvic fracture (excluding falls from standing) • Two or more long bone fractures • Suspected spinal cord injury/paralysis • Motor vehicle crash with: – Ejection or death of a passenger – Intrusion > 12 in. into passenger area • Falls > 20 ft (>10 ft or 2  height in age < 15) • Inhalation injury or second- and third-degree burns involving >20 % body surface area • Transfers from other hospitals receiving blood • Discretion of attending physician or nursing None of the above, and any of the following: Physiologic criteria: • GCS < 13 • HR 100–120 Anatomic criteria: • Any fall above standing height with loss of consciousness or falls >10 ft • Substantial (>20 mph impact) auto-pedestrian, auto-bicycle, motorcycle crash • Pregnancy beyond 20 weeks and significant mechanism of injury • First- and second-degree burns 5 % and 20 % body surface area • Discretion of attending physician or nursing • Age > 70 years or anticoagulation None of the above, and any of the following: • Non-emergent consults for trauma not meeting activation criteria • Trauma patients with substantial mechanisms being admitted to other services • Trauma patients > 24 h • Trauma patient transfers not meeting level 1 or 2 criteria

disease is higher in trauma patients than in the general hospital population [4]. Triage of trauma patients is critical to ensure appropriate resource utilization and to decrease morbidity and mortality. When data is available, either pre-hospital or on arrival, patients are typically classified into a three-tiered system of resource utilization, from Level 1 (highest acuity) to Level 3 (lowest acuity) (Table 1.1).

Level 1 activation triggers a high resource emergency trauma team reaction, a Level 2 activation results in a moderate resource urgent trauma team response, and Level 3 activation receives a routine trauma team consult. The tiered activations result in greater resources being made available more rapidly when needed. A tiered system of triage and trauma team activation results in better resource utilization

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and decreased mortality compared to systems where triage triggers do not exist [5]. Triage of trauma patients can occur based on clinical condition, mechanism of injury, age, or comorbid conditions. Clinical criteria such as vital signs, consciousness level, and ventilation assistance are validated as predictive of mortality [6]. A mechanism of injury such as penetrating trauma to the neck or torso justifies a high level of triage even in the presence of normal initial vital signs and mental status. Variation exists in mechanism criteria among trauma centers. For example, a motor vehicle accident would be considered more concerning in a rural trauma center near several major interstate high-speed highways than in an urban setting where driving occurs at lower speeds on congested local streets. Due to their vulnerability, pediatric and elderly patients warrant special consideration during triage. Patients benefit from appropriate triage and prompt evaluation using the ATLS system.

Primary Survey Every trauma patient is evaluated using the primary survey, a rapid, reproducible physical exam designed to diagnose and treat immediately life-threatening conditions first. All patients are evaluated for physiologic or anatomic derangements that could lead to early mortality and morbidity. Treatment of problems identified during the primary survey begins without delay, before the survey is completed. The sequence of the primary survey can be remembered with the following mnemonic: “A.B.C.D.E.” Airway (Maintain a patent airway with cervical stabilization) Breathing (Ensure oxygenation and ventilation) Circulation (Fluid resuscitation and identify and control hemorrhage) Disability (Identify any gross neurologic deficits) Exposure/Environment (Undress patient for complete exam, then prevent hypothermia) Keep in mind that while the primary survey has a clear order to priority, the assessment and

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treatment of problems identified in the primary survey can and should happen in parallel. If an airway problem is identified at the beginning of the survey, and a decision is made to obtain a secure airway for the patient, the rest of the primary survey should continue while the airway is secured. This is accomplished with a team approach to the primary survey, where multiple care providers perform different parts of the primary survey and report to a team leader who “runs the trauma” by coordinating the effort. This team approach reduces resuscitation time significantly (Fig. 1.1) [7]. Full monitoring of the patient, including an electrocardiogram (ECG) if indicated, as well as the administration of oxygen, intravenous fluid, blood products, or medications as warranted should occur in parallel with the primary survey. This can only be accomplished with a team approach to the primary survey. The elements of the primary survey must be continually reevaluated in a sequential manner due to the fact that a trauma patient’s condition can evolve and deteriorate rapidly. This is especially true if at any point a patient is not responding in an expected manner to resuscitation efforts. Consider this scenario: A patient with a head injury secondary to a high fall is intubated on arrival for poor mental status and an inability to protect his airway. Subsequently, the patient was found to have good breath sounds bilaterally with manual ventilation, as well as normal vital signs and circulatory assessment. Ten minutes later, just prior to CT scan, he becomes progressively hypotensive. The astute clinician returns to the primary survey and notes that the endotracheal tube is still in the same position; however, breath sounds are absent on the right side, and new subcutaneous emphysema has appeared over the right chest wall. On closer examination, the patient’s neck veins are now distended, and the trachea appears to be shifted to the left. A right-sided chest tube is inserted to relieve a tension pneumothorax that was exacerbated by positive pressure ventilation after intubation. This example highlights the rapid evolution of a trauma patient’s condition

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C.T. Wilson and A. Clebone Anesthesiologist/ Airway expert

Respiratory therapist

Primary nurse

Surgical resident, PA, or NP Emergency medicine resident, PA, or NP

Secondary nurse Trauma technician (EKG, blood work)

Scribe Team leader

Fig. 1.1 Example of trauma team personnel placement around the bedside of a trauma patient

and the importance of returning to “A, B, C, D, and E” repeatedly during initial management.

