Curr Anesthesiol Rep
DOI 10.1007/s40140-015-0131-8
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Airway Management in Trauma: Defining Expertise
Andreas Grabinsky1 Nancy Vinca2 Joshua M. Tobin3
 Springer Science + Business Media New York 2015
Abstract Prompt attention to airway management is a
fundamental component of the approach to trauma anes-
thesiology. While anesthesiologists manage the greatest
number of airways in their training and practice, a variety
of medical providers perform airway management in the
trauma population (i.e., paramedics, emergency physicians,
anesthesiologists, respiratory therapists). Rates of suc-
cessful intubation can vary widely between groups; there-
fore, a definition of expertise is required to develop training
plans, as well as standards for maintenance of proficiency.
While competency is challenging to define in any field, the
data suggest that individuals with the greatest experience
achieve the highest level of success. Given that anesthe-
siologists manage several thousand airway encounters
throughout their training and careers, their leadership as
subject matter experts is essential to development of
training curricula in airway management of all varieties.
Consensus on training of less experienced providers, as
well as tasking of the most difficult cases to the most
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Joshua M. Tobin
joshua.tobin@med.usc.edu
1
Department of Anesthesiology, Harborview Medical Center /
University of Washington, Box 359724, 325 Ninth Avenue,
Seattle, WA 98104, USA
2
Departments of Anesthesiology and Critical Care, and
Emergency Medicine, Perelman School of Medicine,
Hospital of the University of Pennsylvania, 3400 Spruce
Street, 680 Dulles Suite, Philadelphia, PA 19014, USA
3 that the anesthesiology department supervises most airway
Trauma Anesthesiology, Keck School of Medicine at USC,
1520 San Pablo Street, Suite 3451, Los Angeles, CA 90033,
USA
experienced provider, is imperative for successful airway
management in trauma.
Keywords Airway
Trauma care
Trauma anesthesia

Intubation
Introduction
The ability to safely and efficiently secure the airway is a
cornerstone of trauma anesthesia. While trauma patients in
need of intubation can present with a range of co-morbid
injuries as well as potentially difficult airway management
during resuscitation; the handling of the airway can be
assigned to different groups/specialties depending on the
trauma system. In the United States, some patients receive
airway management by paramedics with varied degrees of
training and experience. Alternatively, in many European
countries, physicians with differing degrees of airway
expertise perform advanced airway procedures in the field.
Individual Emergency Medical Service (EMS) juris-
dictions proscribe the minimum training requirements for
their EMS personnel. However, the degree of training can
vary dramatically, as can the use of various guidelines,
devices, techniques, and medications. For example, some
EMS systems prohibit the use of muscle relaxants for
intubation, and other systems have moved away entirely
from prehospital endotracheal intubation, instead favoring
the use of supraglottic airway devices.
Airway management in the trauma bay of most centers
across the county is similarly varied. While it is common
policies, the actual procedure of airway management is
often outsourced to other providers. In some trauma
123

centers, an anesthesiologist is available at all hours to
assess and mange the airway of arriving trauma patients.
Other centers, however, rely on emergency medicine
physicians for airway management. In other medical cen-
ters, a variety of non-physician providers can be called
upon to serve as airway consultants in emergencies. To
define expertise required for airway management in
trauma, it is important to have an understanding of the
current literature, as well as the applied instruments used to
measure expertise.
Timing of Intubation
It is widely accepted that the airway of a severely injured
trauma patient should be appropriately managed as soon as
possible. The decision to intubate a patient in the prehos-
pital environment, the emergency department, or the
operating room, however, depends not only on the etiology
of the trauma but also on the specific patient situation,
transport time, and expertise of the medical provider caring
for the patient.
Prehospital rapid sequence intubation improves func-
tional outcome for patients with severe traumatic brain
injury. A total of 312 patients with severe TBI were ran-
domly assigned to paramedic rapid sequence intubation or
hospital intubation. The success rate for paramedic intuba-
tion was 97 % [1]. The proportion of patients with favorable
outcome (defined as extended Glasgow Outcome Score of
58) was 80 of 157 patients (51 %) in the paramedic intu-
bation group, compared with 56 of 142 patients (39 %) of the
hospital intubation. This demonstrates a statistically signif-
icant benefit with early paramedic intubation.
