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T R A U M A A N E S T H E S I A
Injuries are estimated to become the number-one cause of death for men and women under the age of 45 by the year 2020. Trauma patients present unique challenges to anesthesiologists. Acute injuries require resource-intensive care and are often complex cases, especially when coupled with underlying, pre- existing medical conditions. Anesthesiologists are involved with trauma patients beginning with airway and shock resuscitation, continuing with intra- operative care during surgery, and extending on to pain management and crit- ical care postoperatively. This new reference focuses on a broad spectrum of traumatic injuries and the procedures anesthesiologists perform to adequately care for trauma patients perioperatively, surgically, and postoperatively. Spe- cial emphasis is given to the assessment and treatment of coexisting disease.
Numerous tables and more than 300 illustrations showcasing various tech- niques of airway management, shock resuscitation, echocardiography, and use of ultrasound for the performance of regional anesthesia in trauma provide an invaluable reference for the anesthesiologist.
Dr. Charles E. Smith is board-certified in anesthesiology and in periopera- tive transesophageal echocardiography, has expertise in trauma care, and has published extensively on topics in trauma anesthesia.
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T R AU M A A N E S T H E S I A
Edited by
C H A R L E S E . S M I T H
MetroHealth Medical Center
Associate Editor
J O H N J . C O M O MetroHealth Medical Center
iii
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
First published in print format
ISBN-13 978-0-521-87058-0 ISBN-13 978-0-511-41388-9
© Charles E. Smith 2008
Every effort has been made in preparing this publication to provide accurate and up-to- date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors, and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.
2008
Information on this title: www.cambridge.org/9780521870580
This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.
Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
Published in the United States of America by Cambridge University Press, New York www.cambridge.org
eBook (EBL)
hardback
C O N T E N T S
Foreword: Adolph H. (Buddy) Giesecke, MD [Anesthesia] pagevii
Foreword: Mark A. Malangoni, MD [Surgery] ix
Preface xi
Acknowledgments xiii
Contributors xv
1. Mechanisms and Demographics in Trauma 1
Pedro Barbieri, Daniel H. Gomez, Peter F. Mahoney, Pablo Pratesi, and Christopher M. Grande
2. Trauma Airway Management 9
William C. Wilson
3. Shock Management 55
Richard P. Dutton
4. Establishing Vascular Access in the Trauma Patient 69
Matthew A. Joy, Donn Marciniak, and Kasia Petelenz-Rubin
5. Monitoring the Trauma Patient 81
Elizabeth A. Steele, P. David Søran, Donn Marciniak, and Charles E. Smith
6. Fluid and Blood Therapy in Trauma 101
Maxim Novikov, and Charles E. Smith
7. Massive Transfusion Protocols in Trauma Care 121
John E. Forestner
8. Blood Loss: Does It Change My Intravenous Anesthetic? 133 Ken Johnson, and Talmage D. Egan
9. Pharmacology of Neuromuscular Blocking Agents and Their Reversal
in Trauma Patients 142
Fran¸cois Donati
10. Anesthesia Considerations for Abdominal Trauma 155
William C. Wilson
11. Head Trauma – Anesthesia Considerations and Management 172 Paul Tenenbein, M. Sean Kincaid, and Arthur M. Lam
12. Intensive Care Unit Management of Pediatric Brain Injury 187 Robert Cohn, Maroun J. Mhanna, Elie Rizkala, and Dennis M. Super
13. Surgical Considerations for Spinal Cord Trauma 202
Timothy Moore
14. Anesthesia for Spinal Cord Trauma 213
M. Sean Kincaid, and Arthur M. Lam
15. Musculoskeletal Trauma 225
Heather A. Vallier, and Mark D. Jenkins
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16. Anesthetic Considerations for Orthopedic Trauma 245
Robert M. Donatiello, Andrew D. Rosenberg, and Charles E. Smith
17. Cardiac and Great Vessel Trauma 260
Naz Bige Aydin, Michael C. Moon, and Inderjit Gill
18. Anesthesia Considerations for Cardiothoracic Trauma 279 Mark A. Gerhardt and Glenn P. Gravlee
19. Intraoperative One-Lung Ventilation for Trauma Anesthesia 300 George W. Kanellakos and Peter Slinger
20. Burn Injuries (Critical Care in Severe Burn Injury) 314 Charles J. Yowler
21. Anesthesia for Burns 322
Jessica Anne Lovich-Sapola
22. Field Anesthesia and Military Injury 343
Peter F. Mahoney and Craig C. McFarland
23. Eye Trauma and Anesthesia 360
Martin Dauber and Steven Roth
24. Pediatric Trauma and Anesthesia 367
Jocelyn Loy
25. Trauma in the Elderly 391
Jeffrey H. Silverstein
26. Trauma in Pregnancy 402
John R. Fisgus, Kalpana Tyagaraj, and Sohail Kamran Mahboobi
27. Oral and Maxillofacial Trauma 417
Ketan P. Parekh and Cecil S. Ash
28. Damage Control in Severe Trauma 431
Michael J. A. Parr and Ulrike Buehner
29. Hypothermia in Trauma 445
Eldar Søreide and Charles E. Smith
30. ITACCS Management of Mechanical Ventilation in Critically Injured Patients 465 Maureen McCunn, Anne J. Sutcliffe, Walter Mauritz, and the International Trauma
Anesthesia and Critical Care Society (ITACCS) Critical Care Committee
31. Trauma and Regional Anesthesia 471
Shalini Dhir and Sugantha Ganapathy
32. Ultrasound Procedures in Trauma 499
Paul Soeding and Peter Hebbard
33. Use of Echocardiography and Ultrasound in Trauma 514
Colin Royse and Alistair Royse
34. Pharmacologic Management of Acute Pain in Trauma 528
Shalini Dhir, Veerabadran Velayutham, and Sugantha Ganapathy
35. Posttrauma Chronic Pain 544
David Ryan and Kutaibba Tabbaa
36. Trauma Systems, Triage, and Transfer 569
John J. Como
37. Teams, Team Training, and the Role of Simulation in Trauma Training
and Management 579
Paul Barach
Index 591
Color plates follow page 294
F O R E W O R D
Dr. Charles E. Smith has been inspiring improved anesthesia for the victims of traumatic injury for many years, having spent the majority of his career at MetroHealth Medical Center, Cleve- land, Ohio, which is the city’s major trauma center. He has regularly served as lecturer in refresher courses for the Interna- tional Trauma Anesthesia and Critical Care Society (now called International TraumaCare). He is a productive author of inno- vative research in the care of the traumatized patient. These attributes easily qualify him to be editor of a multi-authored comprehensive book on trauma anesthesia, to which he is also a major contributor. His invited chapter authors are similarly qualified. The result is an authoritative, readable, and educa- tional resource for the student, resident, or practitioner wishing to stay abreast of a rapidly changing field.
