Trauma and Acute Care

C H A P T E R
17
Trauma and Acute Care
MAUREEN MCCUNN, MD, MIPP, FCCM n
CORRY J. KUCIK, MD, DMCC, FCCP n
JOSHUA M. TOBIN, MD n
THOMAS E. GRISSOM, MD, FCCM n
RICHARD P. DUTTON, MD, MBA n
require surgery to reduce complications; nonurgent cases

Basic Considerations can be safely delayed.
Team Organization and Multiple-Trauma Priorities
n The first priority is assurance of a patent airway, with all
Airway Management
trauma patients assumed to have a full stomach. Rapid-
Damage Control and Fluid Resuscitation
sequence intubation is recommended with cricoid pressure
Specific Conditions (CP), but with release of CP if the mask ventilation or
Traumatic Brain Injury
visualization becomes difficult.
Spinal Cord Injury
n Direct laryngoscopy with manual in-line stabilization is
Ocular Trauma
unlikely to aggravate cervical injury and is safe and appro-
Complex Facial Injuries
priate for most trauma patients.
Penetrating Trauma
n Fluid resuscitation after massive hemorrhage will result
Traumatic Aortic Injury
in extensive hemodilution and coagulopathy; hypotensive
Orthopedic Injuries
resuscitation is indicated until hemorrhage is controlled.
Near-Drowning
n Traumatic brain injury (TBI) causes at least half of all trauma
Smoke Inhalation and Carbon Monoxide Poisoning
deaths. Severe TBI (GCS <8) is highly lethal, and even single
The Pregnant Trauma Patient
episodes of hypotension or hypoxemia can increase mortality.
Geriatric Trauma n Patients with complete spinal cord injury deficits ranging
Prehospital Anesthetic Care from C4 to C7 are likely to require early intubation.
Acute Care Anesthesiology n With implied application of substantial force, pelvic
Conclusion fractures may be life threatening due to hemorrhage, and
early stabilization will restore blood pressure.
n Some lung dysfunction occurs in almost all patients with
long-bone fractures, including life-threatening fat embolism
KEY POINTS (3%-10%); supportive care is the only treatment.
n Trauma is the 10th leading cause of death globally (16,000 n Elderly persons (≥75) have the highest injury-related mortality.
people daily). Motor vehicle crashes, firearms, poisoning, However, for geriatric trauma patients who respond favorably
falls, and suffocation account for 81% of all trauma deaths. to aggressive resuscitative efforts, prognosis for survival and
n Every anesthesiologist will likely care for injured patients return to preinjury function is good.
acutely or for follow-up surgery. n More than 50% of surgeries are not elective (40% urgent,
n Trauma deaths occur in a trimodal distribution: at the 11% emergency, 8% trauma), for patients with intra-
scene, hours after injury, and days to months after injury. abdominal sepsis, soft tissue infection, acute abdominal
n The trauma/acute care anesthesiologist is facile in multiple pathology, and acute hemorrhage. The acute care anesthesi-
settings (ED, OR, ICU, transport, pain clinic, military). ology subspecialty will develop the aspects of practice that
n Emergent trauma cases require surgery as soon as possible; are likely to assume a greater prominence in future health
urgent cases are not immediately life threatening but care systems.
488
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Chapter 17 Trauma and Acute Care 489
n Trauma and acute care anesthesiology practice requires

training and knowledge from all anesthetic disciplines.
Trauma patients often require emergent interventions and
advanced techniques of management and coordination of
care among multiple surgical specialties.
BASIC CONSIDERATIONS
The World Health Organization (WHO) estimates that 16,000
people die of injury each day, making trauma the 10th leading
cause of death globally.1 Trauma—disruption of anatomy and
physiology resulting from application of external energy— is
classified as intentional (e.g., violent injuries) or unintentional
(e.g., motor vehicle crashes, falls). Unintentional injuries are
A – airway provider
the fifth leading cause of death overall in the United States D– doctor
and the leading cause for those under 45 years of age.2 The five N – nurse
leading mechanisms of injury death are motor vehicle crash, T– team leader
Open circles – additional support staff (fellows, residents,
firearm, poisoning, falls, and suffocation, accounting for students, paramedics) to assist with workup
81% of all trauma deaths. Persons 75 years and older have the FIGURE 17-1 Trauma team approach for “horizontal”
highest injury-related mortality rate. resuscitation. Multiple personnel perform concurrent and
Anesthesiologists may see trauma patients in the field, in coordinated tasks of evaluation and management of the injured
the emergency department (ED), in the operating room (OR), patient.
in the intensive care unit (ICU), in transport, in the pain clinic,
and in the military setting. Specialists in trauma anesthesia
are rare, but every anesthesiologist will see trauma patients at
times and must be aware of the specific medical issues associ- and treatment of traumatic injuries. Figure 17-1 illustrates a
ated with this challenging population. team approach to the injured patient.
This chapter begins with an overview of team organiza- Trauma is considered a surgical disease, and in the United
tion and approach to the injured patient; the ABCDE priori- States, seriously injured patients are usually managed by a
ties (airway, breathing, circulation, disability, environment) general surgeon or a fellowship-trained trauma surgeon. The
are considered to determine whether injuries are life or limb surgeon generally is responsible for the sequencing of diag-
threatening. Further management strategies include second- nostic and therapeutic procedures and for resource allocation
ary and tertiary patient care issues, as well as uncommon among multiple patients. Anesthesiologists may be involved in
trauma situations. Perioperative management of nontrauma initial airway management, vascular access, procedural seda-
patients who present to the OR for emergent procedures is tion, hemodynamic resuscitation, and the timing and extent
also discussed. of any surgery. Some team members, including surgeons, may
have incomplete understanding of anesthetic implications,
mass casualties, and triage, or other related factors; therefore it
Team Organization and Multiple-Trauma
is incumbent on anesthesiologists to advise the team through-
Priorities
out clinical decision making. Close communication with the
Trauma care outcomes depend as much on the c oordination surgeon and consultant subspecialties is essential to the appro-
of services as on the quality of each individual practitioner. priate allocation of scarce OR resources.
Studies show the more organized and experienced the trauma Trauma deaths occur in a trimodal distribution: (1) at the
service, the better the outcomes.3,4 Practicing anesthesiologists scene, (2) hours after injury, and (3) days to months after
should understand how the local trauma service or deployed injury.6 The deaths occurring at the scene result from severe
unit is organized and the role of anesthesia personnel in the central nervous system (CNS) or major vascular (aorta, great
larger team. The approach to the initial management of a vessels) disruption and can be impacted only by improved
trauma patient, as developed through the American College prevention. The second peak of injury deaths is impacted
of Surgeons (ACS) Advanced Trauma Life Support (ATLS) by efficient prehospital trauma systems and emergent, coor-
course,5 is a “vertical” resuscitation: one provider perform- dinated care on arrival to the trauma center. Mortality in the
ing each step of the primary and secondary survey alone third “wave” occurs more than 24 hours after injury and results
and in sequence. However, modern health care facilities in from sepsis and/or multiple-organ failure. As OR coordina-
highly developed countries have the resources to support tor, the anesthesiologist is required to determine how trauma
“horizontal” resuscitation: multiple trauma team members cases will be accommodated in a busy elective schedule, and
working cohesively and simultaneously on the primary and understanding surgical priorities based upon these patterns of
secondary survey in an effort to reduce the time to diagnosis death is essential to this process.
490 ANESTHESIA AND UNCOMMON DISEASES
Emergent-Urgent-Nonurgent. Table 17-1 is an outline of Nonurgent cases are those that can be safely delayed until a
trauma case priorities.7 Emergent cases must reach the OR scheduled OR time is available. Although immediate fixation
as soon as possible. Although surgical airway access and of face, wrist, and ankle fractures may shorten the patient's
resuscitative thoracotomy usually occur in the ED, immediate length of stay, early surgeries may be technically more d
ifficult
follow-up in the OR will be necessary if the patient survives. because of swelling and distortion of the surrounding tissue.
Also considered emergent are any exploratory surgeries (lap- Therefore, such procedures are typically postponed days to
arotomy or thoracotomy) in a hemodynamically unstable weeks after injury, when tissue edema has resolved and the
patient and craniotomy in a patient with a depressed or dete- patient's condition is improved. Early pain control is critical
riorating mental status, when evacuation of blood or decom- to mitigate the inflammatory response and development of
pression of severe cerebral edema will result in a survival long-term pain syndromes.
benefit. Limb-threatening orthopedic and vascular injuries
Damage Control Approach. In addition to facilitating
should undergo surgical exploration as soon as the necessary
timely surgery in patients who require it, the anesthesiologist,
diagnostic studies have been performed and interpreted.
surgeon, and other specialists work together to determine the
Urgent cases are not immediately life threatening but require
extent of surgery allowed by the patient's physiology. The con-
surgery as soon as possible to reduce the incidence of subse-
cept of “damage control” has revolutionized s urgical thinking
quent complications. Examples include exploratory laparotomy
in the last two decades, limiting initial therapeutic procedures
in stable patients with free abdominal fluid; irrigation, debride-
only to those required for the achievement of hemostasis and
ment, and initial stabilization of open fractures; and repair of
homeostasis, while delaying reconstructive p rocedures until
contained rupture of the thoracic aorta. Angiographic proce-
adequate resuscitation has been achieved, and in a ppropriate
dures have increasingly replaced open surgeries for splenic,
cases, edema has subsided.8 In a typical example, the surgeon
hepatic, pelvic, and aortic injuries in hemodynamically stable
treating an unstable patient with blunt trauma might p erform
patients. Early fixation of closed fractures, especially spine and
an exploratory laparotomy, rapid splenectomy, staple resection
long-bone fractures, has been shown to benefit trauma patients
of injured bowel (without attempt at reanastomosis), ligation
by reducing the incidence of subsequent pulmonary compli-
of bleeding large vessels, and packing of the abdomen. The
cations. Definitive repair within 24 hours is recommended in
abdomen would be left open under a sterile, watertight wound
otherwise stable and non–brain-injured patients.
vacuum and the patient taken to the ICU. Angiographic
embolization might be necessary to facilitate hemostasis in the
TABLE 17-1 n Surgical Priorities in Trauma Patients liver and retroperitoneum (e.g., because of pelvic f ractures).
The goal with “damage control” surgery is to avoid the
Priority Procedure “lethal triad” of hemorrhage, acidosis, and coagulopathy
that can r apidly develop in a patient with massive bleeding
Immediate Airway access
Available OR or at Thoracotomy or laparotomy to control
and resuscitation. After resolution of shock, warming, and
bedside hemorrhage normalization of laboratory values, the patient would return
Evacuation of epidural or subdural serially to the OR in 24 to 48 hours for further exploration
hematoma and debridement of nonviable tissue, reconstruction of the
Urgent Perforated viscus bowel, placement of enteral feeding access, and a bdominal
First available OR Unstable spine with no deficit or partial closure.
deficit The concept of damage control may also be applied to
Decompressive craniotomy or orthopedic injuries: initial external fixation of the pelvis and
laparotomy
long bones is adequate for temporary stabilization of f ractures,
Fasciotomy or limb-salvage procedure
without assuming the additional physiologic risks of intra-
As soon as possible Open fractures medullary nailing or open fixation.9 The damage control
Next unscheduled Irrigation; debridement of soft tissue approach should be considered in any patient with persistent
OR wounds
Open-globe injury or entrapped ocular
hypoperfusion, elevated lactate, or transfusion requirement in
muscle excess of one blood volume.
Isolated closed long-bone fracture
Elective Small-bone fractures: wrist, ankle,

Next scheduled OR hand, foot Airway Management
Facial surgery
The first priority in the care of any trauma patient is assur-
Second-look laparotomy or thoracotomy
Acetabular reconstruction ance of a patent airway that can provide adequate oxygenation
Fixation of stable spinal fractures and ventilation.5 Anesthesiologists are expert consultants for
Plastic surgery and wound reconstruction airway management, including those in which trauma patients
Repeat irrigation; debridement of open are managed initially by emergency medicine physicians.
wounds
Whether in the ED or the OR, the ability to intubate injured
OR, Operating room. patients swiftly and safely may be lifesaving.
Pathophysiology. Baseline indications for intubation of the All trauma patients must be assumed to have a full stomach;
trauma patient are similar to those of any critically ill patient obtaining an accurate history in the injured patient is difficult,
and can be organized under basic categories of (1) inability and trauma itself will lead to a drastic decrease of gastrointes-
to oxygenate, (2) inability to ventilate, and (3) inability to tinal (GI) motility, with ileus persisting for hours to days after
maintain a patent airway. Indications may also include need injury.10 Trauma patients are also at risk for aspiration of blood
for pain control (multiple fractures), diagnostic workup, or from open fractures or penetrating wounds of the face and air-
plan to proceed to the OR. Box 17-1 lists specific examples. way. Impaired mental status resulting from TBI or intoxication
Hypoxemia may be the result of impaired respiratory effort, may make aspiration more likely, particularly when combined
obstruction of the upper airway, aspiration of blood or gastric with the use of sedative or analgesic drugs given to facilitate
contents, mechanical disruption of the chest cavity, or severe diagnostic procedures such as computed tomography (CT)
hemorrhagic shock. Traumatic brain injury (TBI) and intox- or minor surgical procedures such as reducing a fracture or
ication with alcohol or other drugs contribute to impaired suturing a laceration.
effort, upper airway obstruction, and aspiration, whereas
Evaluation. Ideally, assessment of the patient before airway
direct trauma to the face, neck, or chest may cause bleeding,
management is no different than assessment of an elective sur-
anatomic disruption of the airways or lung tissue, pneumo-
gery patient. However, it must often be adjusted for the urgency
thorax, or severe pulmonary contusions. Ventilatory failure is
of the situation. A thorough history and physical examination
common in trauma patients, both at initial presentation and
of the face, neck, and chest is appropriate when possible. Any
in the following days. Pulmonary contusion, with subsequent
suggestion that intubation will be difficult warrants the need
consolidation of alveolar space, may take hours to develop and
for additional equipment or personnel. Presence of a cervi-
may not be obvious until after fluid resuscitation and initial
cal collar, facial fractures, or blood or vomitus in the airway
surgeries have been completed. Ventilatory failure may also
add to traditional predictors of difficult intubation. When the
result from exacerbation of underlying chronic cardiac or
urgency of the situation does not allow for a thorough assess-
pulmonary disease or from other acute causes, such as pul-
ment, the anesthesiologist must gather what information is
monary embolus (PE). Trauma patients are at very high risk
immediately available from other providers, make a quick
for PE from their hypercoagulable state, vascular trauma, or
assessment of the patient, and then proceed as necessary.
fat emboli, and PE should be suspected in any patient with
Box 17-2 summarizes factors predicting a difficult airway.
an abrupt decline in respiratory status. Patients with multiple
The need for “discretionary” intubation in the combative
injuries are at increased risk of developing the systemic inflam-
or uncooperative patient is controversial, and the provider
matory response syndrome (SIRS), which can be complicated
must carefully assess the risks and benefits of intervention.
by progressive respiratory compromise and recurrent sepsis
Induction of anesthesia will allow for immediate diagnos-
and may lead to multiorgan system failure.
tic studies and more rapid identification of life-threatening
conditions, such as epidural hematoma or splenic rupture.
Induction and intubation may also prevent the patient from
injuring self or others and may allow for deeper, safer levels of
BOX 17-1 n INDICATIONS FOR INTUBATION sedation during diagnostic studies. Induction, laryngoscopy,
Apnea and intubation are not without risks. However, h emodynamic
Hypoxemia instability may be precipitated even in previously normotensive
Airway obstruction
Upper airway injury or hemorrhage
Airway burn
Pulmonary injury BOX 17-2 n FACTORS PREDICTING A DIFFICULT
Contusion INTUBATION
Hemothorax/pneumothorax
Aspiration Emergency setting
Cardiac contusion/ischemia with pulmonary edema Presence of hypoxemia
Neurologic injury with decreased cough or respiratory effort History of difficult intubation (may be noted on Medic-Alert bracelet)
Severe traumatic brain injury (GCS <8) Obesity
Cervical spine injury with deficit History of sleep apnea
Intoxication Presence of a cervical collar and backboard
Medication effect Soft tissue injury to the neck or face
Carbon monoxide poisoning Known cervical spine injury (possibility of prevertebral edema)
Limited mouth opening
Need for Anesthesia
Limited neck extension (ankylosing spondylitis, previous cervical
Painful injuries
fusion)
Urgent surgical procedures
Upper airway hemorrhage
Combative or uncooperative patient
Tongue injury
Foreign bodies in the airway
GCS, Glasgow Coma Scale score. Previous attempts at intubation
patients with either the induction agent or the institution Blood and other debris in the oropharynx can also make
of positive-pressure ventilation (PPV) with a subsequent fiberoptic
laryngoscopy difficult. If properly p erformed,
decrease in venous return and cardiac output. Also, technical direct laryngoscopy with manual in-line stabilization is
complications of rapid-sequence intubation (aspiration, oral unlikely to aggravate an existing cervical spine injury and
trauma, need for surgical airway) may exacerbate the care of has been judged safe and appropriate for the majority of
an otherwise minimally injured patient.11,12 trauma patients. Unfortunately, any manipulation of the air-
Early intubation, diagnostic imaging, and rapid extubation way, including mask ventilation, intubation, even placement
of the intoxicated patient without significant trauma are pos- of a laryngeal mask airway (LMA), can cause cervical spine
sible in some settings but can carry a substantial economic motion.14 Cadaveric models of cervical injury demonstrated
burden. Ultimately, the trauma team, including the anesthesi- significantly less movement with in-line stabilization than
ologist, must evaluate the potential for life-threatening trauma, with a cervical collar,16 and this technique has been judged safe
the patient's ability to tolerate CT (with or without additional and appropriate for the m ajority of trauma patients.17 Whereas
sedation), and the likely ease of intubation when deciding how some advocate routine use of fiberoptic intubation for all
to proceed. No matter what course is elected, close monitor- trauma patients with the potential for c ervical instability, this
ing of the patient's neurologic status and respiratory effort is approach is time and resource intensive, with no data showing
required. improved outcomes. Multiple initial options that are less likely
to exacerbate cervical instability (e.g., intubating LMA, light
Preparation. Sufficient trained personnel must be avail- wand) may also be c onsidered, given availability and provider
able to manage the airway physically, administer induction experience.
drugs, provide cricoid pressure (now controversial), and sta- Preprocedural preparation should include the availability of
bilize the cervical spine. The anesthesiologist performing or a device to facilitate intubation of an anterior larynx (e.g., Parker
directing the intubation coordinates this process to ensure Directional Stylet, “trigger tube,” gum elastic bougie), rescue
that all participants know their role. When possible, the plan devices for failed intubation (e.g., LMA, Combitube, Cobra
of care should be discussed with the patient and family and Perilaryngeal Airway, King Laryngeal Tube), and an interdis-
any questions answered. ciplinary understanding of when c ervical protection should
While other preparations are being made, preoxygenation be abandoned in favor of achieving a successful intubation.
should be maximized to the extent possible, whether through The likelihood of an anterior larynx argues for the routine
use of blow-by oxygen (O2), assisted bag-valve-mask (BVM) use of a stylet in the endotracheal tube (ETT). A stethoscope
support of spontaneous ventilations, or ideally, a tight-fitting and capnometry should be available to c onfirm endotracheal
face mask. Although an apneic patient often must be pre- placement and adequacy of ventilation. Equipment should
oxygenated through BVM ventilation, inspiratory pressures also be on hand for emergent p ercutaneous or surgical
should be kept as low as possible to minimize the chance of cricothyroidotomy in the worst-case scenario.
gastric insufflation, regurgitation, and pulmonary aspiration The American Society of Anesthesiologists (ASA) Difficult
of stomach contents. A high-flow suction device should be Airway Management Algorithm has been adapted for trauma,
immediately available should regurgitation occur. All neces- because “awakening” the patient who is hemorrhaging or
sary intubating equipment, including primary and backup unable to maintain an airway is not appropriate.18 In a review
airway equipment, reliable sources of O2 and PPV, induction of 10 years’ experience with intubation on arrival to a busy
and emergency medications, and confirmatory equipment, Level I trauma center, 6088 patients required i ntubation within
should be close at hand. the first hour of care. All were supervised or done by attending
Patient positioning can greatly facilitate intubation and trauma anesthesiologists. Of these patients, 21 (0.3%) received
is often overlooked in the emergent situation. The bed or a surgical airway. Unanticipated difficult upper airway anat-
stretcher should be placed at a convenient height for the anes- omy was the leading reason for surgical airway. All these
thesiologist, with enough space at the head of the bed to allow intubations were performed or attempted with direct laryn-
room for unhindered motion. Ergonomic design of the trauma goscopy.19 The leading causes of the need for surgical airway
bay has been shown to improve the process of emergency were difficult anatomy (11), foreign body (6), and injury to
i ntubation.13 Cervical spine instability is a consideration in head or neck (5).
most trauma victims; cervical injuries occur in 1.5% to 3% Several small studies have investigated various types of
of all major trauma cases, and up to 50% of cervical fractures indirect/video laryngoscopes (GlideScope, Bullard, McGrath,
may be unstable.14 Airtraq, Pentax Airwayscope, Truview EVO2, Viewmax),
Exclusion of cervical spine instability requires at least which provide a theoretic advantage in minimizing cervi-
a cooperative patient without distracting injuries and may cal spine motion during intubation. Simulation,20,21 cadaver
further require appropriate diagnostic studies (see later).
model,22 and live-patient23–25 evaluations generally show that
The traditional “sniffing position” (head extension plus neck the Cormack-Lehane grade is improved,22,23 cervical spine
flexion) is thus contraindicated, whereas the presence of a motion is reduced,24 and time to intubation is similar with
rigid cervical collar and the maintenance of in-line cervical indirect laryngoscopy compared with direct laryngoscopy
stabilization also contribute to the difficulty of intubation.15 (DL).20,22 However, a cinefluoroscopic study of 20 patients
without cervical pathology, using manual in-line stabilization Although a standard-of-care in emergency intubations,
by an assistant, showed no decrease in movement of the cervical the efficacy of cricoid pressure has been questioned. In 1961,
spine with GlideScope versus DL.26 Recently, p rehospital dif- Sellick described CP as a method to reduce the risk of aspira-
ficult intubation management by experienced European anes- tion during the induction phase of anesthesia,29 and although
thetists improved with the GlideScope.25 widely used, its method of application, timing, and role in dif-
ficult airways are not standardized.30–32 For emergency airway
Induction/Intubation Considerations. A rapid-sequence
management, the risk of aspiration is thought to be higher
intubation (RSI) technique is recommended, with the use of
than in elective cases, ranging up to 22% in ED-performed
cricoid pressure (CP, Sellick maneuver) from induction of
RSI,33 and CP is a theoretic preventive maneuver. However,
anesthesia (or onset of apnea) until confirmation of correct
the amount of pressure needed and the optimal method of
ETT positioning. Although how consistently CP prevents
application are unknown,34–36 and the pressure may displace
regurgitation and aspiration of gastric contents has been
rather than occlude the esophagus.37,38 Also, CP may make
q
uestioned,27 the technique is also beneficial in moving the
both mask ventilation39,40 and laryngeal view33 more difficult,
larynx into a position of better visualization, the backward-
both of which can be improved by release of CP. In the United
upward-rightward pressure (BURP) technique, thus maxi-
Kingdom, where anesthetists work as prehospital physicians, a
mizing the laryngoscopic view of the vocal cords. If active
prospective study of CP for RSI in the field reported that of 402
vomiting (vs. passive regurgitation) begins while CP is being
intubations, CP was released in 22 patients to improve laryn-
held, the c ricoid cartilage should be released to minimize the
geal view, bimanual manipulation was used in 25 intubations,
risk of spontaneous esophageal rupture (Boerhaave's syn-
and BURP was applied in 14 intubations; 98.8% of patients
drome). Suction and positioning should be employed (e.g.,
were intubated on the first or second attempt.41 Two patients,
turning patient en masse if on spine board) to minimize the
who had prolonged bag-mask ventilation and d ifficult intu-
risk of pulmonary aspiration.
bations, regurgitated after release of CP. This illustrates a
With adequate dosing of induction/intubation agents and
larger unanswered question: are trauma patients at risk for
suction immediately available to the intubator, aspiration is
aspiration simply because they have a full stomach, or is it
unlikely during direct airway visualization. Specific manipula-
caused by often-inadequate induction doses of medications
tion techniques may optimize visualization of the glottic open-
(from hemodynamic instability) and challenging airways
ing, whereas other techniques may worsen the view. A study
with c ervical spine immobilization, blood/vomitus, or facial
of 104 emergency medicine physicians performing 1530 sets
injuries? Many suggest using CP for RSI, with release of CP if
of laryngoscopy on fresh cadavers suggested that the percent-
the mask ventilation or visualization becomes difficult.
age of glottic opening using a validated scoring scale improved
more with bimanual laryngoscopy than with CP, BURP, or no Induction/Intubation Medications. Advantages and disad-
manipulation.28 vantages of various induction drugs are shown in Table 17-2.
TABLE 17-2 n Medications Used During Emergency Airway Management
Medication Class Comments*
Sodium thiopental Sedative Fast, inexpensive, negative inotrope and vasodilator
Etomidate Sedative Fast, expensive, fewer cardiovascular effects, may cause transient myoclonus
Propofol Sedative Fast, expensive, easily titrated, negative inotrope and vasodilator
Ketamine Sedative Fast, inexpensive, positive inotrope; may cause “bad dreams” or dysphoric reactions
Lidocaine Sedative/ Blunts airway reactivity; negative inotrope

