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anesthesia for trauma


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Title: anesthesia for trauma

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anesthesia for trauma
  • Injury is the leading cause of death between the
    ages of 1 and 45 years and the third leading
    cause of death overall.
  • 3th leading cause of death and disability in all
    age groups
  • Mortality increased by 2020 in low and middle
    income countries
  • Decreased mortality in trauma center

  • Anesthesiologists are involved
  • beginning with airway and resuscitation
    management in the emergency department (ED) and
    proceeding through the operating room (OR) to the
    intensive care unit (lCU).
  • Critical care and pain management specialists see
    trauma patients as a large fraction of their
  • in European practice anesthesiologist working in
    the prehospital environment, as an ED director,
    or as leader of a hospital's trauma team.

  • The presence of an experienced anesthesiologist
    and the immediate availability of an open OR are
    both core resource standards for accreditation of
    a "level 1" trauma center.

  • Anesthesia for trauma patient is different
    from routine OR practice
  • Most urgent cases occur during off-hours
  • Small hospital-military and humanitarian
    practice,auster condition (Resources avibility)
  • limitation in Patient information
  • Full stomach-intoxicate-cervical spine
  • Multiple positioning-multiple procedure-need to
    consider priorities in management
  • Occult injuries such as tension Pneumothorax can
    be manifested at unexpected times
  • Multiple injury

  • The advanced trauma life support (ATLS) course of
    the American College of Surgeons is the most
    popular training program for trauma physicians
  • ATLS
  • Based on primary survey that means
  • simultaneous diagnostic and therapeutic
    activities intended to identify and treat life
    and limb-threatening injuries, beginning with the
    most immediate.
  • This focus on urgent problems is first captured
    by the " Golden hour catch phrase and is one of
    the most important lessons of ATLS.

  • ATLS begins with the ABCDE
  • airway, breathing, circulation, disability, and
    exposure and secondary survey.
  • adequate open airway and acceptable respiratory
    mechanics is of primary Importance because
    hypoxia is the most immediate threat to life.
  • Trauma patients are at risk for airway
    obstruction and inadequate respiration for the
    reasons listed later.

  • cause of obstructed airway or inadequate
    ventilation in trauma patients
  • Airway Obstruction
  • Direct injury to the face, mandible, or neck
  • Hemorrhage in the nasophrynx, sinuses, mouth, or
    upper airway
  • Diminished consciousness secondary to traumatic
    brain injury, intoxication, or analgesic
  • Aspiration of gastric contents or a foreign body
    (e.g., dentures)
  • Misapplication of oral airway or endotracheal
    tube (esophageal intubation)
  • Inadequate Ventilation
  • Diminished respiratory drive secondary to
    traumatic brain injury, shock, intoxication,
    hypothermia, or over sedation
  • Direct injury to the trachea or bronchi
  • Pneumothorax or hemothorax
  • Chest wall injury
  • Aspiration
  • Pulmonary contusion
  • Cervical spine injury
  • Bronchospasm secondary to smoke or toxic gas

  • Endotracheal intubation must be immediately
    confirmed by
  • capnometry for patients who have vital signs
    esophageal intubation or endotracheal tube
    dislodgement is common
  • Patients in cardiac arrest may have very low
    end-tidal CO2 values
  • direct laryngoscopy should be performed if there
    is any question about the location of the
    endotracheal tube.
  • 10

  • continue
  • If establishment of a secure airway and adequate
    ventilation require a surgical procedure such as
    a tracheostomy, tube thoracostomy, or open
    thoracotomy, this procedure must be precede.
  • Subsequent surgery to convert a cricothyroidotomy
    to a tracheostomy or close an emergency
    thoracotomy may then follow in the OR on an
    urgent basis.

  • Hemorrhage is the next most pressing concern
    because ongoing loss of blood will be fatal in
    minutes to hours.
  • Shock is presumed to be a consequence of
    hemorrhage until proved otherwise.

  • Assessment of the circulation consists of
  • an early phase, during active hemorrhage
  • late phase, which begins when hemostasis is
    achieved and continues until normal physiology
    is restored.
  • In the early phase, diagnostic efforts will focus
    on the five sites of bleeding detailed
  • they are the only areas in which Exanguinating
    hemorrhage can occur.