Epochal changes have occurred in the practice of anesthesi- ology in the last ten years. Improved monitors, safer drugs, and better-trained anesthesiologists, nurse anesthetists, and anes- thesia assistants have all reduced the morbidity and mortal- ity of anesthesia. Anesthesia has become safer. Safer anesthe- sia improves the outcome of traumatic injuries. Our surgical colleagues have contributed to the improvements in trauma care. Innovations in the care of serious fractures, use of dam- age control in abdominal injuries, and improved care of burns have reduced morbidity and mortality. Dr. Smith has included all of the latest innovations in this text. Despite the advances, the importance of trauma as a cause of disability and lost life remains and, in fact, when expressed as a proportion to overall mortality in young people, is increasing in importance.
Throughout history significant advances have been made in anesthetic care during times of war. The war in Iraq is no exception, and the lessons learned in that conflict are included.
The technology of vascular access has greatly improved. Ultra- sonic localization of major veins for central access is a major advance greatly enhancing safety for the patient. The tech- nique of intraosseous infusion was once painful and cum- bersome to establish, such that it was considered a circus stunt and not of much practical value. Newly designed equip- ment has revolutionized the technique. It is now fast, pain- less, convenient, and effective in any patient with difficult IV access. Having established vascular access, the choice and vol- ume of fluid therapy is critical to survival and outcome of the
traumatized patient. This book discusses the established and the controversial concepts. Also discussed is a new protocol- driven, multidisciplinary approach to massive transfusion. This approach, which requires cooperation between the blood bank, the trauma surgeons, and anesthesiologists, takes the guesswork out of massive transfusion. No longer do we have to stand at the OR table and ponder, “Is it time for platelets and fresh frozen plasma?” These collaborative decisions have been made in advance, and all we have to do is to activate the proto- col and administer whatever comes in the incremental allot- ments.
Patients now expect to be relieved of significant pain, and pain is considered the fifth vital sign. Significant advances have been made in the techniques for relief of acute traumatic and postoperative pain. Entire teams of people are now dedicated to this practice. Nobody questions the value of pain relief, but it comes with some risk. A multimodal approach appears to accomplish the goal and simultaneously minimize the risks.
Thermal injuries, brain injuries, and spinal cord injuries are specialized forms of trauma that are occasionally neglected.
Not so in this text. The public health implications are presented along with the practical considerations for safe clinical man- agement. The practical considerations are important because, for example, drugs and procedures that may be beneficial in the management of orthopedic injuries are contraindicated in neurologic injuries. We must be able to recognize these con- flicts when they occur together in the same patient and create an anesthetic plan that will benefit the patient.
Dr. Smith and his invited authors have done a magnifi- cent job of pulling together the diverse concepts of the man- agement of the traumatized patient and presenting us with a valuable resource for the anesthesiologist. Although directed at the anesthesiologist, the text is useful for emergency medicine physicians, surgeons, orthopedists, and, in fact, any health care professional who deals with trauma. Congratulations to the entire group of authors!
Adolph H. (Buddy) Giesecke MD, Emeritus Professor Anesthesiology and Pain Management University of Texas Southwestern Medical Center Dallas, Texas
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F O R E W O R D
The challenge of managing seriously injured patients encom- passes an expanse of issues linked by a common factor – trauma.
In these critical situations, anesthesiologists are often faced with the need to simultaneously address emergent airway manage- ment, resuscitation, massive blood loss, acidemia, coagulopa- thy, hypothermia, and the consequences of damage to vari- ous organs. The management of each of these conditions alone can be essential for survival, and their convergence presents a unique situation in which the likelihood of death or a bad out- come is real. Success in this stressful situation requires a sophis- ticated understanding of basic sciences and expertise in the clin- ical and technical skills of anesthetic management. Together, the anesthesiologist and trauma surgeon must orchestrate the human and physical resources of the trauma center with a patient’s life on the line.
Recent advances in the field of trauma anesthesiology paral- lel those in other related medical disciplines. Concepts promul- gated by experiences in recent military conflicts have affected resuscitation and the use of blood products. The adoption of damage control operations and the use of simultaneous sur- gical teams to address multiple critical injuries have improved survival. Rules regarding the transfusion of blood and blood components and the use of recombinant clotting factors such as Factor VII concentrate have led to a “sea change” in trauma management that has resulted in the survival of soldiers and others injured under war conditions beyond what was possible just a few years ago. These concepts have been readily adopted in civilian trauma centers. The intensity associated with their
use has placed an increased demand on anesthesiologists who are already taxed in their care for the critically injured.
