Chapter 63
- Anesthesia for Trauma
- Richard P. Dutton
- Maureen McCunn
Injury is the leading cause of death between the ages of 1 and
45 years in the United States and the third leading cause of death overall.[1]
Because it affects primarily the young, trauma is the leading cause of years of
life lost before the age of 75 years. The World Health Organization estimates that
injury is the leading cause of death worldwide for both men and women from the ages
of 15 to 44, and by 2020, injuries will be the third leading cause of death and disability
in all age groups.[2]
Fifty percent of injured
victims die at the scene in some countries. The preventable death rate is about
25% in Poland, 30% in Greece, 37% in Italy, and 43% to 62% in the United Kingdom.
In the United States, the preventable death rate dropped from 13% to 7% over the
past decades because of better and more efficient systems of trauma care.[3]
Trauma patients present unique challenges to the health care system
because they require resource-intensive care, they have multiple injuries to multiple
body systems, and their acute injuries overlie and interact with a variety of chronic
medical conditions. Anesthesiologists in practice at designated trauma centers are
involved in the care of trauma patients beginning with airway and resuscitation management
in the emergency department (ED) and proceeding through the operating room (OR) to
the intensive care unit (ICU). Trauma patients are a significant portion of all
OR cases during night and weekend shifts. Critical care and pain management specialists
see trauma patients as a large fraction of their practice. Even practitioners at
outpatient surgery centers will encounter trauma patients in need of reconstructive
orthopedic or plastic surgery.
At the same time, very few anesthesiologists in the United States
consider trauma their primary specialty. This situation is distinct from European
practice, where it is not unusual to find an anesthesiologist working in the prehospital
environment, as an ED director, or as leader of a hospital's trauma team. Indeed,
European anesthesiologists make up a large fraction of the membership of the International
Trauma Anesthesia and Critical Care Society. The U.S. model, in which all anesthesiologists
treat trauma patients but few do so exclusively, has led to a relative dearth of
research, publication, and education in this field. This state of affairs is unfortunate
because trauma is a rapidly evolving field of study that presents unique challenges
to the clinician, as well as one in which improvements in care can have a dramatic
impact on individual patients and on society as a whole.
As with other endemic diseases, successful treatment of trauma
extends well beyond the boundaries of an individual hospital. Community-based prevention
has included efforts to incorporate airbags in motor vehicles, mandate helmet use
on motorcycles, encourage citizens to wear seat belts, punish intoxicated drivers,
and promote responsible handgun ownership.[4]
All
these factors have had an impact on the demographics of injury in much the fashion
that smoking cessation, dietary modification, and routine mammography have affected
the incidence of heart disease and cancer. When prevention fails, outcomes after
injury are heavily influenced by the community's commitment to an organized system
of trauma care.[5]
The degree to which the trauma
system is organized and regulated varies widely from state to state across the United
States. States such as Maryland, Pennsylvania, Connecticut, and Illinois have established
protocols for the care of trauma patients that begin at the moment of first contact
with the emergency medical system. In other states the system may be more fragmentary,
and care may vary widely between one jurisdiction and another. Mature trauma systems
include protocols for patient triage and transport, standards for hospitals providing
trauma care, and data collection systems that facilitate benchmarking of care.
Although some states have written their own standards for certifying
trauma hospitals, the most influential national document is Resources
for Optimal Care of the Injured Patient, published by the American College
of Surgeons Committee on Trauma.[6]
This reference
offers standards for accreditation of trauma hospitals based on the availability
of key resources, the volume of trauma patients treated, and the institutional commitment
to prevention and education. 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. Prospective studies have demonstrated improved patient
outcomes when a hospital pursues and attains designation as a trauma center.[7]
The need for ongoing education of trauma care providers is brought
home by the numerous innovations in trauma care witnessed in just the past decade.
Such innovations include technologies for rapid volume resuscitation; "damage control"
surgical techniques; diagnostic modalities such as high-speed computed tomography
(CT), angiography, and focused abdominal ultrasound; and perfusion-focused strategies
for managing traumatic brain injury (TBI). The coming decades will see new pharmacologic
therapies for shock and reperfusion, new strategies for achieving hemostasis, and
better patient monitoring. Improving patient outcomes requires a commitment to continuing
education on the part of the anesthesiologist and every member of the trauma team.
This chapter will provide an overview of important areas of trauma
care for the anesthesiologist. We begin with a description of the initial approach
to an injured patient, followed by discussions of emergency airway management, fluid
volume resuscitation, and the care of patients with central nervous system (CNS)
injuries. We will briefly cover the needs of orthopedic and reconstructive surgery
patients and then conclude with a discussion of postoperative and critical care issues
for the trauma anesthesiologist.