analgesic
Midazolam Sedative Expensive, slower onset; negative inotrope and vasodilator; may cause retrograde amnesia
Fentanyl Analgesic Blunts airway reactivity; does not produce amnesia
Morphine Analgesic Slower onset and longer half-life than fentanyl; may cause histamine release; has euphoric effect
Succinylcholine Paralytic Most rapid onset; produces fasciculations; will cause potassium release in vulnerable patients
(burns, spinal cord injury >48 hours)
Vecuronium Paralytic Slower onset and longer duration; no hemodynamic side effects
Rocuronium Paralytic Intermediate onset and duration, but less predictable than vecuronium; no hemodynamic side
effects
*Note that any sedative or analgesic medication will reduce the endogenous catechol response and may precipitate hemodynamic instability.
Although agents that lack a negative inotropic effect (e.g., undertaken in a reasonably cooperative, maximally preoxy-
ketamine, etomidate) are more likely to preserve cardiovascu- genated patient, PPV can often be completely avoided, to min-
lar function in the euvolemic patient, any induction drug—and imize gastric distention and increased likelihood of aspiration.
even the change to PPV alone—can precipitate hemodynamic In the emergent, desaturating patient, or when preoxygenation
instability in the patient in shock. This is because the hypovo- is limited or impossible, BVM ventilation throughout RSI may
lemic patient is relying on a high serum level of catecholamines be considered. No data support or refute this practice, and
to support the blood pressure. Some degree of catecholamine the clinician must use best judgment in obtaining an airway.
depletion should be assumed in the trauma patient.42 Many Preoxygenation may be difficult if the patient is combative
sedative or analgesic agents may depress sympathetic tone, or if anatomic positioning is suboptimal, and even transient
impair the adrenal response to hemorrhage, “unmask” hypo- hypoxemia may be dangerous to the patient with TBI or hem-
volemia, and cause profound hypotension. Internal hemorrhagic shock.
orrhage may not be readily apparent at induction, and vital With trained providers, RSI of the trauma patient has been
signs are at best a crude indicator of volume status; therefore reported to be successful on the first attempt more than 90%
care should be taken with any anesthetic agent. Such situa- of the time.19,40,41,49 In the remaining cases, knowledge of the
tions demand the use of smaller-than-normal doses, carefully local difficult airway algorithm becomes essential. Providers
titrated to the patient's response. vary in their skills, institutions vary in available equipment,
Although etomidate may seem to be the ideal agent for and time pressures of an emergent intubation makes creative
use in trauma patients because it maintains hemodynamic thought difficult. The adage that “no one gets smarter in an
s tability,43 reported complications related to etomidate induc- emergency” is particularly apropos in dealing with the air-
tion in trauma patients may preclude its use. Occult adrenal way of a trauma patient. It is therefore incumbent on every
insufficiency has been noted in up to 60% of severely injured anesthesiologist to plan for the steps to follow if a given intu-
patients and is associated with persistent systemic inflamma- bation proves challenging. Some “difficult airway” carts
tion, a hyperdynamic cardiovascular state, and vasopressor- include complex equipment, which is associated with com-
dependent shock.44 In a retrospective study of ICU patients at plications,50 and alternative devices are used less frequently.51
a Level I trauma center, 137 patients had undergone cosyntro- Small sets of more frequently used equipment are more helpful
pin stimulation testing; there was no difference in age, gender, in emergency situations.52
race, injury severity or mechanism, rates of sepsis/septic shock, Every anesthesiologist should be familiar with the ASA
mechanical v entilation, or mortality. Patients who had received Difficult Airway Management Algorithm,53 modified for
etomidate were more likely to have adrenal insufficiency, as trauma,18 which should be followed in most cases. The
defined by “nonresponders” to cosyntropin.45 A more recent algorithm for emergent intubations is considerably simpler,
study analyzed 94 patients who had received etomidate for pre- because awakening the patient usually is not a viable option.
hospital intubation. Again, with no differences between those Successful intubation by whatever route should ideally be
who did or did not receive etomidate, its use was associated confirmed by multiple methods, including the detection of
with a higher incidence of acute respiratory distress syndrome carbon dioxide (CO2) in exhaled breaths. In areas where intu-
(ARDS) and multiple-organ failure, thought to be caused by bation and mechanical ventilation are common, such as the
etomidate's effect on the inflammatory system (inhibition of ED trauma bay or ICU, continuous-waveform capnography
11β-hydroxylase).46 A larger, randomized prospective trial of is highly recommended. For other areas, a disposable CO2
etomidate (234 patients) v ersus ketamine (235) for RSI did not capnometer should be part of the emergency intubation setup.
assess mortality; the primary endpoint was the maximum score Exhalation of CO2 is possible only in patients with a perfus-
of the sequential organ failure assessment (SOFA) during the first ing rhythm; thus, patients with no cardiac output may produce
3 days in the ICU.47 The mean maximum SOFA score between no exhaled CO2. The lack of positive capnometry despite a
the two groups did not differ significantly, but the p
ercentage of properly placed ETT may be the first indication in the field
patients with adrenal insufficiency was significantly higher in or remote setting that cardiac arrest has occurred. Even with
the e tomidate than in the ketamine group. cardiopulmonary resuscitation in progress, the patient may
Succinylcholine is the standard paralytic agent for RSI and still produce little or no detectable CO2. In these patients,
is recommended in the absence of obvious contraindications successful intubation should have been confirmed by initial
(pre-existing neuromuscular disease, known or suspected DL examination, with auscultation confirming bilateral breath
hyperkalemia; burn, spinal cord deficit, or massive mus- sounds, the absence of gastric sounds, the presence of equal
cle trauma occurring more than 24 hours previously; recent chest rise, and misting in the tube, or by the use of an esopha-
prolonged bed-bound status; known history of malignant
geal detector device (EDD). Inspection by repeat DL may also
hyperthermia). Rocuronium or vecuronium can be used in be considered, as opposed to improperly pulling a correctly
place of succinylcholine and will provide similar intubating placed ETT.
conditions and almost the same speed of onset, at the cost of After confirmation of successful intubation, the anesthesi-
greatly prolonged paralysis thereafter.48 ologist in some trauma centers is responsible for assessment
The administration of positive-pressure breaths by BVM of hemodynamic stability after induction, initial ventilator
during RSI is controversial. In trauma cases in which RSI is settings, vascular access, and ongoing sedation and analgesia.
Patient awareness during intubation and mechanical venti-

lation is a significant problem in trauma cases, particularly
when hypotension limits the amount of induction or sedation
agent, and paralytic agents have been used to facilitate diag-
nostic studies or minor procedures. Ketamine, scopolamine,
or small amounts of a benzodiazepine may be considered in
patients at particular risk for awareness. Awareness moni-
tors, such as the Bi-Spectral Index, may be considered in such
cases, although at present these do not constitute the standard
of care and should not interfere with the application of defini-
tive care that will allow adequate levels of sedation. Even if not
directly involved in this phase of care, the anesthesiologist can
contribute substantially to the prevention and recognition of
this problem, as well as to the education of other hospital staff.
Airway and breathing are the first priorities in trauma care,
followed closely by assessment of the circulation—the ABCs.5
The anesthesiologist may share responsibility for hemody-
namic management in the ED with other members of the
trauma team, but in the OR this becomes their primary task.
In the ED the anesthesiologist should be ready to take pri-
mary responsibility for the ABCs if this critical task is being
neglected.
Damage Control and Fluid Resuscitation FIGURE 17-2 Penetrating extremity injury with potential for life-
threatening hemorrhage.
Pathophysiology. Trauma causes disruption of blood ves-
sels of all sizes, and hemorrhage, whether frank and focused or
insidious and diffuse, is a hallmark of trauma. Although low- death. Early diagnosis and control of hemorrhage are essential,
pressure bleeding can be managed expectantly or with sim- but equally important are nonsurgical hemorrhage control
ple techniques, in other trauma patients, active intervention is and ongoing resuscitation, which may be underappreciated.
required to prevent hypovolemia, hypotension, and exsangui- Shock is the term used to describe the complex pathophysi-
nation. Although control of hemorrhage is paramount and may ology that arises from inadequate tissue perfusion (Box 17-4).
be easy to achieve in some injuries, airway management must Shock was first described in trauma patients, in whom hemor-
remain the priority, and practitioners need to avoid d istraction rhage is a common cause.54 Trauma patients may exhibit shock
in completing the ABCs (Fig. 17-2). Uncontrolled, life-threatening caused by an aberration in any or all components of cardiovas-
and noncompressible hemorrhage can occur from venous cular physiology: preload (mechanical impairment of blood
bleeding in “open book” pelvic fractures and in some severe flow, as in tension pneumothorax or cardiac tamponade), con-
liver injuries (Figs. 17-3 and 17-4). Life-threatening hemor- tractility (cardiac dysfunction, as in blunt myocardial injury
rhage occurs into one of five “compartments,” summarized in or secondary to severe TBI, ingestion of toxins, or anesthetic
Table 17-3.7 Although not a complete list, patients with any of overdose), and afterload (spinal cord injury, m edications).
the injuries in Box 17-3 should be considered at high risk of Affecting preload, hemorrhage is considered to be the source
FIGURE 17-3 A, “Open book”

pelvic fracture with disruption
of multiple venous plexuses.
B, External pelvic compression
with a “binder” (a sheet may
also be used) to reapproximate
bone edges and stop
hemorrhage.
A B
BOX 17-4 n SYMPTOMS OF SHOCK
Patient Appearance
Pallor
Diaphoresis
Prolonged capillary refill
Poor skin turgor
Mental status
Agitation, then progressive obtundation
Thirst
Vital Signs
Hypotension (automated devices may be inaccurate)
Narrowed pulse pressure
Tachycardia
Tachypnea
Diminished or absent pulse oximeter signal
Laboratory Signs
FIGURE 17-4 Severe liver laceration. Metabolic acidosis
Elevated serum osmolarity
Elevated serum lactate
Decreased hematocrit (takes time to develop)
TABLE 17-3 n Sites of Exsanguinating Hemorrhage: Coagulopathy
Diagnostic and Therapeutic Options
Diagnostic Therapeutic
Compartment Mechanism Options of shock in all trauma patients until it is definitively ruled out.
Much of the ATLS curriculum is devoted to this important
Chest Auscultation Tube thoracostomy
Chest radiography Exploratory diagnostic and therapeutic process.5
Computed thoracotomy Hemorrhage reduces circulating blood volume, leading to
tomography decreased preload and reduced cardiac output. Vasoconstriction
Abdomen FAST Nonsurgical
and increased inotropy mediated by the sympathetic nervous
Computed management system allow for continued blood flow to vital organs in
tomography Angiographic the presence of blood loss as severe as 40 mL/kg, the cutoff
embolization between a class III and class IV hemorrhage per ATLS guide-
Exploratory lines, or about 2 L of the 5 L of total blood volume in a 70-kg
laparotomy
previously healthy patient. Acute blood loss in excess of this
Retroperitoneum Computed Pelvic stabilization amount causes a critical reduction of perfusion to the heart
tomography Angiographic and brain, manifesting as coma, pulseless electrical a ctivity,
Angiography embolization
and death. Lesser blood loss may also be lethal, p articularly
Thigh or thighs Physical Fracture reduction in elderly patients or those with medical comorbidities,
examination Fracture fixation because reduced perfusion leads to anaerobic metabolism
Radiography Vascular and accumulation of lactic acid and other toxins. Individual
Angiography exploration
cells react to ischemia by hibernation (reduction of all non-
“The street” Physical Direct pressure essential activities), apoptosis (programmed cell death),
(outside the examination Surgical closure or outright necrosis, depending on the organ system in
body) Paramedic report
question.55 Many ischemic cells, especially gut and muscle
FAST, Focused assessment by sonography for trauma. cells, react to ischemia by absorption of e xtracellular fluid56;
this loss of potential circulating volume can be e xacerbated
by overaggressive or repetitive “running of the bowel” by
the surgeon, which also causes edema and dysfunction of
BOX 17-3 n INJURIES ASSOCIATED WITH LIFE-
THREATENING HEMORRHAGE the luminal wall. The end result of this tissue edema is both
locally and systemically disruptive, by clogging capillary
Traumatic aortic injury pathways (no-reflow phenomenon) and further hampering
Inferior vena cava (IVC) injury
autoresuscitation
(reclamation of interstitial volume into
Femoral or iliac artery injuries
High-grade pelvic fractures (“open book”) vascular spaces). Ischemic cells also release inflammatory

Severe pulmonary contusions/lacerations mediators, triggering a chemical cascade that perpetuates the
Amputation pathophysiology of shock long after adequate circulation is
restored.57
The “dose” of shock absorbed by the body, a summa-