This excellent book addresses these important and evolving changes in management of the injured patient as well as more traditional issues in trauma anesthesia. The breadth of topics addressed by the authors reflects the challenges and complexi- ties of anesthesia-related care for victims of traumatic injury.
Trauma surgeons realize the tremendous importance of coordinated care promulgated at trauma centers and by trauma systems. Injury accounts for more lost productive years of life than any other disease; therefore, survival and ultimate return to an acceptable level of function are important outcome param- eters both for the patient, their loved ones, and our society.
Because many seriously injured patients will require an opera- tion, the anesthesiologist is an important link in the coordinated approach to trauma care and must be aware of the unique prob- lems related to managing injury. That is why this book is such an important contribution for anesthesiologists who care for trauma patients.
Mark A. Malangoni, MD Surgeon-in-Chief Chairperson, Department of Surgery MetroHealth Medical Center Professor of Surgery Case Western Reserve University School of Medicine Cleveland, Ohio
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P R E F A C E
Trauma is a leading cause of death and disability in modern society. Trauma will continue to be a leading cause of death well into the future. We are all vulnerable to traumatic injury.
Managing adult and pediatric victims of major trauma and burns continues to be a great challenge requiring a tremen- dous amount of dedication and resources. The overall aim of this book is to review the anesthesia considerations for trauma patients and to provide a rational approach to choice of anes- thetic techniques and drugs for injured patients. To accomplish this, I have assembled an outstanding group of clinicians who regularly care for trauma patients at major trauma centers. Each of them was asked to contribute a chapter that would provide an in-depth discussion on their area of expertise and that would concentrate on clinical aspects of trauma management. I have selected members of my hospital to assist with this textbook, as well as notable contributors from other major centers around the globe.
The book consists of thirty-seven chapters that deal in detail with pertinent areas of trauma care, such as airway and shock management, monitoring, vascular access, pharmacology of anesthetic drugs, fluid and blood resuscitation, and the treat- ment of acute and chronic pain after injury. For several pat-
terns of injuries, including extremity and pelvis, spinal cord, burns, cardiac and great vessel, surgical considerations and management principles are presented to the reader in the chap- ter preceding the one dealing with anesthesia considerations.
Specific chapters review the anesthesia considerations of vul- nerable patient populations such as elderly, pediatric, pregnant, and military patients. Other sections deal with important issues of trauma care, including damage control in severe trauma, hypothermia in trauma, mechanical ventilation in critically injured patients, and use of echocardiography and ultrasound in trauma. Training for trauma, including the use of simulation and the role of trauma care systems in facilitating the allocation of resources for optimally managing injured patients are also covered.
I hope that this book will be of use for anesthesia care providers who are faced with caring for trauma patients at all hours of the day and night. I am certain that the text will bene- fit anesthesia residents and staff of major trauma centers, help pave the way to improved care of the injured, and stimulate future advances in trauma care.
Charles E. Smith, MD, FRCPC
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A C K N O W L E D G M E N T S
I would like to thank my mentors in anesthesia from McGill University – Drs. David Bevan, Franc¸ois Donati, and Earl Wynands – for providing teaching and inspiration, instilling in me the confidence to manage complex patients, and stimu- lating my interest in clinical research. I am indebted to all the staff at MetroHealth Medical Center who work long and hard to transport, stabilize, diagnose, treat, and rehabilitate victims of blunt and penetrating injury. Thanks to my associate edi- tor, John Como, and to the many contributors to this book for sharing their experience and knowledge. I am grateful to Marc Strauss of Cambridge University Press, who first approached me with the formidable task of organizing this book, and to
Peg Brady for her tireless secretarial assistance. Appreciation goes to Peggy Rote, Monica Finley, Angela Weaver, Frank Scott, and the staff at Cambridge for their efforts in seeing this book through to publication. I would also like to thank my colleagues at the International Trauma Anesthesia and Critical Care Soci- ety (ITACCS, now called International TraumaCare) who have been a source of strength and guidance, in particular, Chris Grande, Buddy Giesecke, John Stene, and Eldar Søreide for their friendship and support. The love and encouragement of my parents, my wife, Bobby, and my children, Adrienne, Emily, and Rebecca, was ever present and much appreciated.
