Injury is the leading cause of death between the ages of 1 and 45 years and the third leading cause of death overall.

3th leading cause of death and disability in all age groups

Mortality increased by 2020 in low and middle income countries

Decreased mortality in trauma center

• Anesthesiologists are involved:

beginning with airway and resuscitation management in the emergency department (ED) and proceeding through the operating room (OR) to the intensive care unit (lCU).

• Critical care and pain management specialists see trauma patients as a large fraction of their practice.

in European practice anesthesiologist working in the prehospital environment, as an ED director, or as leader of a hospital's trauma team.

• 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.

***Anesthesia for trauma patient is different from routine OR practice:

• Most urgent cases occur during off-hours• Small hospital-military and humanitarian

practice,auster condition (Resources avibility) • limitation in Patient information • Full stomach-intoxicate-cervical spine instability• Multiple positioning-multiple procedure-need to

consider priorities in management• Occult injuries such as tension Pneumothorax can be

manifested at unexpected times• Multiple injury

• The advanced trauma life support (ATLS) course of the American College of Surgeons is the most popular training program for trauma physicians

ATLS:Based on primary survey that means:• simultaneous diagnostic and therapeutic activities intended to

identify and treat life and limb-threatening injuries, beginning with the most immediate.

• This focus on urgent problems is first captured by the " Golden hour“ catch phrase and is one of the most important lessons of ATLS.

• ATLS begins with the ABCDE :• airway, breathing, circulation, disability, and

exposure and secondary survey.

• adequate open airway and acceptable respiratory mechanics is of primary Importance because hypoxia is the most immediate threat to life.

• Trauma patients are at risk for airway obstruction and inadequate respiration for the reasons listed later.

• cause of obstructed airway or inadequate ventilation in trauma patients:

Airway Obstruction:• Direct injury to the face, mandible, or neck• Hemorrhage in the nasophrynx, sinuses, mouth, or upper airway• Diminished consciousness secondary to traumatic brain injury, intoxication, or

analgesic medications• Aspiration of gastric contents or a foreign body (e.g., dentures)• Misapplication of oral airway or endotracheal tube (esophageal intubation)

Inadequate Ventilation• Diminished respiratory drive secondary to traumatic brain injury, shock, intoxication,

hypothermia, or over sedation• Direct injury to the trachea or bronchi• Pneumothorax or hemothorax• Chest wall injury• Aspiration• Pulmonary contusion• Cervical spine injury• Bronchospasm secondary to smoke or toxic gas inhalation

• Endotracheal intubation must be immediately confirmed by :

• capnometry for patients who have vital signs; esophageal

intubation or endotracheal tube dislodgement is common

• Patients in cardiac arrest may have very low end-tidal CO2 values;

• direct laryngoscopy should be performed if there is any question about the location of the endotracheal tube.

10

• continue

• If establishment of a secure airway and adequate ventilation require a surgical procedure such as a tracheostomy, tube thoracostomy, or open thoracotomy, this procedure must be precede.

• Subsequent surgery to convert a cricothyroidotomy to a tracheostomy or close an emergency thoracotomy may then follow in the OR on an urgent basis.

Hemorrhage is the next most pressing concern because ongoing loss of blood will be fatal in minutes to hours.

Shock is presumed to be a consequence of hemorrhage until

proved otherwise.

• Assessment of the circulation consists of:• an early phase, during active hemorrhage • late phase, which begins when hemostasis is achieved and

continues until normal physiology is restored.

• In the early phase, diagnostic efforts will focus on the five sites of bleeding detailed

• they are the only areas in which Exanguinating hemorrhage can occur.

• Neurologic examination:• measurement of the Glasco Coma Scale (GCS) score; examination

of the pupils for size, reactivity, and symmetry• determination of preserved sensation and motor function in each

of the extremities.

• In few patients who require operative evacuation of an epidural or subdural hematoma, the timeliness of diagnosis and treatment has a strong influence on outcome.