TABLE 17-4 n Goals for Fluid Resuscitation during
tion of the depth of hypoperfusion and its duration, largely Active Hemorrhage
determines the patient's clinical outcome, ranging from a mild
inflammatory response to organ system failure to death. The Parameter Goals
typical young male trauma patient has an enormous com-
Total fluids Adequate to prevent worsening of shock
pensatory reserve and may achieve normal pulse and blood
(increasing lactate or base deficit)
pressure while still significantly fluid depleted and highly
vasoconstricted. This phenomenon, known as the occult Vital signs Systolic blood pressure: 80-100 mm Hg
hypoperfusion syndrome, is associated with a high incidence of Heart rate <120 beats/min
Pulse oximeter functioning
organ system failure if not recognized and corrected.58
Isotonic crystalloid infusion increases circulating volume Blood content Hematocrit 20%-30%; higher if risk
and preload, producing an immediate increase in cardiac factors for ischemic coronary disease
Normal prothrombin and partial
output and blood pressure. Volume therapy is a double-edged
thromboplastin time
sword, however, as increased BP before adequate surgical and Platelet count >50,000/mm3
medical hemostasis is achieved can lead to increased bleeding Normal serum ionized calcium
from open vessels and rebleeding from previously h emostatic
Temperature Normal core temperature
injuries (“popping the clot”), in part caused by decreased
blood viscosity and relaxation of compensatory vasonstric- Anesthetic depth Fluid therapy to allow appropriate
tion.59 Further, aggressive crystalloid infusion dilutes red anesthetic and analgesic depth
blood cell (RBC) mass and clotting factor concentration, pos- Overly aggressive resuscitation must be weighed against the risk of
sibly resulting in decreased O2 delivery at the tissue level and exacerbating hemorrhage.
an increase in blood loss, respectively. Unless properly heated,
such infusions may also lead to hypothermia, which should be
catheter) and by immediate and appropriately repeated mea-
cautiously guarded against using fluid warmers and forced-air
surements of arterial blood gases (ABGs), complete blood
warmers. Studies of uncontrolled hemorrhagic shock in rats,60
chemistry, clotting function, and serum lactate determina-
swine,61 sheep,62 and dogs63 have all demonstrated improved
tion. Toxicology screening and electrocardiography may be
survival when initial fluid therapy is titrated to a lower-than-
useful in discovering and addressing underlying reasons for
normal systolic BP (70-80 mm Hg). This finding is supported
suboptimal response to resuscitation. Patients who arrive to
by two human trials.64,65
the hospital with signs of coagulopathy on admission ( elevated
Dilution of RBC mass is inevitable during early resuscita-
activated partial thromboplastin time) have likely developed
tion, because losses to hemorrhage are compounded by intra-
the “acute coagulopathy of trauma” and are at increased
vascular recruitment of extracellular fluid and exogenous
m
ortality risk.67,68
crystalloid administration, the phenomenon of autotransfu-
Response to fluid therapy will provide important diag-
sion. A hematocrit measured soon after hemorrhagic trauma
nostic information. Most patients in shock will demonstrate
may show little change, as whole blood is being lost and the
an improvement in vital signs after bolus fluid administra-
RBC percentage in the remaining volume does not change.
tion. In “responders,” those who have achieved spontaneous
Thus, a stable hematocrit in the face of ongoing loss is mean-
hemostasis (i.e., those with lung injury or peripheral orthope-
ingless information. The longer hemorrhage and resuscita-
dic injuries), the improvement in vital signs will be sustained.
tion persist, the more the hematocrit will fall. Loss of RBCs
“Transient responders,” those with ongoing hemorrhage (e.g.,
leads to decreased blood viscosity, allowing for a compensa-
abdominal visceral trauma, pelvic fracture) will show initial
tory increase in blood flow but a decrease in O2 content, and
improvement in vital signs that decays over about a half hour
tissue O2 delivery begins to decrease. Fluid resuscitation after
and are in need of urgent diagnostic studies and therapeutic
massive hemorrhage will result in extensive hemodilution
procedures. “Nonresponders,” those who do not respond to
and coagulopathy; this hemodilution affects procoagulants
an initial fluid bolus, either have a nonhemorrhagic source of
as well as anticoagulant, profibrinolytic, and antifibrinolytic
shock (e.g., obstruction to venous return to heart, spinal cord
components of the coagulation cascade.66 Factor replacement
injury, cardiac disease) or are bleeding rapidly.
early in resuscitation, with plasma, platelets, and occasionally
The initial choice of crystalloid likely does not matter; it is
cryoprecipitate, may mitigate a severe coagulopathy.
critical, however, to understand the risks and benefits of each
Evaluation. The diagnostic characteristics of hemorrhagic type of fluid infused and, in life-threatening hemorrhage, to
shock and goals for resuscitation are listed in Box 17-4 and begin blood transfusion early. Hemorrhage control depends
Table 17-4. Control of bleeding is the overarching priority in on 13 factors in the coagulation cascade, none of which is
treatment, and nothing must interfere with the indicated diag- contained in crystalloid, packed red blood cells (PRBCs) or
nostic or therapeutic procedures shown in Table 17-3. Relevant in cell-saver blood. Dilutional resuscitation of hemorrhagic
patient physiology is assessed by continuous m easurement of shock with colloid (e.g., hetastarch) or crystalloid reduces the
vital signs (facilitated by early placement of arterial p
ressure concentration of coagulation factors in the circulating blood
volume and impairs hemostasis.69 Resuscitation with normal pressure, prior to hemorrhage control in trauma patients, is
saline results in hyperchloremic acidosis that may be associ- associated with an increase in mortality.78
ated with systemic vasodilation, increased extravascular lung The ability to rapidly administer uncrossmatched type
water, and coagulopathy.70Ringer's lactate became the standard O blood may be lifesaving. Many trauma center blood banks
of care for fluid resuscitation in the 1960s in an effort to replete and EDs maintain a supply for this purpose. Crossmatched
bicarbonate in patients with severe dehydration.71 Ringer's blood, plasma, and platelets should be requested at the earliest
lactate has recently been found to be p roinflammatory and moment that a massive transfusion is anticipated. Additional
to activate neutrophils, which are primary effector cells in personnel, from both the anesthesia and the nursing staff,
reperfusion injury, particularly in the formulations that should be mobilized early to address the multiple needs of
contain the d-lactate isomer (it is not oxidized by l-lactate emergency surgery and resuscitation.
dehydrogenase, and therefore accumulates, and activates High-level trauma centers will maintain a designated trauma
neutrophils).71Plasmalyte is a “balanced physiologic” solution OR that is kept warmed and ready with drugs, IV fluids, and
that contains sodium, potassium, chloride, acetate, gluconate, rapid-infusion devices. As opposed to elective operative cases
and magnesium, but not calcium, and is therefore compati- where the surgery begins after anesthesia has instituted appro-
ble with blood infusions. Small studies in animals have shown priate access and monitoring, the primary goal in treating a
increased mortality with Plasmalyte resuscitation, possibly patient with exsanguination is hemorrhage control; therefore
caused by the peripheral vascular resistance (PVR) effects of it may be necessary for anesthesia access and monitoring to be
magnesium72; no large resuscitation studies have been done. obtained concurrently with surgical intervention.
Although there is no “optimal” crystalloid, these solutions
are still the fluids of choice for initial resuscitation in most Intraoperative Considerations. Resuscitation must be
patients following hemorrhage. The anesthesiologist must carefully choreographed with diagnostic and therapeutic
understand, however, that large volumes of replacement with procedures such that tissue perfusion is optimized without
crystalloid result in distribution throughout the entire extra- unnecessarily large increases in blood pressure that can exac-
cellular compartment, resulting in massive fluid overload and erbate uncontrolled hemorrhage. Recent understanding of
edema, with complications such as acute respiratory failure, the potential for rebleeding and dilution has led to a change
hepatic failure, renal failure, sepsis, and most recently, abdom- away from the traditional ATLS approach of rapid crystalloid
inal compartment syndrome.69 Despite multiple randomized infusion to one of deliberate, controlled fluid administration,
controlled trials (RCTs) comparing albumin and colloids to titrated to specific physiologic end points (see Box 17-4).
crystalloids, no strong data show that colloids are associ- Replacement of RBCs is essential to limiting the severity
ated with improved survival in trauma or burn patients.73 and duration of shock after hemorrhage. PRBCs should be
Multiple studies of hypertonic saline solutions (3%, 5%, 7.5%) administered early in the resuscitative process, using uncross-
for trauma resuscitation have been encouraging, although an matched type O units if necessary. Adverse reaction to this
RCT of 7.5% saline, 7.5% saline/6% dextran, and 0.9% saline therapy is extremely unlikely: more than 100,000 units of
(Resuscitation Outcomes Consortium) failed to show a differ- uncrossmatched blood were administered during the Vietnam
ence in 28-day survival. War without a single documented case of fatal transfusion
Because the civilian community has not yet adopted a reaction, compared with the nine cases that occurred in the
limited-fluid resuscitation strategy as has the military, and 600,000 crossmatched transfusions.79 Immediate transfusion
because clinical trials have shown no significant benefit with of type O blood is sufficiently safe and beneficial that it should
hypertonic fluids, standard use of these fluids cannot be rec- be considered for any patient presenting in extremis from
ommended at this time.74 The recognition that use of fluid hemorrhagic shock. The most appropriate target hematocrit
replacement in severe injuries that was as near to whole for resuscitation must be individualized on the basis of age,
blood as possible (i.e., blood, plasma, and platelets in a 1:1:1 specific injury pattern, pre-existing disease, and the potential
ratio), resulted in increased survival and decreased complica- for further hemorrhage.
tions.75–77 This concept of “damage control resuscitation” has Coagulopathy resulting from acute consumption of coagu-
recently become standard of care. lation factors is likely in any patient losing more than a sin-
gle blood volume (~5 L in 70-kg adult) or receiving more than
Preparation. Resuscitation of the actively hemorrhaging 10 units of RBCs80 (Fig. 17-5). Because coagulopathy is more
patient requires large-bore, high-flow intravenous access, pref- easily prevented than treated, early administration of plasma
erably through at least two separate catheters. Warmed IV flu- to any patient who has lost or will lose this amount of blood
ids are highly recommended, especially early in resuscitation. is highly recommended. Timely initiation of a massive trans-
Commercial fluid-warming technology is highly effective and fusion protocol is associated with improved survival and
should be used as frequently (or more so) in the trauma bay reduced transfusions.81,82 This was first described in military
as in the OR. Rapid infusion systems can warm and deliver resuscitation,83 but it has since also become a standard of care
large volumes quickly and may be lifesaving in the patient at civilian trauma centers.76 This has come to be known as a
with rapid and uncontrolled hemorrhage. However, resuscita- “1:1:1” resuscitation, suggesting that 1 unit of plasma should
tion with a rapid-infusion system targeted to a normal blood be transfused per each RBC unit, and that platelets should be
Coagulation factor concentrates and cryoprecipitate may

not offer a benefit beyond that of plasma infusion in the hem-
orrhaging trauma patient, unless fluid overload is a significant
risk, as in the coagulopathic elderly patient, or the patient is
known to have a specific factor deficiency. In exsanguinating
patients, however, fibrinogen replacement (with cryoprecip-
itate) may enhance clot stability,85 because fibrinogen is the
first coagulation factor to become critically low in patients
with major hemorrhage.86 Anecdotal reports after the early
use of activated recombinant factor VII (rFVIIa) describe
rapid resolution of traumatic coagulopathy after administra-
tion of 20 to 100 units.87 However, the large CONTROL trial,
which randomized patients who had bled 4 to 8 RBC units
to rFVIIa or to placebo, did not show a difference in 30-day
mortality.88 Patients who received rFVIIa had fewer units of
transfused blood overall, and with no increase in thrombotic
complications compared with placebo, it seems safe to use
when indicated.
Electrolyte abnormalities are common during resuscita-
tion from hemorrhage. Hyperosmolarity may result from
alcohol ingestion, dehydration, hypovolemia, or administra-
tion of normal saline (NS). Mild hyperglycemia secondary to
high circulating catecholamine levels is expected. Neither of
these conditions mandates specific treatment during resusci-
FIGURE 17-5 Patient in angiography for traumatic hemorrhage tation, because both will resolve with restoration of adequate
who has developed a dilutional coagulopathy after massive fluid intravascular volume. Hyperchloremic metabolic acidosis is
resuscitation, hypothermia, and acidosis. a significant risk for overresuscitation, especially with mildly
hypertonic solutions such as NS,89 and can be managed with
the titrated addition of hypotonic fluids.
administered similarly (remembering that a “pack” of platelets Hypocalcemia arises from chelation of circulating calcium
is pooled from multiple donors and may represent 4-6 “units”). by the citrate or adenosine additives found in banked blood
Early activation of a massive transfusion protocol is asso- products. IV administration of calcium is indicated in patients
ciated with improved patient survival.45 Plasma should be with low serum Ca++ levels and should be considered for empiric
ordered from the blood bank for any patient presenting emer- administration in the case of massive transfusion, p articularly
gently to the OR with symptoms of acute hemorrhagic shock. in the presence of hemodynamic i nstability. Serum bicarbonate
A ratio of 1:1 replacement of RBCs and plasma is appropri- levels will be lower than normal in the hemorrhaging patient as
ate for any patient who has lost or is likely to lose more than a result of increased lactic acidosis and impaired renal blood
1 blood volume, although this should be guided by clinical flow. Some recommend administration of bicarbonate solutions
assessment and, time permitting, judicious laboratory evalu- to increase systemic pH in acidotic patients, to enhance the
ation. Although concurrent plasma factor replacement with functioning of important protein systems, including coagula-
ongoing blood infusion will promote clot formation, factor tion and catecholamine receptors.90 Bicarbonate also supports
levels (V, VII, VIII, protein S, and von Willebrand) decrease cardiac contractility and can be useful in cardiopulmonary
with storage, so each patient's response will be variable and collapse.91 The clinical utility of bicarbonate therapy, however,
may depend on the age of the blood products.84 Platelet count has never been proved. Vasopressin (antidiuretic hormone) is
usually remains adequate longer than coagulation factors, and emerging as an important advance in the treatment of a variety
platelet therapy is therefore required less often than plasma. of shock states. Plasma levels of vasopressin increase within
Transfused platelets have a very short functional life span in a few minutes of circulatory arrest and also rise in response
the circulation and pose both a significant immune stimulus to hemorrhage, in which endogenous vasopressin release is
and an infective risk. However, factor replacement and platelet an important vasoconstrictor mechanism. Vasopressin does
therapy should not be delayed while awaiting laboratory values not depend on pH for its activity,92 so it would therefore
in patients with exsanguinating hemorrhage. A multicenter offer a theoretic advantage over other vasoactive agents, but
validation of a score to predict which patients will need a mas- there are no large, prospective human trials. Adequate fluid
sive transfusion suggests that penetrating trauma, ED systolic resuscitation remains the primary therapy for restoration of
BP less than 90 mm Hg, heart rate greater than 120 beats/min, normal acid-base status.
and positive FAST score (focused abdominal sonography for Early resuscitation has evolved toward less aggressive fluid
trauma) are indicators of severe hemorrhage.45 administration. Late resuscitation is characterized by the
need to completely restore and support perfusion, usually in A broader military probe in 2010 found that up to half of
the ICU. To do so requires the practitioner to look beyond soldiers with posttraumatic stress disorder (PTSD) or depres-
the vital signs for a more direct measure of tissue perfusion. sion after mild TBI while deployed reported misuse of a lcohol
The speed with which serum lactate level normalizes after or aggressive behaviors (punching, fighting) following their
shock is strongly associated with the risk of death from organ return to society.98 Rates of depression and PTSD were higher
system failure.93 End points of resuscitation should focus on at 12 months than at 3 months after deployment. Many soldiers
organ-specific signs of recovery of function: improved lung do not seek help, but a new U.S. Army program Re-Engineering
function, cardiac contractility, and vasomotor tone; clear- Systems of Primary Care Treatment in the Military (RESPECT-
ance of toxins by the liver and kidney; and absence of infec- MIL) for returning soldiers, families, support systems, and the
tious complications, common after severe traumatic injury. public seeks to decrease the stigma traditionally associated
Although the overall mortality from multiple trauma has with difficulties with reintegration into society.
declined in the past decade, there has been no significant The U.S. National Football League, along with college
decrease in mortality from sepsis after severe trauma. and high school football associations, has also begun a more
Risk factors for posttraumatic sepsis are male gender, age, cautious approach to the management of players with a “con-
pre-existing m edical conditions, Glasgow Coma Scale (GCS) cussion.” Chronic traumatic encephalopathy (CTE), a condi-
score of 8 or less, high injury severity score (ISS), number of tion typically seen in retired or aging athletes, was recently
injuries, n
umber of RBC units transfused, number of surgical reported in a college football player who committed suicide.99
procedures, and laparotomy.94 The diagnosis was unique in two ways: he was the first active
college athlete to be found with the disease, and unlike other
known victims of CTE, he was never diagnosed with a concus-
SPECIFIC CONDITIONS sion. However, this player had been a lineman and a linebacker,
Traumatic Brain Injury positions that typically involve multiple hits to the head d
uring
every game and practice, with estimates of approximately 1000
Traumatic brain injury causes at least half of all deaths from
hits per season or more. CTE is traditionally associated with
trauma.95 As with hemorrhagic shock, the pathophysiology
neurobehavioral disorders and bizarre behavior and is also
of TBI consists of both the primary injury, in which tissue is
called dementia pugilistica, or boxer's dementia. Career box-
disrupted by mechanical force, and a secondary physiologic
ers sustaining repeated blows to the head and concussions
response. Because minimizing secondary injury is critical
may develop the syndrome. CTE is likely caused by large
to outcome, the anesthesiologist plays an important role in
accumulations of tau proteins in the brain that kill cells in the
managing these patients in both the OR and the ICU.
regions responsible for mood, emotion, and executive func-
Pathophysiology. Traumatic brain injury is classified as tioning. Tau proteins are also found in the brains of patients
mild, moderate, or severe, depending on the GCS score on with Alzheimer's disease and dementia.
admission. Mild TBI (GCS score, 13-15) is the most common. Players with mild TBI may be evaluated in the trauma bay
Although mild TBI does not usually necessitate intensive and discharged to home, with no need for anesthesia contact.
treatment, patients may be significantly debilitated by post- However, recognizing the potential long-term c onsequences
concussive symptoms, including headaches, sleep and mem- can be helpful if they present to the OR for other cases,
ory disturbances, and mood swings.96 Progression of mild such as fracture fixation. A systematic review of “brain con-
TBI is rare but may be catastrophic. Research, case reports, cussion” management identified 4319 articles; when the
and media coverage of U.S. soldiers returning from the Iraq search term “mild TBI” was used, 2509 articles were identi-
and Afghanistan wars have highlighted the long-term and fied, and this decreased to 39 articles with “return to play” as
sometimes violent aftereffects of mild TBI that were previ- k eywords.100 Although only few studies address this topic, the
ously underrecognized: depression, mood changes, aggressive Vienna Statement, Prague Statement, American Academy of
behavior, depression, and memory loss.97,98 Neurology, U.S. Team Physician Consensus Statement, and
The most frequently proposed cellular mechanism in mild U.S. National Athletic Trainers Association Position Statement
TBI is diffuse axonal injury (DAI), associated with alterations all agree on the following points:
in many physiologic processes. There is an alteration in
n There should be a period of rest, aerobic exercise, and drills
proteostasis; proteopathy is often evident at the histopatho-
before players with mild TBI return to play (each ~24 hours),
logic level. Here, the pathways of idiopathic and posttraumatic
in addition to evidence of normal cognitive function, and
neurodegeneration apparently overlap, since identical protein
no recurrence of symptoms with exertion.
aggregates accumulate in both conditions. As early as 2 hours
n There is an age-dependent difference in recovery of func-
after severe TBI, increased levels of soluble amyloid-β (Aβ)
tion; highschool athletes take an average of 30 days to
peptide and deposition of amyloid plaques are evident in
recover normal cognitive function, college athletes 7 to
brains of 30% of survivors, regardless of their age. An acute,
10 days, and professional athletes only 3 to 5 days.
single-incident TBI is also found in the history of 20% to 30%
of patients with Alzheimer's disease or parkinsonism, but in Moderate TBI (GCS 9-12) is more likely to be associated
only 8% to 10% of control subjects. with intracranial lesions that require surgical evacuation.
These patients have a higher potential for deterioration and are behavior, the need for diagnostic studies before reaching the
more susceptible to secondary insult if not carefully managed. OR, and the potentially catastrophic consequences of respira-
Severe TBI (GCS ≤8) is a highly lethal condition, often asso- tory depression or pulmonary aspiration. In fact, most patients
ciated with intraparenchymal or intraventricular hemorrhage with moderate or severe TBI will present to the OR having been
or evidence of DAI on cranial CT. Magnetic resonance imag- intubated in the field or ED. There is no consensus on whether
ing (MRI) is more sensitive than CT in the detection of trau- patients with severe TBI should be intubated in the field or
matic brain lesions, especially in nonhemorrhagic DAI.97,101 A in the ED on hospital arrival; studies show improvement with
patient who has a negative brain CT with a poor neurologic each management strategy.106–108 Where intubation occurs
status should be assumed to have DAI, especially without con- likely depends more on the ability of prehospital providers
founding factors such as intoxication or drugs. Patients with to manage an airway acutely, and more importantly, their
severe TBI are usually unable to maintain airway patency training in RSI and access to emergency airway drugs.
and may have diminished or absent respiratory drive, with Arterial pressure monitoring is required for any intra-
inability to protect the airway from aspiration. Most patients cranial procedure, because the dramatic BP swings that can
presenting to the OR will have severe TBI, with elevation of occur throughout such cases need to be closely monitored and
intracranial pressure (ICP) caused by hemorrhage (epidural, limited to the extent possible. Large-bore IV access is neces-
subdural, or intraparenchymal), edema, or both. Failure to sary because blood loss from the open scalp or from the brain
promptly relieve elevated ICP will lead to herniation of brain parenchyma can become excessive, particularly in patients with
tissue, loss of brain blood flow, and death. The surgical goal severe TBI and early onset of coagulopathy. Other m edications
is resolving increased ICP and controlling any active hemor- likely beneficial include induction or maintenance agents such
rhage. Even brief periods of hypotension or hypoxemia can as thiopental, antiepileptics such as phenytoin (Dilantin) or
affect outcomes in head injury.98,102 An investigation of the levetiracetam (Keppra), diuretics such as furosemide (Lasix)
impact on outcome of hypotension (systolic BP <90 mm Hg) or mannitol, and hypertonic saline (HTS). Patients with severe
and hypoxia (Pao2 ≤60 mm Hg or apnea or cyanosis in the TBI should receive a 7-day course of seizure prophylaxis with
field) revealed that these were independently associated with either phenytoin or levetiracetam.102 If not administered in the
significant increases in morbidity and mortality from severe ED, the loading dose needs to be given in the OR. Although
head injury. Hypotension was profoundly detrimental, occur- many clinicians still use mannitol as their osmotic diuretic of
ring in 34.6% of these patients and associated with a 150% choice to decrease ICP, increasing evidence shows that HTS
increase in mortality. solutions are more effective. A meta-analysis of RCTs found
that HTS is more effective than mannitol for the treatment of
Evaluation. Along with imaging studies, the neurologic
elevated ICP.109 HTS can also be effective in lowering ICP after
examination is of critical importance in the preoperative
failure of standard mannitol therapy.110,111 In addition to effects
assessment of the TBI patient. Recovery from TBI is a grad-
of volume expansion, improved cardiac output, improved cere-
ual process. The sedative effects of anesthetic medications may
brospinal fluid (CSF) absorption, and immunomodulation,112
be exaggerated, and the trauma patient will seldom improve
HTS may be superior to mannitol with respect to brain oxy-
immediately at the conclusion of cranial decompression. It
genation and cerebral hemodynamics.110 It is always helpful to
is important to monitor for deterioration in the neurologic
know what therapies a patient has received in the ED or ICU
examination so that critical serial imaging studies and appro-
before coming to the OR.
priate ICU management can commence as soon as possible.
More controversial is the timing of noncranial surgery in
Intraoperative Management. Patients with mild TBI pose
the patient with TBI. Transient hypotension or hypoxemia
few additional anesthetic risks but are more susceptible to the
associated with orthopedic surgery may lead to worsening
effects of sedative medication. Benzodiazepines should be
of neurologic injury, whereas delay in repair of fractures may
used judiciously throughout the perioperative period because
increase the risk of pulmonary complications and sepsis.99,103
they can easily complicate the neurologic examination. The
Although no definitive prospective study has been conducted,
anesthesiologist should strive to have the patient's sensorium
recent retrospective work suggests that early surgery with
as clear as possible as rapidly as possible after any anesthetic.
strict attention to hemodynamic goals does not necessarily
Any change from the patient's preoperative mental status not
worsen TBI.100,104
attributable to anesthetic drugs is an indication for immediate
The anesthesia provider has the responsibility for ensuring
repeat head CT and neurosurgical reassessment.
adequate O2 delivery to the injured brain and the p
enumbra, in
The care of patients with moderate TBI consists of serial
an effort to prevent any further damage. Current Brain Trauma
assessment of neurologic function, with repeat CT at regu-
Foundation guidelines recommend a cerebral perfusion
lar intervals. If close monitoring is not possible, owing to the
pressure (CPP) of 50 to 70 mm Hg; targeting a higher mean
need for general anesthesia or sedating medications, then
arterial pressure (MAP) is associated with a higher incidence
continuous invasive measurement of CPP is indicated.113 An
of ARDS and mortality.101,105
ICP monitor is recommended in any patient with moderate
Preoperative Preparation. Early intubation of the TBI or severe TBI undergoing noncranial surgery likely to last
patient may be required because of combative or agitated longer than 2 hours. Patients with severe TBI are particularly
challenging. Early, rapid focus on restoring systemic homeo- Positional therapy is used in almost every patient with severe
stasis and maximizing perfusion to the injured brain will TBI. Elevation of the head facilitates venous and CSF drainage
produce best possible outcomes. Again, hypoxemia (Pao2
from the cranium, lowering ICP and improving CPP as long
<60 mm Hg) or hypotension (systolic BP <90 mm Hg) in as the patient is euvolemic. Pulmonary v entilation/perfusion
patients with severe TBI is associated with a significant (V/Q) matching may also improve in this position, f acilitating
increase in mortality.102 Management requires a highly skilled maintenance of cerebral O2 delivery. The patient should be
facility, close cooperation among providers, and a stepwise transported to the OR in this position and maintained with
implementation of therapies, as shown in Figure 17-6. the head up during surgery if possible.
Aggressive restoration of intravascular volume is indicated Even in patients with severe TBI, analgesics are indicated
to maintain intracranial perfusion, especially if associated for pain arising from coexisting injuries. Sedatives are use-
pulmonary injuries necessitate the use of high mean air-
ful for control of elevated ICP but may make serial examina-
way pressures to support oxygenation. Hyperventilation, tion difficult. Propofol is popular because it offers the most
previously a mainstay in TBI management for its ability to rapid return of neurologic function when discontinued, but
lower ICP through reduction of intracranial blood flow, is no the clinician must use this drug cautiously. Large doses of
longer appropriate unless the patient shows signs of immi- propofol sustained over days to weeks have recently been
nent brainstem herniation, because this reduction of flow puts associated with the development of lethal rhabdomyolysis,
ischemic brain tissue at further risk for necrosis or apopto- the propofol infusion syndrome.116 This syndrome is more
sis. Hyperventilation is indicated only for patients who pres- common, and should be suspected, in younger patients, those
ent with strong lateralizing signs en route to CT and emergent with severe neurologic injuries, and those who are receiving
decompressive surgery.102 exogenous vasoactive infusions. The use of sedatives to

