Abstract
Trauma-related injury is the leading cause of mortality globally for both men and women between 15 and 45 years of age. This chapter provides an organized three-step approach to the assessment and perioperative anesthetic management of trauma patients: a rapid overview for risk assessment utilizing the revised trauma scoring system; a primary survey to include assessment of the airway, breathing, circulation, and neurologic status; and a secondary survey to include a systematic, comprehensive evaluation of each anatomic region to detect undiagnosed injuries. This chapter includes a table providing a system-based listing of perioperative complications in trauma victims.
Keywords
airway management, blunt trauma, goal directed fluid therapy, golden hour, penetrating trauma, restrictive resuscitation regimen, revised trauma scoring system
Case Synopsis
A 23-year-old man arrives in the emergency department with a gunshot wound to the right upper quadrant of the abdomen. He is combative and confused. His vital signs include systolic blood pressure, 70 mm Hg; heart rate, 119 beats per minute; and respiratory rate, 22 breaths per minute.
Problem Analysis
Definition
Trauma-related injury (TRI) is the leading cause of death in the United States for persons between 1 and 45 years old and is the fifth-leading cause of death overall. Because TRI affects primarily the young, it is the leading cause of years of life lost before age 75 years. The World Health Organization (WHO) estimates that TRI is the leading cause of mortality globally for both men and women between 15 and 45 years of age. Also, WHO estimates that by 2020, TRI will be the third-leading cause of death in all age groups.
TRI victims present unique challenges to the health care delivery system. They often have multiple injuries to multiple organ systems that necessitate resource-intensive care. Further, TRI can adversely interact with many chronic underlying medical conditions. The top four TRI causes are motor vehicle accidents (cars, trucks, motorcycles), falls, assaults, and pedestrians hit by vehicles.
Many trauma injuries are preventable. Alcohol or drug use was documented in 40% of car and truck crash injuries involving adults and in 38% of motorcycle crash injuries. Trauma is classified as either intentional (e.g., homicide) or accidental, as well as according to the mechanism of injury (e.g., penetrating versus blunt). Owing to improvements in trauma care, there has been a decline in trauma-related deaths in recent years.
Recognition
Evaluation of acute trauma victims has three key components: rapid overview, primary survey, and secondary survey. Resuscitation can be initiated at any time during this triage. Rapid overview takes only a few seconds and is used to determine whether the patient is stable, unstable, or dead. The primary survey involves the rapid evaluation of functions that are critical to survival. The ABCs of airway patency, breathing, and circulation are assessed, followed by a brief neurologic examination. Priority is then given to cervical spine injury or impending cerebral herniation. The rapid overview and the primary survey are also referred to as the “golden hour” because rapid intervention to identify and treat life-threatening injuries in the first 60 minutes can affect survival and outcomes of trauma patients. The secondary survey entails a systematic, comprehensive evaluation of each anatomic region and usually detects injuries that were overlooked initially. Three quarters of such previously undetected injuries are orthopedic. Based on the results of the secondary survey, patients are rushed immediately to the operating room for surgery, transferred to the radiology suite for further diagnostic studies, or reexamined and observed in an intensive care unit.
Knowledge of the patterns of injury associated with different mechanisms of trauma (i.e., clusters of injury) can help anticipate and identify injuries early. The presence of the worst possible injuries should be assumed until the diagnoses are either confirmed or excluded. Many trauma-related complications are diagnosed intraoperatively ( Box 53.1 ).
Central Nervous System
Cervical spine instability or injury and possible spinal cord injury
Closed head injury with increased intracranial pressure
Possible brainstem herniation due to increased intracranial pressure
Brain herniation through open skull fracture
Chest and Pulmonary
Endobronchial intubation
Tension pneumothorax or hemothorax
Pneumomediastinum
Rib fracture and possible flail chest
Pulmonary contusion
Bronchopleural fistula
Aspiration pneumonitis
Bronchospasm
Tracheobronchial plugging
Fat embolism with long bone (e.g., femur) fracture
Cardiovascular
Myocardial contusion or cardiac rupture
Pericardial tamponade or pneumopericardium
Aortic dissection or disruption
Disruption of pulmonary vasculature or vena cava
Hypotension: hypovolemic or neurogenic
Hypovolemic circulatory shock
Air embolism
Abdomen
Disruption or laceration of hollow viscera
Hepatic laceration
Splenic rupture
Coagulation
Coagulopathy, especially with massive blood transfusion
Disseminated intravascular coagulopathy
Primary fibrinolysis
Hemolytic transfusion reaction
Electrolyte or Other Imbalance
Hypocalcemia secondary to citrate toxicity
Hyperkalemia, hypomagnesemia
Acid-base imbalance
Blunt trauma causes localized or widespread transfer of energy to the body. Depending on the site of impact and the amount of energy, this can cause visceral rupture or tissue disruption, including multiple fractures. Penetrating trauma is commonly limited to the track along which a bullet or sharp object has traveled.
Risk Assessment
Triage scoring systems are based on the physical examination and physiologic or mechanism-of-injury parameters. They have traditionally been used to determine patterns of patient referral to trauma centers. Survival is the major outcome variable. The revised trauma score (RTS) is a prospective scoring system that exists in two forms: one is designed for use as a triage tool, and the other is used to evaluate in-hospital patient outcomes. The RTS accurately predicts mortality following traumatic injury, but there is a lack of definitive evidence supporting its use as a primary triage tool in the field or as a predictor of functional outcome and quality of life. To determine the RTS, the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate are assigned coded values from 4 (normal) to 0. These are then added and weighted ( Table 53.1 ). When summed, values can range from 0 to 7.84. Higher values indicate a better prognosis. Of the many trauma scoring systems, the RTS is the most popular worldwide.
| Glasgow Coma Scale Score | Systolic Blood Pressure (mm Hg) | Respiratory Rate (breaths/min) | Coded Value |
|---|---|---|---|
| 13–15 | >89 | 10–29 | 4 |
| 9–12 | 76–89 | >29 | 3 |
| 6–8 | 50–75 | 6–9 | 2 |
| 4–5 | 1–49 | 1–5 | 1 |
| 3 | 0 | 0 | 0 |
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