Summary

In study session IV you have learnt

• Trauma also known as injury can be defined as a physical harm or damage to the structure or function of the body, caused by an acute exchange of energy (mechanical, chemical, thermal, radioactive, or biological) that exceeds the body's tolerance.
• The mortality due to injury occurs during one of the following periods; primary injury to major organs or structures, secondary injury due to hypoxia, hemorrhage or any process that leads to inadequate tissue perfusion or after days or weeks in the hospital.
• There are two types of major trauma; blunt trauma usually is the result of a fall or vehicle accident in which injuries are not easily detected, penetrating trauma is usually identified by the visible hole left in the skin.
• It is important for the anesthetist to remember that these patients may have an increased likelihood of being drug abusers, acutely intoxicated, and carriers of hepatitis or human immunodeficiency virus (HIV).
• The initial assessment of the trauma patient can be divided into primary, secondary, and tertiary surveys. The primary survey should take 2 - 5 min and consists of the ABCDE sequence of trauma: Airway, Breathing, Circulation, Disability, and Exposure. If the function of any of the first three systems is impaired, resuscitation must be initiated immediately.
• The purpose of the primary survey is to diagnose immediate life threatening conditions. These should be treated as soon as they are discovered before continuing the survey.
• Establishing and maintaining an airway is always the first priority. If a patient can talk the airway is usually clear, but if unconscious the patient will likely require airway and ventilatory assistance.
• Cervical spine injury is unlikely in alert patients without neck pain or tenderness. To avoid neck hyperextension, the jaw-thrust maneuver is the preferred means of establishing an airway. Oral and nasal airways may help maintain airway patency.
• Assessment of ventilation is best accomplished by the look, listen, and feel approach. In patients with respiratory distress tension pneumothorax and hemothorax should be suspected therefore, pleural drainage may be necessary before anesthesia.
• Adequacy of circulation is based on pulse rate, pulse fullness, blood pressure, and signs of peripheral perfusion. Signs of inadequate circulation include tachycardia, weak or unpalpable peripheral pulses, hypotension, and pale, cool, or cyanotic extremities.
• Two priorities of circulation to be considered in the trauma patient are to stop the bleeding and replace the lost blood.
• The central nervous system should be quickly assessed by ascertaining the level of consciousness, spinal cord function and pupillary response to light.
• The secondary survey begins only when the ABCs are stabilized. The patient is evaluated from head to toe and the indicated studies and history should be obtained
• A tertiary survey is defined as a patient evaluation that identifies and catalogues all injuries after initial resuscitation and operative interventions..
• Trauma score helps to quantify the severity of trauma for purposes of giving priorities in order of severity using parameters which include respiratory rate, systolic BP and GCS.
• Regional anesthesia is usually impractical and inappropriate in hemodynamically unstable patients with life-threatening injuries.
• If time permits, hypovolemia should be at least partially corrected prior to induction of general anesthesia. Fluid resuscitation and transfusion should continue throughout induction and maintenance of anesthesia.
• If the patient is moribund (that is, non-responsive to anything), the blood pressure cannot be detected by conventional means, and there is a high heart rate, then the patient is given oxygen, a fast acting muscle relaxant (succinylcholine), rapidly intubated, and the surgery started. Once the bleeding is stopped, the blood pressure usually comes up, the heart rate down, and the patient is on the way to recovery. Then add a narcotic for pain relief, and finally a very low amount of ketamine or halothane. Each drug added during the resuscitation is given in low doses at first to make sure the patient can withstand the change in physiology induced by the drug.