A systolic BP of 90 mm Hg should be maintained in patients decrease ICP frequently mandates the use of vasoactive drugs
with severe TBI, with MAP of 50 to 70 mm Hg until invasive to maintain MAP. Invasive hemodynamic monitoring with
ICP monitoring can be placed. Previous guidelines suggested a central venous or pulmonary artery (PA) catheter, along
maintenance of CPP at a minimum of 70 mm Hg at all times; with frequent assessment of lactate, base deficit, c ardiac out-
increasing MAP to greater than 70 mm Hg may not improve put, systemic vascular resistance (SVR), and central or mixed
outcome, particularly in patients in whom autoregulation is venous oxygen saturation (Svo2) may be necessary to main-
lost.102 Contrary to past practice, the patient with severe TBI tain appropriate intravascular volume in the presence of
should be maintained in a euvolemic state. Fluid resuscitation the confounding parameters of ongoing shock physiology,
is the mainstay of therapy, followed by vasoactive infusions as pharmacologic agents, and mechanical ventilation.
needed. Controversy surrounds the appropriate “transfusion Osmotic diuretic agents are common first-line agents for
trigger” in patients with severe TBI, and whether these patients severe TBI. Mannitol decreases ICP by drawing edema fluid
should be treated as other critically ill patients in whom a out of brain tissue and into the circulation. Mannitol may
hemoglobin (Hb) concentration of 7 g/dL is a proven trigger. also have a secondary benefit as a scavenger of free radicals
Many neurosurgeons prefer an Hb level closer to 10 g/dL and other harmful inflammatory compounds. Hypertonic
in severe TBI patients, but the most recent data suggest that saline has a similar osmotic effect on the brain, aids in the
blood transfusion itself, rather than the actual Hb value, is repletion of circulating volume, and may also act as a benefi-
associated with a worse long-term functional outcome.114 cial immunologic agent. Use of mannitol or HTS will lead to
Several studies investigating the association of anemia with increased diuresis, necessitating greater attention to adequate
outcome in patients with severe TBI have used Hb of 10 g/dL volume replacement so that euvolemia can be maintained. Use
to define “anemia,” although a few studies used 8 g/dL and one of osmotic agents to reduce elevated ICP is usually titrated to a
used 9 g/dL.115 Thus the appropriate trigger for these patients serum osmolarity of about 310 to 320 mOsm/L.
is unclear, and monitoring of cerebral oxygenation may be a Invasive physiologic monitoring, positional therapy,
more appropriate end point. sedation, and osmotic diuresis apply to most patients with
If surgery is indicated, special care should be taken with severe TBI,113 but the next tier of therapy is reserved for the
the ventriculostomy drain; both failure of drainage and exces- subset with intractable ICP elevation. A small percentage may
sive loss of CSF can occur during transport. Familiarity with respond to barbiturate coma, which not only lowers cerebral
advanced tissue oxygenation monitors, such as those mea- metabolic rate but also decreases excitatory neurotransmit-
suring brain tissue oxygen delivery (Pbro2) and oxygen ters.117 Management of barbiturate coma necessitates rigorous
consumption (the jugular bulb) (Sjvo2) levels can also be attention to intravascular volume, usually requiring a PA
beneficial. There is an association of poor outcomes with low catheter and the use of vasoactive and inotropic agents to
Pbro2 (<15 mm Hg), but it is unclear if higher Pbro2 l evels maintain CPP.
correlate with improved outcomes. Until there is consensus, Decompressive craniectomy is gaining increasing accep-
it is recommended to maintain Pbro2 above 20 mm Hg by tance in the management of intractable ICP elevation.
decreasing O2 demand of the brain (decrease ICP, administer Relieving pressure by removal of a piece of cranium and
analgesia, treat hyperthermia) or by increasing O2 supply to closure with a dural patch may improve outcomes in patients
the brain (increase cardiac output, transfuse RBCs).102 who might not otherwise survive.118 Randomized studies for
Establish airway, breathing, and circulation

Ventilate to maintain PaCO2 of 35 mm Hg
Provide supplemental O2 to keep PaO2 of
90–120 mm Hg or Spo2 95%
Maintain normothermia
Elevate head of bed to optimize CPP and minimize ICP
Reduce unnecessary noxious stimuli
Maintain systolic BP 90 mm Hg
Insert intraparenchymal or IVC
with transducer leveled at the
ICP monitor
phlebostatic axis
Utilize attached protocol to
manage hemodynamic status
Maintain CPP 65 mm Hg
Keep Hct 30%–33%
Maintain serum sodium
140–145 mg/dL
Intracranial hypertension? No
Obtain bedside lower extremity
duplex Doppler ultrasound 20 mm Hg
24 hours after admission and
weekly thereafter. Yes
Administer sedation (see algorithm)

Consider repeating a brain CT scan
Carefully
Intracranial hypertension? No remove
20 mm Hg treatment
for ICP
Yes
Insert IVC and drain CSF

20 mm Hg
Hyperventilation to PaCO2 of 30–35 mm Hg

20 mm Hg
Yes
Mannitol 0.25–1.0 g/kg and/or hypertonic saline

(3% or 7.5% [50% chloride and 50% acetate])
Maintain serum Osmo 320 mOsm/L and
keep patient euvolemic
Intracranial hypertension? No Carefully