Airway The first priority in the primary survey of the trauma patient is a rapid, but accurate assessment of the airway. Typically, little information is

available about a patient’s medical history and previous airway management. Trauma patients may have unstable cervical-spine injuries that cannot be immediately evaluated. As a result, any manipulation of the cervical spine may be unsafe. Tilting the head into “sniffing position” to improve airway patency is therefore often contraindicated. Considering the often spectacular presentation of the most severely injured

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patients, typically with an unknown medical history, occult injuries, and little time to establish an airway (all while maintaining cervical spine precautions), managing the airway in the trauma patient presents a challenge which requires a specialized skill set. Some patients will arrive with an advanced airway placed in the field, which may be an endotracheal tube, supraglottic airway (such as a laryngeal mask airway “LMA”), or duel lumen esophageal tube (CombitubeTM). It is paramount that this airway be assessed by confirming position, effective ventilation, and adequate airway protection. A supraglottic airway or dual lumen esophageal tube is less secure than an endotracheal tube, and possibly ineffective with regard to ventilation and airway protection. In some cases, an airway placed in the pre-hospital setting will need to be replaced with an endotracheal tube, depending on the provider’s assessment of the situation and accompanying risks and benefits. In the conscious trauma patient, the best means of assessment is to simply ask, “what is your name?” A response given in a normal voice is indicative of a currently intact airway. If the patient is unable to speak, or his or her voice sounds altered, then airway compromise may be present, and more investigation is warranted. Keep in mind that some patients are unable to verbalize for reasons unrelated to airway compromise, such as a language barrier, mental disability, or psychiatric illness. Additionally, some injuries, such as burns, cause progressive airway swelling which can lead to progressive airway compromise even in the presence of an initially normal exam. In an apparently unconscious or severely intoxicated patient, assessment of the airway starts with a chin lift and jaw thrust to open the pharynx while avoiding manipulation of the cervical spine. The oropharynx should then be examined and cleared of blood, vomitus, and debris by suctioning. A patient who responds vigorously to attempted suctioning may be able to protect his or her own airway. If obstruction is relieved via these simple maneuvers and airway protection is intact, an advanced airway may not

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be required, and supplemental high flow oxygen via face mask should be provided. In contrast, patients with obvious hoarseness, stridor, retractions, or respiratory distress may need further airway management, and patients with a Glasgow Coma Score of less than 8 or persistent airway obstruction require endotracheal intubation or a surgical airway. Rapid sequence induction (RSI) and intubation with a cuffed endotracheal tube is the most commonly employed method of securing an advanced airway in a trauma patient. The goal of RSI is to decrease the risk of aspiration. The time between complete loss of airway reflexes and obtaining a secured airway is minimized by simultaneously administering a fast acting sedative/hypnotic agent and a muscle relaxant. When possible, bag mask ventilation is not performed due to the potential for insufflating the stomach and causing aspiration of gastric contents. The benefits of an RSI must be balanced with the risks. In a patient who may be difficult to mask ventilate or intubate, securing the airway after applying topical local anesthetics and using minimal sedation (an “awake intubation”) is indicated. Hypotensive patients may not tolerate the loss of sympathetic tone and myocardial depression that accompanies the administration of sedative/ hypnotic medications. Comatose patients often do not require additional sedation for laryngoscopy to be performed. In patients with head and neck trauma, visualization of the glottis and establishment of an airway may be impossible via direct laryngoscopy, and use of a specialized device such as a fiberoptic bronchoscope, video laryngoscope, or rigid bronchoscope or emergent placement of a surgical airway such as a tracheostomy or cricothyroidotomy may be necessary. An alternate plan for ventilation should exist for cases in which direct laryngoscopy fails. Agents for blood pressure support should be immediately available. In the trauma patient, coexisting injuries must be considered. Importantly, cervical spine precautions must be maintained at all times. This is usually accomplished by placing the patient in a rigid cervical collar during or prior

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to the initial assessment. This collar is often removed for airway management to provide room for mouth opening during laryngoscopy. When this collar is off of the patient, an individual must be assigned to maintain manual in-line cervical immobilization at all times until the airway is secured and the collar is replaced.

Breathing Next, the patient’s breathing, ventilation, and oxygenation should be assessed, and any lifethreatening derangements must be treated. Physical exam, pulse oximetry, and continuous end-tidal carbon dioxide monitoring should be used. Inspection involves noting if breathing is comfortable or labored. Hypoxia can be a cause of confusion and combativeness in a patient. The patient’s color is noted (normal, cyanotic, or pale) and the chest wall is observed for normal motion. The chest should be palpated for unstable segments and crepitus. Finally, bilateral auscultation should be performed to determine the presence, symmetry, and quality of breath sounds. Diminished or absent breath sounds on one side is a cause for concern. If the patient is unstable in any way, intervention is warranted emergently. The most common interventions performed during the primary survey to support breathing are supplemental oxygen delivery, assisted or mechanical ventilation, and tube thoracostomy or chest tube insertion. Supplemental oxygen by face mask is used liberally during the primary survey in spontaneously breathing patients until normal oxygenation can be ensured. Common causes of hypoxic respiratory insufficiency in trauma patients are pulmonary contusion and aspiration pneumonitis. A patient who is hypoventilating can be assisted by bag mask if the patient is able to maintain airway protection. Common causes of impaired ventilation in trauma patients are rib fractures/flail chest, intoxication/drug overdose, and severe head injury. A more definitive airway may be needed in those patients with more profound hypoxic or hypoventilatory respiratory failure. Tube

C.T. Wilson and A. Clebone

thoracostomy is indicated in patients with decreased or absent breath sounds and hypotension or severe respiratory distress due to a hemothorax or tension pneumothorax. A hemothorax is the accumulation of blood in the pleural cavity around the lung, which can occur in either blunt or penetrating trauma. The diagnosis is suspected in a patient with diminished or absent breath sounds. In the stable patient, the presence of a hemothorax may be confirmed with a portable chest radiograph. For the patient in distress, a large bore (at least 28 French) chest tube is inserted on the side with diminished breath sounds. Hemodynamic instability or massive hemothorax (an output of greater than 1,500 cm3 of blood from the chest, less in small or pediatric patients) are indications for an operative exploration to control the source of bleeding. In addition to being diagnostic, chest tube insertion is therapeutic via improving ventilation, relieving tension, and collecting blood that can be autotransfused. Autotransfusion of filtered blood in trauma patients can be a safe alternative to transfusing banked blood [8]; however, filtered blood is inherently depleted of clotting factors and platelets, which may also need to be replaced [9]. A pneumothorax is the presence of air in the pleural cavity around the lung, which can also occur in both blunt and penetrating trauma. The diagnosis and symptoms can be subtle on physical exam if the pneumothorax is small and is often only revealed on chest radiograph or computed tomography scan. Of greatest concern during the primary survey is the presence of a tension pneumothorax. Air under pressure in the pleural cavity causes the mediastinum and its contents to shift away from the ipsilateral side of injury towards the contra-lateral side of lower pressure. This can be immediately lifethreatening by causing obstruction of venous return to the heart and cardiovascular collapse. While the diagnosis of small (or occult) pneumothorax is difficult on physical exam, the diagnosis of tension pneumothorax should be able to be made at the bedside without imaging. If a patient is experiencing acute respiratory failure or hemodynamic instability with hypotension and

