Trauma Surgery

Daniel J. Riskin MD¹

David A. Spain MD¹

Ronald Jou MD¹

Charles C. Hill MD²

¹SURGEONS

²ANESTHESIOLOGIST

INITIAL ASSESSMENT AND AIRWAY MANAGEMENT FOR TRAUMA SURGERY

INITIAL ASSESSMENT

The Advanced Trauma Life-Support (ATLS) Program, developed by the Committee on Trauma American College of Surgeons, provides a safe and reliable method for the immediate treatment of injured patients. The crucial components of ATLS are the rapid and accurate assessment of a patient’s condition, the resuscitation and stabilization of the patient according to a sequence of priorities, determining the need for and arranging interhospital transfer, and ensuring optimal care throughout the entire process. The initial assessment and management consists of the primary survey and resuscitation.

During the primary survey, life-threatening conditions are identified and treated following the ABCDE sequence. Airway patency should be assessed while maintaining cervical spine protection. In situations when a patient’s airway integrity is unclear or at risk, a definitive airway should be established. Breathing and ventilation are assessed, paying attention to any chest injuries that can impair adequate gas exchange. Conditions such as tension pneuomothorax, massive hemothorax, flail chest, and open pneumothorax should be identified and treated. Supplemental oxygen should be delivered and oxygenation should be monitored with pulse oximetry. Circulation is assessed, and shock, if present, should be recognized. In trauma, the presence of shock is usually due to hemorrhage, and definitive control of bleeding and replacement of intravascular volume are crucial. Disability from neurologic injury should be assessed. Patients with severe neurologic injury may require definitive airway management or urgent neurosurgical evaluation. Exposure involves undressing the patient to identify any other life-threatening injuries while keeping the patient warm.

EXTENDED FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA (eFAST)

An ultrasound screening examination of the trauma patient that allows for the rapid detection of pericardial fluid (pericardial tamponade), pneumothorax, hemothorax, and peritoneal free-fluid can speed triage and treatment of trauma patients. It is important to note that many injuries cannot be detected by ultrasound (e.g., bowel perforations, torn diaphragm), and that eFast examinations have a small but significant false negative rate. Ultrasound is not a substitute for more definitive diagnostic procedures.

AIRWAY MANAGEMENT

In trauma, indications for definitive airway can be divided into conditions that require airway protection and conditions that require control of ventilation or oxygenation. Airway patency can be compromised by obtundation, severe facial injuries, bleeding or vomiting, or obstruction from neck or airway injuries. The need for ventilation or oxygenation is indicated by apnea, respiratory distress, severe closed head injury, or hemodynamic instability.

Although airway management in injured patients does not differ fundamentally from airway management in other situations, attention must be paid to cervical spine protection, high risk of vomiting and aspiration, and recognition of maxillofacial, neck, laryngeal, or head injuries that can cause airway compromise.

Airway maneuvers such as the chin-lift or jaw-thrust maneuver are useful techniques to improve airway patency in unconscious or obtunded patients, although they must be performed without extending the neck and potentially exacerbating a cervical spine injury.

Airway adjuncts such as oropharyngeal airway, nasopharyngeal airway, or laryngeal mask airway are useful for providing temporary ventilation and oxygenation until a definitive airway (oral or nasal ETT or surgical airway) can be established.

Oraltracheal intubation, with the use of appropriate neuromuscular blockade and cricoid pressure, is the preferred technique. The approach is rapid, but at least three people are required to perform it safely in the patient with suspected C-spine injury.

In-line stabilization of the neck is performed to minimize neck and spine movements. Because a failed intubation may force operative airway intubation, equipment for cricothyrotomy should be immediately accessible. Fiberoptic assistance and other techniques for endotracheal intubation including video laryngoscopy may be used in the stable patient with a difficult airway. Patients in respiratory distress with severe facial or neck trauma or unstable cervical spine injury require a surgical airway. An airway placed in transport should be immediately assessed for position and changed to a definitive airway when appropriate.

Figure 7.13-1. Cricothyrotomy (vertical skin incision not shown). A: Identification of the cricothyroid membrane by palpation and incision of the membrane transversely. B: Insertion of a tracheostomy tube or ETT through the cricothyroid membrane, which is spread with a tracheal dilator. (Redrawn with permission from Greenfield LJ, Mulholland MW, Oldham KT, et al, eds: Surgery: Scientific Principles and Practice, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 1997.)