20 mm Hg remove
treatment
Yes for ICP
Consider repeating brain CT scan

Other second-tier therapies
Decompressive High dose Hyperventilation to PaCO2

craniectomy barbiturate therapy 30 mm Hg
Monitoring Sjvo2, AvjDO2, PbrO2
and/or CBF recommended
FIGURE 17-6 Critical pathway for treatment of cerebral perfusion pressure (CPP). For patients with severe traumatic brain injury.
BP, Blood pressure; Hct, hematocrit; ICP, intracranial pressure; IVC, intravenous catheter; CT, computed tomography; CSF, cerebrospinal
fluid; CBF, cerebral blood flow; Pbro2, brain tissue oxygen delivery; Sjvo2, oxygen consumption (jugular venous bulb); Avjdo2, arteriojugular
venous difference of oxygen.
decompression therapy after TBI have required years of sub- These inflammatory mediators probably play a large part in
ject recruitment, and although some show decreased ICP, the development of nonneurologic organ dysfunction. Of 209
mechanical v entilation, and ICU stay, long-term outcome (at consecutive multiple-trauma patients with severe TBI who
6 months) is not improved.119 Craniectomy will likely remain required more than 48 hours of intensive care management,
the procedure of choice for mass lesions, but for diffuse injury, 89% developed dysfunction of at least one nonneurologic
it is still not known which patients will and will not benefit organ system. Respiratory dysfunction was most common
from decompression. Decompressive laparotomy may also be (81%), followed by cardiovascular (52%). Although seen in
indicated in patients with severe TBI if coexisting injuries or smaller percentages of patients, hematologic (36%), hepatic
vigorous volume infusion have increased intra-abdominal (8%), and renal (7%) dysfunction were also present.127 More
compartment pressure to greater than 20 mm Hg,120 a level importantly, hospital mortality in this study was associated
likely to have adverse effects on intrathoracic, inspiratory, and with organ system failures: 26% for patients without nonneu-
intracranial pressures. rologic organ system failure, 40% for those with one organ
Although vigorous avoidance of fever is an undisputed rec- system failure, 47% for two failures, and 100% in the small
ommendation, deliberate hypothermia to reduce the cerebral proportion of patients with three or more nonneurologic
metabolic rate remains controversial121 and is not currently organ failures.127
recommended. Corticosteroid therapy for severe TBI has not Spinal cord injury (SCI) is also associated with multior-
proved beneficial and is now contraindicated because of its gan failure. In a retrospective review over 15 months, of 1028
high potential for deleterious side effects.102 patients admitted with SCI, 40 were identified with isolated
More recently, the clinical picture of “sympathetic storm” injury and ICU stay longer than 24 hours (AIS >3, with other
(also known as “brain storming”) has been described. Typically organs excluded). “Organ failure,” defined as failure in at least
seen in younger patients with more severe TBI, but possible at one organ system, occurred in 75% of patients by multiple-
all ages, “storming” is caused by massive catecholamine release. organ dysfunction score (MODS) criteria and 85% of patients
This was initially recognized in patients with nontraumatic by sequential organ failure assessment (SOFA) scoring.128
subarachnoid hemorrhage (SAH),122 but storming has since There was an inverse correlation between the American Spinal
been appreciated in patients with TBI. Patients with severe Injury Association (ASIA) score, which defines the motor and
TBI manifest a hyperadrenergic state with adrenal release of sensory level of injury, and MODS/SOFA scores. Patients with
catecholamines and clinically as tachycardia, hypertension, more severe (higher level or complete) SCI may therefore
tachypnea, mydriasis, and diaphoresis. They may have a greater benefit from the specialized care of traumatic SCI units and
than sevenfold increase in norepinephrine, epinephrine, and rehabilitation centers.
metabolites. Most pronounced after the first week of injury,
treatment of storming in patients with TBI c onsists of organ
system support and may require extreme measures, including Spinal Cord Injury
extracorporeal circulation.123,124 TBI should not be considered
Pathophysiology. Spinal cord injury (SCI) with complete
to be a contraindication to extracorporeal m odalities, as long
or partial neurologic deficit occurs in approximately 8000
as exquisite attention is paid to the risks of bleeding and local
Americans each year.129 High-energy falls or motor vehicle
anticoagulation of the circuit.125,126
crashes (MVCs) cause the majority of serious SCIs. Incomplete
A less aggressive treatment available in all hospitals is the use
deficits, sometimes referred to as “stingers,” typically resolve
of beta-adrenergic blockade to decrease the sympathetic out-
within hours to days. Complete deficits imply a total disrup-
flow and to mitigate symptoms. A retrospective review stud-
tion of the spinal cord and are much less likely to improve over
ied trauma patients with an abbreviated injury score (AIS) of 3
time. Cervical spine injuries causing quadriplegia are accom-
or greater who received β-blockade over a 14-month period.45
panied by significant hypotension as a result of inappropriate
“Beta-blocker exposure” was defined as having received
vasodilation and loss of cardiac inotropy (neurogenic shock).
β-blockers for 2 or more days. Of the 420 study patients, the
Autonomous functioning of the lower cord will return over
174 who received β-blocker therapy had a slightly higher
days to weeks, with restoration of autonomic innervation and
injury severity, with predicted survival of 59.1% and actual
vascular tone, but without sensory or motor transmission.
survival of 94.9%; patients who did not receive β-blockers
Patterns of spinal cord fracture are described in Table 17-5
had predicted survival of 70.3% and actual survival of 80.2%.
(see also Orthopedic Injuries later).
Therefore the patients who received β-blockers, despite their
severe injuries, had 5.1% mortality, versus 10.8% mortality in Evaluation. Early intubation is almost universally required
those who did not receive β-blockers. Randomized prospec- for patients with cervical spine fracture and quadriplegia,
tive trials are needed to further elucidate this treatment. because diaphragmatic function will cease in patients with
Multiple-organ failure associated with neurologic injury a deficit above C4. Patients with deficits ranging from C4
is increasingly recognized as a sequela of the initial insult. to C7 are likely to require early intubation due to the loss of
Neuroinflammation may be an important mediator of chest wall innervation, paradoxical and inefficient respiratory
secondary injury; patients with TBI have elevated CSF
mechanics, and the inability to adequately clear secretions.
cytokine levels, with systemic delivery of these cytokines. A retrospective review over 2 years of patients with cervical
TABLE 17-5 n Types of Spinal Cord Fracture
Type Description
Upper cervical spine Usually fatal; considered to be unstable in survivors; Jefferson, hangman's, and odontoid fractures
(occiput to C2)
Lower cervical spine Flexion with axial loading produces vertebral body compression fractures with possible displacement of
(C3 to T1) fragments; often with ligamentous injury; involvement with posterior elements can cause
unilateral or bilateral jumped facets
Thoracic spine (T2-T10) Flexion-extension injuries most common; with axial loading can produce burst fracture;
displacement of fragments into canal frequently associated with complete cord injury secondary
to smaller canal
Lumbar spine (T11-L1) Classified by mechanism: compression fracture with flexion, burst fracture with axial loading, transverse
process fracture, flexion-distraction injury, shear injury
Lower lumbar and sacral Uncommon injuries; can occur with hyperflexion and axial loading; longitudinal sacral fracture may have
spine sacral spine radiculopathy, whereas horizontal fracture associated with injury to cauda equina
Ligamentous injury without Plain radiographs with no evidence of bony injury do not preclude ligamentous injury; may be unstable
bony injury without bony injury and produce subsequent neurologic injury
SCI and neurologic deficit identified 119 patients, 45 with by orthopedic or neurosurgical specialists; this process often
complete SCI; 12 (27%) had C1 to C4 deficits, 19 (42%) had takes days to complete.132 Obtunded patients with gross move-
C5, and 14 (31%) had C6 and below.130 Of 37 survivors, 92% ment of all extremities may be cleared by CT scan.133 Insistence
were intubated, 81% progressed to tracheostomy, and 51% by the anesthesiologist on definitive clearance of cervical spine
were on mechanical ventilation at discharge. All patients with injury before proceeding with urgent or semiurgent surgery is
complete injuries at C5 and above required tracheostomy, and not reasonable, possibly exposing the patient to the risk of pul-
71% of survivors were ventilated at discharge. However, only monary complications posed by leaving underlying orthope-
35% of patients with incomplete SCI required intubation. dic injuries unaddressed. For lower-risk cervical spine injuries
Atelectasis will develop quickly as a result of supine position- and for patients who are uncooperative or hemodynamically
ing and lack of diaphragmatic and intercostal muscle function, unstable, the preferred approach is RSI with maintenance of
leading to rapid, progressive desaturation. Recurrent pneumo- manual in-line axial stabilization throughout the procedure.
nia is a common complication that may often require trache- The safety record of this approach is impressive.14
ostomy in half of all patients with complete deficits at the C5
Intraoperative Management. For the cooperative patient
to C7 level. Patients with complete motor deficits at C5 and
with a known or probable injury (existing deficit, suspi-
above (ASIA “A” classification) will likely require intubation and
cious radiographs, or substantial neck pain), maintaining
tracheostomy before hospital discharge,131 and early, controlled
the patient in a rigid collar, cervical traction, or halo brace
intubation in the trauma bay or OR should be performed.
while performing an awake fiberoptic intubation is both safe
Preoperative Preparation. The urgency of surgical stabili- and common practice. When awake intubation is elected, the
zation of the spine is determined by the anatomic and neuro- nasal route is usually easier; as after serial dilation of the nos-
logic presentation. A patient with a partial deficit and visible tril, a nasal tube may be inserted to the level of the orophar-
spinal canal impingement on imaging studies is considered an ynx, even before fiberscopic visualization is attempted, and
emergency because of the potential for regaining neurologic will likely be in optimal position to find the trachea fiber-
function after decompression. Patients with either no deficit optically. Oral intubation is more challenging technically
or complete deficit may require surgical stabilization to facili- because of the greater pharyngeal anesthesia requirement and
tate mobilization, but are less urgent cases. Surgery is required the need to negotiate not only the tongue but also the more
more often for cervical lesions, whereas supportive bracing of severe angle between the oral cavity and the trachea. It is bet-
the torso is more common for thoracic and lumbar fractures. ter if the patient remains intubated postoperatively because
Determining cervical spine stability can be complicated this reduces risk of sinusitis.134 However, blind nasal or d igital
and time-consuming, and many trauma patients who present intubation, transillumination with the light wand, use of an
to the ED with a rigid cervical collar still in place may main- intubating LMA (e.g., Fastrach) or Bullard laryngoscope,
tain it for some time until cervical spine clearance. Protocols video laryngoscope (e.g., Glidescope), and other systems for
to rule out instability of the cervical spine are controversial indirect laryngoscopy are acceptable per clinical preference.
and often institution specific and may include plain films, As long as tracheal intubation is obtained with the least possi-
CT, flexion-extension radiography, MRI, and examination ble motion of the cervical spine, while preserving the ability to
assess neurologic function after intubation and patient posi- Pathophysiology. Types of ocular trauma are listed in
tioning, the goals of this procedure will have been achieved; Box 17-5. Severe blunt injury to the globe and orbit can cause
anesthetizing clinicians should therefore use their preferred damage to all of the ocular tissue. Force directed against the
technique. globe pushes it back into the orbit, resulting in compression,
Hemodynamic instability may complicate urgent and emer- stretching, and disruption of the softer tissues lining the eye.
gent spinal surgery. Hypotension from neurogenic shock is The thin, bony medial wall and floor of the orbit are prone
characterized by an inappropriate bradycardia due to loss to translation away from the orbit, producing the “blow-
of cardiac accelerator function and unopposed parasympa- out” fracture. Such fractures typically do not require emer-
thetic tone. However, this situation can still be difficult to dis- gent surgery unless there is an open globe or there is actual
tinguish from hypotension caused by acute hemorrhage, and or impending visual loss. With penetrating injuries of the
a trial of fluid administration is still indicated, subject to the eye, closure of the laceration is the primary surgical goal
end points of resuscitation listed earlier. Once hemorrhage has because of concerns about infection and loss of intraocular
been controlled or ruled out, some support exists for mainte- contents, particularly from the posterior segment. Prognosis
nance of an elevated MAP (>85 mm Hg) for 7 days after SCI, for p
enetrating eye injuries is related to many factors, includ-
although this approach is highly controversial.135 Fluid admin- ing initial visual acuity, type and extent of injury, presence of
istration will expand the vascular volume and counter the retinal detachment, and presence of foreign bodies.
effects of inappropriate vasodilation, but volume loading may
Evaluation. Preoperative documentation of visual func-
exacerbate myocardial dysfunction (from SCI, blunt trauma, or
tion and degree of visual loss is important and may affect sub-
pre-existing cardiac disease). Any patient with a poor response
sequent decisions and timing of surgery. The examination
to initial volume loading, particularly the elderly patient, should
should be as complete as practical, but any examination that
be considered for PA catheterization or echocardiographic
risks further injury to the globe should be avoided. Because
examination to guide subsequent resuscitation.
many ocular injuries are accompanied by head and neck
Almost all patients with a persistent deficit after blunt SCI
trauma, a thorough examination, including imaging, should
will be treated with high doses of methylprednisolone in the
evaluate both intraocular and periocular structures. CT may
days after surgery.136 Although this therapy is controversial
also show whether a patient has sustained an intracranial
and the expected benefit is slight, no other alternatives are
injury, such as subdural hemorrhage. Although CT provides
presently available. Improved sensory and motor function can
a helpful adjunct in penetrating ocular trauma, it may not be
be demonstrated if methylprednisolone therapy is initiated
sensitive enough to be the sole means of evaluating a potential
within 3 hours after injury. Less benefit is achieved if initi-
open-globe injury.
ated 3 to 8 hours after injury (after return of full nerve root
level or minor improvement in sensation). There is no b enefit,
and a potential for an increase in complications (infection,
pneumonia), if initiated after 8 hours.137,138 BOX 17-5 n TYPES OF OCULAR TRAUMA
If initiated, corticosteroid infusions should be continued Periocular
during surgical interventions, and the clinician should be Ecchymosis
wary of the development of corticosteroid-related side effects, Lid laceration
including hyperglycemia, adrenocortical insufficiency, gastric Orbital
ulceration, and occult infections. Facial fracture
Autonomic hyperreflexia develops in 85% of patients with Retrobulbar hemorrhage
Traumatic optic neuropathy
a complete injury above T5, resulting from the loss of inhibi-
tory control of vascular reflexes.139 This condition mandates Superficial Ocular
Corneal abrasion
general or regional anesthesia for any subsequent surgery in
Foreign body
a quadriplegic or high-paraplegic patient, even if the planned Chemical injury
procedure is in an insensate region. Thermal injury
Infection
Ocular Trauma Closed Globe

Iritis
Ocular trauma, both penetrating and nonpenetrating, is Iris injury
an important cause of visual loss and disability, with up to Retinal damage
Traumatic cataract
90,000 injuries per year in the United States resulting in Subchoroidal hemorrhage
some degree of visual impairment.140 Many patients with Lens subluxation
severe ocular injuries have concomitant head and neck
Open Globe
trauma that may delay recognition and complete evaluation Globe rupture
of these problems. With current diagnostic methods, surgi- Laceration
cal techniques, and rehabilitation, vision can be salvaged in Penetrating foreign body
many patients.
Preoperative Preparation. Once a known or suspected structures of the eye and orbit and a low risk for extrusion
globe injury has been identified, it becomes important to of intraocular contents, regional anesthesia or local anesthe-
avoid significant increases in intraocular pressure (IOP), as sia with sedation may be adequate. Given patient positioning
may occur during coughing, bucking, straining, or a Valsalva (head draped and airway inaccessible), the risk of overseda-
maneuver. This may require the judicious use of sedation and aspiration must be considered. General anesthesia is
tives, narcotics, and antiemetics in the preoperative period. indicated for severe lacerating injuries, pediatric patients, or
Additionally, the open globe should be protected with a shield, uncooperative patients (anxiety, intoxication), providing an
and because a penetrating injury may be infected with not immobile eye while allowing for maximal control of factors
only skin flora but also Pseudomonas, Bacillus, and anaerobic affecting IOP. During use of any face mask, particular care
species, broad-spectrum antibiotics (e.g., cephalosporin and must be taken not to apply direct pressure to the globe.
aminoglycoside) should be considered as well. Optimal timing Choices of muscle relaxants in open-globe injuries have
for surgical interventions is based on concomitant injuries, proved controversial. Succinylcholine, which can cause
coexisting disease (including pre-existing eye conditions), and contraction of extraocular muscles and choroidal conges-

surgical factors (Table 17-6). Many open-globe injuries occur tion, has been shown to produce slight, transient increases
in children, and specific pediatric considerations should not in IOP during a standard induction. When given without
be neglected in their management.141 IV or inhalational anesthetics, the IOP rise can be as high as
18 mm Hg.142 Typically, however, IOP increase is 2 to 5 mm
Intraoperative Considerations. Management objectives of
Hg with appropriate induction.143 A review of succinylcho-
the open globe include (1) overall patient safety, (2) avoidance
line use in open-globe injuries cited only anecdotal associated
of elevated IOP, (3) provision of a stable operative field, (4)
v itreous loss.144 Further, despite a lack of RCTs, several case
avoidance of external ocular pressure, and (5) minimization
series and animal studies have failed to demonstrate extru-
of bleeding. With most trauma patients, a full stomach must
sion of contents after succinylcholine use, if defasciculating
be assumed, making RSI the technique of choice. As long as a
pretreatment with a nondepolarizing muscle blocker was first
deep level of anesthesia is provided before laryngoscopy, intu-
employed.145,146 Thus, provided a small dose of a nondepolariz-
bation, and any resultant IOP rise, any IV agent except ket-
ing muscle relaxant precedes it to blunt the expected increase
amine is acceptable. General anesthesia is safe, effective, and
in IOP, the use of succinylcholine should be dictated by the
used most often in the repair of penetrating eye injuries; how-
need for rapid onset and termination of muscle relaxation,
ever, in the cooperative patient with injury limited to external
rather than by any concerns about loss of ocular contents.
The use of IV lidocaine, β-blockers, and short-acting narcot-
ics 3 to 5 minutes before induction may similarly be useful to
TABLE 17-6 n Timing of Intervention in Various Forms blunt the increase in heart rate, BP, and IOP associated with
of Ocular Trauma
laryngoscopy and intubation.147,148
Timing Condition After induction and intubation, deep anesthesia with a
combination of narcotics, inhalational agents, and m uscle relax-
Absolute emergency Chemical injury (alkali > acid) ants will reduce extraocular pressure and choroidal congestion
Threat of gas gangrene by eliminating coughing, straining, or m ovement. Although
Orbital abscess
Expulsive choroidal hemorrhage
occurring infrequently during repair of eye lacerations, the
extruding intraocular tissues oculocardiac reflex (severe bradycardia or a systole) may occur
through open wound during manipulation of the globe. Whereas successful place-
Vision loss because of expanding ment of a retrobulbar block will abolish or prevent this reflex,
orbital hemorrhage it should not be used with a potential open-globe injury. If
Urgent Endophthalmitis possible, maintenance of a head-up position will facilitate
High-risk intraocular foreign body venous drainage.
Within 24 hours Open wounds requiring surgical
As with induction and intubation, an increase in IOP is
closure also possible during emergence and extubation. Although less
Intraocular foreign body concern exists about loss of intraocular contents than before
globe repair, the associated straining, emesis, coughing, and
Within a few days Thick, submacular hemorrhage
(24-72 hours agitation may increase the risk of bleeding and adversely
preferred) affect surgical outcome. Placing an orogastric tube, suctioning
gastric contents, and giving a promotility agent can increase
Within 2 weeks Intraocular foreign body
Secondary reconstruction if retina is
the safety of deep extubation but cannot completely obviate
detached the aspiration risk associated with this t echnique. Whether or
Media opacity in the amblyopic age not an awake extubation is p ursued, appropriate antiemetic
group therapy is indicated along with narcotics for pain manage-
Modified from Kuhn F: Strategic thinking in eye trauma management, ment. Postoperative shivering should also be avoided and can
Ophthalmol Clin North Am 15:171-177, 2002. be treated with small doses of meperidine or propofol.
Complex Facial Injuries greater is the severity of the resultant fracture. With gunshot
wounds, damage severity is directly related to the velocity of
Although often gruesome in appearance and frequently dis-
the projectile. Fortunately, the structure of the midfacial skel-
tracting to practitioners who should remained focused on the
eton provides some buttressing and protection for the brain,
ABCDE priorities of the primary survey, severe maxillofacial
while the thinner, laminar bones on the periphery serve as
trauma is only life threatening if there is significant involve-
“crumple zones,” allowing for dispersal of force, which reduces
ment of the airway or severe concomitant hemorrhage. The
energy transmission to more vital structures.153,154
face and head are exposed to a broad range of physical trauma
The face can be divided into three anatomic regions. The lower
(Box 17-6). An estimated 3 million patients require hospital
third consists of the mandible, the temporomandibular joint
treatment for facial injuries every year from MVCs alone.149
(TMJ), and the coronoid process. The middle third comprises
Beyond airway and bleeding problems, severe ocular, nasal,
the maxilla, nasal bones, orbits, and zygomatic arch. The upper
jaw, and cosmetic deformities are potential consequences. The
third contains the frontal bone, frontal sinuses, frontozygomatic
anesthesiologist must be not only aware of all injuries but also
process, and nasoethmoidal complex. Table 17-7 summarizes
familiar with typical treatment plans to ensure appropriate
signs, symptoms, and long-term c omplications associated with
emergent management and optimize surgical correction.
facial fractures in these areas. Along with soft tissue injuries, this
Pathophysiology. The type and severity of facial injury are provides a framework for classification of facial injuries.
determined by the mechanism of injury; the extent, direction, Soft tissue injuries range from minor to severe, including
and duration of force; and the characteristics of the impacted contusions, abrasions, punctures, lacerations, avulsion flaps,
facial structures. Significant bony disruption may be masked
by only modest soft tissue injury; similarly, dramatic soft tis-
sue swelling may occur without any fractures. Each of the
major mechanisms of injury produces distinctive patterns of TABLE 17-7 n Types of Facial Fractures
injury and mandates a search for likely associated trauma.
Long-Term
Massive blunt trauma typically presents with more obvious Type Signs and Symptoms Complications
effects on the facial skeleton than on soft tissue. In cases of
assault or sports-related blunt trauma, edema and hematoma Nasal Pain, obstruction, Malunion,
may be the only soft tissue findings, while significant facial crepitus, swelling, obstruction
epistaxis
fractures lie underneath. Patients involved in MVCs pre-
senting with significant facial trauma should be presumed to Naso-orbital, Pain, obstruction, Malunion,
have both TBI and cervical injury150 until proved otherwise. ethmoid crepitus, swelling, telecanthus
Penetrating trauma from close range (e.g., shotgun, rifle, high- epistaxis
velocity projectile), may result in massive soft tissue loss and Frontal sinus Pain, epistaxis Mucopyocele
facial destruction. Burns can result in progressive cutaneous
Zygomatic arch Lateral pain, trismus, Unstable,
and mucosal edema, which can lead to sudden airway com- asymmetry, lateral recurrent
promise. Early intubation, before swelling produces an airway depression depression
emergency, is often the best approach in dealing with impend-
Zygoma Numb cheek and/or Asymmetry,
ing airway compromise (see Chapter 18).
lip, visual change, entrapment,
The force vectors applied to facial structures determines swelling entrapment, enophthalmos
fracture location. Given that lower forces are required to frac- scleral hemorrhage, associated
ture the thinner nasal bones—zygoma, frontal sinus, and man- epistaxis, step-off, globe injury
dibular ramus—compared with other facial bones, these are enophthalmos,
the most common sites of injury.151,152 As expected with blunt Orbital blowout scleral hemorrhage, Entrapment,
trauma, the greater the energy transferred on impact, the epistaxis, step-off, enophthalmos
enophthalmos,
Le Fort Malocclusion, trismus, Malocclusion,