When early airway intervention in the field is required, it
is important that the provider possess the necessary skill set
to secure the airway. Davis showed an association between
attempted intubation and increased mortality among indi-
vidual trauma patients with a GCS B 8; however, a sub-
group analysis of EMS systems exhibited lower overall
mortality in EMS systems with higher intubation rates [2].
This suggests a need for proficient training and mainte-
nance of airway management skills to favorably impact
trauma care. Failed intubation, unrecognized esophageal
intubation or prolonged intubation attempts can have pro-
found impact in critically injured patients and potentially
worsen outcome. The ideal method to train for and main-
tain the skill set required for successful field intubation is a
subject for future outcome-associated investigations.
Some EMS systems do not allow paramedics to use
muscle relaxation for intubation, presumably to ensure the
maintenance of spontaneous ventilation, in the event of a
failed intubation. Perhaps not surprisingly, intubation
attempts without muscle relaxation can increase the number
of failed intubations and subsequent complication rates [3].
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Curr Anesthesiol Rep
With three or more attempts, success rates are low and a
delay to employ other emergency airway management
techniques may occur. Intubation success is more likely with
muscle relaxants and EMS ground crews that use neuro-
muscular blockers have more successful intubation rates.
The airway management in the emergency room for the
patient in extremis is often done by board certified emer-
gency medicine physicians or residents. In trauma systems
where field intubations are not performed by EMS,
advanced airway management relies heavily upon the
emergency department staff with emphasis on early airway
intervention. For systems in which trauma patient airways
are less aggressively managed by paramedics, early
recognition and treatment of a compromised airway is
essential.
Miraflor found that delayed intubation of moderately
injured patients (ISS \ 20) who arrived without a secure
airway in the emergency room had a higher mortality
(11.8 %), compared to those intubated earlier (1.8 %) [4].
This emphasizes that early airway management and intu-
bation, whether in the field or in the emergency depart-
ment, are crucial to successful advanced airway
management in trauma.
Success Rates for Advanced Airway Management
A range of medical providers performs advanced airway
management in trauma patients. In North America, many
paramedics receive training in advanced airway manage-
ment and the use of induction drugs. However, there is no
standardized approach to this teaching and it varies by
region. As noted above, some EMS systems allow the use
of rapid sequence induction (RSI) drugs, whereas other
systems allow RSI drugs only after failed intubation
attempts without drugs. Still other systems do not allow
RSI drugs at all. The extent of airway training of para-
medics varies from as few as five intubations to advanced
airway training in the operating room under anesthesia
supervision with up to 50 intubations. In many European
countries, emergency medicine physicians and anesthesi-
ologists staff advanced EMS units and perform airway
management in the field. Given the difference in training
and experience, it is difficult to perform outcome studies in
trauma airway management across these populations. The
difference in airway management skills and training among
paramedics, emergency physicians, and anesthesiologists,
as well as differences among American, Canadian, and
European system, makes analysis difficult.
Cobas studied prehospital airway intervention rates and
mortality at the Ryder Trauma Center in Miami in 1320
patients over a 3-year period [5]. Of that total, 1117
patients were intubated by an anesthesiologist in the trauma
bay and 203 (15 %) had prehospital airway management
Curr Anesthesiol Rep
by paramedics. Of the 203 prehospital patients, 140 (69 %)
were successfully intubated and 63 (31 %) had a failed
prehospital intubation of which 25 (12 %) had an unrec-
ognized esophageal intubation. It is important to note that
paramedics in this study performed 13 tracheal intuba-
tions per year. Mortality in the failed prehospital intubation
group was 71 %, as compared to 60 % for the successful
prehospital intubation group; however, this result was not
statistically significant, suggesting that the use of a bag-
valve-mask was adequate for airway management in criti-
cally ill trauma patients.
A recent British study by Lockey examined prehospital
airway intervention in trauma patients in the London area
[6]. Patients were initially treated by paramedics who
attempted intubation without medication. A tiered response
by a later arriving advanced paramedicphysician team
then assessed the airway management by the primary
responding paramedics. Out of a total of 45 intubation
attempts by the primary paramedic team, 64 % were suc-
cessful and 11 % had unrecognized esophageal intubation.
The physician intubations were 100 % successful, and
medications were used for induction as required. The
physicians in this study had a minimum of 5 years of post-
graduate experience, and almost half of them were
anesthetists.
