Trauma



Trauma


Andrew Sosa

Jaideep K. Malhotra

Ralph L. Slepian





A. Medical Disease and Differential Diagnosis



  • How is trauma classified?


  • What are the injuries associated with thoracic trauma?


  • What are the injuries associated with cardiac trauma?


  • What are the complications of acute pericardial tamponade?


  • What are the anesthetic implications for treating cardiac tamponade?


  • How is the initial assessment and management of the trauma patient performed?


  • What constitutes a primary survey and what is its objective?


  • What constitutes a secondary survey, and what is its objective?


  • What are the signs and symptoms of a hemothorax? What is the definition of massive hemothorax?


  • What are the indications for a thoracotomy to treat a hemothorax?


  • How are pneumothoraces categorized?


  • What is an occult pneumothorax?


  • If the patient has a widened mediastinum on chest radiograph, what are your concerns?


  • What are the most commonly injured organs in blunt abdominal trauma?


  • What is a focused abdominal sonography for trauma (FAST) examination?


  • What is diagnostic peritoneal lavage?


  • Why was diagnostic peritoneal lavage not performed for this patient?


  • Define shock.


  • What are the four types of shock?


  • List the signs and symptoms of shock.


  • What is the pathophysiology of hypovolemic shock?


  • How would you classify hemorrhage?


  • What is the initial treatment of hemorrhagic shock?


  • Would you choose crystalloid or colloid therapy to treat hypovolemic shock?


  • Is there a place for dextran or hetastarch (Hespan) in treating hypovolemic shock?


  • Is there a place for hypertonic saline in the treatment of hypovolemic shock?



B. Preoperative Evaluation and Preparation



  • What premedication would you order?


  • What preoperative testing would you order?


C. Intraoperative Management



  • How would you monitor this patient?


  • How would you induce anesthesia?


  • What technique could you use if single-lung ventilation was indicated?


  • What agents would you choose to maintain anesthesia?


  • What muscle relaxant would you choose?


  • What can be done to decrease the incidence of intraoperative awareness?


  • Five minutes after intubation, the peak airway pressure increased from 20 to 40 cm H2O. What are the possible causes?


  • How would you make a diagnosis of tension pneumothorax?


  • What is the treatment of tension pneumothorax?


  • The patient’s blood loss was continuing, and the hematocrit was 18%. What type of blood would you give if the type and crossmatch are not completed?


  • What precautions should be taken if more than 2 units of type O Rh-negative uncrossmatched whole blood is given?


  • What are the complications associated with any blood transfusion?


  • What is considered a massive transfusion?


  • What are the complications associated with a massive transfusion?


  • Can the shift of the oxygen-hemoglobin dissociation curve be quantitated?


  • How is hypothermia defined?


  • What are the adverse effects of hypothermia?


  • What is the treatment of hypothermia?


  • What are the effects of blood transfusion on the immune system?


  • What are the guidelines for transfusion of blood products?


  • What are the guidelines for the ratio of plasma/platelet transfusion to packed red blood cells in a massive transfusion?


  • If a patient were a member of the Jehovah’s Witness religious sect, would you give a blood transfusion?


  • If a child is a Jehovah’s Witness and suffered from hemorrhagic shock, what would you do?


  • What are the concentrated factors available for bleeding patients?


  • What is thromboelastography and thromboelastometry? How can they guide transfusion?


D. Postoperative Management



  • What is acute respiratory distress syndrome (ARDS)? What is acute lung injury?


  • How is ARDS treated?


  • In the recovery room, you are called to see this patient because of oliguria. How would you evaluate and treat this patient?


  • If this patient had a crush injury and low urine output, what other concerns might you have? What if the patient has dark or “tea-colored” urine?


A. Medical Disease and Differential Diagnosis


A.1. How is trauma classified?

Trauma is usually separated into two distinct categories: penetrating and blunt trauma. Both can cause havoc on the body’s vascular, visceral, musculoskeletal, and nervous systems.



A.2. What are the injuries associated with thoracic trauma?

Penetrating injuries associated with thoracic trauma are typically associated with stabbings and gunshot wounds. The latter causes far more destruction because of the large amount of kinetic energy transferred to the thoracic cavity from the impact of the bullet. As a result, gunshot wounds to the thorax are diffuse and much more likely to be fatal when compared to stabbings.