Nasotracheal intubation, used only in spontaneously breathing trauma patients, can be performed without the use of pharmacologic agents or special equipment. It is, however, associated with higher incidence of vomiting and aspiration. In the intoxicated patient with a depressed level of consciousness, the success rate may be as low as 65%. Blind nasal intubation is contraindicated in patients with unstable midface fractures, penetrating neck trauma, or significant neck hematomas.

Cricothyrotomy (Fig. 7.13-1) is the preferred method in adults who require a surgical airway. The important anatomic landmarks of the superior and inferior borders of the thyroid and cricoid cartilages are palpated. The thyroid cartilage is then stabilized, a vertical skin incision is made, and the ETT or tracheostomy tube is rapidly advanced through subcutaneous tissue. The cricothyroid membrane lies very superficially, covered only by the skin and platysma muscle. The cricothyroid membrane is incised transversely with the scalpel. In emergency situations, a standard small-caliber ETT is generally easier to insert than a tracheostomy tube (Fig. 7.13-1B). Cricothyrotomies should be converted to tracheotomies within 72 h after the initial injury, provided the patient’s condition permits.

A tracheostomy is indicated for patients requiring surgical airway in less emergent situations or if a cricothyrotomy cannot be performed due to direct laryngeal injury. A tracheostomy can be accomplished through the same incision, extended caudally, if laryngeal injury is found (see p. 728). Rarely, the injury is in the distal cervical or proximal intrathoracic trachea. In such cases, it may be necessary to intubate the distal end of the airway through the wound. A subsequent median sternotomy may be required to expose the injury. Right thoracotomy provides access to the distal intrathoracic trachea (see Chest Trauma, p. 737).

Usual preop diagnosis: Airway compromise

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Midline longitudinal incision in the neck
Unique considerations	The large number of legal claims involving failed intubation suggests that surgical cricothyrotomy remains an underutilized technique.
Antibiotics	Usually not given until clear indications related to the primary injury are apparent.
Surgical time	2 min
EBL	Minimal
Postop care	Mechanical ventilation
Mortality	Related to the primary injury
Morbidity	Cricothyrotomy is more likely to result in airway stricture or damage to more proximal structures in the larynx. On this basis, cricothyrotomy is converted to tracheostomy within 48-72 h of admission if patient’s general condition permits.
Pain score	3

EMERGENCY TUBE THORACOSTOMY

SURGICAL CONSIDERATIONS

Description: In the United States, trauma is the most common cause of death in young people; 25% of these deaths (˜16,000 per year) are the result of thoracic trauma. Most of these are due to lethal injuries at the scene (e.g., cardiac rupture, free aortic transection). For patients who reach the hospital, proper management is crucial because many deaths can be prevented. Early deaths are due to airway obstruction, tension pneumothorax, massive hemothorax, flail chest, cardiac tamponade, and open pneumothorax. Later deaths are due to respiratory failure, sepsis, and unrecognized injuries.

Eighty percent of blunt thoracic injuries are caused by motor vehicle collisions (MVCs). Penetrating injuries to the chest are almost as common as blunt trauma. The death rate in hospitalized patients with isolated chest injury is 4-8%; this increases to 10-15% when one other organ system is involved and to 35% if multiple additional organs are injured. Eighty-five percent of chest injuries do not require thoracotomy, and the patient can be managed with relatively simple measures, such as airway control, tube thoracostomy, and pain management. Blunt trauma can induce injury by three distinctive mechanisms: direct blow, deceleration injury, and compression injury. Rib fracture is the most common sign of blunt thoracic trauma. Fracture of the upper ribs (1st-3rd), clavicle, or scapula implies high-energy impact and is associated with a higher likelihood of major vascular injury.

Life-threatening injuries caused by penetrating trauma are distinctly different from those caused by blunt trauma. In penetrating chest injuries, pneumothorax is almost always present, and hemothorax is present in 80% of cases. Hemodynamic instability in penetrating chest injury generally heralds a major intrathoracic vascular injury.