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  • Neurologic examination
  • measurement of the Glasco Coma Scale (GCS) score
    examination of the pupils for size, reactivity,
    and symmetry
  • determination of preserved sensation and motor
    function in each of the extremities.
  • In few patients who require operative evacuation
    of an epidural or subdural hematoma, the
    timeliness of diagnosis and treatment has a
    strong influence on outcome.
  • patients with unstable spinal canal injuries and
    incomplete neurologic deficits may benefit from
    early operative intervention.

  • The final step in the primary survey is complete
    exposure of the patient and a
  • head-to-toe search for visible injuries or
    deformity-soft tissue bruising, and any breaks in
    the skins.

  • secondary survey
  • history and physical examination
  • diagnostic studies
  • subspecialty consultation
  • treatment plans established
  • Indications for urgent or emergency surgery
  • pulseless extremity,
  • compartment syndrome
  • near amputation
  • massively fractured extremity
  • must go to the operative room as soon as

  • Infection
  • sepsis is a leading cause of complications and
    death in trauma patien
  • open injuries should be thoroughly debrided-and
    closed if appropriate-at the earliest
  • Other indication for urgent surgery
  • perforation of the bowel
  • open fracture
  • extensive soft tissue wounds
  • The frequency of infectious increases in linear
    fashion with time
  • the anesthesiologist must balance the need for
    early surgery against the need for diagnostic
    studies and adequate preoperative resuscitation.

Surgical priorities(fig72-2)
  • 1Airway management
  • 2Control of exanguinating hemorrhage
  • (Laparaotmy-thoracotomy-pelvic external
    fixation-neck exploration)
  • 3Intracranial mass excision
  • 4Treatment limb or eyesight - High risk sepsis
  • Control of ongoing hemorrhage-Early patient
    mobilization- spinal fixation- Closed long bone
  • Better cosmetic outcome-Facial fracture
    repair-Soft tissue closure

  • Emergency air way management
  • Adequate oxygenation and ventilation
  • Protection from aspiration
  • ASA algorithm for management of difficult air way
    is useful starting point for the trauma
    anesthesiologist whether in the ED or OR.
  • (figure72-4)
  • 20

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  • Indication of endotracheal intubation
  • Cardiac or respiratory arrest
  • Respiratory insufficiency
  • Airway protection
  • The need for deep sedation or analgesia, general
  • Transient hyperventilation of patients with space
    occupying intracranial lesions and evidence of
    increased intracranial pressure (ICP)
  • Delivery of 100 FIO2 patients with carbon
    monoxide poisoning
  • Facilitation of the diagnostic workup in
    uncooperative or intoxicated patients.

Approach to Endotracheal Intubation
  • the anesthesiologist should insist on the same
    monitoring standards for airway management in the
    ED as in the OR, including an electrocardiogram,
    blood pressure (BP), oximetry, and capnometry
  • Appropriate equipment
  • oxygen source,
  • bag-valve-mask ventilating system,
  • mechanical ventilator,
  • suction, selection of laryngoscope blades,
  • endotracheal tubes,
  • devices for managing difficult intubations

  • Neuromuscular usage???
  • Although concern may exist that the use of
    neuromuscular blocking drugs and potent induction
    anesthetics outside the OR will be associated
    with a higher complication rate, the opposite is
    in fact more likely correct.
  • Attempts to secure the airway in an awake or
    lightly sedated patient increase the risk of
    airway trauma ,pain, aspiration, hypertension,
    laryngospasm, and combative behavior.

Prophylaxis against aspiration of gastric content
  • A trauma patient is always considered to have a
    full stomach
  • ingestion of food or liquids
  • swallowed blood from oral or nasal injuries
  • delayed gastric emptying
  • administration of liquid contrast medium
  • If time and patient cooperation allow, it is
    reasonable to administer non particulate antacids
    for patient before induction and intubation.
  • Cricoid pressure-the Sellick maneuver-should
    applied continuously

  • Sellick maneuver consists of elevating the
    patient's chin (without displacing the cervical
    spine) and then pushing the Cricoid cartilage
    posteriorly to close the esophagus.
  • A bimanual technique was later described by
    Crowley and Gieseckel. in which the left hand is
    placed under the patient's neck to stabilize it.
    The cricoid is stabilized between the thumb and
    third finger while the index finger pushes down.
  • Sellick's original paper described ventilation
    during Cricoid pressure in patients with full
  • because preoxygenation may be difficult in a
    trauma patient as a result of facial trauma,
    decreased respiratory effort, or agitation,
    desaturation will occur rapidly.