Blunt injuries to the chest are far more common than penetrating injuries. The most common causes of blunt injuries are deceleration injuries (as a result of motor vehicle accidents) and crush injuries. These can range from relatively minor injuries such as rib fractures to more severe ones such as lung contusion, tracheobronchial tears, flail chest, pneumothorax, hemothorax, injuries to the great vessels, and traumatic ruptures of the esophagus or diaphragm.



Barbeito A, Shaw AD, Grichnik K, eds. Thoracic Anesthesia. New York: McGraw-Hill; 2012:379-402.


A.3. What are the injuries associated with cardiac trauma?

Penetrating cardiac injuries often lead to immediate cardiovascular collapse, and patients rarely survive to reach the operating room. Injuries associated with penetrating cardiac trauma include pericardial tamponade, cardiac perforation, rupture of a chamber, and fistula formation.

Blunt cardiac trauma injuries include cardiac contusion (most common), pericardial ruptures, rupture of a chamber, valvular tears, coronary artery injuries, and ventricular aneurysms.



Barash PG, Cullen BF, Stoelting RK, et al, eds. Clinical Anesthesia. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:1509-1510.

Barbeito A, Shaw AD, Grichnik K, eds. Thoracic Anesthesia. New York: McGraw-Hill; 2012:379-402.


A.4. What are the complications of acute pericardial tamponade?

The primary complication of pericardial tamponade is a decrease in cardiac output secondary to pericardial pressure causing severe diastolic dysfunction. Unstable patients with acute pericardial tamponade present with hypotension, tachycardia, and tachypnea. The diagnosis can be made by the presence of Beck triad (hypotension, distended neck veins, and muffled heart sounds) and pulsus paradoxus; these signs can be easily missed on a hypovolemic trauma patient. Definitive diagnosis of cardiac tamponade can be made with transthoracic echocardiography. If the diagnosis of acute pericardial tamponade is made and the patient is unstable, immediate evacuation of the pericardium via a pericardiocentesis or a pericardial window is required (also see Chapter 12).



Barash PG, Cullen BF, Stoelting RK, et al, eds. Clinical Anesthesia. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:1509-1510.


A.5. What are the anesthetic implications for treating cardiac tamponade?

The anesthetic goal for treating acute cardiac tamponade is to maintain intrinsic sympathetic tone. These patients are extremely dependent on intrinsic sympathetic tone, and therefore, maintenance of heart rate and preload are of utmost importance. A preinduction intra-arterial catheter and large-bore intravenous access are essential. Ketamine and etomidate are considered appropriate agents for induction. A rapid sequence induction with succinylcholine or an awake intubation can be performed. If possible, preinduction sedation should be avoided. Inotropes such as epinephrine should be readily available and can be given in small doses to avoid bradycardia and hypotension. Induction should be delayed until after patient preparation and draping is completed. In the event the patient becomes hemodynamically unstable, the effusion can then be drained as quickly as possible (also see Chapter 12).



Barash PG, Cullen BF, Stoelting RK, et al, eds. Clinical Anesthesia. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:1509-1510.

Barbeito A, Shaw AD, Grichnik K, eds. Thoracic Anesthesia. New York: McGraw-Hill; 2012:310-312, 379-402.



A.6. How is the initial assessment and management of the trauma patient performed?

A systematic and organized approach to the assessment and management of the trauma patient has been developed by the American College of Surgeons and is taught as Advanced Trauma Life Support. Initial evaluation and management as stated by Advanced Trauma Life Support consists of five components:



  • The primary survey


  • Resuscitation


  • The secondary survey


  • Continued monitoring and reevaluation


  • Definitive care



Barbeito A, Shaw AD, Grichnik K, eds. Thoracic Anesthesia. New York: McGraw-Hill; 2012:379-402.


A.7. What constitutes a primary survey and what is its objective?

The assessment of the trauma patient consists of the primary and secondary survey. The function of the primary survey is to identify and treat immediately life-threatening injuries. The life-threatening injuries associated with chest trauma are the following:



  • Lost airway


  • Tension pneumothorax


  • Massive hemothorax


  • Open pneumothorax


  • Cardiac tamponade


  • Flail chest



Barbeito A, Shaw AD, Grichnik K, eds. Thoracic Anesthesia. New York: McGraw-Hill; 2012:379-402.