Tension pneumothorax may be caused by blunt or penetrating trauma. Venous return to the heart is impaired by the increased intrathoracic pressure and compression of the vena cava → ↓ BP resulting in distended neck veins. Loss of lung volume on the ipsilateral side and subsequent compression of the contralateral side leads to
impaired ventilation and hypoxia. The diagnosis of tension pneumothorax is made clinically. The presence of respiratory distress and absent or diminished breath sounds warrant immediate needle decompression (14-16-ga catheter through the 2nd intercostal space, midclavicular line), followed by subsequent tube thoracostomy. Treatment should not be delayed for radiographic confirmation. In the hemodynamically stable patient, however, suspicion of a pneumothorax should be confirmed by x-ray. On the CXR, a 20% loss of lung dimension corresponds to ˜50% loss of lung volume. A small, simple pneumothorax (< 10%) with no respiratory compromise may be observed. These patients require close observation in the hospital and a repeat CXR in 4-6 h. Tube thoracostomy should be performed for a large pneumothorax (> 10%), for patients with respiratory compromise or multiple injuries, or when it is not possible to adequately monitor the patient (e.g., during extended transport). Recent developments in emergency ultrasonography have led to the adoption of the “eFAST” examination, which includes ultrasound examination of the anterior chest to detect pneumothoraces. An abnormal eFAST exam may alert the team to the presence of a significant pneumothorax even before a CXR can be obtained. In the presence of an anterior pneumothorax, the eFAST may even be superior in sensitivity to a supine CXR.

As much as 40% of the circulating blood volume can accumulate in a hemothorax. The most frequent sources of bleeding are the intercostal and internal mammary vessels. Some degree of hemothorax is present in almost every patient with chest injury. A supine CXR may miss up to 1 L of blood. Although an upright CXR is more sensitive, this is generally impractical in a multiple-trauma patient (whose spine often has not been fully evaluated). Following chest tube placement, blood loss > 1200-1500 mL or an ongoing loss of 250 mL/h for 4 h suggest the need for surgical intervention.

Simple pneumothorax without associated hemothorax can be treated with a 20-22 Fr chest tube placed in the 4th intercostal space in the midaxillary line or in the 5th intercostal space in the anterior axillary line. Hemothorax and tension pneumothorax require a large-bore, 28-36 Fr chest tube placed in the midaxillary line through the 5th intercostal space (Fig. 7.13-2). A 20-mL syringe with 1% lidocaine can be used not only to provide local anesthesia, but also to locate the upper edge of the rib in the obese patient. A generous 3-cm incision should be made one interspace below the targeted level. The subcutaneous tissues are dissected bluntly, creating a tunnel that is directed
upward. The pleural space should be entered just above the upper edge of the rib to avoid injury to the intercostal neurovascular bundle, located just below the lower edge of the rib. After the pleural space has been entered bluntly, it should be explored with the operator’s finger swept around to ensure proper location and to free potential adhesions. The chest tube should be inserted and advanced in the posterior and superior direction. The tube then should be connected to a suction/collection system under 20 cm of water-negative pressure, preferably through an autotransfusion device. Repeat chest exam and CXR should immediately follow chest tube placement to evaluate decompression and assess for other injuries. If the pleural space still contains blood, another chest tube could be inserted or video-assisted thoracoscopy (VAT) could be considered if major vascular injury is not suspected.

Figure 7.13-2. Tube thoracostomy. Incision through 4th or 5th interspace at anterior axillary line. Forceps are used to tunnel over the superior edge of the rib and to bluntly enter the pleural space.

Usual preop diagnosis: Tension pneumothorax; pneumothorax; hemothorax

▪ SUMMARY OF PROCEDURE

Position	Supine with arm abducted 90°
Incision	3 cm in interspace below 5th intercostal space in midaxillary line
Special instrumentation	38-40 Fr chest tube should be used in most patients. Small, 20-22 Fr tube reserved for simple pneumothorax in stable patients. Autotransfusion device should be available in ED.
Unique considerations	In tension pneumothorax, a large-bore needle inserted in the 2nd intercostal space of the midclavicular line can relieve tension and save a patient’s life.
Antibiotics	Cefazolin 1-2 g iv
Surgical time	5 min
EBL	Minimal from tube placement. Variable amounts drained out, depending on extent of hemothorax and associated injuries.
Postop care	Chest tube may be removed after at least 48 h, when there is no air leak from lung and < 100-150 mL of fluid drainage per 24 h.
Mortality	Isolated chest injury: 4-8% When one other organ system is involved: 10-15% When two or more organ systems involved: > 35%
Morbidity	Clotted hemothorax Empyema Lung abscess Lung contusion
Pain score	5

EMERGENCY DEPARTMENT THORACOTOMY

SURGICAL CONSIDERATIONS

Description: Rarely, emergency department thoracotomy may offer the only chance of survival in highly selected trauma patients. Its use should be restricted largely to patients who show signs of life in the emergency department (ED) but lose such signs shortly thereafter. The usual indications are (a) massive exsanguination in the left chest, usually due to cardiac, vascular, or pulmonary injuries and (b) pericardial tamponade. For patients with penetrating cardiac injuries who show signs of life in the ED, survival may be as high as 15%. For blunt trauma in this setting, survival is < 1%, regardless of presentation. With either mechanism, functional survival is almost unprecedented if the patient arrives without vital signs and unreactive pupils.