Protection of the Cervical Spine
  • Standard practice dictates that all blunt trauma,
    should be assumed to have an unstable cervical
    spine until this condition is ruled out.
  • laryngoscopy causes cervical motion, with the
    potential to exacerbate spinal cord injury

  • continue
  • The presence of an "uncleared" cervical spine
    mandates the use of in-line manual stabilization
    (not traction) throughout any intubation attempt
  • Emergency awake fiberoptic intubation
  • Indirect larengoscope

  • Personel
  • Three providers are required to ventilate the
    patient, hold Cricoid pressure, and provide
    in-line cervical stabilization a fourth provider
    to administer anesthetic medications
  • Additional assistance may be required to restrain
    a patient who is combative as a result of
    intoxication or TBl.
  • The immediate presence of a surgeon or other
  • Who can perform a cricothyroidotomy is desirable.
  • Urgent tube thoracostomy may prove necessary in
    some trauma patients to treat the tension
    Pneumothorax that develops with the onset of
    positive pressure ventilation
  • 30

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Anesthetic for induction of anesthesia
  • in hemorrhagic shock may potentiate profound
    hypotension and even cardiac arrest as a result
    of inhibition of circulating catecholamines.
  • propofol and thiopental both drugs are
    vasodilators and both have a negative inotropic
  • Effects of anesthetics on brain Increased
  • Etomidate more cardiovascular stability than
    other intravenous hypnotic
  • Ketamine
  • causes a release of catecholamines, primarily by
    direct action on the CNS
  • it is also a direct myocardial depressant.

  • continue
  • In normal patients, the effect of catecholamine
    release masks the cardiac depression and results
    in hyper tension and tachycardia.
  • In hemodynamically stressed patients , cardiac
    depression may be unmasked and lead to
    cardiovascular collapse.
  • Hypovolemic patients will become hypotensive with
    the administration of any the induction

  • Sever hypotension
  • healthy young patients can lose up to 40 of
    their blood volume before experiencing a decrease
    in arterial BP, which can lead to potentially
    catastrophic circulatory collapse with anesthetic
    induction, regardless of the agent chosen.
  • The dose of anesthetic must be decreased in the
    face of hemorrhage in patient with life
    threatening hypovolemia.

Neuromuscular blocking drugs
  • succinylcholine has fastest onset time and short
    of action
  • make it popular for rapid-sequence induction
  • In can not ventilate can not intubated patient
  • The anesthesiologist should not rely on return of
    spontaneous breathing

  • Suuccinylcoline
  • Serum potassium increases of 0.5 to 1.0 mEq/L but
    in certain patients potassium may increase by
    more than 5 mEq/L.
  • The hyperkalemic response is typically seen in
    burn victims, patients with muscle pathology
    caused by direct trauma, denervation (as with
    SCI), or immobilization
  • Hyperkalemia is not seen in the first 24 hours
    after these injuries
  • should be used cautiously in patient with ocular
    trauma and increase ICP
  • Rocuronium (09-1.2 mg/kg) and vecuronium (0.1 to
    0.2 mg/kg). (sugamadex)
  • large doses can be used to achieve rapid (1 to 2
    minutes) systemic relaxation.

  • Awareness Recall
  • Subsequent patient recall of intubation and
    emergency procedures is highly variable and
    affected by the presence of coexisting TBI,
    intoxication, and the depth of hemorrhagic shock
  • Decreased cerebral perfusion appears to inhibit
    memory formation but cannot be reliably
    associated with any particular BP or chemical
  • Administration of 0.2 mg of scopolamine (a
    tertiary ammonium vagolytic) has been advocated
    to inhibit memory formation in the absence of
    anesthetic drugs in this situation,
  • Small doses of midazolam will reduce the
    incidence of patient awareness, but can also
    contribute to hypotension.

  • Specific situation
  • There will always be specific situations where
    maintaining spontaneous ventilation during
    intubation is the preferred and indeed the safest
    manner in which to proceed.
  • If patients are able to maintain their airway
    temporarily but have clear indications for an
    artificial airway (penetrating trauma to the
    trachea), slow induction with ketamine or inhaled
    sevoflurane through Cricoid pressure will enable
    placement of an endotracheal tube without
    compromising patient safety.
  • Fiberoptic intubation can also be performed
    under such circumstances

Adjuncts to endotracheal intubation
  • Equipment to facilitate difficult intubation
    should be readily available wherever emergency
    airway management is performed
  • The gum elastic bougie, or intubating stylet
  • The stylet is placed through the vocal cords
    under the guidance of direct laryngoscopy, with
    the endotracheal tube then advanced over it into
    the trachea.

