Adapted from American College of Surgeons, Committee on Trauma. Shock. In American College of Surgeons, ed. Advanced trauma life support course for physicians. 7th ed. Chicago: American College of Surgeons; 2004:74:108.
b) Respiratory: Assess breath sounds and patterns of respiration.
c) Neurologic: Assess patient using the Glasgow Coma Scale (GCS). Assume a cervical spine injury until it is definitively ruled out by x-ray examination or computed tomography (CT). There are three categories of the GCS to which a value is assigned: eye opening, motor response, and verbal response. For eye opening: 4 = spontaneous, 3 = to speech, 2 = to pain, and 1 = none. For motor response: 6 = to verbal, 5 = localizes to pain, 4 = withdraws to pain, 3 = decorticate flexion to pain, 2 = extends to pain, and 1 = none. For verbal response: 5 = oriented, 4 = confused, 3 = inappropriate words, 2 = incomprehensible sounds, and 1 = none. A normal GCS score is 15. A score of 8 or less indicates a severe brain injury.
d) Renal: Assess the color and amount of urine.
e) Gastrointestinal: All trauma patients are considered to have a full stomach. Gastric emptying slows or stops at the time of the trauma. The presence of a nasogastric tube also provides a “wick” that may allow gastric fluid: to be aspirated.
f) Endocrine: The release of stress hormones transiently elevates blood glucose levels.
g) Hematologic: Severe physical stress can lead to coagulopathies, as can dilution of clotting factors during massive volume resuscitation.
h) Patient preparation
(1) Baseline laboratory tests are obtained as available: hemoglobin, hematocrit, and others as indicated by history and physical examination.
(2) Type and cross-match for at least 4 units.
(3) Other diagnostic tests are as indicated by history and physical examination.
(4) Premedication is usually avoided but can be individualized in trauma patients.
3. Room preparation
a) Standard monitoring equipment
b) Difficult airway equipment such as multiple laryngoscope blades, video laryngoscope, laryngeal mask airway (LMA) of various sizes, intubating LMA, bougie stylet, and emergency airway access kits.
c) Arterial line, arterial blood gas measurement, pulmonary artery catheters, blood warmers, rapid infuser, and patient warming equipment
d) Full range of standard and emergency resuscitative drugs immediately available
e) Transesophageal echocardiogram capabilities can aid in the assessment of heart function.
f) Position usually supine unless otherwise indicated.
4. Anesthetic technique
Immediate establishment of the airway is the priority. Anesthetics are introduced depending on the stability of the patient as assessed by vital signs and physical assessment. Muscle paralysis is provided to facilitate surgical procedures, which can lead to intraoperative awareness in the trauma patient.
5. Perioperative management
a) Induction
(1) This is individualized based on the patient’s condition and the severity of trauma.
(2) Rapid-sequence induction and immediate establishment of the airway are necessary.
(3) Ketamine, propofol, and thiopental (Pentothal) may be administered depending on hemodynamic status. The specific anesthetic considerations for various trauma conditions are listed in the boxes on pg. 480.
Conditions Presented by Trauma Patients That Contraindicate the Use of Specific Anesthetic Agents
Shock
Most anesthetic agents cause dose-related cardiovascular depression. IV induction agents are used cautiously in small incremental doses. Inhalation agents are added slowly as cardiovascular stability improves. Use of histamine-releasing muscle relaxants (e.g., atracurium) and narcotics (e.g., morphine, codeine) that could aggravate shock are avoided.
Head injury
Ketamine causes increases in ICP. N2O causes increases in pneumocephalic tension. All inhalation agents tend to increase ICP as a result of increases in cerebral blood volume. However, inhalation agents decrease CMRO2. The effects are temporarily attenuated by moderate hyperventilation of patients to Paco2 levels of 30 to 35 mmHg. Succinylcholine causes rises in ICP that may be detrimental in certain situations of significant ICP elevation. Hyperventilation with a Paco2 of 25 mmHg or less is not recommended.
Burns, spinal cord injury, and crush injuries
In these categories, succinylcholine can produce dangerous rises in potassium levels if it is administered approximately 24 hours after the injury. This problem can occur indefinitely in patients with permanent spinal cord injuries (e.g., paraplegia, quadriplegia).
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