A left anterolateral thoracotomy is the preferred approach because pericardiotomy, open cardiac massage, and aortic occlusion are best achieved by this means. This incision can be extended easily across the sternum and into the right chest to improve exposure and to control massive blood loss and/or air embolism from the right lung. The entire chest is prepped liberally, and left anterolateral thoracotomy is performed rapidly in the 5th intercostal space
using a large-blade scalpel. Heavy scissors can be used to quickly divide the intercostal muscles and to cut across the sternum. If pericardial tamponade is encountered, the pericardium is opened longitudinally, anterior to the phrenic nerve. Blood and clot are evacuated and bleeding sites controlled with gentle digital pressure. Large, full-thickness lacerations that extend into the chambers may be controlled by inserting a Foley catheter, inflating the balloon, and pulling it snug against the myocardium. The open end of the Foley can be clamped or used as an infusion line for resuscitation. During ED thoracotomy, placement of clamps on the atria or ventricles should be avoided as they may extend the laceration. Attempts to repair cardiac lacerations should be delayed until resuscitative measures have been completed. In the nonbeating heart, suturing is performed prior to defibrillation. If coronary or systemic air embolism is present, the appropriate hilum is cross-clamped and air is aspirated from the left ventricle through the elevated apex. Cardiac arrest is an indication for immediate internal massage. The two-hand method is preferred, and internal defibrillation should be instituted. If internal defibrillation does not restore proper cardiac activity, cross-clamping of the aorta will improve coronary perfusion. To cross-clamp the aorta, the left lung is retracted anteriorly and superiorly, and the posterior pleura is dissected under direct vision. An orogastric or nasogastric tube placed in the esophagus aids in the identification of the esophagus by feel, allowing for cross-clamping of the aorta without risking injury to the adjacent esophagus.

Usual preop diagnosis: Penetrating chest trauma with cardiac arrest and recent recorded signs of life

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Left anterolateral thoracotomy. Extension of incision across sternum could be considered for improved exposure.
Special instrumentation	ED thoracotomy tray; internal defibrillator paddles; suction device; Foley catheter; rapid-infusion device; O(-) blood
Unique considerations	Airway should be secured first. OG/NGT tube should be placed if possible. Typically, patients are not anesthetized for this procedure.
Antibiotics	Cefazolin 1-2 g iv
Surgical time	10 min
EBL	1-2 L
Postop care	ICU
Mortality	Blunt trauma: 98% All penetrating chest injuries requiring ED thoracotomy: 85% Penetrating cardiac injury: 50%
Morbidity	Arrhythmias Acute MI
Pain score	10

EXPLORATORY SURGERY FOR NECK TRAUMA

SURGICAL CONSIDERATIONS

Description: The neck contains vital structures in a relatively unprotected region of the body (Fig. 7.13-3). The cardiovascular, respiratory, digestive, endocrine, and CNS systems are all represented in the neck; injury to any of these can be fatal.

Injuries to the neck may result from blunt or penetrating trauma. In blunt trauma, < 5% of cases will have C-spine injuries. Because the consequences are so grave, however, all patients should be evaluated for C-spine injuries (H&P, x-rays, CT), and full spinal precautions should be maintained until the C-spine is cleared. Blunt airway injuries can
be devastating and present significant management difficulties; however, the majority of blunt neck trauma consists of minor soft-tissue injuries that can be managed nonoperatively. Blunt cerebrovascular injuries can occur from a direct blow to the cartoid or vertebral arteries, or from a severe hyperextension or rotation mechanism.

