Resuscitation Equipment (also see Chapter 78 )

Fluid resuscitation of any kind is impossible in the absence of intravenous access. Immediate placement of at least two large-bore catheters (16 gauge or larger) is recommended during the primary assessment of any trauma patient. ^[62] Table 63-11 lists common sites for circulatory access in order of preference for the trauma team, with the understanding that the patient's underlying state of health and specific injury pattern may eliminate some sites from consideration. Practitioners should have a low threshold for placement of a large-caliber central line in any patient in whom antecubital or other peripheral placement attempts have been unsuccessful. Potential sites

TABLE 63-11 -- Sites for emergency intravenous access in order of desirability

Large-bore (16 gauge or greater) antecubital vein

Other large-bore peripheral veins

Subclavian vein

Femoral vein

Internal jugular vein

Intraosseous (tibia or distal end of femur)

for central line placement include the internal jugular, subclavian, and femoral veins, each of which has its own benefits and potential risks. The internal jugular approach, though familiar to most anesthesiologists, will require removal of the cervical collar and manipulation of the patient's neck and is therefore not recommended in the acute setting unless other options have been exhausted. 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 possible.

Femoral vein catheterization carries a high risk of deep venous thrombosis formation,^[93] 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 stabilizes. 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 directly traumatized. This approach carries the highest risk for creation of a pneumothorax, although many patients will already have indications for tube thoracostomy in one or both chest cavities; when possible, the same side is preferred for subclavian line placement. Placement of an arterial line facilitates frequent laboratory analysis and allows close monitoring of BP, which should be undertaken as soon as possible but should not impede other diagnostic or therapeutic maneuvers.

The anesthesiologist should work to maintain thermal equilibrium in any trauma patient. Although deliberate hypothermia has been suggested as a management strategy for both hemorrhagic shock^[94] and TBI, ^[95] at present, evidence is insufficient to support this approach. Hypothermia will potentiate dilutional coagulopathy and systemic acidosis, and shivering and vasoconstriction in response to cold will demand an additional metabolic effort that may predispose the patient to myocardial ischemia. Because many trauma patients arrive at the ED already cold from exposure to the elements, early active warming measures are required. All intravenous fluids should be prewarmed or infused through a warming device. The patient should be kept covered with warmed blankets whenever possible, and the environment should be kept warm enough to make the patient comfortable. If hypothermia has already developed, the use of forced hot air warming is strongly indicated to restore normothermia. Even though all these measures are routine and obvious in the OR, anesthesiologists caring for a trauma patient can perform a valuable service by ensuring that they are available and applied in the ED, CT scanner, and angiography suite as well.

Commercial rapid infusion devices are of great benefit in trauma care, particularly in the presence of hemorrhagic shock. These machines offer a number of benefits whenever large quantities of fluid resuscitation are likely ( Table 63-12 ). Early experience with these devices demonstrated higher patient temperature and reduced acidosis at the conclusion of the initial surgery,^[96] although others

2467