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has unilateral diminished breath sounds, one should strongly suspect a tension pneumothorax, and a chest tube should be placed immediately to alleviate the pressure. Other physical exam findings that are suggestive of tension pneumothorax are distended neck veins, subcutaneous emphysema, and tracheal deviation. If a chest tube cannot be safely placed in an expeditious manner, needle thoracostomy is an acceptable alternative, which is performed by inserting an angiocatheter (usually 14 gauge) between the ribs, into the second intercostal space in the mid clavicular line. Although technically simple, needle thoracostomy can cause a puncture of the lung or laceration of a blood vessel (such as the internal mammary artery), therefore it should only be employed in an emergency situation. An open pneumothorax (“sucking chest wound”) is an injury to the chest wall that communicates freely with the pleural space. Inspiration generates negative pressure, pulling air into the pleural space through the wound, potentially causing lung collapse and acute respiratory failure. The definitive treatment is tube thoracostomy (a “chest tube”) and repair/ dressing of the wound. If a chest tube is not available, however, an alternate treatment is to place a partially occlusive dressing over the wound. The goal of the partial occlusion is to achieve a one-way valve to avoid pulling in air through the wound while allowing an opening for pressure to be relieved, in order to decrease the risk of a tension pneumothorax. This is classically achieved by taping the dressing on three sides to hold the dressing over the wound, but leaving the fourth side free so that air can escape from that side of the dressing (Fig. 1.2).

Circulation After addressing the highest priorities in the primary survey (airway and breathing), circulation must be assessed to determine the presence or absence of shock. Shock is defined as inadequate organ perfusion and tissue oxygenation. In the trauma patient, shock is assumed to be hypovolemic/hemorrhagic and

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Fig. 1.2 Partially occlusive dressing (taped on three sides only) for open pneumothorax functions as a oneway valve, to relieve any tension, but not allow air to be sucked into the wound

resuscitation begins as soon as vascular access can be obtained. The possibility of neurogenic shock (e.g., spinal cord injury) or cardiogenic shock (e.g., pericardial tamponade) should also be considered. The focus of this segment of the primary survey should be assessing for the presence of shock, determining the cause (usually blood loss) and beginning resuscitation. Assessment of shock begins with performing a physical exam and evaluating a patient’s vital signs. Patients with hemorrhagic shock typically develop derangements in their blood pressure and heart rate that are proportional to the amount of blood loss and degree of shock (Table 1.2). Hemorrhage will lead to a decreased preload, which triggers a compensatory increase in heart rate to maintain cardiac output. Blood pressure will fall as hypovolemia worsens. These changes

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C.T. Wilson and A. Clebone

Table 1.2 Classes of hemorrhagic shock by ATLS designation for a 70 kg patient [3] Blood loss (mL) Blood loss (%) Heart rate (bpm) Systolic blood pressure Pulse pressure Respiratory rate (resp/min) Urine output (mL/h) Mental status

Class 1 120 Decreased Decreased 30–40 5–15 Anxious/confused

Class 4 >2,000 >40 >140 Decreased Decreased >35 Negligible Confused/lethargic

Rapidly diagnosing the source of blood loss in a trauma patient is critical for hemorrhage control and should be done in conjunction with the most skilled member of the trauma team. Resuscitation of the trauma patient should begin as early as possible and often occurs in the pre-hospital setting. The first priority is to obtain vascular access. The standard of care is the rapid placement of two large bore intravenous (IV) lines in the upper extremities. If this cannot be performed in an expeditious manner, alternate vascular access such as an intraosseous (IO) line or central line placement should be performed. In the past, IO lines were used only in pediatric patients, but new designs and insertion devices have made IO access a viable option in adult patients. IO lines can be comparable to central access in the care of trauma patients [10]. The location of intravascular access should be dictated by injuries and suspected sites of blood loss, and severely traumatized extremities should not be used for IV sites when possible. In general, patients with a suspected injury below the diaphragm such as a liver laceration or pelvic fracture benefit from vascular access above the diaphragm (such as an upper extremity peripheral IV, subclavian/internal jugular central line, or humerus/sternal IO line). Similarly, patients with trauma above the diaphragm such as a slash wound to the neck should be provided access below the diaphragm such as femoral central line or a tibial IO line. In a patient who may be hypoperfused, resuscitation with crystalloid fluids (or blood products in severe cases) should begin immediately after vascular access is obtained. ATLS

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recommends starting with an initial bolus of 1–2 L of warmed isotonic IV fluids in adults or 20 mL/kg in pediatric patients [3]. If a patient becomes hemodynamically stable following this bolus and hemorrhage control is obtained, then this may be the only fluid resuscitation that is needed. However, a patient who remains hypotensive after this intervention, or has only a transient response, requires further resuscitation utilizing blood products. Cross-matched and screened blood products are preferred, however, in urgent cases. O negative blood may be used while the team is waiting for type specific blood to arrive. The goal of resuscitation is to maintain tissue perfusion and homeostasis. Over resuscitation (in particular with isotonic fluids) can lead to complications of volume overload. Aggressive efforts must be made to preserve homeostasis during resuscitation with particular attention paid to the avoidance of hypothermia, acidosis, and coagulopathy, the so-called “triad of death.” In particular, coagulopathy can be caused by the simultaneous consumption and dilution (with IV fluids) of platelets and clotting factors. Deliberate attention must be focused on making blood products available in large amounts and ensuring that packed red blood cells, plasma, and platelets are transfused in an appropriate ratio. Most trauma centers employ a massive transfusion protocol (MTP) to be instituted for those trauma patients who require the rapid administration of large amounts of blood products [11]. Recently, substantial literature has supported transfusion of a high ratio of FFP and platelets to packed red blood cells [12, 13], and the components of the MTP have evolved accordingly [14]. While the ideal ratio of plasma and platelets to packed red blood cells, as well as the use of other pro-coagulants is often debated, the mainstay of treatment for hemorrhagic shock continues to be fluid resuscitation with warm crystalloid fluids followed by blood products, and immediate localization and source control of bleeding.