  • esophageal combitube (Kendall Sheridan Catheter)
  • Because placement of the Combitube has been
    associated with esophageal injury, its use should
    be reserved for emergency situations

The laryngeal mask airway (LMA)
  • LMA placement is possible in most patients who
    cannot be intubated and will permit adequate
    oxygenation and ventilation
  • The LMA is an appropriate rescue device for
    difficult air way situation in trauma, provide
    that there is no major anatomic injury or
    hemorrhage in the mouth and larynx.
  • 40

  • Trans tracheal jet ventilation
  • through a Percutaneous catheter attached to a
    high-pressure fresh gas source
  • After initial successful placement the catheter
    may kink or pull out of the trachea with motion
    of the patient's head or neck.
  • Tension Pneumothorax ,this condition should be
    suspected whenever a patient deteriorates
    suddenly after jet ventilation
  • reserved for only the most urgent situations and
    should be closely followed by open

Oral versus nasal intubation
  • oral intubation is preferred over nasal
    intubation in the emergency setting because of
    the risk of direct brain trauma from nasal
    instrumentation in a patient with a basal skull
    or cribriform plate fracture
  • nasal intubation poses a
  • risk of sinusitis in a patient who will be
    mechanically ventilated for more than 24 hours
  • use of a smaller-diameter tube will also increase
    the difficulty of subsequent airway suctioning
    and fiberoptic bronchoscopy.

  • Facial and pharyngeal trauma
  • Serious skeletal derangements may be masked by
    apparently minor soft tissue damage
  • Failure to identify an injury to the face or neck
    can lead to acute airway obstruction secondary
    swelling and hematoma.
  • Laryngeal edema is also a risk patients who have
    suffered chemical or thermal injury the
    pharyngeal mucosa.
  • indications for early intubation
  • Intra oral hemorrhage
  • pharyngeal erythema
  • change in voice

  • Continue
  • both maxillary and mandibular fractures will make
    mask ventilation more difficult, whereas
    mandibular fractures will make intubation easier
  • Palpation of facial bones before manipulation of
    the airway help to diagnosis
  • Patients with jaw and zygomatic arch injuries
    often have trismus.
  • trismus will resolve with the administration of
    neuromuscular blocking agents
  • Bilateral mandibular fractures and pharyngeal
    hemorrhage may lead to upper airway obstruction,
    particularly in a supine patient

  • A patient arriving at the ED in the sitting or
    prone position because of airway compromise is
    best left in that position until the moment of
    anesthetic induction and intubation.

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Resuscitation from hemorrhagic shock
  • refers to the restoration of normal physiology
    after injury specifically to the restoration of
  • normal circulating blood volume
  • normal vascular tone
  • normal tissue perfusion.

  • Pathophysiology of hemorrhagic shock
  • Decreased BP leads to vasoconstriction and
    catecholamine release.
  • Pain, hemorrhage, and cortical perception of
    traumatic injuries lead to the release of a
    number of hormones, including
  • renin-angiotensin
  • vasopressin
  • anti diuretic hormone
  • growth hormone
  • glucagon
  • Cortisol
  • epinephrine, and norepinephrine

  • continue
  • Individual ischemic cells respond to hemorrhage
    by taking up interstitial fluid
    further depleting intravascular fluid.
  • Cellular edema may choke off adjacent capillaries
    and result in a "no-reflow" phenomenon that
    prevents the reversal ischemia in the presence
    of adequate macro perfusion.
  • Ischemic cells produce lactate and free
    radicals, which accumulate in the circulation if
    perfusion is diminished.
  • 50

  • continue
  • These compounds cause direct damage to the cell,
    as well as form the bulk of the toxic load that
    will be washed back to the central circulation
    when flow is reestablished.
  • The ischemic cell will also produce and release a
    variety of inflammatory factors
  • prostacyclin
  • thromboxane
  • prostaglandins
  • leukotrienes, endothelin,
  • complement
  • interleukins
  • tumor necrosisfactor
  • and others

  • This why a patient may die of multiple organ
    failure after traumatic hemorrhage, even when
    bleeding has been controlled and the patient
    resuscitated to normal vital signs and perfusion.

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  • The CNS is the prime trigger of the
    neuroendocrine response to shock, which maintains
    perfusion to the heart, kidney, and brain at the
    expense of other tissues.
  • Regional glucose uptake in the brain changes
    during shock.
  • Reflex activity and cortical electrical activity
    are both depressed during hypotension these
    changes are reversible with mild hypoperfusion
    but become permanent with prolonged ischemia.