Chest trauma: initial evaluation. www.trauma.org/archive/thoracic/CHESTintro.html. February 2004. Accessed October 20, 2015.


A.8. What constitutes a secondary survey, and what is its objective?

The secondary survey is a more detailed examination aimed at identifying other non-life-threatening injuries, planning further laboratory and radiographic studies, and forming a workable differential diagnosis. Examples of chest injuries identified on secondary survey are the following:



  • Simple pneumothorax or hemothorax


  • Rib fractures


  • Pulmonary contusion


  • Non-life-threatening blunt myocardial injury



Barbeito A, Shaw AD, Grichnik K, eds. Thoracic Anesthesia. New York: McGraw-Hill; 2012:379-402.

Chest trauma: initial evaluation. www.trauma.org/archive/thoracic/CHESTintro.html. February 2004. Accessed October 20, 2015.


A.9. What are the signs and symptoms of a hemothorax? What is the definition of massive hemothorax?

The signs and symptoms of a hemothorax include diminished breath sounds on the affected side, hemorrhagic shock, and mediastinal shift. A massive hemothorax is defined as a rapid accumulation of greater than 1,500 mL of blood in the thoracic cavity.



Reed AP, Yudkowitz FS. Clinical Cases in Anesthesia. 4th ed. London: Elsevier Saunders; 2014:395-410.


A.10. What are the indications for a thoracotomy to treat a hemothorax?

Hemothorax, if severe enough, can lead to hemorrhagic shock. Therefore, timely diagnosis and treatment are of utmost importance. After a chest tube is placed, if drainage of blood is greater than 1,200 mL or if drainage is greater than 200 mL per hour for over 4 hours, a thoracotomy is indicated. Alternatively, if the patient is older than 60 years, then if drainage is
greater than 100 mL per hour for over 4 hours, a thoracotomy is also indicated. If the patient does not meet these criteria but is still hemodynamically unstable or if ventilation is difficult, emergent surgery should be performed.



Reed AP, Yudkowitz FS. Clinical Cases in Anesthesia. 4th ed. London: Elsevier Saunders; 2014:395-410.


A.11. How are pneumothoraces categorized?

Pneumothoraces are categorized into three broad categories: open, closed, and tension pneumothorax. Pneumothoraces, like hemothoraces, can cause severe hypoxemia, impair venous return, and cause a severe mediastinal shift.

Open pneumothoraces are a result of penetrating wounds and allow intrathoracic pressure to equalize with atmospheric pressure. The result is introduction of outside air every time the patient takes a breath. Definitive treatment is to close the wound and placement of a chest tube.

Closed pneumothoraces can result from both blunt and penetrating trauma to the chest. It is defined as the presence of air in the pleural space. Diagnosis can be made radiographically, via a chest radiograph or computed tomography (CT), although in many trauma situations, the patients’ condition precludes obtaining a chest radiograph. In such cases, diagnosis can be made by physical examination, that is, by percussion or by diminished or absent breath sounds. In addition, a diagnosis can be made by ultrasound examination of the chest. Recent studies have suggested that using ultrasound detection of a pneumothorax can be a faster and more sensitive test than a supine chest radiograph. Treatment for a pneumothorax is the placement of a chest tube if the patient is unstable or if the pneumothorax is greater than 10% of the pleural cavity.

Tension pneumothorax is the progressive build-up of air within the pleural space that cannot escape. Essentially, it is a “one-way valve” that is exacerbated by positive pressure ventilation. This progressive build-up of air can cause a mediastinal shift, an acute rise in airway pressures, and obstruction of venous return. All of these factors can result in a sudden and dramatic cardiovascular collapse.



Barbeito A, Shaw AD, Grichnik K, eds. Thoracic Anesthesia. New York: McGraw-Hill; 2012:382-383.

Pneumothorax: an overview of pneumothoraces-diagnosis & management. www.trauma.org/index.php/main/article/393/. Published May 9, 2009. Accessed May 2, 2015.

Wilkerson RG, Stone MB. Sensitivity to bedside ultrasound and supine anteroposterior chest for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17:11-17.


A.12. What is an occult pneumothorax?