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Table 1.3 Glascow Coma Scale scoring system Eye opening (E) • 4 ¼ spontaneous • 3 ¼ to voice • 2 ¼ to pain • 1 ¼ none Verbal response (V) • 5 ¼ normal conversation • 4 ¼ disoriented conversation • 3 ¼ words, but not coherent • 2 ¼ no words, only sounds • 1 ¼ none Motor response (M) • 6 ¼ normal • 5 ¼ localized to pain • 4 ¼ withdraws to pain • 3 ¼ decorticate posture • 2 ¼ decerebrate posture • 1 ¼ none The score in each section is added for a cumulative score of 3–15: • GCS 3–8: severely depressed consciousness • GCS 9–12: moderately depressed consciousness • GCS 13–15: normal to mildly depressed consciousness

Disability Once airway, breathing, and circulation are addressed in the primary survey, the next priority is to assess disability. The primary focus is on rapidly determining a patient’s mental status and neurologic function via physical exam. The Glascow Coma Scale (GCS) is a rapid and reliable way to quantify a patient’s level of consciousness (Table 1.3) [15]. The GCS score allows for quick communication among clinicians about a patient’s current mental status and can be important for decision-making. The neurologic assessment also includes an examination of the cranial nerves, pupils, and sensory and motor function. If there is an obvious extremity deformity or wound, the clinician should document gross neurologic and vascular

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function distal to the injury prior to any manipulation, wound exploration, or tourniquet application. For severely deformed limbs with obvious underlying fractures, a gross reduction should be performed to approximate more normal alignment (if tolerated by the patient), which will often result in improved perfusion of the limb. One serious disorder that will be diagnosed and treated during the disability segment of the primary survey is intracranial hypertension. Signs of intracranial hypertension include an abnormal GCS, a unilaterally blown pupil, and Cushing’s triad (bradycardia, hypertension, and abnormal respiratory variation) in a patient with a suspected head injury. Mild hyperventilation is a temporary way to control elevated intracranial pressure (ICP), with a goal pCO2 of 30–35 mmHg. Deep sedation is also helpful, but may obscure the clinician’s ability to assess the patient. All patients suspected of having an elevated ICP should be considered for hyperosmolar therapy until neurosurgical assessment and intervention can be performed. Hyperosmolar therapy consists of either a bolus of 23.4 % hypertonic saline (0.5 mL/kg) or the administration of mannitol (1 g/kg). Note that mannitol can precipitate hypotension, so it should be administered carefully, and its use may necessitate subsequent resuscitation with isotonic crystalloid.

C.T. Wilson and A. Clebone

area should be warm. If the patient is wet, he or she should be dried immediately. Critically injured patients with hypothermia may require more aggressive methods of rewarming, such as warm lavage of body cavities (e.g., pleural, peritoneal, and bladder lavage), warming/cooling catheters, and/or extracorporeal blood warming (e.g. venovenous cardiopulmonary bypass) [16].

Reevaluation Frequent reevaluation should be the rule for trauma patients, even after all five components of the primary survey have been addressed. For some patients the primary survey will need to be completed multiple times. For the critically ill, it is often helpful to repeat the primary survey every time the patient is transferred to a new area of care (e.g., from the emergency department to the intensive care unit). The physiology of the trauma patient is dynamic as injuries may evolve during the assessment. If at any point, the patient begins to respond in a way not consistent with the initial primary survey, then the primary survey should be repeated quickly to assess if a new, immediately life-threatening situation has arisen.

Adjuncts to the Primary Survey Exposure/Environment

Monitoring

Exposure and environment are the final components of the primary survey. While lowest in priority, they are still vital to the successful management of the trauma patient. The patient should be completely exposed (all clothing removed) so that injuries can be fully assessed. Decontamination may also be needed, depending on the nature of the trauma. Protection from hypothermia and continuous temperature monitoring are essential. Warm resuscitation fluids should be given. The patient should be covered with warm blankets or a forced-air warming device (e.g. Bair Hugger), and the temperature in the resuscitation

While not explicitly a part of the primary survey, monitors should be placed on the patient to facilitate assessment as soon as possible. Continuous monitoring of cardiac rhythm is helpful to quickly detect changes in heart rate as well as arrhythmias. Continuous O2 saturation and continuous end-tidal CO2 monitoring are essential to remain vigilant about changes in the respiratory status of a patient. Automatic noninvasive blood pressure measurements can alert the trauma team to trends or sudden changes in blood pressure. In some patients with hemodynamic variability, a more invasive monitor

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will be needed such as an arterial line to monitor blood pressure continuously. Monitoring central venous pressure or pulmonary artery pressure can be a useful adjunct to managing complex trauma patients, especially those with known cardiac disease or suspected cardiac injury.