  • Specific organ systems respond to traumatic shock
    in specific ways
  • The kidney and adrenal glands are prime
    responders to the neuroendocrine changes
    associated with shock these organs produce
    renin, angiotensin, aldosterone, cortisol,
    erythropoietin, and catecholamines.
  • The kidney itself maintains glomerular filtration
    in the face of hypotension by selective
    vasoconstriction and concentration of blood flow
    in the medulla and deep cortical area.
  • Prolonged hypotension leads to decreased cellular
    energy and an inability to concentrate
    urine(renal cell hibrination), followed by patchy
    cell death, tubular epithelial necrosis, and
    renal failure

  • continue
  • The heart is relatively preserved from ischemia
    during shock because of an increase in nutrient
    blood flow
  • cardiac dysfunction as the terminal event in the
    shock spiral because of Lactate, free radicals,
    and other humoral factors released by ischemic
    cells all act as negative inotropes and, in a
    decompensated patient
  • A patient with cardiac disease or cardiac
    trauma(fixed stroke volume).
  • Shock in the elderly may therefore be rapidly
    progressive and may not respond predictably to
    fluid administration.

  • Continue
  • Accumulation of immune complex and cellular
    factors in pulmonary capillaries leads to
    neutrophils and platelet aggregation, increased
    capillary permeability, destruction of lung
    architecture, and respiratory distress syndrome.
  • This is evidence that traumatic shock is more
    than just a hemodynamic disorder.

  • continue
  • The Gut is one of the earliest organs affected by
    hypoperfusion and may be the prime trigger of
  • Intestinal cell death causes a breakdown the
    barrier function of the gut that results in
    increased translocation of bacteria to the liver
    and lung, thereby potentiate ARDS.
  • The liver has a complex microcirculation and has
    been demonstrated to suffer reperfusion injury
    during recovery from shock.
  • Failure of the synthetic functions of the liver
    after shock are almost always lethal

  • continue
  • Skeletal muscles
  • tolerates ischemia better than other organs
  • The large mass of skeletal muscle, though, makes
    it important in the generation of lactate and
    free radicals from ischemic cells.
  • Sustained ischemia of muscle cells leads to an
    increase in intracellular sodium and free water
    with an aggravated depletion of fluid in the
    vascular and interstitial compartments.

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  • Resuscitation of these patients should be
    considered in two phase
  • Early, while active bleeding is still ongoing
  • Late once all hemorrhage has been controlled.
  • Early resuscitation is much more complex because
    the risks of aggressive volume replacement
    summarized in Table 63-6 including the potential
    for exacerbating hemorrhage and thus prolonging
    the crisis, must be weighed against the risk of
    ongoing hypoperfusion.
  • 61

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  • Early resuscitation
  • Fluid administration is the cornerstone of acute
  • Intravascular volume is lost because
  • hemorrhage
  • uptake by ischemic cells
  • extravasation into the interstitial space.
  • The ATLS curriculum advocates the rapid infusion
    of up to 2 L of warmed isotonic crystalloid
    solution for any hypotensive patient, with the
    goal of restoring normal BP .

  • Fluid administration
  • reduces oxygen delivery
  • hypothermia
  • coagulopathy.
  • Elevation of Blood pressure leads to
  • increased bleeding as a result of disruption of
  • reversal of compensatory vasoconstriction.
  • The result of aggressive fluid administration is
    often a transient rise in BP, followed by
    increased bleeding and another episode of
    hypotension, followed by the need for more volume
  • This vicious cycle has been recognized since the
    First World War and remains a complication of
    resuscitation therapy today.

Deliberate hypotensive
  • Application of this technique to the initial
    management of a hemorrhaging trauma victims
    highly controversial and has been the focus of
    numerous laboratory and clinical research

  • A large body of laboratory data have shown the
    benefits of limiting fluid administration to
    actively hemorrhaging animals
  • Moderate resuscitation (to a lower than normal
    BP) improved perfusion of the liver.
  • Burris and coworkers found that rebleeding was
    correlated with higher mean arterial pressure
    (MAP) and that survival was best in groups
    resuscitated to a lower than normal MAP.