An occult pneumothorax is a pneumothorax that is diagnosed by CT but was not identified previously on the chest radiograph. In many cases, this type of pneumothorax is managed conservatively and resolves over time, without requiring placement of a chest tube. Frequently, a trauma patient with an occult pneumothorax will require general anesthesia and positive pressure ventilation. Whether these patients should have a chest tube placed preemptively is currently debated. For now, the decision should be made on a case-by-case basis.

When any trauma patient is placed on positive pressure ventilation, a history of a negative chest radiograph alone does not rule out the presence of an occult pneumothorax. As many as 50% of all pneumothoraces are occult, with an overall incidence of 5% in all trauma patients.



Ball CG, Kirkpatrick AW, Feliciano DV. The occult pneumothorax: what have we learned? Can J Surg. 2009;52:E173-E179.

Ouellet JF, Trottier V, Kmet L, et al. The OPTICC trial: a multi-institutional study of occult pneumothoraces in critical care. Am J Surg. 2009;197:581-586.


A.13. If the patient has a widened mediastinum on chest radiograph, what are your concerns?

A chest radiograph revealing a widened mediastinum may indicate the presence of a thoracic aortic injury. These types of injuries are often life-threatening, necessitating immediate identification and intervention. Blunt aortic injury is associated with high-speed deceleration and
is the second leading cause of death in trauma patients, accounting for 16% of all traumarelated deaths. Open surgical repair requires a double-lumen tube, single-lung ventilation, and clamping of the proximal aorta while taking measures to protect the spinal cord. In patients with coexisting injuries, such as increased intracranial pressure, profound bleeding, or hypoxemia, this procedure may be contraindicated. These patients may be medically managed with blood pressure control until these other issues have resolved. They may also be candidates to undergo a less invasive endovascular repair, a technique that has been increasingly used over the last 20 years.



Ekeh AP, Peterson W, Woods RJ, et al. Is chest x-ray an adequate screening tool for diagnosis of blunt thoracic aortic injury? J Trauma. 2008;65:1088-1092.

Neschis DG, Scalea TM, Flinn WR, et al. Blunt aortic injury. N Engl J Med. 2008;359:1708-1716.


A.14. What are the most commonly injured organs in blunt abdominal trauma?

In blunt abdominal trauma, the most commonly injured organs are the spleen, liver, kidneys, and bowel. Generally, blunt abdominal trauma leads to higher mortality rates than penetrating trauma. The reason is multifactorial and includes greater difficulty in diagnosis and frequent association with other injuries, such as head injury, chest trauma, and fractures.


A.15. What is a focused abdominal sonography for trauma (FAST) examination?

FAST is a rapid ultrasonography examination performed in the trauma resuscitation room. It has been used to determine the presence of fluid (blood) within the peritoneum, pericardium, and thorax. Currently, FAST is particularly helpful in the bedside examination of hemodynamically unstable blunt trauma patients. It may also have a role in some patients with penetrating trauma.



Ng A. Trauma ultrasonography: the FAST and beyond. www.trauma.org/archive/radiology/FASTintro.html. December 2001. Accessed October 20, 2015.

Rozycki GS, Root HD. The diagnosis of intraabdominal visceral injury. J Trauma. 2010;68(5):1019-1023.


A.16. What is diagnostic peritoneal lavage?

In penetrating trauma, diagnostic peritoneal lavage allows for rapid identification of a hemoperitoneum and, therefore, the discovery of an intraperitoneal injury. Peritoneal lavage is a procedure performed in the emergency room to help determine whether a patient has internal bleeding that requires an exploratory laparotomy. It is done by performing a minilaparotomy under local anesthesia. A catheter is then placed into the abdomen and is aspirated for gross blood. Aspiration of 10 mL of blood is considered a positive finding. A grossly bloody aspirate is indicative of solid or vascular injury. If less than 10 mL of blood is aspirated, then 1 L of lactated Ringer’s solution or normal saline is allowed to drain into the abdomen. The lavage fluid is then allowed to return by gravity and is sent to the laboratory for analysis. Criteria for a positive peritoneal lavage are an erythrocyte count of 100,000 per µL, a white blood cell count of 500 per µL, the presence of bile or food particles, and a fluid amylase concentration of 175 units per dL. The white blood cell level itself should not determine the need for laparotomy. The level of white blood cells also does not rise initially but requires several hours to rise. Alkaline phosphatase and amylase are contained in the small bowel and spill into the abdominal cavity after injury. These levels tend to rise early in injury. Amylase in lavage fluid has been seen as a more accurate marker than alkaline phosphatase. If the peritoneal lavage meets one or more of these criteria, the patient goes to the operating room for an exploratory laparotomy.