Imaging In most trauma centers, rapid portable X-rays are available in the emergency department. X-rays are only adjuncts to the primary survey, but can be very helpful in identifying problems that may impact the primary survey. Most commonly, a portable chest radiograph is performed in the resuscitation area of the emergency department. Chest radiography can confirm the position of an advanced airway, as well as diagnose pneumothorax, hemothorax, pulmonary contusion, aspiration, and broken ribs, all common diagnoses which are important to identify early. Blunt trauma patients often benefit from a portable pelvic plain film. The presence of a pelvic fracture can explain occult blood loss in a hemodynamically unstable patient. Patients with penetrating trauma, especially from a projectile, also can benefit from a plain film to localize the presence of any foreign bodies and guide interventions. Ultrasound has an important role as an adjunct to the primary survey in localizing occult hemorrhage. In particular, the Focused Assessment Sonography in Trauma (FAST) exam is used to rapidly and reliably identify free fluid in the peritoneum or fluid around the heart. The FAST Exam is a bedside sonographic exam that utilizes four views or “windows.” Three abdominal views examine the perihepatic space, the perisplenic space, and the pelvis. The fourth view looks for fluid in the pericardium. For example, in a hemodynamically unstable patient, the FAST exam can quickly identify intraabdominal hemorrhage as the likely source of bleeding and alert the trauma team that the patient should be transferred to the operating room expeditiously for laparotomy and hemorrhage control [17]. Likewise, a positive

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pericardial view (especially in a patient with penetrating trauma to the chest) can alert the surgeon that exploration of the chest may be needed [18]. The FAST exam has become the modality of choice to assess the unstable trauma patient and has supplanted diagnostic peritoneal lavage (DPL) as a noninvasive way to look for intra-abdominal hemorrhage [19]. DPL should be used when ultrasound is unavailable, the FAST is equivocal, or a patient has unexplained profound hypotension despite a negative FAST exam. Computed tomography (CT) is a useful tool in the management of trauma patients, due to the fact that it is more sensitive and specific for most anatomic injury patterns than plain films or ultrasound. In particular, for head injury, CT scan is the primary modality used to guide intervention. For the unstable patient, however, a CT scan can be unsafe due to the time required for the scan, as well as the relatively uncontrolled environment that occurs during transportation and within the scanner. The barriers to obtaining a CT scan expediently and safely vary greatly between institutions, but the general rule is that only patients with a stable airway, good oxygenation and ventilation (mechanical or spontaneous), and hemodynamic stability should receive a CT scan. If a patient becomes unstable in the CT scanner, the team should reevaluate according to the primary survey paradigm and consider abandoning the study if the patient cannot be stabilized.

Laboratory While laboratory studies are not considered to be an integral component of the primary survey, they can often serve as useful adjuncts. During resuscitation, an arterial blood gas measurement is performed to assess oxygenation, ventilation, and pH. Often, rapid arterial blood gas results are used for close monitoring and to help establish an end point for resuscitation. Venous blood samples are usually obtained during the primary survey, while IV access is being obtained. Importantly, a “type and screen” must be sent

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to establish blood type and screen for antibodies to red blood cells. A complete blood count and coagulation studies are especially important in patients who are anemic or anticoagulated. A pregnancy test should be performed in any woman of child-bearing age. Toxicology studies are also helpful in any patient with altered mental status. In patients with abdominal or pelvic trauma, a urinalysis should be checked for hematuria. Blood sugar and other chemistries are also important, especially in patients with unexplained altered mental status.

Tubes A clinician must be particularly cautious when placing a urinary catheter in a patient with a pelvic fracture (especially in a male patient) or penetrating trauma near the pelvis and perineum. This is particularly true when there is concomitant gross hematuria or blood at the urethral meatus. Gastric tubes are helpful adjuncts in patients who are mechanically ventilated, to decompress the stomach and decrease the risk of aspiration of stomach contents. After confirmation of correct positioning of the gastric tube, medication and later enteral nutrition can be delivered. In a patient with a complex facial or basilar skull fracture, a nasogastric tube could inadvertently be passed through the fracture site and into the intracranial space. An orogastric tube is a safer alternative until the presence of these types of injuries can be excluded.

Secondary Survey Next, attention is turned to the secondary survey, whose purpose is to characterize injuries and uncover any occult injuries that did not require immediate attention during the primary survey. In practice, the secondary survey often begins while the primary survey is still being completed. The primary survey, however, should never be interrupted by the secondary survey. Additionally, at any time, a change in the status of the patient may necessitate a return to the primary survey.

C.T. Wilson and A. Clebone

History In the conscious individual, a history can be obtained directly; however, in a severely incapacitated trauma patient, this information must be acquired from pre-hospital personnel, witnesses, and friends or family members. Due to the time-sensitive nature of treatment, a concise history is gathered utilizing the mnemonic AMPLE: Allergies Medications Past medical problems and surgery Last Meal Events related to the Injury In some cases, this information will be obtained from items in the patient’s belongings such as medical bracelets, medication bottles, or medical/insurance wallet cards. Pre-hospital personnel may have spoken to witnesses of the traumatic event and can give information about the patient’s status in the field and treatment delivered. Taking a trauma history is skill that improves with experience. As a provider sees certain patterns of injury repeatedly, history taking will become tailored for those circumstances. For example, inquiries should be made as to tetanus status in patients with lacerations or abrasions, helmet use in motorcyclists, and weapons and ballistics in patients with gunshot wounds.

Physical Exam The secondary survey should include a careful “head to toe” physical exam. Remember that the primary survey is focused on an assessment for immediately life-threatening problems, and the secondary survey is used to uncover occult injuries that might have substantial morbidity and mortality if missed. The physical exam will guide the diagnostic and therapeutic approach to be undertaken during the critical hours after the initial resuscitation and assessment, therefore ensuring that the problems with greatest priority are addressed most expeditiously.