• patients with unstable spinal canal injuries and incomplete neurologic deficits may benefit from early operative intervention.

• The final step in the primary survey is complete exposure of the patient and a

head-to-toe search for visible injuries or deformity-soft tissue bruising, and any breaks in the skins.

• secondary survey:• history and physical examination• diagnostic studies • subspecialty consultation• treatment plans established

• Indications for urgent or emergency surgery:• pulseless extremity,• compartment syndrome• near amputation • massively fractured extremity

must go to the operative room as soon as possible.

Infection:• sepsis is a leading cause of complications and death in trauma patien: open injuries should be thoroughly debrided-and closed if

appropriate-at the earliest opportunity.

• Other indication for urgent surgery:• perforation of the bowel• open fracture • extensive soft tissue wounds

• The frequency of infectious increases in linear fashion with time

**the anesthesiologist must balance the need for early surgery against the need for diagnostic studies and adequate preoperative resuscitation.

Surgical priorities:(fig72-2) 1:Airway management

• 2:Control of exanguinating hemorrhage (Laparaotmy-thoracotomy-pelvic external fixation-neck exploration)

3:Intracranial mass excision

4:Treatment limb or eyesight - High risk sepsisControl of ongoing hemorrhage-Early patient mobilization- spinal fixation-

Closed long bone fixation

Better cosmetic outcome-Facial fracture repair-Soft tissue closure

Emergency air way management:• Adequate oxygenation and ventilation• Protection from aspiration• ASA algorithm for management of difficult air way

is useful starting point for the trauma anesthesiologist whether in the ED or OR.

• (figure72-4)

• 20

Indication of endotracheal intubation:• Cardiac or respiratory arrest• Respiratory insufficiency • Airway protection• The need for deep sedation or analgesia, general anesthesia • Transient hyperventilation of patients with space occupying

intracranial lesions and evidence of increased intracranial pressure (ICP)·

• Delivery of %100 FIO2 patients with carbon monoxide poisoning ·

• Facilitation of the diagnostic workup in uncooperative or intoxicated patients.

Approach to Endotracheal Intubation:

• the anesthesiologist should insist on the same monitoring standards for airway management in the ED as in the OR, including an electrocardiogram, blood pressure (BP), oximetry, and capnometry

• Appropriate equipment:oxygen source, bag-valve-mask ventilating system, mechanical ventilator, suction, selection of laryngoscope blades,endotracheal tubes, devices for managing difficult intubations

• Neuromuscular usage???

• Although concern may exist that the use of neuromuscular blocking drugs and potent induction anesthetics outside the OR will be associated with a higher complication rate, the opposite is in fact more likely correct.

• Attempts to secure the airway in an awake or lightly sedated patient increase the risk of airway trauma ,pain, aspiration, hypertension, laryngospasm, and combative behavior.

Prophylaxis against aspiration of gastric content

• A trauma patient is always considered to have a full stomach

• ingestion of food or liquids • swallowed blood from oral or nasal injuries• delayed gastric emptying • administration of liquid contrast medium• If time and patient cooperation allow, it is reasonable

to administer non particulate antacids for patient before induction and intubation.

• Cricoid pressure-the Sellick maneuver-should applied continuously

• Sellick maneuver consists of elevating the patient's chin (without displacing the cervical spine) and then pushing the Cricoid cartilage posteriorly to close the esophagus.

• A bimanual technique was later described by Crowley and Gieseckel. in which the left hand is placed under the patient's neck to stabilize it. The cricoid is stabilized between the thumb and third finger while the index finger pushes down.

• Sellick's original paper described ventilation during Cricoid pressure in patients with full stomachs.

• because preoxygenation may be difficult in a trauma patient as a result of facial trauma, decreased respiratory effort, or agitation, desaturation will occur rapidly.

Protection of the Cervical Spine• Standard practice dictates that all blunt trauma, should

be assumed to have an unstable cervical spine until this condition is ruled out.