Penetrating neck trauma is defined as penetration of the platysma muscle. For these injuries, the neck is usually divided into three horizontal zones (Fig. 7.13-3, inset). Zone I extends from the sternal notch to the cricoid cartilage. Penetrating injuries in this area are associated with a high mortality. Zone II extends from the cricoid cartilage to the angle of the mandible. Because this is the most exposed region of the neck, injuries can be evaluated and explored using standard operative techniques. Zone III extends from the angle of the mandible to the base of the skull. Because of anatomic constraints, injuries to Zones I and III can be difficult to identify and repair. In patients with a Zone I injury, iv access should be established in the contralateral upper extremity because of the possible injury to the ipsilateral internal jugular vein or subclavian vein.

Figure 7.13-3. Cervical structures contained in Zones I, II, and III: (1) facial artery; (2) esophagus; (3) internal carotid artery; (4) external carotid artery; (5) thyroid cartilage; (6) sympathetic trunk; (7) vagus nerve; (8) cricothyroid membrane; (9) cricoid cartilage; (10) thyroid cartilage; (11) common carotid artery; (12) subclavian artery; (13) right innominate vein; (14) SVC; (15) ascending aorta; (16) descending aorta; (17) PA; (18) subclavian vein; (19) clavicle; (20) brachial plexus; (21) IJ vein; (22) vertebral artery; (23) phrenic nerve; (24) submandibular gland; (25) lingual artery; (26) hypoglossal nerve; (27) parotid gland and duct; (28) facial nerve and its branches; (29) maxillary artery; (30) sternal manubrium. The thoracic duct is not shown in this figure. (Adapted with permission from Ordog GJ, et al: J Trauma 1985; 25:238). (Inset reproduced with permission from Baker RJ, Fischer JE: Mastery of Surgery. Lippincott Williams & Wilkins, Philadelphia: 2001.)

Until recently, evaluation and management of stable patients with neck injuries that penetrated the platysma depended on location of injury. Injuries to Zones I and III were evaluated radiographically, whereas injuries to Zone II were indications for mandatory exploration. With the increased availability of CT and arteriography, however, a selective exploration strategy is now favored. The presence of so-called hard signs, including airway compromise, shock, active bleeding, an expanding hematoma, an evolving stroke, or extensive subcutaneous air generally mandate operative exploration. “Soft signs,” which include hoarseness, hemoptysis, hematemesis, dysphagia, or prominent ecchymosis, can be evaluated with CT and endoscopy.

Management of hemodynamically unstable or symptomatic patients with penetrating neck injuries should be limited to applying direct pressure, protecting the airway, establishing iv access, and obtaining a CXR. Exploration and definitive management of the injury in the OR should follow as soon as possible. In stable patients with penetrating injuries and no indications for exploration, CT is generally the first diagnostic test.

A median sternotomy incision may be used for patients with right-neck Zone I injuries or if injuries to the mediastinum involving the innominate artery or right subclavian artery are suspected. Exposure of injuries to the proximal left subclavian artery is extremely difficult via median sternotomy. In this case, a left anterior thoracotomy is preferred. The chest and left arm should be prepped and draped to allow arm manipulation.

Usual preop diagnosis: Penetrating neck injury

▪ SUMMARY OF PROCEDURE

Position	Supine with head turned away from side of exploration and neck extended. If both sides of neck require exploration, head should be in midposition. It is helpful to clear the C-spine before exploration.
Incision	Sternocleidomastoid anterior border
Unique considerations	Monitor BP and HR carefully during carotid sinus manipulation.
Antibiotics	Cefazolin 1-2 g iv. If pharyngoesophageal injury: ampicillin 1 g and gentamicin 80 mg iv.
Surgical time	1 h
Closing considerations	Wound requires drainage, especially in Zone I exploration and if esophagus or airway was violated.
EBL	Variable
Postop care	ICU 12-24 h for neurologic and airway monitoring. After carotid injury repair, angiography should be considered.
Mortality	1%
Morbidity	Hemorrhage: acute from injuries; delayed from pseudoaneurysms Airway injury: acute loss of airway; delayed tracheal stenosis Damage to neural or vascular structures Esophageal fistula
Pain score	4

ANESTHETIC CONSIDERATIONS FOR NECK TRAUMA SURGERY

PREOPERATIVE

Patients with neck injuries often present unique challenges for ET intubation. Extensive internal damage may be present despite minimal external signs. High-velocity deceleration events, or “clothesline” injuries, are often associated with airway compromise. Vascular injuries, particularly involving the carotid artery, can markedly distort internal anatomy and prevent visualization of laryngeal structures or passage of an ETT. Known or suspected C-spine injuries will restrict optimal positioning of the head and neck for laryngoscopy. Facial or dental injuries may impede access for laryngoscopy because of limited mouth opening or the presence of blood in the oropharynx. The use of alternative methods to secure the airway (e.g., fiberoptic bronchoscopy or video laryngoscopy) or a surgical approach may be the safest option. Equipment for a surgical airway should be available prior to attempting ET intubation.