Charles E. Smith, MD, FRCPC
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C O N T R I B U T O R S
CE C I L S. AS H, DDS, MS Department of Oral and Max- illofacial Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio NA Z BI G E AY D I N, MD Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
PAU L BA R AC H, MD, MPH Maj (ret.) Department of Anes- thesia and Emergency Medicine, Utrecht University Medical Center, Utrecht, Netherlands
PE D RO BA R B I E R I, MD Department of Anesthesia, Hospital Britanico de Buenos Aires, University of El Salvador School of Medicine, Buenos Aires, Argentina
UL R I K EBU E H N E R, MD FCARCSIAnesthetic Department, St James’s University Hospital, Leeds, United Kingdom RO B E RT CO H N, MDDepartment of Pediatrics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
JO H N J. CO M O, MD Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
MA RT I NDAU B E R, MDDepartment of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
SHA L I N I DH I R, MD Department of Anesthesia and Peri- operative Medicine, University of Western Ontario, London, Ontario, Canada
FR A N C¸O I S DO NAT I, PHD, MD, FRCPC Department of Anesthesiology, H ˆopital Maisonneuve-Rosemont, Universit´e de Montr´eal, Montr´eal, Quebec, Canada
RO B E RT M. DO NAT I E L LO, MDDepartment of Anesthesiol- ogy, Hospital for Joint Diseases and Orthopedic Surgery, New York University Medical Center, New York, New York
RI C HA R DP. DU T TO N, MD, MBADivision of Trauma Anes- thesiology, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
TA L MAG ED. EG A N, MDDepartment of Anesthesiology, Uni- versity of Utah School of Medicine, Salt Lake City, Utah JO H N R. FI S G U S, MD Department of Anesthesia, Mai- monides Medical Center, New York, New York
JO H N E. FO R E S T N E R, MD Department of Anesthesiology and Pain Management, Parkland Memorial Hospital, University of Texas Southwestern Medical School, Dallas, Texas
SU G A N T HAGA NA PAT H Y, MD, FRCA, FRCPCDepartment of Anesthesia and Perioperative Medicine, University of West- ern Ontario, London, Ontario, Canada
MA R KA. GE R HA R D T, MD, PHDDepartment of Anesthesi- ology, Ohio State University Medical Center, Columbus, Ohio AD O L P HH. (BU D DY) GI E S E C K E, MDDepartment of Anes- thesiology and Pain Management, University of Texas South- western Medical School, Dallas, Texas
IN D E R J I T GI L L, MDDepartment of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
DA N I E LH. GO M E Z, MDDepartment of Anesthesia, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
CH R I S TO P H E R M. GR A N D E MD, MPH Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and International TraumaCare (ITACCS), Baltimore, Maryland
GL E N N P. GR AV L E E, MD Department of Anesthesiol- ogy, University of Colorado Health Sciences Center, Denver, Colorado
PE T E R HE B B A R D, MBBS, FANZCADepartment of Anaes- thesia and Pain Management, Department of Pharmacology, Northeast Health Wangaratta, School of Rural Health Univer- sity, Melbourne, Victoria, Australia
MA R KD. JE N K I N S, MDDepartment of Orthopedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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KE N JO H N S O N, MDDepartment of Anesthesiology, Univer- sity of Utah School of Medicine, Salt Lake City, Utah
MAT T H E W A. JOY, MD Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
GE O RG E W. KA N E L L A KO S, MD, FRCPC Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
M. SE A NKI N CA I D, MDDepartment of Anesthesiology, Har- borview Medical Center, University of Washington Medical Center, Seattle, Washington
ART H U R M. LA M, MD, FRCPCDepartment of Anesthesi- ology, Harborview Medical Center, University of Washington Medical Center, Seattle, Washington
JE S S I CAAN N E LOV I C H-SA P O L A, MDDepartment of Anes- thesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
JOYC E LY N LOY, MD Department of Anesthesiology, Metro- Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
SO HA I LKA M R A NMA H B O O B I, MDDepartment of Anesthe- sia, Maimonides Medical Center, New York, New York
PE T E R F. MA H O N E Y, MD MSC, MBBS, FRCA,
FFARCSI, FIMCRCSEDMilitary Critical Care, Royal Cen- tre for Defence Medicine, Birmingham, United Kingdom MA R KA. MA L A N G O N I, MDDepartment of Surgery, Metro- Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
DO N N MA RC I N IA K, MD Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
WA LT E R MAU R I T Z, MD, PHD Department of Anesthesi- ology and Intensive Care, Trauma Hospital Lorenz Bohler, Vienna, Austria
MAU R E E N MCCU N N, MD, MIPP, FC CMDepartment of Anesthesia and Critical Care, Division of Trauma Anesthesi- ology, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
CR A I G C. MCFA R L A N D, MD, MAJ, MC, FSDepartment of Anesthesiology, Uniformed Services, University of the Health Sciences, Bethesda, Maryland
MA RO U NJ. MHA N NA, MDDepartment of Pediatrics, Metro- Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
MI C HA E L C. MO O N, MD Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
TI M OT H YMO O R E, MDDepartment of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
MA X I M NOV I KOV, MD Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
KE TA N P. PA R E K H, DDS Department of Oral and Max- illofacial Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio MI C HA E L J. A. PA R R, MBBS, FRCP, FRCA, FANZCA, FJFICM Department of Intensive Care, Liverpool Hospital, University of New South Wales, Sydney, Australia
KA S IA PE T E L E N Z-RU B I N, MD Department of Anesthesiol- ogy, MetroHealth Medical Center, Case Western Reserve Uni- versity School of Medicine, Cleveland, Ohio
PA B LO PR AT E S I, MD Department of Emergency Medicine, Austral University Hospital, Pilar, Buenos Aires, Argentina EL I E RI Z KA L A, MDDepartment of Pediatrics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
AN D R E W D. RO S E N B E RG, MDDepartment of Anesthesiol- ogy, Hospital for Joint Diseases and Orthopedic Surgery, New York University Medical Center, New York, New York
ST E V E N ROT H, MDDepartment of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
AL I S TA I R ROYS E, MBBS, MD, FRACS Department of Anaesthesia and Pain Management, Department of Pharma- cology, Royal Melbourne Hospital, University of Melbourne, Carlton, Victoria, Australia
CO L I N ROYS E, MBBS, MD, FANZCA Department of
Anaesthesia and Pain Management, Department of Pharma- cology, Royal Melbourne Hospital, University of Melbourne, Carlton, Victoria, Australia
DAV I D RYA N, MD Department of Anesthesiology, Metro- Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
JE F F R E Y H. SI LV E R S T E I N, MDDepartment of Anesthesiol- ogy, Mount Sinai School of Medicine, New York, New York PE T E R SL I N G E R, MD, FRCPC Department of Anesthe- sia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
CHA R L E S E. SM I T H, MD, FRCPC Department of Anes- thesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
PAU L SO E D I N G, MBBS, FANZCA Department of Anaes- thesia and Pain Management, Department of Pharmacology, Royal Melbourne Hospital, University of Melbourne, Carlton, Victoria, Australia
P. DAV I DSøR A N, MDDepartment of Anesthesiology, Stan- ford University Medical Center, Stanford, California
EL DA R SøR E I D E, MD, PHDDepartment of Anesthesia and Intensive Care, University of Bergen, Stavanger University Hos- pital, Stavanger, Norway
EL I Z A B E T H A. ST E E L E, MDDepartment of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
DE N N I S M. SU P E R, MD, MPHDepartment of Pediatrics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
AN N EJ. SU TC L I F F E, MB, CHB, FRCADepartment of Anes- thesia and Critical Care, Alexandra Hospital, Worcestershire, United Kingdom
KU TA I B B A TA B B A A, MD Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
PAU L TE N E N B E I N, MD, FRCPCDepartment of Anesthesi- ology, Harborview Medical Center, University of Washington Medical Center, Seattle, Washington
KA L PA NA TYAG A R A J, MD Department of Anesthesiology, Maimonides Medical Center, New York, New York
HE AT H E R A. VA L L I E R, MD Department of Orthopedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
VE E R A B A D R A N VE L AY U T HA M, FRCADepartment of Anes- thesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
WI L L IA M C. WI L S O N, MD, MADepartment of Anesthesi- ology, University of California San Diego Medical Center, Uni- versity of California San Diego School of Medicine, La Jolla, California
CHA R L E S J. YOW L E R, MD Department of Surgery, Metro- Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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M E C H A N I S M S A N D D E M O G R A P H I C S I N T R A U M A
Pedro Barbieri, Daniel H. Gomez, Peter F. Mahoney, Pablo Pratesi, and Christopher M. Grande
Objectives
The aim of this chapter is to put trauma in context as a major health issue and give practitioners an understanding of the underlying causes and mechanisms.
