I. In the United States, trauma is the leading cause of death for patients 1 to 44 years of age and the third overall leading cause of death for all age groups. It accounts for more deaths in individuals aged 1 to 34 than all other causes combined.
II. Assessment of the trauma patient must rapidly identify life-threatening injuries and initiate appropriate supportive therapies. Strict adherence to Advanced Trauma Life Support (ATLS) guidelines ensures efficient management of the trauma patient. The primary survey, resuscitation, secondary survey, definitive treatment or transfer of care, and tertiary survey are the principal steps of ATLS. Of note, assessment of the trauma patient is dynamic. Clinical deterioration should prompt a return to the primary survey.
A. The primary survey includes the evaluation of airway, breathing, circulation, disability, and exposure (ABCDE). Providers should be familiar with the Glasgow Coma Scale (GCS) and normal hemodynamic values as outlined in Tables 11.1 and 11.2, respectively. A detailed approach to the primary survey is reviewed in Table 11.3.
1. The Focused Assessment with Sonography for Trauma (FAST) exam or Extended-FAST (eFAST) has become an integral part of the primary survey. Serial FAST examinations following nonoperative management of trauma are commonplace. Indications for FAST examination in the postoperative setting include hemodynamic instability, changes in physical examination (e.g., increasing abdominal tenderness or distention, decreased breath sounds, chest pain, etc.), persistent anemia despite transfusions, and sudden-onset dyspnea.
B. Following appropriate interventions to address life-threatening injuries discovered during the primary survey, as well as managing hemodynamic instability, the resuscitation phase commences.
C. Following resuscitation, ATLS then calls for a secondary survey, which involves a thorough evaluation of the patient, including a history and comprehensive physical evaluation. Radiographic studies are often used as adjuncts to the secondary survey. Of note, the secondary survey may have been deferred or only completed partially if emergent operative intervention was required. Communication with the surgical team is important to ascertain the extent to which a secondary survey was completed to facilitate completion and timely acquisition of pending diagnostic studies.
D. The tertiary survey seeks to identify any missed injuries after initial resuscitation and operative intervention. A thorough review of the patient’s history, medical record, diagnostic studies, and a repeat physical examination are all elements of the tertiary survey.
III. The disposition of trauma patients from the OR must account for the complex and resource-intense nature of their care.
A. Admission to the postanesthesia care unit (PACU) should be considered only for well-resuscitated patients with limited trauma burden who are unlikely to require emergent reoperative intervention. Although intraoperative resuscitation may have been adequate, vigilance is of the utmost importance because patients may have missed injuries or further decompensate owing to the physiologic response to traumatic and operative insults.
TABLE 11.1 Glasgow Coma Scale
1
2
3
4
5
6
Eyes (open to)
None
Pain
Verbal command
Spontaneous
Verbal
None/intubated
Incomprehensible sounds
Inappropriate/incomprehensible words
Disoriented conversation
Oriented conversation
Motor (response to painful stimuli)
None
Extensor posturing
Flexure posturing
Withdrawal
Localizes
Obeys verbal commands
TABLE 11.2 Normal Hemodynamic Values by Age Group
Age Group
Respiratory Rate
Heart Rate
Minimum Systolic Blood Pressure
Newborn
40-60
100-170
50
3 mo
30-50
100-170
50
6 mo
30-50
100-170
60
1 y
30-40
110-160
70-90
1-2 y
25-35
100-150
80-95
2-5 y
25-30
95-140
80-100
5-12 y
20-25
80-120
90-110
>12 y
15-20
60-100
100-120
TABLE 11.3 Elements of the Primary Survey
Airway: Assess for obstruction because of direct injury, foreign bodies, or edema as well as identify patients at risk due to their inability to protect the airway secondary to a depressed level of consciousness. Establish a definitive airway.
Breathing: Assess for the absence of breath sounds or presence of diminished breath sounds (consistent with either pneumothorax or hemothorax), gross chest wall injuries (flail chest, sucking chest wound), dyspnea, hyperresonance or dullness to chest percussion (suggesting tension pneumothorax or hemothorax). Perform thoracentesis for hemothorax and nontension pneumothoraces and needle decompression for tension pneumothorax.
Circulation: Assess for the presence of hypovolemia, sources of hemorrhage, and cardiac dysfunction. Evaluate the jugular veins for distention and distant heart sounds to evaluate for cardiac tamponade requiring pericardiocentesis. Control hemorrhage with packing, clotting products, pressure, and temporary sutures. Ensure adequate access for volume resuscitation (e.g., bilateral upper extremity large-bore intravenous catheters).
Disability: Determine gross mental status and assess for neurologic dysfunction including motor examinations. Identify the presence of head or spinal cord injury. Utilize the Glasgow Coma Scale (Table 11.1).
Exposure: Complete removal of patients’ clothing to perform a brief physical examination while controlling for hypothermia.