  • A 1994consensus panel on resuscitation from
    hemorrhagic shock mammalian species are capable
    tolerate Sustaining MAP as low as 40 mm Hg for
    periods as long as2 hours without deleterious
  • this panel conclude that spontaneous hemostasis
    and long-term survival were maximized by reduced
    administration of resuscitation fluids during the
    period of active bleeding while seeking to keep
    perfusion only above the threshold for ischemia.

  • in another study The authors concluded that
    administration of fluids to an actively
    hemorrhaging patient should be titrated to
    specific physiologic end points, with the
    anesthesiologist navigating a course between the
    risk of increased hemorrhage and hypoperfusion.

  • Blood loss without shock does not produce
    systemic complications such as ARDS in
    experimental models
  • The emphasis in this situation must be on rapid
    diagnosis and control of ongoing hemorrhage
  • the anesthesiologist should attempt to
  • restore vascular volume
  • provide anesthesia
  • in equal measure such that the patient is moved
    from a vasoconstricted state to a vasodilated
  • facilitating hemostasis by maintenance of a lower
    than normal BP.
  • 70

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Vulnerable Patient Populations
  • Clinical trials of deliberate hypotensive
    resuscitation have restricted this teqnique
  • ischemic coronary disease
  • elderly patients (reduced physiologic reserve)
  • Those with injuries to the brain or spinal cord
  • Clinical care of these patients is focused on
    avoidance of ischemic stress and rapid correction
    of hypovolemia

Resuscitation Fluids
  • isotonic Crystalloids (normal saline, lactated
    Ringer's solution Plasma-Lyte ) are the initial
    resuscitative fluids administered, to any trauma
  • Advantages
  • Inexpensive
  • readily available
  • non allergenic
  • noninfectious,
  • efficacious in restoring total-body fluid.
  • mix well with most infused medications,
  • rapidly warmed to body temperature.
  • Disadvantages
  • lack of oxygen-carrying capacity,
  • their lack of coagulation capability,
  • and their limited intravascular half-life.
  • immunosuppressant and triggers of cellular
    apoptosis(is the process of programmed cell death
    that may occur in multicellular organisms)
  • apoptosis is an important element of reperfusion

  • In a rat model of controlled hemorrhage, animals
    receiving LR solution showed an immediate
    increase in apoptosis in the liver and small
    intestine after resuscitation with LR.
  • Neither whole blood nor hypertonic saline
    increased the amount of apoptosis.

  • Hypertonic saline solutions, with or without the
    addition of polymerized dextran have been
    extensively studied in resuscitation from
    hemorrhagic shock.
  • HS will draw fluid into the vascular space from
    the interstitium, HS a popular choice for fluid
  • Multiple studies of otherwise lethal hemorrhage
    in animals have demonstrated improved survival
    after resuscitation with HSD versus either normal
    saline solution or the components of HSD alone.

  • Studies of the efficacy of HSD in trauma patients
    have been inconclusive
  • the most obvious benefit has been in a subset of
    poly traumatized patients with both hemorrhage
    and TBI, where improved neurologic status was
    demonstrated in patients who received HSD as a
    resuscitation fluid
  • HS is commonly used as an osmotic agent in the
    management of TBI with increased ICP.

  • Colloids
  • hetastarch solutions and albumin, have long been
    advocated for rapid plasma volume expansion.
  • colloids are readily available
  • easily stored and administered
  • relatively inexpensive.
  • As with the hypertonic solutions, colloids will
    increase intravascular volume by drawing free
    water back into the vascular space.

  • Continuous
  • When intravenous access is limited, colloidal
    resuscitation will restore intravascular volume
    more rapidly than crystalloid infusion will and
    at a lower volume of administered fluid.
  • Because colloids do not specifically transport
    oxygen or facilitate clotting, their dilutional
    effect on blood will be similar to that of
  • recent Studies have demonstrated no great
    benefit of colloids over crystalloids in a
    variety of resuscitation models.
  • 80

  • Continuous
  • Recognition of dilutional effects of fluid
    administration and continued improvement in the
    safety of donated blood have led to
  • increased use of blood products in the management
    of early hemorrhagic shock .
  • The risk of systemic ischemia is decreased by the
    maintenance of an adequate hematocrit, and the
    potential for dilutional coagulopathy can be
    avoided with the early administration of plasma.