The same group found a statistically different success
rate for prehospital intubation between anesthetists and
non-anesthetists. Non-anesthetists performed 4394 intuba-
tions with 41 failures (0.9 %), whereas anesthetists per-
formed 2587 intubations with 11 failures (0.4 %)
(P = 0.02) [7]. A high rate of anesthesiologist success in
airway management in trauma was also demonstrated in a
Norwegian study [8]. The authors evaluated endotracheal
intubation (ETI) in trauma by prehospital anesthesiologists
and found a 99.2 % success rate.
Breckwoldt evaluated the expertise in prehospital intu-
bation by prehospital physicians using the Dreyfus and
Dreyfus framework of expertise [9]. The groups were
classified into experts (i.e., anesthesiologists) and
proficient performers (i.e., internal medicine physi-
cians). The mean years of professional experience were
similar between the physician groups, but the median ETI
experience differed significantly with 18/year for profi-
cient performers and 304/year for experts (P \ 0.001).
The incidence of difficult ETI was 17.7 % for proficient
performers and 8.9 % for experts (P \ 0.05). Unex-
pected difficult ETI occurred in 6.1 % for proficient
performers compared with 2.0 % for experts
(P = 0.08).
While these data demonstrate higher success rates in
endotracheal intubation with anesthesiologists, another
group found no difference in success rates between
physician specialties. A prospective, observational study
described trauma intubations supervised by anesthesiology
staff compared to those supervised by emergency medicine
staff in 673 adult trauma patients [10]. Intubation within
two attempts was accomplished with anesthesiology
supervision in 94.6 % of cases in comparison to 95.25 % of
cases with emergency physicians (OR 1.1, 95 % CI
0.4982.522). Failure of intubation with anesthesiologist
supervision occurred in 3.4 % of cases in comparison to
1.9 % of cases with emergency physicians (OR 0.55, 95 %
CI 0.151.8). The authors cite several limitations including
the fact that 80 % of patients in the first phase (i.e., anes-
thesiology supervision) were intubated by emergency
physicians, suggesting that the study does not accurately
reflect a side-by-side comparison.
Ultimately, it is reassuring to know that physician-led
RSI in trauma is safe. A retrospective study from the Shock
Trauma Center in Baltimore showed a very high success
rate for RSI with direct laryngoscopy [11]. In the study by
Stephens, 6088 patients arriving in the trauma bay who
required intubation within the first hour of arrival were
intubated by anesthesia or emergency medicine residents
under supervision of an experienced trauma anesthesiology
attending. Intubation was successful in 99.7 % and a sur-
gical airway was required in 0.3 % of the patients.
It appears that the more intubations one performs, the
better his/her skill set becomes. What exactly leads to an
expert skill set? Perhaps standardization of training can
offer higher success rates across all specialties.
Training for Advanced Airway Management
Problems with airway management can arise for less
experienced providers. Lower numbers of airway man-
agement opportunities result in fewer opportunities to learn
different methods or to use different equipment. Laryn-
goscopy skills can be limited to one or two different
intubation techniques and some may lack the skills in
rescue/alternative airway management techniques (e.g.,
awake fiberoptic intubation, intubating LMA, supraglottic
airway devices, different laryngoscope blades).
It remains difficult to define how many intubations and
what sort of advanced airway training is required to gain
expertise in advanced airway management. Emergency
medicine residents are required to perform 35 intubations
for graduation, and some physicians have limited oppor-
tunity to maintain their skill set later in their career. While
the number of intubations for anesthesia residents is not
typically tabulated during residency, it is not uncommon
for them to perform over a thousand intubations throughout
residency. Both anesthesiology and emergency medicine
residents are trained in alternatives to endotracheal
123

intubation during an emergency (e.g., catheter access,
surgical cricothyroidotomy).
The importance of a rigorous airway training system for
prehospital care provider was shown in a study by Prekker,
which examined prehospital airway interventions in 7523
patients, over a period of 5 years in King County, Washing-
ton [12]. Although, this study did not differentiate between
trauma and non-trauma patients, 77 % were successfully
intubated on the first attempt and over 99 % were success-
fully intubated by the third attempt. Paramedics in this study
underwent initial airway training with up to 50 intubations in
the operating room and the field. Annual currency training
included a minimum of 12 successful intubations, either in the
field or in the operating room. The use of RSI drugs was
encouraged as part of the intubation protocol.