I N T R O D U C T I O N
Injury is the leading cause of death in people aged between 1 and 44 years in the United States and a leading cause of death worldwide [1]. It 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, radioac- tive, or biological) that exceeds the body’s tolerance” [2, 3].
In 2002, 33 million patients were processed by emergency departments in the United States, and 161,269 died by traumatic injury [4]. Trauma is the leading cause of years of potential life lost for people younger than 75 years and this implies a huge expense to the health care system and massive amounts of resources used for care and rehabilitation [5].
Demographics is the statistical study of human popula- tions, especially with reference to size and density, distribution, and vital statistics. Data on the demographics of trauma in the United States have been obtained from a number of sources listed in the references to this chapter.
A L C O H O L
In a recent report from the Federal Bureau of Investigation’s (FBI) Uniform Crime Reporting Program, the FBI estimated that more than 1.4 million drivers were arrested for driving under the influence of alcohol or narcotics, and an estimated 254,000 persons were injured in crashes where police reported that alcohol was present – an average of one person injured approximately every two minutes. In 2005, 21 percent of the children aged 14 and younger killed in motor vehicle crashes were killed in alcohol-related crashes.
Unintentional motor vehicle traffic-related injuries statis- tics:
Between 2000 and 2004, 366,021 persons suffered injuries by unintentional motor vehicle-related injuries. Of these 266,491 were vehicle occupants, 37,340 were motorcyclists, and 43,502 were pedestrians [6]. In 2005, 43,200 victims died on the highways of the United States.
Safety belts are approximately 50 percent effective for pre- venting fatality in severe crashes. Belts save 13,000 lives each year, while 7,000 persons die because they do not use belts.
Air bags, combined with lap/shoulder safety belts, offer the most effective safety protection available today for pas- senger vehicle occupants. But, air bags are only to be regarded as supplemental protection to seat belts and are not designed to deploy in all crashes. Most airbags are designed to inflate in a moderate-to-severe frontal crash. In 2005, an estimated 2,741 lives were saved by air bags.
Children from 0 to 14 years are at great risk for unintentional motor vehicle-related injuries. In 2004, 1,638 children died as occupants in motor vehicle crashes (5 deaths and 586 injuries each day) and half of those killed in motor vehicle accidents were unrestrained [7].
Twenty-five percent of occupant deaths among children younger than 14 years involve a drinking driver.
Restraint use among young children depends on the driver’s restraint use; almost 40 percent of children riding with unbelted drivers were themselves unrestrained.
1
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Figure 1.1. Road traffic collision overview. Important prehospital infor- mation about the collision will be lost if hospital personnel do not get a good handover from prehospital crews. Photo courtsey of PF Mahoney.
U N I N T E N T I O N A L M O T O R V E H I C L E T R A F F I C - R E L AT E D I N J U R Y M E C H A N I S M S
Unless anesthesia providers are involved in prehospital care, their usual experience with trauma patients will be having them presented in the resuscitation room, packaged by prehospital ambulance crews (Figure 1.1).
To understand what has happened to the patient and to appreciate the likely injuries, it is vital to get a clear handover.
Information needed includes:
■ Estimated speed of vehicles involved
■ Direction of impact
■ Whether the vehicle rolled over
■ Whether the occupants were wearing seat belts
■ Whether the air bags deployed
■ What damage occurred to the passenger compartment
■ How long the extrication took.
To understand the magnitude of the injury, it is necessary to be able to develop a mental image of the interaction between energy and body anatomy, an intuitive concept and understand- ing about forces of acceleration–deceleration, and energy trans- ferred to the body. Unintentional motor vehicle-related injuries involve a complex interaction of forces, including:
■ Primary collision: impact of vehicle with another object
■ Secondary collision: the casualty strikes internal parts of the vehicle that may have intruded into the passenger compartment due to the primary collision
■ Damage due to organs and tissue moving within the body and tearing vessels and attachments.
Unintentional motor vehicle-related injuries usually are categorized as:
■ Head-on or frontal
■ Rear impact
■ Side impact
Figure 1.2. High-energy impact on a car after casualty has been removed.