Roberts JR, Hedges JR, Custalow CB, et al, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. Philadelphia, PA: Elsevier Saunders; 2014:852-872.


A.17. Why was diagnostic peritoneal lavage not performed for this patient?

Peritoneal lavage was not done for two reasons. First, it is felt that all penetrating wounds to the abdomen need to be surgically explored. Second, this patient was exhibiting signs of shock and obviously needed to be sent to the operating room without delay.


Before CT and ultrasonography technologies, diagnostic peritoneal lavage was the only diagnostic test available to rapidly evaluate the abdomen for injury. Although diagnostic peritoneal lavage is highly sensitive, it can also result in false-positive results, leading to unnecessary exploratory laparotomies. CT now allows for evaluation of all intraperitoneal organs, the diaphragm, and the retroperitoneum (an area inaccessible to diagnostic peritoneal lavage) while also allowing for identification of the specific organ injured. CT should be used in the evaluation of hemodynamically stable trauma patients.



Rozycki GS, Root HD. The diagnosis of intraabdominal visceral injury. J Trauma. 2010;68(5):1019-1023.


A.18. Define shock.

Shock is defined as the circumstance of insufficient oxygen delivery to sustain aerobic metabolism in vital cells of essential organs. Shock of all forms appears to be invariably related to inadequate tissue perfusion. The low-flow state in vital organs seems to be the final common denominator in all forms of shock.



Townsend CM Jr, Beauchamp RD, Evers BM, et al, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:66-119.


A.19. What are the four types of shock?

For a working classification of shock, the following classification offered by Blalock in 1934 is still useful and functional:



  • Hematogenic (hypovolemic, hemorrhagic) shock: characterized by a loss of circulatory blood volume


  • Cardiogenic shock: characterized by an inability of the myocardium to pump blood


  • Vasogenic (septic) shock: characterized by an infection that causes a decrease in peripheral vascular resistance


  • Neurogenic shock: characterized by an impairment of the central nervous system-mediated control of vascular tone



Townsend CM Jr, Beauchamp RD, Evers BM, et al, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:66-119.


A.20. List the signs and symptoms of shock.

Tachycardia, hypotension, cool extremities, pallor, oliguria, tachypnea, decreased capillary refill, anxiety, restlessness, and loss of consciousness are signs and symptoms of shock.


A.21. What is the pathophysiology of hypovolemic shock?


Cardiovascular Derangement

An acute decrease in circulating blood volume leads to an increase in sympathetic activity with an outpouring of epinephrine and norepinephrine from the adrenal gland. The α-adrenergic response causes vasoconstriction, which shunts blood from the skin, viscera, and muscle, thereby preserving the coronary and cerebral circulation. With constriction of both precapillary and postcapillary sphincters, a reduction occurs in hydrostatic pressure of the capillary bed, which allows the osmotic pressure to draw fluid back into the vascular space from the interstitial space. This process of hemodilution tends to expand the patient’s blood volume. In addition to the vasoconstriction and hemodilution, a tachycardic response may be noted.

Myocardial-depressant factor is a peptide thought to be released from the pancreas during low-flow states. This peptide is thought to be responsible for some of the decreased cardiac performance seen in trauma patients. Pancreatectomy and various myocardial-depressant factor antagonists demonstrate protective myocardial effects during shock in animals.


Acid-Base Disturbance

Metabolic acidosis is almost always seen in association with a shock state. As a result of decreased blood flow or a low rate of perfusion, oxygen delivery to vital organs is reduced, and consequently, a mandatory change occurs from aerobic to anaerobic metabolism. This shift
will lead to the production of lactic acid instead of carbon dioxide as the end product of metabolism. The increase in lactic acid leads to a metabolic acidosis.



Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine-Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:67-74.

Townsend CM Jr, Beauchamp RD, Evers BM, et al, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:66-119.


A.22. How would you classify hemorrhage?