BOX 17-6 n MAJOR CAUSES OF FACIAL INJURIES numbness, visual malunion,
changes, massive dental loss,
Vehicle crash: motorized and nonmotorized swelling, epistaxis, asymmetry,
Pedestrian accident scleral hemorrhage lacrimal
Industrial accident midface mobility obstruction
Violence
Blunt force such as fist or club Mandible Lower lip numbness, Malocclusion,
Penetrating such as knife or gunshot trismus, pain referred malunion,
Sports to ear, crepitus, osteomyelitis,
Falls malocclusion, ankylosis, dental
Thermal injury open bite loss, nerve injury
Chemical injury Modified from Darian VB: Maxillofacial trauma. In Trunkey DD, Lewis FR, editors:
Current therapy of trauma, ed 4, St Louis, 1999, Mosby.
and frank tissue loss. Early management usually consists of life-threatening problems and complete assessment of
of debridement, conversion of unfavorable wounds to more emergent injuries. Upper and occasionally lower air-
favorable wounds (with acceptable cosmetic appearance),
way obstruction can occur with facial trauma, necessitating
and meticulous closure. Careful examination and multidis- a detailed evaluation of the airway and careful, continuous
ciplinary management may be required for injuries involving monitoring for impending compromise. Patients with multiple
important structures, such as the facial nerve, parotid gland, mandibular fractures or combined maxillary, mandibular, and
and lacrimal apparatus. Lacerations in the vicinity of the zygo- nasal fractures are more likely to obstruct early. Mandibular
matic arch may include injury to the frontal branch of the fractures disrupt the support structure of the tongue and the
facial nerve. Large hematomas, particularly those involving floor of the mouth, permitting posterior displacement and
the nasal septum and auricular cartilage, may require drain- easy airway compromise. Obstruction of the nasopharynx
age to prevent infection, necrosis of underlying cartilaginous may occur with some midface fractures. Although mouth
structures, and subsequent cosmetic deformity.155 breathing will still be possible in these patients, impaired con-
Mandibular fractures are the second most common form sciousness can contribute to obstruction. Alternatively, swell-
of facial fracture after fractures of the nasal bones. More than ing of the tongue, pharynx, palate, or floor of the mouth from
50% of mandible fractures are composed of two or more frac- trauma or burns may allow progressive occlusion.
ture locations, so additional fracture sites should be highly Diagnosis of facial injuries is typically accomplished by his-
suspected whenever the mandible is evaluated.155 The strong tory, physical examination, and radiographic analysis. Careful
jaw musculature attached to the mandible tends to displace observation for abnormalities in soft tissue f ullness, facial sym-
fracture fragments laterally, leading to asymmetry, maloc- metry, gross skeletal shape, eye movements, and alterations in
clusion, and even airway compromise. Midface fractures may muscle tone should be documented precisely. Palpation may
affect the nasal, maxillary, orbital, and zygomatic arch struc- reveal pain, crepitus, numbness, and deformity. Malocclusion
tures. Again, the nasal bones are the most frequently injured is an important sign of maxillofacial fracture. Any limitation
facial bones. Disruption of the nasal septum may result in of or pain with mouth opening should be ascertained, and
local airway obstruction as well as significant hemorrhage that mechanical causes versus pain or spasm should be differen-
can complicate global airway management. tiated. Anesthetics and muscle relaxants can relieve spasm or
The classic midface fractures as described by Rene Le Fort trismus, but inappropriate use in the patient with mechani-
in 1902 are the Le Fort I (horizontal dentoalveolar separation), cal obstruction may lead to airway loss and even inability to
Le Fort II (pyramidal or triangular separation of maxilla and perform direct laryngoscopy. Finally, loose or missing teeth,
zygoma with a central fragment consisting of maxillary alveo- tongue mobility, and source of hemorrhage should be noted.
lus, medial orbital wall, and nose), and Le Fort III (complete Blunt trauma causing facial injury should raise suspicion
dislocation of facial and cranial skeletons running parallel to for concomitant cervical spine and closed-head injury.150,151
skull base and involving ethmoid bones and cribriform plate, Extreme care should be taken in the airway management
allowing a compromised anterior cranial fossa). The presence of patients such that SCI is avoided. Radiographic analysis,
of clear rhinorrhea may constitute CSF and should raise sus- including plain films and CT, are essential in evaluating the
picion of a cribriform plate or basilar skull fracture; however, extent of facial injuries. Imaging studies also provide imme-
absence of this rhinorrhea does not rule out these injuries. diate information on associated intracranial and cervical
Although useful in describing a midface fracture, these classic injuries, and their judicious use can efficiently inform both
patterns rarely are identified in isolation. Le Fort fractures are anesthetic and surgical management.
rarely bilateral, may be seen in combination with other facial
Preoperative Preparation. The majority of penetrat-
fractures, and are obscured by soft tissue injury.
ing facial injuries will require urgent exploration. However,
Zygomatic arch fractures are caused by blows to the lat-
the timing of surgical repair of blunt facial injuries depends
eral aspect of the midface. Trismus may result from masseter
on associated injuries, extent of soft tissue damage, edema,
muscle hematoma or direct mechanical impingement of arch
and overall patient condition. Definitive repair is sometimes
fragments on the coronoid process of the mandible. Fractures
undertaken shortly after the injury, particularly if associated
of the zygoma and orbital walls may allow entrapment of the
injuries require surgical intervention. However, definitive
periorbital soft tissue and extraocular muscles. Direct globe
repair of many facial fractures can be delayed 7 to 10 days until
trauma may also occur, although obscured by the edema of
edema subsides, provided that soft tissue injuries are treated
surrounding tissues. Fractures of the upper skull include fron-
and intermaxillary fixation is applied, if necessary.
tal sinus and frontal bone fractures. Concomitant nasoeth-
Airway management in the patient with significant facial
moidal, supraorbital, zygomatic, and cranial base fractures
trauma is the principal task of the anesthesiologist dur-
are common and may involve the anterior cranial fossa. Thus,
ing the preoperative phase. This management depends on
particular attention must be paid to assessing for frontal lobe
the significance of airway compromise, state of conscious-
contusion, CSF rhinorrhea, and pneumocephalus.
ness, etiology and type of injuries sustained, identifiable or
Evaluation. Because facial trauma may only be a small por- known premorbid conditions, and need for medical or sur-
tion in the constellation of injuries in a trauma patient, ini- gical intervention. Partial airway obstruction is common for
tial evaluation should focus on identification and treatment the reasons described previously, and placement of an oral or
nasal airway may alleviate the problem. A nasal airway is less e vidence is insufficient to conclude that rates of reintubation
likely to stimulate gagging if airway reflexes are present, but it are reduced. In adults, corticosteroids do not appear to reduce
should not be used when a nasal or basilar skull fracture may the need for reintubation. Unobstructed venous drainage
be present.156 Stable patients with severely distorted airway of the head should be ensured, both through positioning
anatomy may be best managed with an elective tracheostomy, and nonconstrictive bandaging. If intermaxillary fixation is
with or without first securing the airway by other means. applied, wire cutters should be immediately available at the
Preoperative preparation for emergent facial surgery bedside in the event of airway obstruction or hemorrhage.
should proceed as with any other traumatized patient, ensur-
ing adequate respiration and circulation while maintain-
Penetrating Trauma
ing cervical spine immobilization. When surgical repair is
delayed, every attempt should be made in the interim to clear While fortunately rare in most hospitals, knife and gunshot
the cervical spine of injury in order to facilitate subsequent air- wounds cause up to 30% of all admissions to busy urban trauma
way management, increase patient comfort, and decrease both centers. Penetrating injuries can affect all organ systems, but
sedation need and potential for skin breakdown. Judicious considerations for the anesthetic care of penetrating trauma
use of sedatives and analgesics may ameliorate muscle spasms victims are not substantially different than for the victims of
associated with TMJ fractures. blunt trauma. “Scene safety” is not solely a prehospital con-
cept; some hidden weapons may accompany patients into the
Intraoperative Considerations. Mask ventilation can be noto-
ED, and gang violence has been known to extend into hospital
riously difficult and even self-defeating in facial trauma patients.
wards. Initial patient assessment should establish the trajectory
Given the disruption of bony structures that support the perioral
and energy transmission of the injury, to indicate the organ sys-
tissues, achieving airway opening and adequate mask seal can
tems at risk. Gunshot wounds, particularly from high-velocity
be difficult. Improper technique may exert excessive pressure on
weapons such as assault rifles, may cause significant concussive
fracture sites or may extend the cervical spine. In stable patients
and cavitation damage to organs in the proximity of the bul-
with an injury-compromised airway, an awake intubation may
let path, even in the absence of direct penetration. Narcotic or
be the safest management choice. To optimize surgical access,
alcohol intoxication may mask pain, whereas youthful physiol-
procedures involving the lower face and mandible are best man-
ogy and cocaine use encourage underestimation of blood loss.
aged with a nasal intubation, if this approach is not contraindi-
Patients who are hemodynamically unstable after penetrating
cated. Likewise, patients undergoing procedures on the upper
trauma should be taken immediately to the OR for e xploration;
face and midface should receive oral intubation (optimally with
the only exceptions are those with limited thoracic penetration
oral right-angle ETT, or RAE) or a surgical airway.
who respond satisfactorily to tube thoracostomy. “Damage
Submental intubation (SI) has been proposed as an alterna-
control” principles will focus on stopping hemorrhage as soon
tive to nasoendotracheal intubation when oral endotracheal
as possible, completing resuscitation in the ICU, and then
intubation is contraindicated. In patients who require intuba-
returning to the OR for definitive reconstruction after 24 to
tion for maxillofacial reconstruction, SI is an alternative to a
48 hours of stability.
traditional tracheostomy.157 SI avoids the dangers of nasoen-
Stable patients will receive diagnostic testing with plain
dotracheal intubation in patients with midfacial fractures and
radiographs, CT, and ultrasound. The proportion of hemo-
avoids complications related to tracheostomy. The technique
dynamically stable, penetrating-trauma patients requiring
is easy to perform with coordination between the anesthe-
exploratory surgery has decreased in recent years because
sia and surgical teams. The risks and benefits of approaching
of the increasing capability of modalities such as CT and
the airway with alternative blind techniques, either orally or
angiography to exclude surgical injury. Exploration of neck
nasally, must be weighed and tempered by the anesthesiolo-
wounds, the diagnostic pericardial window, and e xploratory
gist's experience. Choice of anesthetic technique should take
laparotomy for flank wounds are increasingly uncommon.
into account that facial reconstructions are often long, compli-
However, noninvasive technology is not sufficiently sensitive
cated cases that have intermittent intervals of intense stimula-
as yet to exclude diaphragm or bowel penetration reliably, and a
tion, that may require the ability to monitor nerve function,
penetrating wound suspected to have violated the p eritoneum
and that may involve significant blood loss. Surgeons will
remains a strong indication for urgent exploratory laparotomy.
require unencumbered access to the face and neck and may
request controlled hypotension at times.
Postsurgical edema may further affect airway patency, and Traumatic Aortic Injury
patients should be awake with intact reflexes before extuba-
tion. In cases of soft tissue edema, IV dexamethasone (4-8 mg) Pathophysiology. Any high-velocity blunt trauma resulting
has been traditionally administered, but no data support this in sudden acceleration or deceleration of the torso may result
practice. A Cochrane review of RCTs in patients who received in a catastrophic injury to the aorta. Shear vectors exert tre-
steroids before extubation showed a trend toward a reduced mendous force at the aortic isthmus, where the relatively free-
incidence of reintubation in neonates receiving prophylactic floating heart and aortic arch are tethered to the descending
dexamethasone before extubation.158 In children, prophylactic thoracic aorta by the ligamentum arteriosum. The spectrum
dexamethasone reduces postextubation stridor, but the of anatomic injury ranges from “cracking” of the intima, with
creation of a small intravascular flap, to complete transection. hemorrhage. Intraoperative management of the open surgical
Many patients with complete resection are found dead at the approach necessitates a double-lumen tube to allow adequate
scene of injury, but survival to hospital admission does occur exposure from a left-sided thoracotomy. Partial cardiac bypass
because of the tamponading effect of the surrounding pleura is often used to support systemic perfusion.163
and pericardium. Patients with aortic trauma have a high risk Stent graft has resulted in major advances in the treat-
of rupture, loss of this tamponade effect, and exsanguination ment of trauma patients with blunt traumatic aortic injury
during the hours immediately after injury. The natural history and has become the preferred method of treatment at many
of small intimal flaps is unknown, although some patients trauma centers. A recent review of the role of stent grafts in
form pseudoaneurysms that may become symptomatic years management showed that thoracic endovascular aortic repair
after the initial injury.159 Patients with underlying atheroscle- (TEVAR) repair of aortic injury offers a survival advantage and
rotic disease are at particular risk of proximal or distal dissec- reduction in major morbidity, including paraplegia, compared
tion of the aorta arising from the site of injury. with open surgery.164 However, endovascular procedures in
trauma patients require a sophisticated multidisciplinary and
Evaluation. Timely diagnosis of aortic injury requires a experienced team approach.
high degree of suspicion in any patient who has suffered a The intraoperative double-lumen tube should be changed
high-speed frontal- or lateral-impact motor vehicle collision under controlled conditions to a single-lumen tube at the
(particularly when no airbag deployed), any pedestrian struck earliest practical time, before admission to the ICU if possible,
by a motor vehicle, any motorcyclist, and any patient who because of basic unfamiliarity with and uncommon use of this
has fallen more than 10 feet. Symptoms of aortic injury are device and the resulting complications.
nonspecific, consisting mainly of a thoracic back pain often
described as “tearing.” Blood pressure is usually labile, with
exaggerated peaks and troughs in response to painful stimu- Orthopedic Injuries
lation, hemorrhage from other injuries, and sedating medica- Orthopedic trauma produces life- and limb-threatening mus-
tions. Common coexisting injuries include fractured ribs or culoskeletal injuries, including hemorrhage from open wounds
sternum, left hemothorax, humeral fracture, splenic rupture, and open or closed fractures, infection from open fractures,
and left-sided femur or acetabular fracture, although none of limb loss from vascular damage and compartment syndrome,
these is a highly sensitive marker for aortic trauma. and loss of function from spinal or peripheral nerve injuries.
Chest radiography is warranted and sensitive but usually The management of these patients presents many challenges
not specific. If the aortic contour is normal and well visual- for the anesthesiologist. Musculoskeletal injuries comprise the
ized, the chance of aortic injury is small, but a confident inter- most common indication for operative management in most
pretation of the anteroposterior chest radiograph is possible trauma centers. Because many procedures might be optimally
in less than 50% of patients at risk. Visible disruption of the managed under regional anesthesia, familiarity with such
aortic contour or other unusual shadowing of the mediasti- techniques is essential.
num may be caused by injury to small vessels near the aorta In addition to a familiarity with an array of regional a nesthetic
and is a strong indication for further diagnostic assessment. procedures, skill with fiberoptic intubation, hypotensive tech-
The traditional “gold standard” was contrast aortography, but niques, hemodilution, intraoperative autotransfusion for
advanced chest CT has improved resolution and accuracy, minimizing intraoperative blood loss, and invasive hemody-
making it the new standard in large centers with experienced namic and evoked potential monitoring may be needed. The
radiographers.160 Transesophageal echocardiography (TEE) is duration of many procedures, particularly of those involving
highly sensitive and specific and is an appropriate diagnostic multiple extremity injuries, necessitates attention to body
approach when an experienced operator is available. positioning, maintenance of normothermia, fluid balance,
tourniquet times, and preservation of peripheral blood flow,
Preoperative Preparation. Transfer of the patient to a especially in reimplantation procedures.
trauma center with experience in aortic surgery is highly desir-
able if it can be effected expeditiously. Preoperative β-blocker Pathophysiology. For more than two decades, trauma man-
therapy is indicated to reduce shear-force stresses on the prox- agement of the multiply injured patient has de-emphasized
imal aorta. Large-bore IV access, right radial artery pressure early stabilization of long-bone, spinal, pelvic, and a cetabular
monitoring, and central venous and PA catheterization, or fractures in order to decrease morbidity, pulmonary complica-
TEE, are strongly indicated.161 tions, and length of hospital stay.165,166 In one study, only 2% of
patients with femoral shaft fractures stabilized within the first
Intraoperative Management. Surgical or angiographic 24 hours of injury had pulmonary complications, versus 38%
treatment of an aortic injury is indicated in any patient who of patients in whom fracture stabilization was delayed for more
can tolerate the procedure. Angiographic vascular stenting than 48 hours.167 Thus the treatment and anesthetic manage-
is playing an increasingly important role in recent years.162 ment of orthopedic trauma necessitates surgical intervention.
Whatever the method, aortic surgery should be approached Classification of orthopedic injuries considers the mech-
on an urgent basis, following only emergent procedures such anism and site of injury, the type of fracture, soft tissue
as damage control laparotomy or evacuation of intracranial involvement, angulation, presence of vascular or nerve
15% lumbar.168 The most basic classification of spinal cord