Note the intrusion of metal into the occupant compartment. Significant injury can be expected. Photo courtsey of PF Mahoney.
■ Rotational impact
■ Rollover.
Examples of these injury mechanisms are shown in Figures 1.2–1.5. Half of deaths are related to head-on impact, and the rest involve side impact (25%), rear impact (less than 10%), and rollover [8].
An unrestrained front seat occupant is likely to suffer one of two injury patterns in a frontal impact, depending on whether the mechanism was “down and under” or “up and over.” With the down-and-under approach the passenger slumps in the seat and the knees move forward, usually striking the underside of the dashboard. Forces are transmitted through the femurs to the hips and pelvis, resulting in fracture-dislocation of hips.
Impact of the feet on the floor causes fracture-dislocations and soft tissue damage below the knees. As the upper body moves forward, it hits the steering wheel, dashboard, and windshield, resulting in injury to the face, head, neck, chest, and abdomen.
In the up-and-over pattern the face and head are the first points to strike the windshield, followed by the chest. Face and head injuries result, and cervical spine injuries occur as a result of extension and/or compression. Direct injury to the front of the neck from contact with the steering wheel, dashboard, or windshield may produce severe tracheal injuries [9].
Rear impact is frequently associated with whiplash injury.
Depending on the forces involved and the amount and design of
Figure 1.3. High-energy impact removing side structures of a vehicle.
Significant injuries would be expected to vehicle occupants. Photo court- sey of PF Mahoney.
head restraint, injury may range from minor soft tissue injuries to extensive fractures with spinal cord injury.
In the side collision, parts of the vehicle frame intrude on the passenger compartment. Because the side of the driver’s or passenger’s body is relatively exposed and unrestrained, injury may affect any region as the body strikes the side of the vehicle.
The cervical spinal column is not tolerant of lateral forces, so cervical injuries are common in side impacts [10].
Complex patterns of injury arise from vehicle rollovers. The vehicle is often severely damaged, and the risk of ejection of unrestrained passengers is usually more significant than with other types of collision.
The correct and incorrect use of seat belts may also produce specific patterns of injury. Lap belts offer little protection to the head and upper body and may cause lumbar spine and intra- abdominal injuries to the duodenum, pancreas, small bowel, spleen, liver, and gravid uterus. A diagonal shoulder belt with- out a lap component allows the body to slide under, possi-
Figure 1.4. Vehicle rollover can be associated with complex patterns of injury. Photo courtsey of PF Mahoney.
Figure 1.5. Building hit by a bus. Injuries to be expected include crush from falling bricks. Photo courtsey of PF Mahoney.
bly producing severe head and neck injuries. Wearing the diag- onal component below the arm instead of above it may result in severe chest and abdominal injuries. Incorrect placement of the lap belt above the pelvis leaves the lower abdomen and lumbar spine susceptible to injury. Even the correct use of well-designed seat belts may result in injuries, the most common of which are fractures to the ribs, clavicle, and sternum [11].
M O T O R C YC L E C O L L I S I O N S TAT I S T I C S
In 2005, in the United States, 4,553 motorcyclists died in motor- cycle collisions and an additional 87,000 were injured. Compar- ing the vehicle miles traveled in 2004, motorcyclists were about thirty-four times more likely than passenger car occupants to die in a motor vehicle traffic crash and eight times more likely to be injured.
Helmets are estimated to be 37 percent effective in prevent- ing fatal injuries to motorcyclists. This means that for every 100 motorcyclists killed in crashes while not wearing a helmet, 37 of them could have been saved had all 100 worn helmets. Reported
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helmet use rates for fatally injured motorcyclists in 2005 were 58 percent for operators and 50 percent for passengers.
M O T O R C YC L E C O L L I S I O N M E C H A N I S M S
Injury to motorcyclists results from impact with the ground, street furniture, or the colliding vehicle. Injury can be expected to all body regions. Injuries of particular note include:
■ Closed head injury
■ Facial trauma
■ Cervical spine fractures
■ Chest injuries including injuries typical of deceleration such as aortic disruption
■ Abdomen – liver and spleen injury
■ Extremities – long-bone fractures.
P E D E S T R I A N V E H I C L E C O L L I S I O N
In 2005, in the United States, about 4,881 pedestrians were killed in traffic crashes and 64,000 were injured. On average, a pedestrian is killed in a traffic crash every 108 minutes and injured in a traffic crash every 8 minutes. Seventy percent of the pedestrians killed in 2005 were males; and 16 percent were older than 70 years. Forty-three percent of the 388 young (under age 16) pedestrian fatalities occurred in crashes between 3 p.m.
and 7 p.m. and nearly one-half (48%) of all pedestrian fatalities occurred on weekends.
Adult pedestrian injury typically involves three impacts:
■ Impact with the lower limbs as the impacting vehicle brakes and decelerates, lowering the front of the vehicle
■ Impact with the hood of the vehicle as the casualty is thrown forward, causing head and chest injuries
■ Impact with the ground, commonly causing head injury.
Pedestrian child injury is less predictable, but a typical pat- tern of trauma is “knocked down and run over,” resulting in chest, femur, and head injuries and secondary trauma resulting from hitting the vehicle or ground.
FA L L S
Falls exceeded motor vehicle accidents as the leading cause of nonfatal injuries treated in hospital emergency departments in the United States in 2004. Falls are the most frequent cause of injuries and hospital admissions in the elderly population aged 65 years and older. Falls in the elderly are frequently associ- ated with a concurrent medical event, such as cerebrovascular accident or myocardial ischemia.
Falls involve a sudden deceleration in the vertical plane.