• laryngoscopy causes cervical motion, with the potential to exacerbate spinal cord injury

• continue• The presence of an "uncleared" cervical spine mandates the use

of in-line manual stabilization (not traction) throughout any intubation attempt

• Emergency awake fiberoptic intubation

• Indirect larengoscope

Personel:• Three providers are required to ventilate the patient,

hold Cricoid pressure, and provide in-line cervical stabilization; a fourth provider to administer anesthetic medications

• Additional assistance may be required to restrain a patient who is combative as a result of intoxication or TBl.

• The immediate presence of a surgeon or other physicianWho can perform a cricothyroidotomy is desirable.

• Urgent tube thoracostomy may prove necessary in some trauma patients to treat the tension Pneumothorax that develops with the onset of positive pressure ventilation

• 30

Anesthetic for induction of anesthesia:

• in hemorrhagic shock may potentiate profound hypotension and even cardiac arrest as a result of inhibition of circulating catecholamines.

• propofol and thiopental both drugs are vasodilators and both have a negative inotropic effect

• Effects of anesthetics on brain Increased• Etomidate more cardiovascular stability than other

intravenous hypnotic • Ketamine :causes a release of catecholamines, primarily by direct action

on the CNS it is also a direct myocardial depressant.

• continue:• In normal patients, the effect of catecholamine release masks the

cardiac depression and results in hyper tension and tachycardia.

• In hemodynamically stressed patients , cardiac depression may be unmasked and lead to cardiovascular collapse.

• Hypovolemic patients will become hypotensive with the administration of any the induction anesthetic :

• Sever hypotension:• healthy young patients can lose up to 40% of their blood volume

before experiencing a decrease in arterial BP, which can lead to potentially catastrophic circulatory collapse with anesthetic induction, regardless of the agent chosen.

• The dose of anesthetic must be decreased in the face of hemorrhage in patient with life threatening hypovolemia.

Neuromuscular blocking drugs:

• succinylcholine has fastest onset time and short of action

• make it popular for rapid-sequence induction

• “In can not ventilate can not intubated patient”

• The anesthesiologist should not rely on return of spontaneous breathing

• Suuccinylcoline ………• Serum potassium increases of 0.5 to 1.0 mEq/L but in

certain patients potassium may increase by more than 5 mEq/L.

• The hyperkalemic response is typically seen in burn victims, patients with muscle pathology caused by direct trauma, denervation (as with SCI), or immobilization

• Hyperkalemia is not seen in the first 24 hours after these injuries

• should be used cautiously in patient with ocular trauma and increase ICP

• Rocuronium (09-1.2 mg/kg) and vecuronium (0.1 to 0.2 mg/kg). (sugamadex)

• large doses can be used to achieve rapid (1 to 2 minutes) systemic relaxation.

• Awareness &Recall:• Subsequent patient recall of intubation and emergency procedures

is highly variable and affected by the presence of coexisting TBI, intoxication, and the depth of hemorrhagic shock

• Decreased cerebral perfusion appears to inhibit memory formation but cannot be reliably associated with any particular BP or chemical marker.

• Administration of 0.2 mg of **scopolamine (a tertiary ammonium vagolytic) has been advocated to inhibit memory formation in the absence of anesthetic drugs in this situation,

• Small doses of **midazolam will reduce the incidence of patient awareness, but can also contribute to hypotension.

• Specific situation:• There will always be specific situations where maintaining

spontaneous ventilation during intubation is the preferred and indeed the safest manner in which to proceed.

• If patients are able to maintain their airway temporarily but have clear indications for an artificial airway (penetrating trauma to the trachea), slow induction with ketamine or inhaled sevoflurane through Cricoid pressure will enable placement of an endotracheal tube without compromising patient safety.