1. Changing trends in the management of trauma, including damage control surgery and hemostatic resuscitation, have shifted the priorities of initial efforts away from vigorous resuscitation to permissive hypotension until hemostasis can be achieved. Accordingly, patients may be relatively underresuscitated at the conclusion of surgery. These patients are often unsuitable for admission to the PACU.
2. Sufficient expertise and personnel must be available given the often unpredictable postoperative course of trauma patients and high incidence of shock, respiratory failure, and other complications as outlined below.
3. Heightened physical security may be required in certain circumstances, and the receiving PACU must be able to accommodate such needs.
B. Admission to an intensive care unit (ICU) should be pursued for patients who require ongoing resuscitation, mechanical ventilation, or who have suffered multisystem injuries. When limited physical space within an ICU precludes admission, involvement of the ICU team while the patient remains in the PACU should be advocated.
IV. MANAGEMENT OF COMMON PACU PROBLEMS
A. Circulatory shock, a low-perfusion state marked by inadequate tissue oxygenation, is commonly encountered in trauma patients. Resuscitation is the process by which shock is treated, perfusion is restored, and tissue oxygenation is normalized. Intraoperatively, resuscitation may be purposefully delayed or slowed until hemostasis is obtained because robust systemic perfusion may worsen hemorrhage and preclude clot formation. However, the goal of resuscitation shifts postoperatively following the accomplishment of hemostasis and then focuses on normotension and normovolemia.
1. An approach to the differential diagnosis of shock is presented in Table 11.4. Although there are numerous potential etiologies, hemorrhagic shock is the most common in this patient population. (Please refer to Chapter 21 for a detailed discussion.) As such, hypotension in trauma patients is typically synonymous with hypovolemia. However, obstructive shock should always be considered in the differential because it can be rapidly progressive and fatal.
Bedside ultrasonography, including transthoracic ultrasound, can help to quickly assess the etiology of shock as demonstrated through experience with FAST and the growing utilization of ultrasound in critical care environments.
2. The systemic inflammatory response syndrome (SIRS) describes a cytokine response to surgical stress or antecedent trauma, which is marked by tachycardia, tachypnea, fever, and leukocytosis. When coupled with hypovolemia or a sufficiently robust inflammatory response, SIRS can progress to include hypotension and resultant distributive shock. Even when faced with likely SIRS, other etiologies of shock should be carefully considered and excluded.
TABLE 11.4 Differential Diagnosis of Shock in the Immediately Postoperative Trauma Patient
Bacteremia, pneumonia, pancreatitis, surgical site infection, catheter-related infection
Neurogenic
Spinal cord injury
Anaphylactic
Antibiotics, latex
Endocrine
Acute and relative adrenal insufficiency, thyrotoxicosis
Toxic
Group A Streptococcus, necrotizing soft tissue infection
3. The treatment of shock relies on accurate diagnosis, and correction, of the underlying cause. As a general principle, hypovolemia should be convincingly corrected prior to the use of vasopressors so as not to mask inadequate hemostasis. Refractory hypovolemia may represent inadequate or failed hemostasis, and the surgical team should be immediately notified if such a suspicion develops. Multiple laboratory markers have been used to judge the adequacy of resuscitation following trauma, including pH, lactate, base excess, and central or mixed venous oxygen saturation. Although base excess is easy to measure and of clear prognostic value, lactate appears to be a more accurate biomarker.
a. Aggressive resuscitation during hemorrhage requires coordination of multiple considerations: adequate intravascular access, supply of blood products, equipment (warmers and/or rapid infusers), and personnel. A plan to quickly address all of these needs must be in place for all PACUs that admit trauma patients.
b. Intravenous fluids should be used judiciously and only when faced with clinical evidence of severe hypovolemia. Reflexive infusion of fluid to rectify all causes of hypotension can quickly lead to pulmonary edema, abdominal compartment syndrome (ACS), dilutional coagulopathy, and other consequences of overt fluid overload. Available evidence does not support the use of colloids, compared to crystalloids, in trauma patients. Furthermore, albumin has been associated with higher mortality rates in the setting of traumatic brain injury (TBI).
B. Hypothermia is a frequent complication of general anesthesia, and trauma patients are particularly susceptible following transport and evaluation, hemorrhage, resuscitation, and often extensive surgical exposure. Even a mild degree of hypothermia has been associated with numerous adverse outcomes and contributes heavily toward the development of coagulopathy, acidosis, and death in trauma patients. Core temperature should be measured no less often than every 15 minutes until a definitive trend has been established. Values less than 36.0°C must prompt immediate intervention. Forced air warming devices are a mainstay of treatment given both their safety and efficacy, and fluids should be warmed during ongoing resuscitation. The vasodilatation that accompanies rewarming may precipitously unmask hypovolemia; as such, close attention should be paid to hemodynamics during this period. Please refer to Chapter 22 for a detailed discussion.
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