A recent study by Bernhard concluded that complica-
tions during the first 200 attempts at endotracheal intuba-
tion performed by anesthesiology residents justified
experienced supervision [13]. Out of all residents, 52 %
reached the target of 200 intubations after 50.2
14.8 weeks, with a success rate of 95 % stabilizing after
150 intubations were performed.
While a specific number of intubations required to
demonstrate expertise are difficult to quantify, the assess-
ment of competency in this procedure is integral to the safe
conduct of airway management in trauma.
Competency
Competency in any skill can be difficult to assess. Given
the complex nature of medical procedures (e.g., varied
patient condition, provider experience, clinical setting,
time of day), complex techniques are sometimes required
to provide a thoughtful assessment of competency.
DeMeo used Bayesian analysis to evaluate 477 intu-
bation attempts by 105 pediatric residents in the neonatal
intensive care unit [14]. Bayesian analysis is a unique
methodological technique that relies on the initial condi-
tions set in a mathematical analysis to predict an outcome
and may be useful in modeling complex systems. In this
investigation, competency was defined as four cumulative
successful intubations. Roughly one quarter (23 %) of
residents achieved competency in the 8-year study period.
Initial failure on two intubation opportunities predicted a
requirement of nearly double the time to achieve com-
petence, as compared to those residents that were suc-
cessful on their first two intubation opportunities. This
study is remarkable in that it illustrates how challenging it
can be to define and achieve competence in intubation
regardless of the setting.
A variety of devices have been developed to assist less
skilled providers with endotracheal intubation. Video
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Curr Anesthesiol Rep
laryngoscopy provides an improved view of the vocal
cords; however, this does not always translate to
improved first pass success or decreased time to intu-
bation [15]. When used by non-expert laryngoscopists
video laryngoscopy can be beneficial, however, that
benefit is not statistically significant after the fourth
intubation [16].
In other medical procedures, competency is similarly
difficult to define. An evaluation of competency in per-
forming basic critical care echocardiography evaluated
seven critical care fellows who performed 343 scans [17].
After thirty scans, fellows were able to reliably produce
imaging/assessments in [90 % of six pre-defined domains.
This varies remarkably from the lower numbers noted
above for intubation and demonstrates that definition of
competency remains an elusive goal, perhaps best descri-
bed as you know it when you see it.
Conclusion
Prompt attention to airway management is a fundamental
component of the approach to trauma anesthesiology.
While anesthesiologists manage the greatest number of
airways in their training and practice, a variety of medical
providers perform airway management in the trauma
population (i.e., paramedics, emergency physicians,
anesthesiologists, respiratory therapists). Rates of suc-
cessful intubation can vary widely between groups;
therefore, a definition of expertise is required to develop
training plans, as well as standards for maintenance of
proficiency. While competency is challenging to define in
any field, the data suggest that individuals with the
greatest experience achieve the highest level of success.
Given that anesthesiologists manage several thousand
airway encounters throughout their training and careers,
their leadership as subject matter experts is essential to
development of training curricula in airway management
of all varieties. Consensus on training of less experienced
providers, as well as tasking of the most difficult cases to
the most experience provider, is imperative for successful
airway management in trauma.
Compliance with Ethics Guidelines
Conflict of Interest Andreas Grabinsky declares that he has no
conflict of interest. Nancy Vinca has served as a board member of
both the American Board of Emergency Medicine and the American
Board of Anesthesiology. Joshua M. Tobin declares that he has no
conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
Curr Anesthesiol Rep
References
Papers of particular interest, published recently, have been
highlighted as:
Of importance
Of major importance
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Cooper DJ, et al. Prehospital rapid sequence intubation improves
functional outcome for patients with severe traumatic brain
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95965. doi:10.1097/SLA.0b013e3181efc15f.
2. Davis DP, Koprowicz KM, Newgard CD, Daya M, Bulger EM,
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management and outcome among trauma patients with Glasgow
Coma Scale Scores of 8 or less. Prehosp Emerg Care.
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Curr Anesthesiol Rep
DOI 10.1007/s40140-016-0144-y
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Management of Analgesia Through Multiple Phases of Trauma
Roland Short1 Ryan Almeida1
 Springer Science + Business Media New York 2016
Abstract Managing the pain in a patient with traumatic
injuries can be a delicate and difficult task. In the acute
phase the options for pain control are often limited to
opioids, which must be administered cautiously as to not
further disrupt the homeostasis of an already fragile patient.