• Fiberoptic intubation can also be performed under such circumstances

Adjuncts to endotracheal intubation:

• Equipment to facilitate difficult intubation should be readily available wherever emergency airway management is performed

• The gum elastic bougie, or intubating stylet• The stylet is placed through the vocal cords under the guidance of

direct laryngoscopy, with the endotracheal tube then advanced over it into the trachea.

• esophageal combitube :(Kendall Sheridan Catheter)

• Because placement of the Combitube has been associated with esophageal injury, its use should be reserved for emergency situations

The laryngeal mask airway (LMA):

LMA placement is possible in most patients who cannot be intubated and will permit adequate oxygenation and ventilation

The LMA is an appropriate rescue device for difficult air way situation in trauma, provide that there is no major anatomic injury or hemorrhage in the mouth and larynx.

40

• Trans tracheal jet ventilation:• through a Percutaneous catheter attached to a high-pressure

fresh gas source

• After initial successful placement the catheter may kink or pull out of the trachea with motion of the patient's head or neck.

• Tension Pneumothorax ,this condition should be suspected whenever a patient deteriorates suddenly after jet ventilation

• reserved for only the most urgent situations and should be closely followed by open cricothyroidotomy

Oral versus nasal intubation:oral intubation is preferred over nasal intubation in the emergency

setting because of the risk of direct brain trauma from nasal instrumentation in a patient with a basal skull or cribriform plate fracture

nasal intubation poses a:

• risk of sinusitis in a patient who will be mechanically ventilated for more than 24 hours;

• use of a smaller-diameter tube will also increase the difficulty of subsequent airway suctioning and fiberoptic bronchoscopy.

Facial and pharyngeal trauma:Serious skeletal derangements may be masked by apparently

minor soft tissue damageFailure to identify an injury to the face or neck can lead to acute

airway obstruction secondary swelling and hematoma.

Laryngeal edema is also a risk patients who have suffered chemical or thermal injury the pharyngeal mucosa.

indications for early intubation: Intra oral hemorrhage pharyngeal erythema change in voice

Continue:

• both maxillary and mandibular fractures will make mask ventilation more difficult, whereas mandibular fractures will make intubation easier

• Palpation of facial bones before manipulation of the airway help to diagnosis

• Patients with jaw and zygomatic arch injuries often have trismus.

• trismus will resolve with the administration of neuromuscular blocking agents

• Bilateral mandibular fractures and pharyngeal hemorrhage may lead to upper airway obstruction, particularly in a supine patient

• A patient arriving at the ED in the sitting or prone position because of airway compromise is best left in that position until the moment of anesthetic induction and intubation.

http://www.wjes.org/content/4/1/21/figure/F1

Resuscitation from hemorrhagic shock:

• refers to the restoration of normal physiology after injury specifically to the restoration of:

• normal circulating blood volume• normal vascular tone• normal tissue perfusion.

• Pathophysiology of hemorrhagic shock:

• Decreased BP leads to vasoconstriction and catecholamine release.

• Pain, hemorrhage, and cortical perception of traumatic injuries lead to the release of a number of hormones, including

• renin-angiotensin• vasopressin• anti diuretic hormone• growth hormone• glucagon• Cortisol• epinephrine, and norepinephrine

continue• Individual ischemic cells respond to hemorrhage by taking up

interstitial fluid further depleting intravascular fluid.

• Cellular edema may choke off adjacent capillaries and result in a "no-reflow" phenomenon that prevents the reversal ischemia in the presence of adequate macro perfusion.

• Ischemic cells produce lactate and free radicals, which accumulate in the circulation if perfusion is diminished.

• 50

• continue• These compounds cause direct damage to the cell, as well as form

the bulk of the toxic load that will be washed back to the central circulation when flow is reestablished.

• The ischemic cell will also produce and release a variety of inflammatory factors

• prostacyclin• thromboxane• prostaglandins• leukotrienes, endothelin,• complement• interleukins• tumor necrosisfactor• and others

• This why a patient may die of multiple organ failure after traumatic hemorrhage, even when bleeding has been controlled and the patient resuscitated to normal vital signs and perfusion.

