Trauma and Orthopedic Surgery

Trends revealed from the National Trauma Data Bank

1. The majority of reported traumas occur in young males

2. Case fatality rises with age at time of injury

3. Motor vehicle accidents are the main cause of injury in young and middle-aged patients, with falls becoming predominant in elderly patients

4. The vast majority of injuries are blunt

5. Penetrating injuries have the highest associated mortality

6. Burns result in the longest hospital stays

7. America leads the world in firearm related deaths in both adults and children, with an incidence 4× higher than any other industrialized country

8. Firearm deaths occur predominantly in African-American men

Patient Assessment

Traumatic injuries seldom occur in isolation, meaning that a dislocated shoulder following a motor vehicle accident is probably not the patient’s only injury. A number of scoring systems have been developed to reduce variability and ensure uniformity in how trauma patients are approached.

Airway/Breathing/Circulation/Disability represents the “A, B, C, and D” approach to initial assessment. Advanced Trauma Life Support (ATLS) is taught by the American College of Surgeons and is designed to assess a patient in a standardized fashion. The patient’s clothes are removed, IV access is obtained, and the entire body is visually examined for injury (“fingers and tubes in every orifice”).

The Glasgow Coma Scale (GCS) was developed to assess the level of neurologic injury, and includes assessments of movement, speech, and eye opening (see Table 26.2 below). Brain injury is often classified as severe (GCS ≤8), moderate (GCS 9–12), or minor (GCS ≥13).

Table 26.2

Glasgow coma scale

Eye opening
Spontaneous	4
To loud voice	3
To pain	2
None	1
Verbal response
Oriented	5
Confused, disoriented	4
Inappropriate word	3
Incomprehensible sounds	2
None	1
Best motor response
Obeys	6
Localizes	5
Withdraws (flexion)	4
Abnormal flexion posturing	3
Extension posturing	2
None	1

Regardless of assessment method, it is vital to remember that these scores do not predict ease of intubation, ventilation, or reflect volume, pulmonary, or cardiac status. In other words, a patient with a high GCS may still require urgent intubation or may be suffering myocardial ischemia due to injury stress. Also, post-traumatic patients frequently have a change of status, and frequent reassessments are mandatory as they might change anesthetic management.

Specific Challenges

Anesthesia personnel are frequently called to the emergency department for incoming trauma patients. As a result, we are frequently involved in resuscitation and airway management within minutes of the patient’s arrival. Since initial trauma care occurs on a continuum from the emergency department to operating room, many of the following discussion points are pertinent to both the specialties of emergency medicine and anesthesiology at each locale. As a result, anesthesia providers must be prepared to “work” in a potentially unfamiliar environment with a different (not necessarily better or worse) level of help and equipment than is typically available in a well-stocked trauma operating room.

The Trauma Arrest

Patients requiring CPR following trauma have an almost universally poor prognosis. In particular, patients presenting with blunt trauma in cardiac arrest have a mortality rate that approaches 100 %. Patients who are young, otherwise healthy, and receive hospital care within one hour of their injury tend to have better outcomes. For any hope of survival, early intubation with appropriate oxygenation and ventilation, as well as adequate fluid management are required.

The Trauma Airway

Emergency airway management of the trauma can be the single most challenging aspect of anesthesia care, and proper preparation and multiple backup plans are equally important. Airway damage, cervical spine injury, intoxication, and coexisting injury can combine to create a situation requiring experience, expertise, and luck! Fiberoptic intubation may be impossible due to airway blood or patient combativeness. LMA placement may be complicated by a full stomach. The patient may also come with a Combitube (see Chap. 9, Airway Evaluation and Management) or endotracheal tube already in place.

One plan to manage the airway of a combative trauma patient may look something like Fig. 26.1.

Figure 26.1

Sample plan to manage the airway of a combative trauma patient. RSI rapid sequence induction

If the airway appears “easy”, then one might proceed with an asleep intubation using in-line neck stabilization. If the airway appears “difficult”, one might either proceed with RSI (rapid sequence induction) with surgery backup (meaning that they are standing nearby ready to assist with a surgical airway) or try to hedge one’s bet and give a dose of intravenous or intramuscular ketamine in hopes that ventilation can be maintained, and an awake intubation technique can be used.

If a patient is stable from a respiratory standpoint and you are truly concerned about being able to manage the airway, consider bringing the patient to the operating room for the intubation. There you can manage your equipment more easily, have the assistance of those who are used to complex airway management, and have a well lit, nonchaotic environment to work in.

Remember: “Good judgment comes from experience, and experience comes from bad judgment.”

Clearing the C-Spine

A typical scenario: A patient comes to the operating room from the CT scanner for urgent splenectomy. He has been poked, prodded, and scanned prior to arrival, but is still wearing a C-collar. Is it OK to take it off? Just how does one clear the C-spine definitively? The short answer is that all imaging studies must be negative, and the patient must be able to clearly tell you that nothing hurts (to rule out a distracting injury). That said, patients frequently cannot do that. So in this case, to clear a C-spine, one would need:

Cleared films (X-ray, CT, and/or MRI). Note that following an MVA the most likely injuries are to C1 > C5 > C6 > C7, and following a fall C5 > C6 > C7

The patient has to be awake, coherent, and cooperative

The patient cannot be intoxicated (alcohol, drugs, or otherwise)

The patient cannot have a distracting injury that is causing more pain than he may have in his neck

The patient cannot have received a significant dose of opioids (just how much is significant is unclear, but if the patient is somnolent, do not trust that opioids have not blunted subjective pain complaints)

The patient cannot have tenderness to neck palpation or tenderness to gentle neck flexion/extension

If all of these criteria are not met (they rarely are), then one might still proceed with a rapid sequence induction with in-line stabilization (given a normal-looking airway). The job of the person holding stabilization is to not only hold the head/neck in neutral position, but also to inform the person intubating if the neck is moving due to vigorous laryngoscopy. Note that there will be another person holding cricoid pressure during this process, and therefore the anterior portion of the cervical collar should be removed during intubation.

Head Trauma

Patients presenting with head trauma can pose a difficult challenge to anesthesia providers. Laryngoscopy and succinylcholine are associated with increases in intracranial pressure (ICP), and sedation and hypoventilation result in an increase in ICP. The goals include maintaining cerebral perfusion pressure >60 mmHg (MAP minus ICP or CVP), protecting potentially ischemic brain tissue near the area of injury, and keeping the patient’s ICP as low as possible.

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