  • 141 patients received massive blood transfusions
    (20 U or more of packed red blood cells (PRBC)
    during preoperative and intraoperative
  • Eleven variables were significantly different
    aortic clamping for control of BP, use of
    inotropic drugs, time with systolic BP less than
    90 mm Hg, time in the OR, temperature lower than
    34C, urine output, pH less than 7.0, Pao2/Flo2
    ratio less than 150, Paco2 higher than 50 mm Hg,
    potassium greater than 6 mM/L, and calcium less
    than 2 mM/L

  • Continuous
  • Of these variables, the presence of the first
    three in the face of transfusion of more than 30
    U of PRBCs was invariably fatal.
  • Total blood loss and the amount of
    transfused blood were less critical than the
    depth and duration of shock.
  • These concern to the concept of damage
    control surgery, which emphasizes rapid control
    of active hemorrhage.

  • Red blood cell
  • are the mainstay of treatment of hemorrhagic
  • A unit of RBCs
  • will predictably restore oxygen-carrying capacity
  • expand intravascular volume as well as any
    colloid solution will.
  • cross matching is desirable when time allows
  • Type O blood the "universal donor can be given
    to patients of any blood type with little risk of
    a major reaction
  • If O positive blood is given to Rhesus-negative
    woman who survives, prophylactic administration
    of anti-Rh antibody is indicated.

  • Continuous
  • Risks of PRBC administration include
  • transfusion reaction
  • transmission of infectious agents
  • hypothermia.
  • PRBCs are stored at 4C and will lower the
    patient's temperature rapidly if not infused
    through a warming device

  • FFP
  • Plasma required blood typing but not crossmatched
  • Very busy centers are experimenting with Keeping
    2-4 units as prethawed plasma Universal donor
  • Plasma and PRBCs should be administered
    prophylactic in a 11 ratio to any patient with
    obvious massive hemorrhage, even before
    confirmatory laboratory studies are available.

  • Platelet
  • Platelet transfusion should be reserved for
    clinically coagulopathic patients with a
    documented low serumlt50000
  • Platelets should not be administered
  • filter
  • Warmer
  • rapid infusion devices.
  • When the patient in shock and blood loss is
    likely to be substantial palates should be
    empirically administrated in proportion of RBC
    and plasma(111)

  • Rapid transfusion of banked blood
  • caries the Risk of inducing citrate intoxication"
    in the recipient.
  • Every component unit is packaged with one of
    several anticoagulation agents (citrate being a
    common choice) that bind free calcium, an
    essential requirement of the clothing cascade
  • Consecutive administration of multiple units of
    banked blood overwhelms the body's ability to
    mobilize free calcium and causes a marked
    reduction in circulating serum calcium with a
    profound negative inotropic effect on the heart.
  • unrecognized hypocalcaemia is a common cause of
    hypotension that persists despite an adequate
    volume of resuscitation.
  • Ionized calcium levels should be measured at
    regular intervals in a hemorrhaging patient, and
    calcium should be administered as needed (in a
    separate intravenous line from That for
    transfusion products)

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  • Resuscitation equipment
  • Immediate placement of at least two large bore
  • patient's underlying state of health and specific
    injury pattern may eliminate some sites from
  • The internal jugular approach, thought familiar
    to most anesthesiologists, will require removal
    of the cervical collar and manipulation of the
    patient's neck and is therefore not recommended
  • 90

  • Continuous
  • The femoral vein is easily and rapidly accessed
    and is an appropriate choice in patients without
    apparent pelvic or thigh trauma who require
    urgent drug or fluid administration.
  • Caution should be used in patients with
    penetrating trauma to the abdomen because fluids
    infused through the femoral vein may contribute
    to hemorrhage from an injury to the inferior vena
    cava or iliac vein these patients should have
    intravenous access placed above the diaphragm if

  • Continuous
  • Femoral vein catheterization carried a high risk
    of deep venous thrombosis ,thereby limiting the
    use of this approach to the acute setting.
  • Femoral lines should be removed as soon as
    possible after the patient's condition
  • the subclavian vein is the most common site for
    early and ongoing central access in trauma
    patients because the subclavian region is easily
    visible and seldom difficulty traumatized.
  • Risk of Pneumothorax
  • Arterial line

  • Hypothermia
  • Anesthesiologist must maintain thermal
    equilibrium in any trauma patient
  • Potentiate dilutional coagulopathy
  • Potentiate systemic acidosis
  • shivering and vasoconstriction lead to
    myocardial ischemia.
  • Increase subsequent rate of sepsis
  • Because many trauma patients arrive at the ED
    already cold from exposure to the elements, early
    active warming measures are requited.