• The CNS is the prime trigger of the neuroendocrine response to shock, which maintains perfusion to the heart, kidney, and brain at the expense of other tissues.

• Regional glucose uptake in the brain changes during shock.

• Reflex activity and cortical electrical activity are both depressed during hypotension; these changes are reversible with mild hypoperfusion but become permanent with prolonged ischemia.

• Specific organ systems respond to traumatic shock in specific ways:

• The kidney and adrenal glands are prime responders to the neuroendocrine changes associated with shock; these organs produce renin, angiotensin, aldosterone, cortisol, erythropoietin, and catecholamines.

• The kidney itself maintains glomerular filtration in the face of hypotension by selective vasoconstriction and concentration of blood flow in the medulla and deep cortical area.

• Prolonged hypotension leads to decreased cellular energy and an inability to concentrate urine(renal cell hibrination), followed by patchy cell death, tubular epithelial necrosis, and renal failure

• continue• The heart is relatively preserved from ischemia during shock

because of an increase in nutrient blood flow

• cardiac dysfunction as the terminal event in the shock spiral because of Lactate, free radicals, and other humoral factors released by ischemic cells all act as negative inotropes and, in a decompensated patient

• A patient with cardiac disease or cardiac trauma(fixed stroke volume)…….

• Shock in the elderly may therefore be rapidly progressive and may not respond predictably to fluid administration.

Continue

• Accumulation of immune complex and cellular factors in pulmonary capillaries leads to neutrophils and platelet aggregation, increased capillary permeability, destruction of lung architecture, and respiratory distress syndrome.

• This is evidence that traumatic shock is more than just a hemodynamic disorder.

• continue

• The Gut is one of the earliest organs affected by hypoperfusion and may be the prime trigger of MOSF.

• Intestinal cell death causes a breakdown the barrier function of the gut that results in increased translocation of bacteria to the liver and lung, thereby potentiate ARDS.

• The liver has a complex microcirculation and has been demonstrated to suffer reperfusion injury during recovery from shock.

• Failure of the synthetic functions of the liver after shock are almost always lethal

• continue• Skeletal muscles: tolerates ischemia better than other organs

• The large mass of skeletal muscle, though, makes it important in the generation of lactate and free radicals from ischemic cells.

• Sustained ischemia of muscle cells leads to an increase in intracellular sodium and free water with an aggravated depletion of fluid in the vascular and interstitial compartments.

• Resuscitation of these patients should be considered in two phase:

• Early, while active bleeding is still ongoing• Late; once all hemorrhage has been controlled.

• Early resuscitation is much more complex because the risks of aggressive volume replacement summarized in Table 63-6 including the potential for exacerbating hemorrhage and thus prolonging the crisis, must be weighed against the risk of ongoing hypoperfusion.

• 61

• Early resuscitation:

• Fluid administration is the cornerstone of acute resuscitation.• Intravascular volume is lost because:• hemorrhage• uptake by ischemic cells• extravasation into the interstitial space.

• The ATLS curriculum advocates the rapid infusion of up to 2 L of warmed isotonic crystalloid solution for any hypotensive patient, with the goal of restoring normal BP .

Fluid administration:• reduces oxygen delivery • hypothermia • coagulopathy.

Elevation of Blood pressure leads to: • increased bleeding as a result of disruption of clots • reversal of compensatory vasoconstriction.

• The result of aggressive fluid administration is often a transient rise in BP, followed by increased bleeding and another episode of hypotension, followed by the need for more volume administration.

• This vicious cycle has been recognized since the First World War and remains a complication of resuscitation therapy today.

Deliberate hypotensive

• Application of this technique to the initial management of a hemorrhaging trauma victims highly controversial and has been the focus of numerous laboratory and clinical research efforts.

• A large body of laboratory data have shown the benefits of limiting fluid administration to actively hemorrhaging animals

• Moderate resuscitation (to a lower than normal BP) improved perfusion of the liver.