Careful management of sedation during this period is also
crucial to patient comfort and stability. In the recovery
phase, a multimodal approach to pain control is preferred,
utilizing opioid and non-opioid medications, regional and
neuraxial blocks if appropriate, and other treatments to
help limit the patients discomfort. Multimodal therapy
may also more effectively prevent long-term sequelae
including conversion to a chronic pain syndrome and opi-
oid dependence and abuse.
Keywords Pain
Trauma
Multimodal
Analgesia

Regional
Opioid-sparing
Introduction
Significant barriers to treating the pain of a polytrauma
patient exist at all stages of injury recovery. In the imme-
diate/resuscitative stage there is concern for worsening
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Roland Short
rtshort@uabmc.edu
1
Division of Pain Management, Section of Trauma and Acute
Care Anesthesiology, Department of Anesthesiology and
Perioperative Medicine, University of Alabama at
Birmingham, JT 865 619 19th St. S., Birmingham,
AL 35249-6810, USA
hemodynamic instability, respiratory depression, and cog-
nitive impairment. Intravenous administration is often the
only practical route, limiting the number of analgesics from
which to choose. Furthermore, it is difficult for severely
injured patients to communicate levels of distress or pain.
Many of these concerns may continue to affect how
treatment is provided in the ICU or the floor. As recovery
progresses, however, new barriers arise, many of which
revolve around the use of opioid analgesics. Concerns for
facilitating addiction, dependence, and opioid-induced
hyperalgesia often frustrate the patientpractitioner rela-
tionship and can hinder the ability to effectively manage
pain. This paper reviews the current evidence regarding
pain management for polytrauma patients, specifically the
role of multimodal, multidisciplinary therapies that are
opioid-sparing. It also provides a brief overview on various
sedation strategies that may be employed in the ICU.
Unfortunately, there is a paucity of data regarding the
topic of analgesia and sedation focusing specifically on the
polytrauma patient [1]. Therefore, this review will also
draw from evidence regarding postsurgical pain, which can
serve as a surrogate for studying trauma-induced pain.
Additional insight has been gleaned from the recent mili-
tary conflicts in Iraq and Afghanistan. Improved protective
outfitting has increased the survivability of many injuries,
and as a result, more injured personnel are needing to
receive treatment in the field. The austere and often dan-
gerous environment of military medicine has prompted
practitioners to implement creative strategies, particularly
involving regional anesthesia, that treat severe pain without
impairing cognition or hemodynamic stability. Techniques
to more aggressively manage post-trauma pain that have
proven effective within the military should be borrowed
and adapted by the civilian community in order to continue
improving patient care [2].
123

Epidemiology
Inadequate acute pain management for the trauma patient
has been recognized. One study evaluating polytrauma
patients in the ICU found that almost 75 % of patients rated
their pain as either moderate or severe [3]. More recently, a
survey of 110 soldiers injured in the battlefield revealed
that even after being admitted to a fully equipped medical
care facility the average worst pain score was greater than
7/10 [4]. These findings are comparable to what has been
found for patients undergoing elective surgical procedures.
Apfelbaum et al. surveyed 250 adults who had undergone
surgery, both inpatient and outpatient. Approximately
80 % of the respondents reported they had experienced
acute pain in the post-procedural time period, and most
reported the severity of pain as being moderate, severe, or
extreme [5]. Interestingly, the number of patients reporting
extreme pain had actually increased when compared to a
similar study performed a decade earlier [6].
Evidence also suggests that patients who experience a
traumatic injury are likely to develop chronic pain. Macrae
et al. in a survey of 10 pain clinics throughout North Bri-
tain, reported that trauma was the third most common
source of pain [7]. The prevalence of continued pain found
from a survey of 3047 patients 12 months following trauma
was 62.7 %. Joints and extremities (44.3 %), back
(26.2 %), head (11.5 %), neck (6.9 %), abdomen (4.4 %),
chest (3.8 %), and face (2.8 %) were listed as the most
common regions of pain [8]. Similar to another study that
evaluated patients for chronic pain seven years following
traumatic lower extremity injury, untreated depression and
poorer socioeconomic status were risk factors for ongoing
pain. In Castillo et al., high reported pain intensity and
sleep dysfunction 3 months following the injury were also
risk factors for developing chronic pain [9].