  • Continuous
  • All intravenous fluid should he prewarmed
  • blankets whenever possible, and the environment
    should be kept warm enough to make the patient
  • If hypothermia has already developed, the use of
    forced hot air warming is strongly indicated to
    restore normothermia.
  • This devices must prepare in ct scan room and
    angiography room and ED

  • rapid infusion devices are of great benefit in
    treatment care, particularly in the presence of
    hemorrhagic shock.
  • Reduce acidosis
  • Higher patient temperature
  • Disadvantages
  • over infusion of fluids
  • Inappropriate blood pressure
  • rebleeding

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  • Late resuscitation
  • Late resuscitation begins once bleeding is
    definitively controlled
  • by surgery
  • angiography
  • the passage of time.
  • Fluid administration is an integral, mandatory
    component of late resuscitation
  • The adequacy of resuscitation should not be
    judged by the presence of normal vital signs but
    by normalization of organ and tissue perfusion
  • resuscitate the patient with the appropriate
    fluid, in the appropriate amount, at the
    appropriate time.
  • The practitioner's goal at that time is to
    rapidly restore normal perfusion to all organ
    systems while continuing to support vital

  • Hypoperfusion caused by hemorrhagic shock
    triggers a predictable cascade of biochemical
    events that will cause physiologic derangements
    persisting long after adequate blood flow is
  • The extent of hypoperfusion and the depth and
    duration of shock-is highly correlated with the
    development of subsequent organ system failure
  • traditional vital sign markers such as BP, heart
    rate, and urine output have been shown to be
    insensitive to the adequacy of resuscitation.

  • Occult hypoperfusion syndrome
  • is common in postoperative trauma patients,
    particularly young ones
  • normal BP maintained by intense systemic
  • intravascular volume is low
  • cardiac output is low
  • and organ system ischemia persists.
  • Such patients are at high risk for MOSF if
    hypoperfusion is not promptly corrected.

  • Technique shorcomings
  • Vital signs
    Will not indicate occult hypoperfusion
  • Urine output
    confounded by intoxication, diuretic renal injury
  • Systemic acid-base status
    Confounded by respiratory status
  • Lactate clearance
    Requires time to obtain laboratory result
  • Cardiac output
    pulmonary artery catheter or use of noninvasive
  • Mixed venous oxygenation Difficult to
    obtain, but a very accurate marker
  • Gastric tonometry
    Requires time to equilibrate, subject to artifact
  • Tissue oxygenation
    Emerging technology, appears beneficial
  • Stroke volume variation Emerging
    technology, requires an arterial line
  • Acoustic blood flow
    Investigational technology, unproven
  • 100

  • Invasive monitoring change to noninvasive
    approaches that assess of adequate
    metabolism,respiration, and oxygen transport in
    peripheral tissue beds.
  • One minimally invasive technique is tissue oxygen
    monitoring (skin, subcutaneous tissue, or
    skeletal muscle).
  • Skeletal muscle blood flow decreases early in the
    course of shock and is restored late during
    resuscitation, thus making the skeletal partial
    pressure of oxygen a sensitive indicator of low

  • Early goal directed treatment of septic shock
    ,with an emphasis on measurement of mixed venous
    oxygen saturation ,has influenced the care of
    trauma patient ,and many of ICUs are now using
    continiucely measured venous oxygenation to guide
  • Stroke volume variation Change
    in arterial pressure driven by the respiratory
    cycle(during positive pressure ventilation) a
    reliable predictor of decrease intravascular

  • Tissue hypercapnia
  • has been suggested as a universal indicator of
    critically reduced perfusion
  • measurement of gastric mucosa Pco2 through
    gastric tonometry has been used in trauma
    patients as an indicator of restoration of
    splanchic blood flow, and distal gut PH has
    shown promise as a reliable indicator.
  • the most proximal area of the gastrointestinal
    tract, the sublingual mucosa, has been shown
    to be a useful site for measurement of Pco2

  • continuous
  • When sublingual Pco2(PsLco2) exceeded a threshold
    of 70 mm Hg (normal 45.2 0.7 mm Hg), its
    positive predictive value for the circulatory
    shock was 100.
  • Inadequate tissue perfusion as indicated by these
    specific monitoring or by the traditional
    systemic markers of serum lactate, base deficit,
    and decreased PH, must be treatment promptly once
    ongoing hemorrhaged is controlled.
  • The rate at which a shock patient's lactate
    returns to the normal range is strongly
    correlated with outcome
  • failure to reach to normal range within 24 hours
    of a traumatic injury carries a greater of organ
    system failure and eventual death