• Burris and coworkers found that rebleeding was correlated with higher mean arterial pressure (MAP) and that survival was best in groups resuscitated to a lower than normal MAP.

• A 1994consensus panel on resuscitation from hemorrhagic shock: mammalian species are capable tolerate Sustaining MAP as low as 40 mm Hg for periods as long as2 hours without deleterious effects.

• this panel conclude that spontaneous hemostasis and long-term survival were maximized by reduced administration of resuscitation fluids during the period of active bleeding while seeking to keep perfusion only above the threshold for ischemia.

• in another study The authors concluded that administration of fluids to an actively hemorrhaging patient should be titrated to specific physiologic end points, with the anesthesiologist navigating a course between the risk of increased hemorrhage and hypoperfusion.

Blood loss without shock does not produce systemic complications such as ARDS in experimental models

• The emphasis in this situation must be on rapid diagnosis and control of ongoing hemorrhage

the anesthesiologist should attempt to:• restore vascular volume • provide anesthesia in equal measure such that the patient is moved from a vasoconstricted

state to a vasodilated

• facilitating hemostasis by maintenance of a lower than normal BP. 70

Vulnerable Patient Populations• Clinical trials of deliberate hypotensive resuscitation have restricted this

teqnique:

• ischemic coronary disease• elderly patients (reduced physiologic reserve)• Those with injuries to the brain or spinal cord

• Clinical care of these patients is focused on avoidance of ischemic stress and rapid correction of hypovolemia

Resuscitation Fluids:• isotonic Crystalloids (normal saline, lactated Ringer's solution Plasma-Lyte ) are

the initial resuscitative fluids administered, to any trauma patient. • Advantages:• Inexpensive• readily available• non allergenic• noninfectious,• efficacious in restoring total-body fluid. • mix well with most infused medications, • rapidly warmed to body temperature.Disadvantages:• lack of oxygen-carrying capacity,• their lack of coagulation capability,• and their limited intravascular half-life. • immunosuppressant and triggers of cellular apoptosis(is the process of

programmed cell death that may occur in multicellular organisms)

• apoptosis is an important element of reperfusion injury

• In a rat model of controlled hemorrhage, animals receiving

LR solution showed an immediate increase in apoptosis in the liver and small intestine after resuscitation with LR.

Neither whole blood nor hypertonic saline increased the amount of apoptosis.

• Hypertonic saline solutions, with or without the addition of polymerized dextran have been extensively studied in resuscitation from hemorrhagic shock.

• HS will draw fluid into the vascular space from the interstitium, HS a popular choice for fluid resuscitation

• Multiple studies of otherwise lethal hemorrhage in animals have demonstrated improved survival after resuscitation with HSD versus either normal saline solution or the components of HSD alone.

• Studies of the efficacy of HSD in trauma patients have been inconclusive

• the most obvious benefit has been in a subset of poly traumatized patients with both hemorrhage and TBI, where improved neurologic status was demonstrated in patients who received HSD as a resuscitation fluid

• HS is commonly used as an osmotic agent in the management of TBI with increased ICP.

• Colloids: hetastarch solutions and albumin, have long been advocated for

rapid plasma volume expansion.

colloids are readily available easily stored and administeredrelatively inexpensive.

As with the hypertonic solutions, colloids will increase intravascular volume by drawing free water back into the vascular space.

Continuous :

When intravenous access is limited, colloidal resuscitation will restore intravascular volume more rapidly than crystalloid infusion will and at a lower volume of administered fluid.

Because colloids do not specifically transport oxygen or facilitate clotting, their dilutional effect on blood will be similar to that of crystalloids.

recent Studies have demonstrated no great benefit of colloids over crystalloids in a variety of resuscitation models.

80

Continuous• Recognition of dilutional effects of fluid administration and

continued improvement in the safety of donated blood have led to

• increased use of blood products in the management of early hemorrhagic shock .