Airway	Preop assessment of the airway and nature and extent of the cervical injury is crucial. Stridor and hoarseness may be present with laryngeal injury or compression of the trachea. Assess patient’s ability to talk as a part of the airway evaluation. C-spine injury (though not common with penetrating neck injuries) should be evaluated by x-ray or CT scan. Airway injury can be associated with subcutaneous emphysema or pneumothorax. The extent of mouth opening, dental injuries, and any distortion of internal and external structures due to tissue swelling or hematoma should be determined before intubation. The CXR or CT should be examined carefully for evidence of tracheal deviation compression or pneumothorax. Tests: x-ray; CT scan; ABG
Cardiovascular	The patient should be evaluated for the extent of blood loss (eFAST results, BP, HR, capillary refill, peripheral pulse, skin condition). In addition to vascular injuries, associated facial and dental injuries may result in significant occult blood loss accumulated in the stomach. Venous lacerations can allow air embolism.
Neurological	Deficits associated with acute compromise of cerebral arterial blood flow should be evaluated on physical exam. Damage to the recurrent laryngeal nerve can occur, resulting in changes in voice and ↑ aspiration risk. C-spine injuries should be assessed by physical exam (neck pain, neurologic examination) and radiologic studies (lateral C-spine x-rays [including C-7] CT scan, MRI).
Premedication	Full-stomach precautions (see p. B-5).

INTRAOPERATIVE

Anesthetic technique: GETA

Induction	The induction technique will depend on the associated injuries and physical exam. In the hypovolemic patient, induction doses of propofol should be reduced by 50-75% to minimize ↓↓ BP. Consider etomidate (0.2-0.3 mg/kg) or ketamine (0.5-1 mg/kg iv) as alternative induction agents. A rapid-sequence iv induction with cricoid pressure is usually required. In the presence of a vascular injury, the cough reflex and the BP response to intubation should be suppressed (e.g., remifentanil 1 mcg/kg iv), in addition to induction agents, to prevent expansion of the hematoma. A wide range of ETT sizes (5.0-8.0 mm) should be available. If C-spine injury is suspected, in-line stabilization of the patient’s head and neck should be provided by an assistant. In the presence of an unstable C-spine, cricoid pressure may be associated with further injury. If a difficult intubation is anticipated, fiberoptic intubation (see p. I-2), video laryngoscopy, or an awake surgical airway (cricothyrotomy or tracheotomy) should be considered. In patients with penetrating neck injuries; “blind” intubation techniques should be avoided.
Maintenance	Standard maintenance (p. B-3) is usually appropriate for the normotensive neck-trauma patient. In cases of vascular injury, careful control of BP in the low normal range is advantageous. When nerve testing is anticipated, either no muscle relaxation or a short-acting agent (e.g., mivacurium) should be used.
Emergence	Postop intubation and mechanical ventilation is prudent in patients with residual neurological deficits or oropharyngeal swelling. BP control at low normal levels and slight elevation of the head of the bed (10-20°) will help to resolve tissue edema. Awake extubation is the goal in patients with minimal distortion of the airway at the conclusion of the procedure.
Blood and fluid requirements	IV: 14-16 ga × 2 NS/LR @ 4-6 mL/kg/h	Blood transfusion may be necessary with vascular injuries.
Monitoring	Standard monitors (see p. B-1). ± Arterial line	Invasive monitoring may be indicated for patients with major vascular injuries; however, the placement should not delay the start of emergency surgery.
Positioning	[check mark] and pad pressure points [check mark] eyes	With suspected or known C-spine injuries, stabilization of the head and neck in the neutral position is required.
Complications	Awareness Hypothermia

POSTOPERATIVE

Complications

Hemorrhage

Hematoma

Airway compromise

BP control at low normal levels (SNP infusion, labetalol, NTG) and elevation of the head of the bed (10-20°) will help minimize tissue edema and hematoma formation, which could lead to airway compromise.

Pain management

See p. C-1.

Tests

As indicated.