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Initial Assessment and Management of the Trauma Patient

Neurologic assessment in the primary survey focuses on the level of consciousness (Glasgow Coma Score and gross neurologic function). The secondary survey goes into greater detail. For instance, in a conscious patient with a GCS of 15, it may be important to assess the level of orientation or confusion. More subtle deficits might be found with a mini-mental exam, for example, when attempting to determine if a patient can safely be discharged after a concussion. Other parts of the neurologic assessment that occur during the secondary survey include cranial nerve assessment, rectal tone, reflexes, and coordination. In addition, obvious injuries should elicit a careful neurologic assessment. For instance, cranial nerve VII will be checked carefully in a patient with a deep facial laceration. Likewise, a complete neurologic and functional examination of the hand should be performed in a patient with a wrist deformity or fracture. The head, scalp, and face require careful attention on the secondary survey. Ongoing blood loss from a scalp laceration can be hidden in long hair. The skull should be palpated for discontinuities, “step-offs”, or other signs of fracture. Rhinorrhea, hemotympanum, raccoon’s eyes (bruising around the eyes), or Battle’s sign (blood over the mastoid process) are suggestive of basilar skull fracture and should be noted during the secondary survey. Facial lacerations and fractures are common in trauma, can be quite disfiguring, and often impact long-term function. An unstable midfacial area or maxilla are physical exam signs that may help diagnose a LeFort fracture prior to imaging studies. The presence of malocclusion or difficulties in mouth opening should be noted and are especially relevant in cases in which a patient later needs an advanced airway. The neck receives special attention in trauma patients. Patients usually arrive in the emergency room with a rigid cervical collar in place. For the neck exam, this collar should be removed while the spine is held in an immobilized position. In particular, tracheal deviation, neck hematomas, bruits, subcutaneous emphysema, lacerations, and gunshot wounds should be considered

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carefully. If the cervical spine collar is interfering with the ability to care for obvious neck injuries, it should not be used, and an individual should hold the spine in alignment until these injuries are stabilized and the collar can be replaced. The chest, abdominal, back, and genital exams should be performed more carefully during the secondary survey. Chest wall point tenderness, rales, and wheezing may be found. Abdominal tenderness, especially in patients with penetrating trauma, is an indication for urgent surgical exploration. The back exam is performed with the patient’s spine in stable alignment using the “log roll” maneuver. The clinician should look for any additional penetrating wounds to the back or axillae. In men, the genitalia are examined to look for gross blood at the urethral meatus, priapism, or degloving injuries. In women, blood at the vaginal introitus and any lacerations to the perineum should be noted. Extremities should be inspected for deformity and color and palpated for point tenderness, instability, or crepitus. All limbs should be moved throughout their range of motion to assess for mobility or laxity in the joints. A peripheral vascular and neurologic evaluation of the extremity should be carefully performed when an injury is found.

Disposition from the Trauma Resuscitation Area The amount of time a patient initially spends in the emergency department resuscitation area can vary greatly. Some patients will be whisked away to the operating room for treatment of lifethreatening injuries after mere seconds. Others may require more than an hour of resuscitation, reevaluation, and intervention. The care of every patient begins with the primary survey. If lifethreatening injuries are encountered that can only be managed elsewhere, such as the operating room or angiography suite, then the primary survey will continue until that life-threatening problem is addressed. The primary survey is not

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complete until the patient is stabilized. Most trauma patients will receive a complete primary survey and secondary survey before being transferred from the resuscitation area. Commonly, patients will be transferred to one of the following destinations: radiology (CT scan, MRI), intensive care unit, inpatient unit, procedure/treatment room (operating room, angiography, endoscopy), or to a less acute section of the emergency department for observation and possible discharge to home. It is important that patients are monitored appropriately and that the new care team receives adequate information as part of transfer. Oftentimes, a nurse, respiratory therapist, physician, and transport personnel will accompany the patient to the next level of care (e.g., the ICU). Vigilance is key. A suicidal patient may have an unremarkable primary and secondary survey, but will need careful monitoring for elopement or self-injury. Evolution of a trauma patient’s condition can be quick and occur in the hours after the patient’s initial assessment. For example, a patient with a delayed hemorrhage will deteriorate over the next several hours, even in the presence of initially normal vital signs. The clinician should have a low threshold to return to the primary survey if anything unexpected occurs. Good care of the trauma patient means going “back to the ABCs” as many times as it takes until the patient is truly stable.

References 1. Collicott PE, Hughes I. Training in advanced trauma life support. JAMA. 1980;243(11):1156–9. 2. Collicott PE. Advanced Trauma Life Support (ATLS): past, present, future–16th Stone Lecture, American Trauma Society. J Trauma. 1992;33(5):749–53. 3. Advance trauma life support student course manual. 9th ed. American College of Surgeons Committee on Trauma. 2012. 4. Weiss ES, Cornell III EE, Wang T, et al. Human immunodeficiency virus and hepatitis testing and prevalence among surgical patients in an urban university hospital. Am J Surg. 2007;193(1):55–60.

C.T. Wilson and A. Clebone 5. Petrie D, Lane P, Stewart TC. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. Trauma and Injury Severity Score. J Trauma. 1996;41(5):870–3. 6. Purtill MA, Benedict K, Hernandez-Boussard T, et al. Validatin of a prehospital triage tool: a 10-year perspective. J Trauma. 2008;65(6):1253–7. 7. Driscoll PA, Vincent CA. Organizing an efficient trauma team. Injury. 1992;23(2):107–10. 8. Sinclair A, Jacobs Jr LM. Emergency department autotransfusion for trauma victims. Med Instrum. 1982;16(6):283–6. 9. Broadie TA, Glover JL, Bang N, et al. Clotting competency of intracavitary blood in trauma victims. Ann Emerg Med. 1981;10(3):127–30. 10. Leidel BA, Kirchhoff C, Bogner V, et al. IS the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg. 2009;3(1):24. 11. Fraga GP, Banal V, Coimbra R. Transfusion of blood products in trauma: an update. J Emerg Med. 2010;39:253–60. 12. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805–13. 13. Texeira PG, Inaba K, Shulman I, et al. Impact of plasma transfusion in massively transfused trauma patients. J Trauma. 2009;66(3):693–7. 14. Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg. 2009;209(2):198–205. 15. Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir. 1976;34 (1–4):45–55. 16. Gentellio LM, Jurkovich GJ, Stark MS, et al. Is hypothermia in the victim of major trauma protective or harmful? A randomized, prospective study. Ann Surg. 1997;226(4):439–49. 17. Liu M, Lee CH, P’eng FK. Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma. 1993;35 (2):267–70. 18. Rozycki GS, Feliciano DV, Ochner MG, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma. 1999;46(4):543–52. 19. Rozycki GS, Shackford SR. Ultrasound, what every trauma surgeon should know. J Trauma. 1996;40(1):1–4.