Morbidity of Pain
The endocrine, metabolic, and inflammatory responses to
traumatic injury augment physiological responses to nocicep-
tive stimuli worsening pain. Furthermore, spino-bulbo-spinal
pathways involving higher brain regions including the para-
brachial nucleus, periaqueductal gray, nucleus tractus solitar-
ius, insular cortex, anterior cingulate cortex, amygdala, and
hypothalamus establish a bidirectional relationship allowing
nociception, in turn, to influence autonomic and endocrine
systems [10]. Inadequate pain control in the perioperative
period has been linked to many adverse events including
myocardial ischemia, impaired pulmonary function, ileus,
thromboembolism, impaired immune function, and anxiety
[11]. Unrelieved pain also affects patient recovery, prolongs
hospital stay, and adds to overall health care costs [12].
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Curr Anesthesiol Rep
For a significant number of trauma patients, acute pain
will ultimately transition into a chronic pain state. The
process by which this occurs is complicated and incom-
pletely understood. Most theories are based on the nervous
systems ability to alter how it responds to stimuli, a
property termed neuronal plasticity. Inflammatory media-
tors from tissue trauma sensitize nociceptors resulting in
peripheral sensitization. The resulting nociceptive signal-
ing barrage that is then relayed to the dorsal horn initiates a
more widespread cascade of neuroplastic changes includ-
ing NMDA-receptor wind-up, long-term potentiation, and
central sensitization [13]. Changes at the level of the
brainstem and cortex also occur that alter how ascending
nociceptive signals are processed, becoming more facili-
tative rather than inhibitory [14].
Psychologically, acute pain worsens anxiety and
increases the risk of developing post-traumatic stress dis-
order (PTSD) [15]. In the setting of prolonged unrelieved
pain, hopelessness and depression may develop. Patients
living with chronic pain are more prone to social with-
drawal, loss of function, loss of income, and reliance upon
social security disability than the general population [16].
Role of Multimodal Analgesia
With the large number of ligands, receptors, and neural
pathways involved in the pain signaling cascade, it is
reasonable to infer that interference of multiple parts of the
process is more likely to produce greater pain relief. The
practice of multimodal analgesia hinges on this concept
and can be defined as the administration of two or more
drugs that act by different mechanisms to provide analge-
sia [17]. In addition to traditional pain medications such
as NSAIDs, acetaminophen, and opioids, multimodal
analgesic regimens also utilize a variety of medications,
termed as adjuvant analgesics, which were not initially
intended to be used for analgesic purposes. Examples of
adjuvant analgesics include gabapentinoids, antidepres-
sants, and alpha-2 agonists.
For many years, it was hypothesized that administration
of an analgesic prior to the onset of nociception was
superior to the same dose delivered afterwards. This con-
cept was based on animal studies which suggested that
such preemptive analgesia could more effectively blunt the
central sensitization that occurs following tissue injury
[18]. Clinical studies, however, have not supported this
theory [19]. Lack of supportive clinical findings may in
part be due to flaws in study design wherein only one
single-dose medication delivered pre-incision versus post-
incision was expected to significantly reduce overall pain
scores. Given the complexity of nociceptive processing, it
is not surprising that such a minor intervention would fail.
Curr Anesthesiol Rep
The model of preemptive analgesia has subsequently
evolved into one of the preventive analgesia in which a
more comprehensive multimodal regimen is provided to
the patient throughout the entire perioperative period. The
goal is to achieve a more complete blockade of the pain
signaling cascade. In the setting of trauma, where pre-
emptive analgesia is impossible, preventive analgesia is the
only option. While earlier administration may remain
important, success is no longer solely predicated on pre-
incision delivery but instead on a more complete inter-
ruption of the process. Indeed, some evidence suggests the
model of preventive analgesia may not only reduce acute
pain more effectively but also decrease the incidence of
chronic postsurgical pain [20].
Acetaminophen
Acetaminophen is one of the most commonly used anti-
pyretic and analgesic medications in the world. Despite its
popularity, its mechanism of action is still unknown. The-
ories include centrally mediated cyclooxygenase (COX)
inhibition, its properties as a peroxidase, inhibition of nitric
oxide synthase, and interactions involving cannabinoid and
serotonergic systems. Acetaminophen does not exhibit sig-
nificant anti-inflammatory action, interfere with platelet
function, or alter renal blood flow which distinguishes it
from non-steroidal anti-inflammatories (NSAIDs). Because
of its significant hepatic metabolism, acute liver toxicity is
possible following large doses. For patients with known
liver disease, history of alcoholism, or injury affecting liver
function acetaminophen should be dosed carefully or avoi-
ded [21].