The magnitude of injury depends on height, transference and absorption of energy, and orientation of the victim. Falls of 8 to 10 meters (25–30 feet, three stories in a building) are fatal in 50 percent of victims. If the victim is standing, foot, heel, tibia, fibula, femur, pelvis, spine, and internal organs can suffer
the impact. Head-first impact can produce facial-cranial injury, lesions of neck, cervical spine, shoulders, and pelvis.
T R AU M AT I C B R A I N I N J U R Y ( T B I )
Traumatic brain injuries contribute to a substantial number of deaths and cases of permanent disability annually. Of the 1.4 million who sustain a TBI each year in the United States 50,000 die, 235,000 are hospitalized, and 1.1 million are treated and released from an emergency department.
Among children aged 0 to 14 years, TBI results in an esti- mated 2,685 deaths, 37,000 hospitalizations, and 435,000 emer- gency department visits annually [12].
The leading causes of TBI are falls (28%), motor vehicle- traffic crashes (20%), struck by/against events (19%), and assaults (11%) [13].
F I R E A N D B U R N D E AT H S
Deaths from fires and burns are the fifth most common cause of unintentional injury deaths in the United States [14]. The average extent of a burn injury admitted to a burn center is about 14 percent of total body surface area (1991–93) while burns of 60 percent total body surface area or more account for 4 percent of admissions.
Most victims of fires die from smoke or toxic gases and not from burns [15]. Smoking is the leading cause of fire-related deaths, and cooking is the primary cause of residential fires [16]. Approximately half of home fire deaths occur in homes without smoke alarms [17].
F I R E C O S T S
In 2005 residential fires caused nearly $7 billion in property damage [18]. Fire and burn injuries cost about $7.5 billion each year [5]. Fatal fire and burn injuries cost $3 billion. Hospitalized fire and burn injuries total $1 billion.
F I R E A R M – G U N S H O T
In 2003, 30,136 persons died from firearm injuries in the United States, accounting for 18.4 percent of all injury deaths. Males had an age-adjusted rate that was 6.8 times that for females, the black population had a rate that was 2.1 times that of the white population, and the non-Hispanic population had a rate that was 1.3 times that of the Hispanic population.
In 2004, the number of deaths due to homicides was 16,611, of which firearms homicides caused 11,250 deaths [19]. Homi- cide is the leading cause of death for black males aged 15 to 24 years, and 75 percent of homicides were firearm related.
School shootingsare devastating events that raise many con- cerns about the safety of the young population. However, the vast majority of youth homicides occur outside school hours and property. Fewer than 1 percent of the total number of chil- dren and youth homicides (5–19 years of age) is related to school shootings.
A B
C
Figure 1.6. These three pictures show a bullet entry wound (a), the path through the liver (b), and the exit wound (c). The extent of the injury only becomes clear at surgery or at forensic examination. On first inspection it is often difficult to be confident about which is the entry and which is the exit wound. Photo courtsey of PF Mahoney.
P E N E T R AT I N G T R AU M A M E C H A N I S M S Low-Energy Transfer Sharp Implements
Knives: The main issue to appreciate when managing knife wounds is that tissue is elastic. The dimensions of the observed wound in a patient may not relate to the weapon used. A knife assailant may turn the blade in the target’s body, caus- ing increased damage as structures are deliberately cut.
Swords: Different swords are designed to be used in different ways. For example, a sharp Samurai sword is designed with a cutting edge and if used in this fashion will produce injury different from a sword designed for thrusting, or another type, the broad sword.
Projectiles
Arrows: In general, injuries from arrows can be considered as
“low-energy transfer” wounds and the area of injury is closely related to the arrow trajectory. This is not to dismiss how dam- aging arrows from a powerful bow or bolts from a crossbow can be.
Bullets: Modern firearm ammunition is a combination of a projectile (the bullet) and a case. The bullet is held in the front end of the case. The case contains propellant. When this is
initiated the bullet is propelled down the barrel of the weapon.
Many weapons have grooves inside the barrel that cause the bullet to spin, giving a degree of stability in flight, although bullets may become unstable in flight and “tumble.”
The wounding effect on tissue is a combination of:
■ The properties of the tissue. Elastic tissue is pushed away; nonelastic tissue may shatter.
■ The energy of the projectile. Kinetic energy of the pro- jectile equals half the mass of the bullet times velocity squared (1/2 M×V×V).
■ The energy transferred by the projectile to the tissue.
This varies according to how the bullet strikes: nose first or side first. A larger surface of the bullet striking usually means more energy given up.
■ Whether or not the projectile breaks up in the tissue.
The resulting fragments cause their own wounds.
■ Vital structures hit (Figure 1.6, see also color plate after p. 294).
There is an arbitrary division between high-velocity (2,000–2,500 feet per second) and low-velocity bullets, but a better terminology is “high- and low-energy transfer wounds”
depending on how much energy is dumped into the tissue,
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which in turn is influenced by the preceding factors. Projectiles moving at more than 1,000 feet per second are associated with a significant “temporary cavity” in tissue – that is, the kinetic energy given up to the tissues forces them away from the missile tract – and this can be many times the size of the permanent cavity left by the missile. This temporary cavity generally lasts only a few milliseconds.
Dirt and clothing can be carried into the wound by the projectile and drawn in by the vacuum effects of the temporary cavity, leading to wound contamination.
Types of Bullets
Some broad examples are:
■ Full metal jacket: metal casing around a lead core. A nonexpanding round that produces a deep wound.
■ Jacketed hollow point: an exposed hollowed lead tip allows expansion of the round on impact. Less tis- sue penetration than full metal jacket but more energy transfer to tissue.
■ Soft point: exposed lead tip allows rapid expansion.