2

Airway Management in Trauma Levon M. Capan and Sanford M. Miller

Ultimately, the goal of airway management in trauma is to establish and/or maintain adequate oxygenation, ventilation, and airway protection. It is the first priority in the acute phase of care of the trauma patient and consists of evaluation and, when indicated, intervention using various techniques and devices. It involves the recognition of any trauma to the airway or surrounding tissues, anticipation of their respiratory consequences, and planning and application of management, keeping in mind the potential for exacerbation of existing airway or other injuries by the contemplated strategies. It also involves prediction and prevention of progression of airway or surrounding tissue injury with increasing airway compromise. Although with certain modifications, the American Society of Anesthesiologists (ASA) difficult airway algorithm can be applied to various trauma-induced airway issues [1], it may not be applicable in some clinical scenarios. For example, cancellation of airway management when difficulty arises may not be an option in the acute trauma setting. Likewise, awake rather than asleep intubation or a surgical airway from the outset may be the preferred choice in some situations. Modifications of the ASA

L.M. Capan, M.D. (*)  S.M. Miller, M.D. Department of Anesthesiology, NYU School of Medicine, Bellevue Hospital Center, 550 First Avenue, New York, NY 10016, USA e-mail: [email protected]; [email protected]

difficult airway algorithm are available for various trauma-induced clinical situations [2].

Frequently Encountered Clinical Conditions Full Stomach Commonly, the unknown time of the last food intake, the frequent presence of alcohol and/or illicit drugs, and trauma-induced reduction or absence of gastrointestinal motility imply that almost all acute trauma victims have a full stomach and are at risk for pulmonary aspiration. Pharyngeal blood, secretions, and foreign bodies in some maxillofacial and neck injuries are additional factors for aspiration after trauma. It is generally considered, although without much proof, that at least 24 h are needed after injury to decrease the risk of aspiration from a full stomach. In most instances, the urgency of securing the airway does not permit adequate time for pharmacologic measures such as bicarbonate or H2 blockers to reduce gastric volume and acidity, and indeed these agents may be unreliable. Thus, rather than depending on pharmacology, emphasis should be placed on selection of a safe technique for securing the airway when necessary. Rapid-sequence induction (RSI) is recommended for those patients without serious airway problems. Awake intubation, with sedation and topical anesthesia, if possible, should be performed in

C.S. Scher (ed.), Anesthesia for Trauma, DOI 10.1007/978-1-4939-0909-4_2, # Springer Science+Business Media New York 2014

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L.M. Capan and S.M. Miller

Fig. 2.1 Local anesthetic solution injected via the epidural catheter introduced through the working channel of the fiberoptic bronchoscope provides topical anesthesia of the

larynx and trachea under direct vision with minimal stimulation during intubation attempt

those with anticipated serious airway difficulties, in whom taking irretrievable steps such as administering intravenous anesthetics and muscle relaxants may be associated with uncorrectable airway obstruction and severe hypoxia. Rapid sequence induction should be achieved with the following objectives in mind: (a) adequate sedation and paralysis, (b) adequate oxygenation, (c) optimal hemodynamics and perfusion, (d) avoidance of intracranial hypertension, and (e) prevention of vomiting and aspiration. Any of the intravenous agents including propofol, etomidate, ketamine, or midazolam can be used provided that their doses are adjusted to satisfy the above objectives [3]. Although even a single dose of etomidate has been shown to cause adrenocortical suppression [4], increased likelihood of adult respiratory distress syndrome (ARDS), and multiple organ failure (MOF) [5], it is still used for emergency airway management because of its rapid onset and relatively lower risk of hypotension in comparison to propofol. Succinylcholine is still the preferred agent for muscle relaxation, because it has the shortest time to effect in relation to other agents. Large doses (1.2–1.5 mg/kg) of rocuronium may provide an onset of action comparable to succinylcholine, but its long duration may represent a disadvantage in patients with difficult mask ventilation or tracheal intubation, since return of spontaneous breathing may be excessively delayed. As in any tracheal intubation the use of pulse oximetry, end tidal

CO2 monitoring, and an available experienced operator is essential. Additionally, the neck must be maintained in neutral position and equipment and personnel for invasive airway management must be present. The use of cricoid pressure for RSI is controversial. Although standard since Sellick’s recommendation in 1960s [6], recent findings from 402 trauma patients suggest that its use actually decreases the view of the larynx during direct laryngoscopy and does not seem to prevent regurgitation and aspiration [7, 8]. Although it is difficult to recommend elimination of cricoid pressure during RSI at this time, its removal when the laryngeal view is compromised during direct laryngoscopy or when mask ventilation is hindered appears to be an appropriate maneuver. Awake intubation with preservation of spontaneous breathing should be performed, if at all, with minimal sedation and topical anesthesia of the tongue, pharynx, epiglottis, and the superior surface of the vocal cords. Topical anesthesia of the trachea can be obtained just before introduction of the tracheal tube during direct laryngoscopy or fiberoptic bronchoscopy (FOB) using a tracheal local anesthetic applicator or the working channel of the FOB. Advancement of an epidural catheter that fits the working channel of the FOB, beyond the tip of the device and into the laryngotracheal opening, decreases laryngeal stimulation, minimizing cough and patient movement (Fig. 2.1).