Acetaminophen is relatively lipophilic molecule that is
absorbed almost entirely in the small intestine. Opioids and
surgery have been shown to significantly decrease
bioavailability secondary to delayed gastric emptying [22].
Despite this finding, single-dose acetaminophen still seems
to be beneficial in the management of acute postoperative
pain [23]. Intravenous delivery of acetaminophen is
available and provides a much more reliable plasma con-
centration of the drug; however, its formulation is more
costly. Furthermore, the increased plasma concentrations
obtained from intravenous dosing preoperatively have not
translated into increased clinical effectiveness over the oral
route, but this comparison has not been looked at for the
trauma population [24]. Gastric emptying is known to be
extremely delayed in critically ill trauma patients com-
pared to healthy individuals, a fact that might reduce the
effectiveness of orally administered acetaminophen [25].
Acetaminophen should be included within a multimodal
analgesic plan whenever possible. For critically ill trauma
patients, especially those who are unable to receive any
form on enteral medication, intravenous acetaminophen
should be considered.
Non-steroidal Anti-inflammatories
In the presence of tissue injury, increased production of
pro-inflammatory prostaglandins results induces a hyperal-
gesic state. Non-steroidal anti-inflammatories (NSAIDs)
work by inhibiting cyclooxygenase (COX), an enzyme
involved in prostaglandin production pathway. Two types
of COX enzymes exist. The COX 1 enzymes are consti-
tutively expressed by a variety of cell types. COX 2
enzymes maintain a low basilar level of expression until
they are upregulated in the presence of inflammation and
tissue injury. NSAIDs can be categorized based on their
respective COX 1/COX 2 selectiveness. Traditional
NSAIDs are fairly nonselective, significantly inhibiting
both COX 1 and COX 2 enzymes. A newer group of
NSAIDs, the coxibs, are much more selective for COX 2.
Both traditional NSAIDS as well as the coxibs have been
shown to reduce pain scores, opioid consumption, and
nausea in the postsurgical setting [26, 27].
Because of the broad range of functions COX enzymes
serve, NSAIDs have numerous side effects that prescribers
should consider prior to initiating. The introduction of the
coxibs has mollified the side effect profile to an extent, but
not completely. The coxibs have reduced the risk of
bleeding related to gastrointestinal ulceration and platelet
dysfunction [28]. There is further evidence that the cur-
rently available coxibs are associated with reduced risks of
renal toxicity compared to traditional NSAIDs [29].
However, for patients with orthopedic injuries, any benefit
coxibs offer over traditional NSAIDs with regard to an
increased incidence of fracture malunion is unclear.
Finally, there is no clear advantage of coxibs over tradi-
tional NSAIDs regarding increased risk of cardiovascular
disease. Although incompletely understood, the most likely
hypothesis involves NSAID-induced hypertension. In par-
ticular, diclofenac has been associated with worse cardio-
vascular outcomes even compared to other NSAIDs;
therefore, an alternative choice might be reasonable for
patients with preexisting cardiovascular disease [30].
Ultimately, it is probably best to limit the use of any
NSAID to as short a duration as possible [31, 32].
Opioid
Opioids remain the mainstay of pain treatment for the
injured patient. They are a key component of the analgesic
regimen in the acute care and prehospital setting. As part of
a multimodal regimen they are often continued throughout
123

the hospitalization and even after discharge during the
weeks and months of recovery.
Opioids, which include all substances with opium-like
effects, bind to specific receptors in the central nervous
system, peripheral nervous system, and along the GI tract.
The effect of this binding is dependent upon the receptor
that is bound and whether the opioid is an agonist or
antagonist at that receptor site. Binding of mu, kappa, and
delta receptors by opioid agonists can result in a multitude
of effects including analgesia, respiratory depression,
miosis, reduced bowel motility, vasodilation, euphoria/
dysphoria, sedation, and physical dependence.
Opioids are indicated for the acute relief of moderate to
severe pain. The risks and side effects must be considered
in the context of the patient with one or multiple injuries.