■ Altered ammunition: actions taken after ammunition has been manufactured to increase the wounds pro- duced, for example, altering the shape or structure to increase tumble or fragmentation in the body. (Military use of altered and expanding ammunition was limited by the 1899 Hague Convention.)
Explosive Munition Injury
The injury produced by a bullet is the result of a complex inter- action between the bullet and tissue. Injury produced by an explosive device is also the result of complex interactions that can be broken down into a number of mechanisms.
Explosives are categorized ashigh orderorlow orderdepend- ing on how rapidly they change their state once initiated. High- order explosives undergo almost instantaneous change from solid to gas, rapidly releasing energy, and are associated with sudden increases in pressure and a supersonic shock wave/shock front. Low-order explosives change less rapidly and are not asso- ciated with the overpressure wave.
Blast injury has been classified as follows:
Primary: due to the actions of the blast or overpressure wave. This can completely disintegrate a casu- alty. The blast wave interacts with the body or component tissue, dumping energy into the tissue and producing stress waves that cause microvas- cular injury and shear waves that produce asyn- chronous tissue movement, which causes tearing.
Secondary: due to fragments projected by the energy of the explosion. Fragments can be “natural” from the random fragmentation of the bomb’s compo- nents, or “preformed” from notched wire, metal balls, or squares packed into the bomb. These cause multiple penetrating injuries.
Tertiary: due to the casualty being thrown/displaced by the explosion or injured due to structural collapse.
This is generally “blunt” injury.
Quaternary: all other effects, including fires from the explosive components or from ignited fuel, toxic effects of fumes, and exacerbation of medical conditions.
There is a question as to whether human tissue from homicide bombers or bombs in crowded places that ends up embedded in another victim should be classified as a separate wounding mechanism.
Practically, casualties will often have complex combinations of these mechanisms.
■ A casualty in a military vehicle blown up by a bomb may be sheltered from the worst of the fragments but injured by the blast wave and fires within the vehicle.
■ A soldier injured by a roadside bomb may escape the blast effect but suffer multiple penetrating injuries from fragments.
This can lead to conflicting requirements during surgery and anesthesia and will be considered further in the chapter on military and field anesthesia.
S U M M A R Y
This chapter has provided an introduction to trauma mecha- nisms and the wider impacts of trauma on the population and the economy. Clinical issues will be expanded in the relevant chapters throughout the book.
M U LT I P L E C H O I C E Q U E S T I O N S 1.Which of the following is correct?
a. Trauma deaths occur equally in all age groups.
b. Sporting accidents are the leading cause of death in peo- ple older than 75 years.
c. Falls in the elderly are often associated with events such as transient ischemic attacks or myocardial ischemia.
d. Alcohol use is not associated with traffic collisions.
2.With regard to motorcycle collisions, which of the following is correct?
a. When compared mile for mile, motorcycles are a safer mode of transport than cars.
b. In motorcycle crashes only the riders’ limbs suffer injury.
c. It is safe to use narcotics and ride motorcycles.
d. Wearing a helmet can significantly reduce death from head injury in motorcyclists.
3.Considering children injured in road collisions, which of the following is correct?
a. Children are rarely injured in road accidents.
b. Alcohol use by a driver is a significant cause of children being injured both as passengers and as pedestrians.
c. Children do not need to wear seat belts.
d. Children have more flexible bones than adults so are not as badly hurt if hit by a car.
4.Concerning adult pedestrians hit by cars, which of the fol- lowing is correct?
a. Adult pedestrians typically suffer three impacts when hit by a car – hit in the lower limbs, impact with the vehicle hood, then a further impact with the road.
b. Weekends are the safest time for pedestrians.
c. Males and females are injured equally in pedestrian col- lisions.
d. Vehicle speed has no influence on pedestrian injuries suffered.
5.Regarding death and injury caused by fires, which of the following is correct?
a. Carbon monoxide and flames cause an equal number of fatalities.
b. Smoking at home when under the influence of alcohol is safe.
c. Fire and burn injuries cost the United States about $1 million every year.
d. Approximately half of home fire deaths occur in homes without smoke alarms.
6.Which of the following statements about firearm incidents is correct?
a. Firearm deaths in the United States affect males and females equally.
b. Firearm deaths in the United States affect all ethnic groups equally.
c. Firearm deaths in the United States affect all age groups equally.
d. Less than 1 percent of the total number of children and youth homicides (5 to 19 years of age) are related to school shootings.
7.Concerning penetrating trauma, which of the following is true?
a. All bullets have the same kinetic energy.
b. Expanding ammunition was endorsed by the 1899 Hague Convention.
c. The properties of the tissue struck by a bullet influence the injury produced.
d. The kinetic energy of a bullet is given by its height mul- tiplied by its weight.
8.Regarding knife injuries, which of the following is true?
a. You can guess the length of the knife used to cause a wound by looking at the wound.
b. Knives used for stabbing and swords used for slashing always produce identical wounds.
c. If a patient presents with a knife in situ, wait until the patient is in the operating room before the surgeon takes it out.
d. Knives always do more damage to people than bullets.
9.Concerning explosive injury, which of the following is true?
a. Low-energy explosives cause a huge shock wave.
b. A casualty in a vehicle will always be protected from the heat of an explosion.
c. The effects of fires in an explosion are termed primary blast injury.
d. The effects of fragments in an explosion are termed sec- ondary blast injury.
10.With regard to trauma mechanisms, which of the following is true?
a. Injuries after falling from more than twenty feet are gen- erally very minor.
b. Traumatic brain injury rarely occurs in the United States.
c. The average size of burns admitted to burn centers is about 80 percent.
d. Dirt and clothing fragments carried into a bullet wound are sources of contamination.
A N S W E R S 1. c 2. d 3. b 4. a
5. d 6. d 7. c
8. c 9. d 10. d
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