TABLE 17-8 n Classification of Open-Fracture Wounds
injuries assesses for complete or partial loss of function at a
Type Description given level. A complete injury implies total loss of sensory and
motor function lasting for more than 48 hours in areas inner-
I Clean wound less than 1 cm long vated more than two levels below the level of bony injury.169
II Laceration greater than 1 cm without extensive Late injury may still occur if stability has been compromised.
soft tissue damage, skin flaps, or avulsions The mechanism and site of an injury may produce typical
fracture patterns and will frequently determine the need for
IIIA Extensive soft tissue lacerations or flaps with
adequate soft tissue coverage of bone; result surgical stabilization (see Table 17-5). Chapter 8 provides a
of high-energy trauma more complete discussion of spinal cord injury.
IIIB Extensive soft tissue loss with periosteal Evaluation. Initial attention must necessarily focus on the
stripping and bony exposure; usually adequacy of the patient's airway, quality of ventilation, and
contaminated status of perfusion. Once these concerns have been addressed,
IIIC Arterial injury requiring repair regardless of size of subsequent evaluation should focus on the identification
soft tissue wound and treatment of associated injuries. In the multiply injured
patient, this requires prioritization of the injuries and coordi-
nation of care throughout the surgical and anesthetic teams.
Many orthopedic injuries require emergent intervention to
impairment, and whether the fracture is open or closed. The
effect limb salvage, hemorrhage control, nerve repair, or infec-
anticipated rate and severity of fracture-related complica-
tion prevention.
tions (e.g., amputation, infection, nonunion) and prognosis
Although not always possible, a thorough history and phys-
are related to the classification of open fractures (Table 17-8).
ical examination can be vital. Time of the injury is important;
The mechanism of injury for a given site can aid in the pre-
many orthopedic surgeons choose to address all open frac-
diction of potential complications that might affect or alter
tures within 6 hours of the initial trauma. Further, a history
the anesthetic plan. For example, approximate blood loss
inconsistent with the extent of injury, particularly in at-risk
from fracture hemorrhage varies from 500 mL with a closed
groups, may suggest a pathologic fracture or abuse. After the
tibia fracture to life-threatening hemorrhage (several liters)
initial assessment, secondary examination should document
with a pelvic fracture.
a thorough neurologic assessment, including function and
Extremity injuries include fractures, dislocations, and/or
sensation in injured extremities. This may be of particular
soft tissue damage. Knowledge of anatomy and the mecha-
importance if regional anesthesia is considered, because pre-
nism of injury help in predicting associated nerve and vascu-
existing postoperative deficits may be incorrectly attributed to
lar injuries. For example, displaced intracapsular femoral neck
the regional technique. Distal perfusion should also be docu-
fractures carry a high risk of avascular necrosis of the femoral
mented by palpation or Doppler assessment of distal pulses.
head, whereas posterior dislocation of the knee carries a high
Capillary refill alone is inadequate clinical evidence of intact
risk of popliteal vessel injury.
perfusion and does not exclude compartment syndrome or
The presence of pelvic fractures implies the application of
vascular injury.
substantial force and may therefore be associated with sig-
Regional anesthetic techniques (epidural or nerve block)
nificant morbidity and mortality from direct pelvic trauma
may place the patient at risk for a missed diagnosis of com-
combined with other injuries. Such fractures are classified
partment syndrome. Close monitoring and a high degree of
as having anteroposterior (AP) compression, lateral com-
suspicion for compartment syndrome are always indicated in
pression, or vertical shear patterns. Noting the mechanism
these patients, but there is minimal to no evidence (class 3 case
of injury is essential because the relative risk of hemorrhage
reports) to suggest that regional anesthesia masks extremity
from internal iliac artery or posterior pelvic venous plexus
compartment syndrome.170,171
disruption is increased with AP compression and vertical
shear injuries.167 Early stabilization of these fractures with Preoperative Preparation. The initial management of
external compression or fixation, with or without angiogra- orthopedic trauma is not substantially different from that of
phy and selective embolization, may be lifesaving, especially any other injured patient. Airway and ventilatory manage-
if other life-threatening injuries must be addressed immedi- ment remain the highest priorities. Early definitive manage-
ately. In addition to significant hemorrhage, other direct inju- ment in patients with multiple extremity fractures, serious
ries include nerve injury, rectal or vaginal laceration, bladder pelvic injury, and high spine injuries with deficit should be
rupture, and urethral injury. The presence of the latter two will considered. The evaluation process will often include mul-
require urologic intervention, possibly complicating intraop- tiple evaluations and treatments in remote locations, such as
erative and postoperative fluid management. the radiology suite, CT, and angiography, where there may
Trauma to the spinal column is a common injury and fre- not be suitable provisions for emergent airway management.
quently associated with neurologic dysfunction. The level of Early intubation, often before the clearance of the cervical
injury is most often cervical (55%), with 30% thoracic and spine, is frequently needed to allow for reduction of fractures
or dislocation. Continuous vigilance of the adequacy of ven- and proper positioning should allow for adequate diaphrag-
tilation and oxygenation must be maintained throughout the matic excursion and thoracic expansion without excessive air-
evaluation process. Maintaining adequate circulation becomes way pressures. All extremities should be placed in positions
the next highest priority. Intravenous access should be estab- of comfort, preventing torsion, traction, or compression of
lished with large-bore peripheral catheters if possible, but neurovascular bundles, particularly the brachial plexus at the
extremities with known injuries should be avoided. Use of cen- axilla and the ulnar nerve at the olecranon groove. All pressure
tral venous lines may be necessary, although femoral or lower points should be padded, especially where nerves are placed in
extremity cutdowns should be avoided in suspected pelvic or a dependent position. The eyes, ears, nose, breasts, and geni-
lower extremity injuries, respectively, because of the potential talia should be protected when the patient is lateral or prone.
for venous injury and exacerbation of pre-existing blood loss.
Temperature. Hypothermia contributes to CNS depres-
In addition, it is important to anticipate the need for blood
sion, cardiac irritability, coagulopathy, shivering, increased
products171 and to be prepared for massive blood transfusion
O2 consumption, suboptimal wound healing, and altered liver
if indicated.
and kidney function. Thus, hypothermia can severely affect
outcomes in trauma patients, particularly those with multi-
INTRAOPERATIVE CONSIDERATIONS ple extremity injuries. Many patients entering a trauma cen-
Choice of anesthetic technique will depend on m ultiple factors, ter already have a low body temperature from environmental
including hemodynamic stability, associated injuries, ability exposure. Further exposure to cold ambulance and hospital
to cooperate with the anesthetic plan, coexisting disease, and environments, evaporative heat loss from the respiratory tract,
patient preference. Patients present along a c ontinuum of injury infusion of cold fluids, and loss of heat production secondary
severity, and thus no anesthetic technique is clearly superior to shock or anesthetic-mediated sympathectomy can produce
for all patients. Presentations range from minor injuries man- further significant drops in core temperature and even reduce
aged with local anesthetic infiltration, to injuries amenable to the effectiveness of warming efforts.
peripheral nerve or subarachnoid block, to those requiring With recent and appropriate emphasis on early fracture
general anesthesia and invasive monitoring. Typically, general stabilization and definitive repair, patients with multiple
anesthesia is the technique of choice for nonfasted patients extremity fractures will have long operations, large fluid vol-
with m ultiple injuries. While regional a nesthesia may seem ume requirements, and significant amounts of surface area
attractive because it interferes less with the patient's cardio- exposed to ambient temperatures. It is critical that all skin
pulmonary function and avoids airway manipulation, patients surfaces not in the surgical field be covered to reduce convec-
with serious trauma often require definitive airway control tive and radiant heat loss, and forced-air warming should be
and mechanical ventilation because of concomitant injuries used where possible. Humidification of inspired gases through
and may not cooperate during placement of a block or lie still the use of heat-moisture exchange units reduces evaporative
during prolonged surgery. Further, neuraxial blockade pulmonary heat loss. The combination of active surface heat-
can interfere with sympathetically-mediated hemorrhage ing and moisturization of inspired gases can produce optimal
compensation, leading to increased blood loss and refractory active warming of the patient. Only appropriately warmed IV
shock. Thus, regional anesthesia is most useful for isolated fluids should be used; that is, the temperature of the infusate
limb trauma (e.g., infraclavicular block for hand fracture, should be known, and methods such as microwaving fluids to
lumbar plexus block for hip pinning in elderly cardiac unknown temperatures can be harmful to the patient. In situ-
patient). ations where large volumes of fluid or blood will be needed,
Some specific considerations for the intraoperative man- heat exchangers capable of rapidly infusing fluids that have
agement of patients with orthopedic trauma are positioning, been warmed to 37° C are ideal.
temperature management, use of tourniquets, potential for fat
Tourniquet Problems. Tourniquets are increasingly applied
embolism, and development of deep vein thrombosis (DVT).
in the prehospital setting, particularly in the military environ-
Optimal outcomes for unstable, multiply injured patients are
ment, and are frequently used in extremity surgery to reduce
frequently achieved if all injuries can be corrected at the initial
blood loss and improve surgical visualization. When used for
surgery. The blunt-trauma victim with m ultiple fractures bene-
long durations or at extreme pressures, tourniquets can cause
fits from early fixation, which will reduce ongoing hemorrhage
injury to underlying nerves, muscles, and blood vessels and
and intravascular release of bone marrow, decrease postoper-
may produce systemic effects as well. Effects can be seen at
ative complications of immobilization, o bviate the need for
initial inflation, during prolonged inflation, and on deflation.
multiple return OR visits, and facilitate early extubation.165,172
Exsanguination of an injured limb with an Esmarch bandage
During prolonged surgery, the anesthesiologist must closely
and inflation of the tourniquet typically produce only small
monitor blood loss, hematocrit, coagulation abnormalities,
increases in central venous and arterial pressures. The appli-
electrolytes, fluid balance, and adequacy of oxygenation and
cation of bilateral lower extremity cuffs, however, may result
ventilation.
in a significant elevation of central venous pressure.166 Patients
Positioning. Many orthopedic surgical procedures require under general anesthesia may develop systemic hypertension
a nonsupine position. Ventilation should not be compromised, 45 to 60 minutes after inflation.173 The mechanism for this
elevated BP is not clearly understood and does not always of the femur to external fixation. PA catheter monitoring or
respond to increasing anesthetic depth. Tourniquet deflation TEE may be necessary to optimize hemodynamics and main-
and reperfusion of the ischemic limb may be associated with tain intravascular volume. The possibility of acute right-sided
significant decreases in central venous and arterial pressures. heart failure resulting from elevated PA pressure requires
The sudden reduction in PVR, the increase in volume of the careful avoidance of volume overload. Also, the early use
intravascular space compared with a relatively fixed circulat- of corticosteroids has been advocated after treatment of fat
ing volume, and the circulatory effects of ischemic m etabolites embolism syndrome.182–185
most likely account for these changes.174 Finally, awake patients
Deep Vein Thrombosis. Deep venous thrombosis is a
undergoing regional anesthesia may complain of tourniquet
common complication of orthopedic trauma, and resultant
pain despite an otherwise adequate block. Use of small doses
pulmonary embolism is a major contributor to p ostoperative
of IV narcotics or transient deflation (10-15 minutes) may
mortality. The incidence of DVT varies by site and type of
mitigate this hemodynamic lability or patient discomfort.
operative procedure (Table 17-9). Thromboses can form
Recommended pressure levels are 100 mm Hg above s ystolic
during periods of venous stasis at any point in the perioperative
pressure for thigh cuffs and 50 mm Hg above systolic pressure
period. Prevention is critical and should begin as soon as
for upper extremity cuffs.175 Duration of cuff inflation should
practical after a nonambulatory patient presents for care,

generally not exceed 120 minutes.176,177 As previously mentioned,
should be instituted in the OR if not already in place, and
preoperative vascular and neurologic function should be
should continue into the postoperative period.186
accurately documented whenever p ossible, because regional
Mechanical prophylaxis methods such as intermittent
anesthetic techniques may be blamed for postoperative deficits
pneumatic compression devices and foot pumps speed venous
actually caused by tourniquet injury.
flow in the extremity, increase the volume of blood returned
to the heart, and induce endothelial changes that decrease
Fat Embolism Syndrome. Some lung dysfunction occurs
the risk of thromboembolic phenomena. These measures
in almost all patients with long-bone fractures, ranging from
have no effect on the coagulation system and thus should be
minor laboratory abnormalities to life-threatening fat embo-
used in all patients undergoing orthopedic procedures, unless
lism syndrome. A lack of universally accepted diagnostic cri-
contraindicated by injury. Sequential compression devices

teria combined with varying levels of pre-existing pulmonary
work through the mechanical effect of decreasing venous
and cardiovascular comorbidities account for the varying
stasis, and subsequently the rate of DVT, as well as a fibrinolytic
reported incidence of fat embolism. Most studies suggest clini-
effect from decreased plasminogen activator inhibitor-1 levels.
cally significant fat embolism syndrome occurs in 3% to 10% of
However, the Seventh ACCP Conference on Antithrombotic
patients, although the presence of multiple long-bone fractures
and Thrombolytic Therapy noted that “no mechanical pro-
is associated with the higher incidence. Patients with coexist-
phylaxis option has been shown to reduce the risk of death
ing lung injury are at additional risk of fat embolism.178 Signs
or PE.”187
include hypoxia, tachycardia, mental status changes, and pete-
Epidural and spinal anesthesia have been shown to reduce
chiae on the upper portions of the body, including the axillae,
DVT rates after total-knee replacement by 20% and after
upper arms and shoulders, chest, neck, and conjunctivae. Fat
total-hip replacement by approximately 40%.188 Although
embolism syndrome should be suspected whenever the alve-
postoperative epidural analgesia does not appear to provide
olar-arterial oxygen gradient deteriorates, especially in con-
additional benefit in reducing DVT rates,189 it may still be
junction with decrements of pulmonary compliance and CNS
beneficial by allowing earlier mobilization and ambulation.
function. CNS changes will manifest after general anesthesia
For postoperative thrombosis, there is good evidence for an
as a failure to emerge after surgery. If central hemodynamic
monitoring is available, PA pressure will be elevated, often
accompanied by decreases in cardiac index. Early surgical
correction of fractures and minimization of trauma to the TABLE 17-9 n Incidence of Deep Vein Thrombosis
bone marrow may lessen the incidence or severity of embo- by Site or Procedure
lism, whereas excessive reaming of the medullary canal can Surgery/Fracture Site Rate of DVT
contribute to perioperative morbidity and severity of the fat
embolism syndrome.179 Knee arthroscopy 3%
Diagnosis of fat embolism syndrome in the OR is largely Total hip replacement 30%-50%
based on clinical presentation and ruling out other treat-
able causes of hypoxemia. Fat globules in the urine are not Total knee replacement 40%-60%
diagnostic, but lung infiltrates on chest radiography c onfirm Tibial plateau 43%
the presence of lung injury and the need for appropriate
Femoral shaft 40%
v entilatory management.180,181
Treatment is limited to early recognition, O2 administration, Tibial shaft 22%
and judicious fluid management. Alteration of the orthope- Distal tibia 13%
dic procedure may be indicated, such as converting “rodding”
association between impaired fibrinolytic activity measured sampling, with specific co-oximetric measurement of the
either preoperatively or postoperatively and increased risk of fraction of carboxyhemoglobin, is therefore essential.194
postoperative thrombosis. Whether this association is causal
Evaluation. Although soot staining of oral mucosa
or coincidental is unclear.190 Current guidelines suggest that
is common, patients with visible burns of the soft palate
a low-molecular-weight heparin (LMWH) such as enoxapa-
(erythema or blistering) should be promptly intubated, as
rin provides the best prophylaxis for venous thromboembo-
should any patient with laryngeal edema, indicated by stri-
lism in the high-risk trauma patient.191 Once started, LMWH
dor or progressive change in voice. Hypoxia may present as
should be withheld for 12 hours before surgery, if possible,
agitation or lethargy, and therefore any burn or CO-poisoned
and restarted a minimum of 3 hours after surgery. Recent
patient with an altered mental status should be intubated and
guidelines for neuraxial anesthesia in the patient undergo-
mechanically ventilated until diagnostic studies are complete.
ing thromboprophylaxis detail the timing of the anesthetic
For less symptomatic patients, humidified oxygen and nebu-
procedure and the v arious thromboprophylactics.192 In high-
lized bronchodilator therapy will contribute to clearance of
risk patients or those in whom postoperative prophylaxis is
soot particles from the airways and resolution of edema.
contraindicated, vena cava filters may be placed periopera-
tively, although this is controversial. Perioperative Management. Initial management consists
of strict adherence to the ABCs of trauma. The CO-poisoned
patient should receive high O2 concentrations, which will
Near-Drowning competitively displace CO from Hb. At Fio2 of 1.0, the half-life
As experts in airway management and pulmonary sup- of carboxyhemoglobin is approximately 90 minutes. Patients
port, anesthesiologists are consulted in the care of victims of without neurologic symptoms generally respond well to face
asphyxia secondary to near-drowning. Prompt intubation and mask administration alone. For neurologically impaired
restoration of normal oxygen saturation is crucial. Subsequent patients or those with special risk factors (pregnancy, extremes
management is symptomatic, consisting of frequent assess- of age, significant comorbidity) intubation will ensure the
ment of ABGs and iterative weaning of mechanical ventilation highest possible Fio2 and an adequate ventilatory rate, while
to achieve adequate recruitment of collapsed lung units with increasing mean airway pressures and optimally oxygenat-
the lowest possible airway pressures. Of all human reflexes, ing unbound Hb. Hyperbaric oxygen therapy is indicated for
those causing laryngoconstriction are among the strongest, severe CO poisoning cases and will significantly shorten the
and many near-drowning victims do not aspirate significant half-life of carboxyhemoglobin.195 Life-threatening ARDS
amounts of water at all. Patients after near-drowning may from CO poisoning may be successfully treated with extracor-
manifest with hyponatremia or hypernatremia.193 Those with poreal support, allowing the lungs to recover from the initial
evidence of aspiration likely suffered more profound lev- injury.196
els of hypoxia as well. Significant pulmonary aspiration not
only removes surfactant from the lungs but also contaminates
the alveoli, leading to significant acute lung injury and fluid The Pregnant Trauma Patient
volume loss into the pulmonary interstitium. Ventilatory sup- Trauma in pregnancy poses unique problems for the anesthe-
port may be required for days after the acute event. Return siologist and resuscitation team. The significant alterations
of normal pulmonary function is likely in most patients, and in physiologic demand associated with pregnancy will com-
long-term outcomes therefore depend predominantly on the plicate the evaluation, treatment, and management of these
patient's neurologic injury secondary to the initial period of patients. Trauma is the leading cause of maternal death in the
hypoxia. United States, with 3 to 4 per 1000 pregnancies requiring hos-
pital admission for trauma.197 A high index of suspicion for
Smoke Inhalation and Carbon Monoxide abuse should be maintained in this population. Even minor
Poisoning trauma poses significant risk to the fetus and requires extra
vigilance during routine cases. The primary focus of resuscita-
Pathophysiology. Patients exposed to fire or resulting toxic
tion and early management is the mother; there can be no fetal
gases may be hypoxic from three mechanisms: (1) thermal
survival without maternal survival. Stabilization of the moth-
injury to the upper airway, with edema and stricture of the lar-
er's condition typically takes priority over fetal concerns, with
ynx; (2) particulate inhalation and subsequent bronchocon-
the possible exception during the third trimester, when in rare
striction; and (3) carboxyhemoglobin formation secondary
cases, the maternal prognosis is poor and immediate cesarean
to carbon monoxide (CO) poisoning. CO binds hemoglobin
section may save the fetus. (See also Chapter 19.)
with an affinity approximately 250 times greater than oxy-
gen, leading to decreased O2-carrying capacity and delivery Pathophysiology. The physiologic changes of pregnancy
with resultant hypoxia and acidosis at the tissue level. Pulse alter the normal responses to traumatic injury. Table 17-10
oximetry will not accurately reflect tissue O2 delivery because summarizes the significant changes seen in the pregnant
such oximeters cannot discriminate the spectral signature of patient and their implications on trauma care. Maternal
carboxyhemoglobin from that of oxyhemoglobin. Early ABG plasma volume expands by 40% to 50% by the end of the first
TABLE 17-10 n Physiologic Changes of Pregnancy
Organ System Change Implications
Cardiovascular Decreased peripheral vascular resistance Reduced baseline blood pressure

Increased cardiac output
Increased heart rate Resting tachycardia
Aortocaval compression Supine hypotension
Hematopoietic Increased plasma volume Dilutional anemia

Hypercoagulable state Thromboembolism
Increased leukocyte count
Respiratory Increased minute ventilation Respiratory alkalosis

Decreased residual capacity
Elevated diaphragm Abnormal chest radiograph
Gastrointestinal Decreased motility Aspiration

Decreased lower esophageal sphincter tone Aspiration
Renal Increased filtration rate

Dilated collection system Hydroureter, hydronephrosis
Musculoskeletal Pelvic ligament laxity Widened pubic symphysis