• The risk of systemic ischemia is decreased by the maintenance of an adequate hematocrit, and the potential for dilutional coagulopathy can be avoided with the early administration of plasma.

• 141 patients received massive blood transfusions (20 U or more of packed red blood cells (PRBC) during preoperative and intraoperative resuscitation

• • Eleven variables were significantly different: aortic clamping for

control of BP, use of inotropic drugs, time with systolic BP less than 90 mm Hg, time in the OR, temperature lower than 34°C, urine output, pH less than 7.0, Pao2/Flo2 ratio less than 150, Paco2 higher than 50 mm Hg, potassium greater than 6 mM/L, and calcium less than 2 mM/L

• Continuous• Of these variables, the presence of the first three in the face of

transfusion of more than 30 U of PRBCs was invariably fatal.

Total blood loss and the amount of transfused blood were less

critical than the depth and duration of shock.

These concern to the concept of damage control surgery, which emphasizes rapid control of active hemorrhage.

• Red blood cell:

• are the mainstay of treatment of hemorrhagic shock.

A unit of RBCs :• will predictably restore oxygen-carrying capacity • expand intravascular volume as well as any colloid solution will.

• cross matching is desirable when time allows • Type O blood the "universal donor“ can be given to patients of

any blood type with little risk of a major reaction

• If O positive blood is given to Rhesus-negative woman who survives, prophylactic administration of anti-Rh antibody is indicated.

Continuous

• Risks of PRBC administration include• transfusion reaction• transmission of infectious agents• hypothermia.

• PRBCs are stored at 4°C and will lower the patient's temperature rapidly if not infused through a warming device

• FFP:Plasma required blood typing but not crossmatched

Very busy centers are experimenting with Keeping 2-4 units as prethawed plasma Universal donor (AB)

Plasma and PRBCs should be administered prophylactic in a 1:1 ratio to any patient with obvious massive hemorrhage, even before confirmatory laboratory studies are available.

• Platelet:• Platelet transfusion should be reserved for clinically

coagulopathic patients with a documented low serum<50000

Platelets should not be administered :• filter• Warmer• rapid infusion devices. When the patient in shock and blood loss is likely to be

substantial palates should be empirically administrated in

proportion of RBC and plasma(1:1:1)

• Rapid transfusion of banked blood:• caries the Risk of inducing citrate intoxication" in the recipient.• Every component unit is packaged with one of several

anticoagulation agents (citrate being a common choice) that bind free calcium, an essential requirement of the clothing cascade

• Consecutive administration of multiple units of banked blood overwhelms the body's ability to mobilize free calcium and causes a marked reduction in circulating serum calcium with a profound negative inotropic effect on the heart.

• unrecognized hypocalcaemia is a common cause of hypotension that persists despite an adequate volume of resuscitation.

• Ionized calcium levels should be measured at regular intervals in a hemorrhaging patient, and calcium should be administered as needed (in a separate intravenous line from That for transfusion products)

• Resuscitation equipment:• Immediate placement of at least two large bore catheter

• patient's underlying state of health and specific injury pattern may eliminate some sites from consideration

The internal jugular approach, thought familiar to most anesthesiologists, will require removal of the cervical collar and manipulation of the patient's neck and is therefore not recommended

90

• Continuous:

• 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.

• Continuous:

• Femoral vein catheterization carried a high risk of deep venous thrombosis ,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 difficulty traumatized.

• Risk of Pneumothorax

• Arterial line

• Hypothermia:

• Anesthesiologist must maintain thermal equilibrium in any trauma patient:

• Potentiate dilutional coagulopathy • Potentiate systemic acidosis• shivering and vasoconstriction lead to myocardial ischemia.• Increase subsequent rate of sepsis

• Because many trauma patients arrive at the ED already cold from exposure to the elements, early active warming measures are requited.

• Continuous

• All intravenous fluid should he prewarmed

• 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.