Classification of hemorrhage based on blood loss is as follows:

Class I: Blood loss of up to 15% of the blood volume: normal pulse and blood pressure

Class II: Blood loss of up to 30% of the blood volume: tachycardia, decreased urine output, and anxiety

Class III: Blood loss of up to 40% of the blood volume: marked tachycardia, hypotension, tachypnea, oliguria, and anxiety

Class IV: Blood loss of more than 40% of the blood volume: tachycardia and hypotension, tachypnea, anuria, confusion, and lethargy



Dutton RP. Shock and trauma anesthesia. Anest Clin North Am. 1999;17:83-95.


A.23. What is the initial treatment of hemorrhagic shock?

The initial treatment of hemorrhagic shock is to attempt to stabilize hemodynamics by administering intravenous fluids and blood products as needed to maintain tissue perfusion and oxygen delivery. Recently, trauma centers have revised the standard approach to resuscitation for major traumatic hemorrhage requiring massive transfusion. Trauma centers have adapted the practice of initial resuscitation with hemostatic components such as plasma and platelets as well as packed red blood cells. This strategy for treating massive hemorrhage was pioneered from knowledge gained from combat hospitals in Iraq and Afghanistan. This approach involves limiting the total volume of crystalloid and replacing intravascular volume with packed red blood cells and fresh frozen plasma (FFP) in a ratio approaching 1:1. This strategy is geared to avoid the acute coagulopathy associated with major trauma and blood loss and has been shown to decrease mortality rates in combat and civilian injuries requiring massive transfusion.



Barash PG, Cullen BF, Stoelting RK, et al, eds. Clinical Anesthesia. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:1509-1510.

Griffee MJ, Deloughery TG, Thorborg PA. Coagulation management in massive bleeding. Curr Opin Anaesthesiol. 2010;23:263-268.


A.24. Would you choose crystalloid or colloid therapy to treat hypovolemic shock?

Crystalloid solutions can sustain hemodynamics and deliver adequate oxygenation in healthy patients who have lost as much as 30% of their total blood volume. Still, controversy remains over the use of crystalloid versus colloid therapy for the initial therapy of hypovolemic shock.

Proponents of crystalloid therapy believe that both intravascular and interstitial fluid losses occur in hypovolemic shock and that these can be readily replaced with crystalloids. Another benefit of crystalloids is the decrease in blood viscosity, which may enhance perfusion. A particular advantage to lactated Ringer’s solution is that lactate is metabolized to bicarbonate, which may help to buffer the patient’s acidosis. Finally, in this age of medical economics, the cost of crystalloid is much less than that of colloid. Because crystalloid leaves the intravascular space and enters the interstitial space, large quantities are needed, and some fear that these quantities may lead to both pulmonary and peripheral edema, although studies have not confirmed this fear.

Proponents of colloid therapy, on the other hand, argue that much less volume of fluid is needed to counteract hypovolemic shock and that early colloid therapy can prevent the complications associated with large-volume crystalloid resuscitation such as dilutional coagulopathy, hyperchloremic acidosis, and edema. Colloids maintain the oncotic pressure and hold the interstitial fluids in the intravascular space, which is felt to possibly prevent pulmonary
edema. If leaky alveolar capillary membranes are seen within the lung, colloids may worsen pulmonary edema.



Choi PT, Yip G, Quinonez LG, et al. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. 1999;27:200-210.

Miller RD, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 8th ed. Philadelphia, PA: Saunders Elsevier; 2015:1767-1810.

Orlinsky M, Shoemaker W, Reis ED, et al. Current controversies in shock and resuscitation. Surg Clin North Am. 2001;81:1217-1262.


A.25. Is there a place for dextran or hetastarch (Hespan) in treating hypovolemic shock?

Dextran and hetastarch are synthetic polysaccharide solutions with varying mean molecular weights. Dextran 40, dextran 70, and hetastarch have all been used as volume expanders. Dextrans are relatively inexpensive, increase effective blood volume, and decrease blood viscosity. Nevertheless, their negative aspects are considerable. They impair coagulation by coating platelets, and they impair typing and crossmatching by coating red blood cells. In addition, anaphylactic reactions have been reported.

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Mar 18, 2021 | Posted by in ANESTHESIA | Comments Off on Trauma
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