Increased venous volume Bleeding with fractures
trimester and peaks by 30 to 34 weeks’ gestation. RBC mass of the uterus laterally, or by lateral tilt of the backboard, bed,
expands to a lesser degree, resulting in dilutional anemia or OR table.
(“physiologic anemia of pregnancy”), often with a normal Significant yet predictable respiratory changes of pregnancy
Hb of 10.5 to 12.9 mg/dL. As a result of this intravascular should also be anticipated. Minute ventilation is increased
volume expansion, mild to moderate blood loss associated by almost 50%, secondary to both an increase in respiratory
with traumatic injury may appear to be well tolerated by the rate and tidal volume, resulting in a compensated respiratory
mother. However, further alterations in uteroplacental circu- alkalosis with a reduction in buffering capacity. A “normal”
lation caused by compensatory mechanisms may have a sig- ABG value in a pregnant patient should therefore prompt
nificant adverse impact on the fetus.198 Other alterations that immediate evaluation of respiratory function. Functional
may impact management include changes to baseline BP and residual capacity is reduced by 15% to 20% at term, whereas
cardiac output. By 28 weeks, normal maternal BP decreases O2 consumption is significantly elevated, resulting in an
by 15% to 20% because of PVR reduction. At the same time, impressive predisposition toward precipitous desaturation.
cardiac output increases by 35% to 50% above baseline, with The circulatory changes associated with pregnancy cause
a 17% increase in heart rate, a moderate increase in stroke global capillary engorgement of respiratory tract mucosa,
volume, and a functional 20% to 30% arteriovenous shunt producing edema in the nasopharynx, oropharynx, larynx,
produced by the low-resistance placental circulation.199 and trachea. Manipulation of this friable tissue requires extra
A further hemodynamic effect that may have an untoward care; further injury might worsen the underlying edema and
impact on the pregnant trauma patient is hypotension result- predispose to airway obstruction. Endotracheal intubation
ing from compression of the inferior vena cava (IVC) by the should incorporate smaller ETTs than might normally be used
gravid uterus. By 24 weeks, the uterus is large enough to pro- in the nonpregnant patient (6.0-0.0 mm) given the probability
duce mechanical compression of the IVC when the patient is of moderate supraglottic edema. GI motility can be affected
in a supine position. In the case of significant hemorrhage or by pregnancy, and the risk of gastric reflux is increased in the
cardiac arrest, hemodynamic instability from IVC compres- gravid patient. While motility alterations are most prominent
sion may become an acute problem, manifesting as a 25% during labor, a decrease in lower esophageal sphincter tone
reduction of effective cardiac output. MVCs account for more and an increased gastric acid secretion suggest that the risk of
than 50% of all trauma during pregnancy, with 82% of fetal aspiration is increased in any pregnant patient near term.201
deaths occurring during these crashes. With life-threatening Renal changes include an increase in both renal blood
trauma, fetal loss is 50%.200 Supine positioning of the severely flow and creatinine clearance. A mild physiologic hydrone-
traumatized pregnant patient should be avoided whenever phrosis should be borne in mind when evaluating the patient
possible, particularly during the third trimester. This can be with abdominal or pelvic trauma. Coagulation parameters
accomplished by using the left lateral decubitus position, or are altered by an estrogen-induced increase in clotting factor
when injury prevents the patient from being placed on the function, placing women at increased risk for thromboem-
side, by means of a right hip wedge, by manual displacement bolic disease in the setting of venous stasis or vessel wall injury.
Fibrinogen is likewise increased by 50%, such that a “normal” After initiation of lifesaving measures, the secondary
level in a term pregnant patient (300 mg/dL) may suggest a s urvey of the stable pregnant patient will include fetal assess-
consumptive process. A moderate leukocytosis is normal ment. If possible, the pregnancy history should consider the
and, in isolation, does necessarily imply an inflammatory or estimated gestational age, the prenatal care, and any compli-
i nfective process. cations (e.g., diabetes, hypertension). Estimated gestational
In addition to understanding the impact of maternal age and viability should be determined quickly because the
physiology on trauma management, the anesthesiologist must presence of a viable fetus (typically 24 weeks’ gestation) may
also consider the effects on the fetus, which will depend on allow for early caesarean section. If the mother cannot provide
gestational age, type and severity of trauma, and the extent of a history, palpation of the uterine fundus at 3 to 4 cm above
disruption of uterine function. Fetal survival requires uninter- the umbilicus typically correlates with a viable gestational age.
rupted uterine perfusion and O2 delivery. Autoregulation is lack- Cardiotocographic monitoring (CTM) should begin as early
ing in the uterine circulation, and therefore uterine blood flow is as possible. Fetal bradycardia is a sensitive indicator of poor
directly related to maternal BP. As the mother approaches hypo- maternal perfusion and may be the first measurable change
volemic shock, further maternal vasoconstriction will increas- secondary to significant maternal hypovolemia. CTM moni-
ingly compromise uterine perfusion. In frank maternal shock, toring of uterine irritability and contractions can be useful in
the chance of fetal survival is severely decreased. detecting placental abruption.205,206 The American College of
Fetal bradycardia or tachycardia, decreased baseline fetal Obstetricians and Gynecologists (ACOG) recommends that
heart rate (FHR) variability, absent normal FHR accelera- any pregnant trauma patient beyond 22 to 24 weeks’ gesta-
tions, and repetitive decelerations suggest that oxygenation tion undergo fetal monitoring for a minimum of 24 hours.206
and perfusion have been compromised. Direct or indirect If the patient presents with ruptured membranes, bleeding,
uterine trauma can injure the myometrium, possibly leading fetal arrhythmias or FHR decelerations, or more than four
to uterine contractions and even the induction of premature contractions per hour, the patient should be admitted with
labor. When maternal injuries are not lethal, placental abrup- continuous fetal monitoring for at least 24 hours, with further
tion is the most common cause of fetal demise.202 As a bruption management as the clinical scenario requires.
can occur even with low energy impacts, all patients with Laboratory evaluation should include hemoglobin/hema-
moderate blunt trauma should undergo FHR monitoring and tocrit, type and crossmatch, coagulation parameters, lactate
close observation.197,203 determination, ABG analysis, and urinalysis. Interpretation
The Kleihauer-Betke test is used to detect the presence and of the results should consider pregnancy-related changes to
degree of fetal-to-maternal hemorrhage after trauma. This can normal values. Physiologic anemia may be confused with ane-
be used to predict fetal anemia (life-threatening hemorrhage) in mia caused by hemorrhage, and a normal fibrinogen level in
utero. If feto-maternal hemorrhage occurs in an Rh-negative the nonpregnant patient may be an early indicator of dissemi-
mother, prophylactic Rho(D) immune globulin (RhoGAM) nated intravascular coagulation (DIC) in the pregnant patient
should be given to protect against isoimmunization result- because of placental abruption. Additionally, given the higher
ing from the transfer of fetal hemoglobin to the maternal minute ventilation associated with pregnancy, a normal or
circulation.204 e levated Paco2 level may suggest pending respiratory failure.
Use of lactate levels as a marker of resuscitation is not affected
Evaluation. Preoperative anesthetic evaluation of the by the pregnant state.
injured pregnant patient should involve immediate and close
Preoperative Preparation. Careful optimization of the
consultation with an obstetrician or maternal-fetal special-
gravid trauma patient's perioperative volume status will help
ist, with the primary goal of stabilizing the mother's condi-
maintain fetal perfusion. As in all trauma cases, large-bore
tion. During the primary survey, treatment priorities remain
IV access is required. When large volumes of crystalloid are
the same as for the nonpregnant patient. However, given the
necessary, normal saline may lead to maternal and fetal hyper-
increased likelihood of aspiration and rapid desaturation,
chloremic acidosis. Coagulation defects should be addressed
as well as the propensity toward fetal distress as a result of
before surgery when possible, with pregnancy-related changes
maternal hypoxia, endotracheal intubation may be consid-
such as elevated fibrinogen levels kept in mind. Prophylactic
ered early. This must be balanced against the likelihood of an
reduction of gastric pH and volume will help to decrease the
edematous, friable, difficult airway, particularly in the later
risk of maternal morbidity and mortality from aspiration of
stages of pregnancy. Although tachypnea is a normal finding
gastric contents on anesthesia induction.
in the physiology of pregnancy, any life-threatening causes of
respiratory compromise should be sought. The baseline heart Intraoperative Considerations. The anesthetic technique
rate elevation of 10 to 15 beats/min can make estimation of chosen in the traumatized pregnant patient will be determined
volume status difficult. While assessment of central and by the urgency and location of the procedure, the presence of
peripheral pulses, capillary refill, skin color and temperature, concomitant injuries and pre-existing conditions, and mater-
and mental status are still useful tools in the pregnant patient, nal preference. When feasible, regional anesthesia offers some
significant hypovolemia can be present despite
minimal advantages to general anesthesia, including the maintenance
changes in these markers. of airway reflexes and the avoidance of airway manipulation,
although no direct evidence shows a reduction in mortality. patients who do not respond to aggressive resuscitative efforts
Any possible limitation of dosages of systemically distributed in a timely manner are likely to have poor outcomes, even with
medications will reduce fetal exposure and should be sought continued aggressive treatment. For g eriatric trauma patients
whenever possible. who do respond favorably to aggressive resuscitative efforts,
General anesthesia is still necessary for many pregnant the prognosis, not only for survival but also for return to their
trauma patients. Preoxygenation before anesthetic induction preinjury level of function, is quite good.211
should be accomplished for more than 3 minutes with 100% Close attention to detail is required to achieve optimal
O2 in an attempt to avoid the rapid onset of hypoxia seen with anesthetic results. This may include perioperative modalities
apnea in these patients.207 This is usually accomplished through such as continuous insulin infusion and perioperative beta-
RSI because of the increased risk of aspiration. Left uterine adrenergic blockade. Surgical procedures required by elderly
displacement must be continued throughout the induction trauma patients are the same as for younger adults, but the
and operative periods to maintain venous return and adequate optimal timing of surgery may be more challenging. Bed-
preload to the heart. Invasive hemodynamic monitoring may bound elderly patients have a predictable, progressive loss of
be dictated by maternal conditions. Maternal Paco2 should be pulmonary function to atelectasis and possibly pneumonia,
kept at 33 to 36 mm Hg, since further degrees of hyperven- even in the presence of attentive nursing care; thus, delaying
tilation may be detrimental to fetal perfusion. Intraoperative surgery in an effort to improve ventilation or pursue diagnostic
fetal CTM can supplement other available information regard- studies may be counterproductive. Similarly, urgent repair of
ing maternal perfusion, although the need for operative access long-bone fractures and open wounds should take precedence
may limit its use. CTM should be continued postoperatively to over additional specialty consultation and risk stratification
monitor for premature labor. studies (e.g., stress cardiac imaging), particularly when these
Concerns about the effects of anesthetic agents on the studies are unlikely to change management. Some patients
growth and development of the fetus should be considered. with pronounced myocardial ischemia or dysrhythmia may
A review of pharmacologic considerations and potential tera- benefit from angioplasty or electrophysiologic intervention
togenicity is provided in Chapter 19. Agents and techniques before intervention, but most will benefit more from prompt
that have historically-proven safety profiles should be used in surgical correction of the traumatic injury.103
the care of the pregnant trauma patient whenever possible. In the absence of confirmation to the contrary, the anesthe-
siologist should assume pre-existing heart disease in patients
with an unclear or unknown cardiac risk. All medications,
Geriatric Trauma
including induction agents, should be selected for efficacy as
Trauma outcomes in elderly patients are dramatically worse well as ability to maintain cardiovascular stability and must
than those of the general population, with significantly be carefully titrated to patient response. Elderly patients can
higher in-hospital morbidity and mortality rates after identi- suffer prolonged sedation and disorientation after IV anxioly-
cal anatomic injuries.208 Persons age 75 years and older have sis, frequently necessitating postoperative mechanical ventila-
the highest injury death rates. Reasons for this difference tion. Invasive pressure monitoring and laboratory assessment
include a decreased basal metabolic rate, limited cardiopul- of perfusion should be considered whenever traumatic or
monary reserve, atherosclerotic disease, impaired wound surgical blood loss is deemed more than “minimal.” PA

healing, and increased susceptibility to sepsis. Pre-existing catheterization and direct assessment of myocardial perfor-
neurologic impairment, including psychiatric disease, is com- mance and fluid volume status may be beneficial,210 although
mon in the elderly trauma patient. For many elderly patients, this technique may be time-consuming or even hazardous. If
a traumatic event heralds the end of independent living and available, TEE and newer, noninvasive technologies may be
the requirement for chronic nursing care or assisted living. more appropriate. (See also Chapter 20.)
Statewide systems-level factors may also determine the qual-
ity of care that elders receive. In a 10-year retrospective review
PREHOSPITAL ANESTHETIC CARE
of 430,081 patients admitted to California acute care hospitals
for trauma-related diagnoses, 27% were older than 65 years. The role of the U.S. anesthesiologist may at times extend beyond
After adjusting for demographic, clinical, and system factors, the medical facility to include the prehospital environment, as
compared with trauma patients age 18 to 25 years, the odds of is standard in many European countries. Many large trauma
admission to a trauma center decreased with increasing age.209 centers have established relationships with local emergency
Although multiple clinical and demographic factors have medical service (EMS) providers to form field-response “go
demonstrated an association with outcome following trauma in teams” capable of extending lifesaving or limb-saving medical
geriatric patients,210 the ability of any specific factor to predict support to disaster situations.212 Physician involvement in
an unacceptable outcome for any individual geriatric trauma prehospital management of trauma is generally limited to
patient is quite limited. An initial course of aggressive therapy consultation and occasional scene response in North America,
seems warranted in all geriatric trauma patients, regardless whereas the military and many other countries may push
of age or injury severity, with the possible exception of those this capability much closer to the point of injury. Physician
patients who arrive in a moribund condition. Geriatric trauma involvement is limited to consultation and occasional scene
response in North America, although Israel, Germany, France, of trauma surgery two decades ago, so have the needs of the
and other countries have mobile ICUs staffed by anesthesiolo- emergency general surgery patient driven the development of
gists and other physicians.213 Better outcomes have been dem- a systematic approach to care,223 leading to a proposal for the
onstrated in patients with head injury or blunt trauma when development of the Acute Care Surgery Fellowship.224
a prehospital physician is present.214,215 Military medical teams Increasing numbers of in-house acute care surgeons
also use the prehospital physician for point-of-injury and and competition for OR time have led to more nonemer-
interfacility transport and resuscitation.216,217 The future role gent general surgery procedures at night, when there are
of the prehospital physician has been discussed.218 fewer faculty, residents, nurses, and support staff avail-
Service on a “go team” assumes many training require- able. Recently, performing nonemergent cases at night has
ments for the unique conditions found in medical disaster been proposed as a safe solution for daytime overcrowding
response. Training with an established anesthetic plan for of ORs.225 A recent report of operative experience at a ter-
austere environments is helpful.219 An effective approach to tiary academic, Level I trauma center documented that more
such challenges is to break the response down to recogniz- than 50% of surgical procedures are not elective cases: 40%
able tasks (Box 17-7). Although involved physicians will likely are urgent operations, 11% emergency procedures, and 8%
not be responsible for most, familiarity with these tasks will trauma-related procedures.226 Patients with intra-abdominal
make their integration into the team much more effective and sepsis, soft tissue infection, acute abdominal pathology, and
will establish a framework that optimizes their unique skills. acute hemorrhage are more likely to require urgent or emer-
Individuals assigned to a “go team” must be facile in hazardous gent evaluation and operative intervention, with subsequent
materials, personal protective equipment (PPE), scene control, ICU admission.227
forensics, public health, decontamination, rescue equipment, As with trauma, patients presenting to the OR for emer-
helicopter medical evacuation, and basic emergency medicine. gency surgery often do not have a thorough preoperative
The most common scenario for civilian “go team” response assessment of baseline cardiac, respiratory, or renal physiol-
is entrapment after an MVC or building collapse. Although ogy. As ASA “E” class would suggest, these patients may be
field amputation is rarely required for safe extrication, flexibil- at greater risk for adverse outcomes. Using the ACS National
ity and familiarity with alternative airway techniques, adverse Surgical Quality Improvement Program (NSQIP) data from
positioning, nonstandard vascular access, and total intrave- 2005 to 2008, Ingraham et al.228 compared the risk factors
nous anesthesia (TIVA) are essential for such cases. The “go and 30-day outcomes associated with a range of emergency
team” may also have the ability to administer blood products and elective general surgery cases. Of 473,619 procedures,
as well as higher degrees of sedation than might otherwise be 14.2% (67,445) were for emergency general surgery (EGS)
possible under most EMS protocols.220 cases (appendectomy, colectomy/colostomy, cholecystectomy,
hernia repair, small intestine resection, anorectal abscess
drainage). Although the EGS patients tended to be younger
ACUTE CARE ANESTHESIOLOGY (49.5 ±20.2 vs. 53.9 ±16.4 years), they were assigned a higher
The U.S. Institute of Medicine has reported on hospital- ASA class and had a lower baseline functional status and more
based emergency care as “at the breaking point.”221 U.S. comorbidities. The “overall morbidity,” defined as surgical site
hospitals report 39.4 million emergency department visits infection, wound dehiscence, cerebrovascular event, cardiac
for injury annually, and a 14.3% hospital admission rate; 7.3 arrest, myocardial infarction, bleeding, pulmonary embo-
million of those injured require operative intervention.222 lism, ventilator dependence, renal failure, or sepsis, in EGS
Anesthesiologists care for these injured patients in the ED or patients was 19.8%, versus 8.8% in the elective surgery patients
in the OR. Just as the needs of injured patients fueled the field (p <0.001), and mortality was 5.8% versus 0.8% (p <0.0001).
It is not known to what degree the skills of the anesthesiolo-
gist caring for these patients impacts outcome, through such
interventions as glucose control, timely administration of

BOX 17-7 n DISASTER RESPONSE TASKS
antibiotics, β-blocker therapy, fluid and blood administration,
Scene Assessment and intraoperative ventilator management.
n Scene description The American College of Graduate Medical Education
n Scene safety
(ACGME) currently requires that anesthesiology residents
n Patient conditions
complete only 20 trauma/emergency cases of patients with
Incident Management “life-threatening” injuries during their training. Subspecialty
n Command and control
n Communications
rotations in thoracic, neurosurgery, orthopedics, vascular, and
cardiac blocks ensure a broad exposure to the pathophysiol-
Victim Care
ogy and anesthetic requirements of managing these patients,
n Search and rescue
n Primary assessment and triage
but the majority of these are scheduled cases.
n Transport Resuscitation strategies have advanced rapidly over the
n Definitive care past several years. Anesthesia and resuscitation for elective
surgical cases differs from anesthesia and resuscitation for
emergency cases, due to the common presence of shock.229 9. Scalea TM, Boswell SA, Scott JD, et al: External fixation as a bridge to
Contrary to elective cases, where large-volume blood loss intramedullary nailing for patients with multiple injuries and with femur
fractures: damage control orthopedics, J Trauma 48:613–621, 2000.
and fluid shifts are anticipated, bleeding or infection in EGS 10. Thierbach AR, Lipp MDW: Airway management in trauma patients,
patients often results in substantial total body fluid deficit at Anesth Clin North Am 17:63–81, 1999.
presentation to the OR. Fluid administration, massive trans- 11. Sise MJ, Shackford SR, Sise CB, et al: Early intubation in the manage-
fusion protocols, prevention of coagulopathy, hypotensive ment of trauma patients: indications and outcomes in 1,000 consecutive
resuscitation, “damage control” surgery, advanced ventila- patients, J Trauma 66:32–40, 2009.
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require surgery to reduce complications; nonurgent cases

n Trauma and acute care anesthesiology practice requires

Elective Small-bone fractures: wrist, ankle,

TABLE 17-2 n Medications Used During Emergency Airway Management

Medication Class Comments*

Sodium thiopental Sedative Fast, inexpensive, negative inotrope and vasodilator

Lidocaine Sedative/ Blunts airway reactivity; negative inotrope

Fentanyl Analgesic Blunts airway reactivity; does not produce amnesia

Patient awareness during intubation and mechanical venti-

FIGURE 17-3 A, “Open book”

BOX 17-4 n SYMPTOMS OF SHOCK

The “dose” of shock absorbed by the body, a summa-

Coagulation factor concentrates and cryoprecipitate may

Establish airway, breathing, and circulation

Administer sedation (see algorithm)

Insert IVC and drain CSF

Hyperventilation to PaCO2 of 30–35 mm Hg

Mannitol 0.25–1.0 g/kg and/or hypertonic saline

Intracranial hypertension? No Carefully

Consider repeating brain CT scan

Decompressive High dose Hyperventilation to PaCO2

TABLE 17-5 n Types of Spinal Cord Fracture

Ocular Trauma Closed Globe

Le Fort Malocclusion, trismus, Malocclusion,

15% lumbar.168 The most basic classification of spinal cord

TABLE 17-10 n Physiologic Changes of Pregnancy

Organ System Change Implications

Cardiovascular Decreased peripheral vascular resistance Reduced baseline blood pressure

Hematopoietic Increased plasma volume Dilutional anemia

Respiratory Increased minute ventilation Respiratory alkalosis

Gastrointestinal Decreased motility Aspiration

Renal Increased filtration rate

Musculoskeletal Pelvic ligament laxity Widened pubic symphysis

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