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Airway Management in Trauma

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Fig. 2.2 Laryngeal airways. Laryngeal Mask Airway Supreme (LMA Supreme) on the left, and I-Gel Airway on the right

The high probability of a full stomach precludes the use of any supraglottic device, such as the Laryngeal Mask Airway (LMA) (Fig. 2.2), Combitube (Fig. 2.3), or King’s airway (LT, LTS, LTS-D) (Fig. 2.4), which does not protect the trachea from aspiration of gastric or pharyngeal contents, as a definitive airway in trauma patients. However, these devices can serve as a bridge for a brief period to establish airway patency or to facilitate intubation. In patients with maxillofacial injuries, aspiration of pharyngeal blood or secretions is more likely than aspiration of gastric contents. If they can be inserted in these circumstances, supraglottic airways may protect the lungs. Although positive-pressure ventilation may be used with supraglottic airways, patients with pulmonary contusion, edema, or aspiration may be difficult to ventilate with these devices. Supraglottic airways may permit rapid blind or FOB-guided tracheal intubation while temporarily allowing ventilation. An important disadvantage of the original intubating LMA is its metal stem that may exert considerable pressure against the cervical vertebrae, potentially exacerbating an unstable injury in this region [9]. Many trauma victims with abdominal injuries return to the operating room several times after damage control surgery performed during the acute stage of injury. These repeat procedures are performed to debride and wash the abdominal cavity and to close the abdomen when the initial

Fig. 2.3 Combitube. In this position of the tube with distal cuff in the esophagus, ventilation takes place by the air delivered through the openings below the proximal cuff

Fig. 2.4 King Airway. The tube with distal cuff enters into the esophagus and permits nasogastric tube introduced from a proximal port to proceed into the stomach. Ventilation takes place by the air exiting through the openings below the proximal cuff. Detailed view of the openings below the proximal cuff is shown in the inset

edema subsides. Many of these patients present with a vacuum dressing placed over the open abdomen. They are often extubated and many have been fed with a feeding tube which allows one-way entry of formula into the stomach owing to an internal valve that prevents drainage of gastric contents. These tubes, unlike sump nasogastric tubes, do not decompress the stomach. Even when the feeding tube is removed

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and the patient is kept NPO for several hours, these patients should be considered to have full stomachs because of hypoactive bowel function, the open abdomen, continuous accumulation of gastroduodenal fluid, and remaining feeding solution in the stomach. Airway management in these patients necessitates using rapid sequence induction with cricoid pressure.

The Agitated Uncooperative Patient Pain, anxiety, alcohol intoxication, and illicit drug use may cause agitation and uncooperative behavior in many acutely injured patients. In these patients, topical anesthesia of the airway may be impossible, whereas administration of sedative agents may result in apnea or airway obstruction, with an increased risk of aspiration of gastric contents and inadequate conditions for tracheal intubation. These patients are best managed with RSI with direct laryngoscopy, provided that the cricothyroid membrane is located, the lung is denitrogenated, and personnel and material necessary to perform translaryngeal ventilation or cricothyroidotomy are prepared and ready to provide a rapid surgical airway if intubation with RSI fails.

Airway Obstruction Airway obstruction is probably the most frequent cause of asphyxia; it may result from pharyngeal soft tissue edema, laceration, hematoma, bleeding, secretions, foreign bodies, or displaced bone or cartilage fragments. Bleeding into the cervical region may produce airway obstruction not only because of compression by the hematoma, but also from venous congestion and upper airway edema as a result of neck vein compression. Signs of upper and lower airway obstruction include dyspnea, cyanosis, hoarseness, stridor, dysphonia, subcutaneous emphysema, and hemoptysis. Cervical deformity, edema, crepitation, tracheal tug and/or deviation, or jugular venous distention may be present before these

L.M. Capan and S.M. Miller

symptoms appear and may help indicate that specialized techniques are required to secure the airway. The initial steps in airway management are chin lift, jaw thrust, clearing of the oropharyngeal cavity, placement of an oropharyngeal or nasopharyngeal airway and, in inadequately breathing patients, ventilation with a self-inflating bag/mask assembly. Cervical spine immobilization and administration of oxygen are essential. Blind passage of a nasopharyngeal airway or a nasogastric or nasotracheal tube should be avoided if a basilar skull or maxillary sinus fracture is suspected; it may enter the cranial cavity or the periocular fat pad. Supraglottic airways may permit ventilation with a self-inflating bag, although they do not provide protection against aspiration of gastric contents. They may be used as temporary measures, and if they do not provide adequate ventilation, the trachea must be intubated immediately using either direct laryngoscopy or videolaryngoscopy. Cricothyroidotomy may have to be performed if mask or supraglottic airway ventilation fails to overcome airway obstruction, tracheal intubation is unsuccessful, and hypoxia is severe and cannot be corrected. In all trauma patients airway assessment should include a rapid examination of the anterior neck for feasibility of access to the cricothyroid membrane. Between 0.3 % and 2.7 % of airway management attempts fail in the trauma population, necessitating cricothyroidotomy [10, 11]. Tracheostomy is not desirable during initial management because it takes longer to perform than a cricothyroidotomy and requires neck extension, which may cause or exacerbate cord trauma in patients with cervical spine injuries. Conversion to a tracheostomy should be considered later to prevent laryngeal damage if a cricothyroidotomy will be in place for more than 2–3 days. Possible contraindications to cricothyroidotomy include age younger than 12 years and suspected laryngeal trauma; permanent laryngeal damage may result in the former, and uncorrectable airway obstruction may occur in the latter situation.

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Airway Management in Trauma

Airway Evaluation in the Trauma Patient As in any patient requiring airway management, airway evaluation in trauma victims is of crucial importance for optimal preparation and thus prevention of undesirable outcomes. Assessment should be made for mask ventilation, tracheal intubation, and a surgical airway. The LEMON score, an airway assessment tool for trauma patients, is included in the current version (8th edition) of the Advanced Trauma Life Support Manual (ATLS) [12, 13]. The components of the score are similar to those used in routine airway assessment, but it is more organized and standardized for trauma patients. Following are the criteria that may indicate difficulty: L stands for Look at the cervicofacial region for evaluation of facial or neck trauma, large incisors, presence of beard, large tongue, or orofacial soft tissue stiffness such as the effect of radiation therapy. One point is assigned for each of four conditions present that can possibly cause difficulty. Thus, this criteria leads to a maximum of four points. E stands for Evaluate. The 3-3-2 rule is used for this purpose to specify an interincisor distance