• This devices must prepare in ct scan room and angiography room and ED

• rapid infusion devices are of great benefit in treatment care, particularly in the presence of hemorrhagic shock.

• Reduce acidosis• Higher patient temperatureDisadvantages:• over infusion of fluids• Inappropriate blood pressure• rebleeding

• Late resuscitation :Late resuscitation begins once bleeding is definitively controlled :• by surgery• angiography• the passage of time.• Fluid administration is an integral, mandatory component of late

resuscitation

• The adequacy of resuscitation should not be judged by the presence of normal vital signs but by normalization of organ and tissue perfusion

• resuscitate the patient with the appropriate fluid, in the appropriate amount, at the appropriate time.

• The practitioner's goal at that time is to rapidly restore normal perfusion to all organ systems while continuing to support vital functions.

• Hypoperfusion caused by hemorrhagic shock triggers a predictable cascade of biochemical events that will cause physiologic derangements persisting long after adequate blood flow is restored.

• The extent of hypoperfusion and the depth and duration of shock-is highly correlated with the development of subsequent organ system failure

• traditional vital sign markers such as BP, heart rate, and urine output have been shown to be insensitive to the adequacy of resuscitation.

Occult hypoperfusion syndrome• is common in postoperative trauma patients, particularly young ones

• normal BP maintained by intense systemic vasoconstriction• intravascular volume is low• cardiac output is low• and organ system ischemia persists.

• Such patients are at high risk for MOSF if hypoperfusion is not promptly corrected.

• Technique shorcomings• Vital signs Will not indicate occult hypoperfusion • Urine output confounded by intoxication, diuretic renal injury • Systemic acid-base status Confounded by respiratory status• Lactate clearance Requires time to obtain laboratory result• Cardiac output pulmonary artery catheter or use of noninvasive technology

• Mixed venous oxygenation Difficult to obtain, but a very accurate marker• Gastric tonometry Requires time to equilibrate, subject to artifact• Tissue oxygenation Emerging technology, appears beneficial • Stroke volume variation Emerging technology, requires an arterial line• Acoustic blood flow Investigational technology, unproven

100

• Invasive monitoring change to noninvasive approaches that assess of adequate metabolism,respiration, and oxygen transport in peripheral tissue beds.

• One minimally invasive technique is tissue oxygen monitoring (skin, subcutaneous tissue, or skeletal muscle).

• Skeletal muscle blood flow decreases early in the course of shock and is restored late during resuscitation, thus making the skeletal partial pressure of oxygen a sensitive indicator of low flow.

• Early goal directed treatment of septic shock ,with an emphasis on measurement of mixed venous oxygen saturation ,has influenced the care of trauma patient ,and many of ICUs are now using continiucely measured venous oxygenation to guide resuscitation.

• Stroke volume variation Change in arterial pressure driven by the respiratory cycle(during positive pressure ventilation) a reliable predictor of decrease intravascular volume.

• Tissue hypercapnia has been suggested as a universal indicator of critically reduced

perfusion

• measurement of *gastric mucosa Pco2 through gastric tonometry has been used in trauma patients as an indicator of restoration of splanchic blood flow, and **distal gut PH has shown promise as a reliable indicator.

• the most proximal area of the gastrointestinal tract, the ***sublingual mucosa, has been shown to be a useful site for measurement of Pco2

• continuous

• When sublingual Pco2(PsLco2) exceeded a threshold of 70 mm Hg (normal = 45.2 ± 0.7 mm Hg), its positive predictive value for the circulatory shock was 100%.

• Inadequate tissue perfusion as indicated by these specific monitoring or by the traditional systemic markers of serum lactate, base deficit, and decreased PH, must be treatment promptly once ongoing hemorrhaged is controlled.

• The rate at which a shock patient's lactate returns to the normal range is strongly correlated with outcome:

• failure to reach to normal range within 24 hours of a traumatic injury carries a greater of organ system failure and eventual death