For example, the desire to keep the patient comfort-
able must be weighed against the need to obtain serial
mental status exams or prevent hypercarbia and increased
cerebral blood flow in a head-injured patient.
Opioid-induced hyperalgesia (OIH), a paradoxical
response whereby a patient receiving opioids for the treat-
ment of pain becomes more sensitive to painful stimuli, is
well-established in the literature for chronic opioid use [33].
There are now a small number of published studies that have
looked at the development of OIH in the setting of acute
perioperative opioid exposure. Guinard et al. demonstrated
increasing postoperative requirements of morphine in
patients who were administered a remifentanil infusion in
the operative room [34]. A similar response of increasing
pain and opioid requirements were reported by Chia et al.
when high-dose fentanyl was administered in the operating
room [35].
These reports are in contrast with several other studies
that demonstrated no signs of OIH in patients that received
intraoperative opioids. Further investigation is needed to
help clarify these mixed findings and to better guide clin-
ical practice.
There is an epidemic of opioid use and misuse in the United
States. Accordingly, there is increasing state and federal
oversight of prescribing practices and a de facto limiting of
qualified prescribers. In addition, although there is a strong
indication for the prescribing of opioids in the acute setting
there is much more debate on the role of chronic opioids in
noncancer pain. For these reasons, it is important to use a
multimodal approach to the treatment of pain in the injured
patient and to continue to work towards weaning the patient
from opioid medications as clinical improvement occurs.
During the early phase of trauma, when patients are
often hemodynamically unstable and require further
resuscitation, opioids may exacerbate lability. In several
animal models of hypovolemic shock, opiate antagonists
have been found to decrease the hemodynamic response to
volume loss. Potential mechanisms include reduction of the
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Curr Anesthesiol Rep
normal sympathetic response to injury and volume loss,
parasympathetic stimulation via vagus nerve, and direct
myocardial depression [36]. Although human studies are
limited, one meta-analysis concluded that use of naloxone
improved the mean arterial pressure (MAP) of patients in
shock [37].
Peripheral Nerve Blocks
Over 50 % of patients presenting with an Injury Severity
Score (ISS) [16 will have an accompanying peripheral
extremity injury [38]. Regional anesthesia is able to provide
the patient with superior analgesia while avoiding many of
the systemic side effects associated with other analgesics,
particularly opioids. A complete list of the potential benefits
of regional anesthesia is found in Table 1 [39, 40]. The
advent of ultrasound-guided techniques has allowed many
more practitioners to gain confidence in their ability to
successfully and safely employ this modality [41]. As the
availability of ultrasound continues to increase, use of
regional anesthesia has also expanded from the perioperative
arena to the ICU, ER, and even the field of combat.
Continuous catheters allow for analgesia beyond the
1218 h provided by most single injection techniques.
Ropivicaine, with its reduced cardiotoxicity compared to
bupivacaine, is the local anesthetic most often used. If
needed, temporary administration of a higher concentration
through the catheter will provide a denser blockade
allowing for certain procedures (e.g., debridement, graft-
ing, fracture fixation) to be performed without the need
for a general anesthetic.
Buckenmaier et al. reported on peripheral nerve cathe-
ters used for 187 combat-related injured military personnel.
Catheters remained in place for a median of 8 days (range
133 days). Complications were identified in only 7
patients (3.7 %) and included two catheter malfunction-
kinking, catheter tip dislodgement in situ, two superficial
catheter site infections, and two catheter dislocations [42].
Table 1 Potential benefits of regional anesthesia
Avoidance of a difficult airway/ability to maintain protective airway
reflexes
Avoidance of the need for heavy sedation/general anesthesia
Reduced postoperative pain scores
Opioid-sparing/reduced opioid-related adverse events
Reduced time in postanesthesia care unit (PACU)
Decreased hospital length of stay
Reduced postoperative bleeding
Decreased incidence of deep vein thrombosis (DVT)
Increased range of motion/decreased rehabilitation time
Increased patient satisfaction
Curr Anesthesiol Rep
No adverse events related to bleeding were identified
despite these patients being concurrently treated with
enoxaparin 30 mg BID for DVT prophylaxis.
In addition to demonstrating how regional anesthesia may
be better integrated into care pathways for trauma patients,
the study by Buckenmaier et al. also discussed the appro-
priateness of regional anesthesia in the setting of anti-co-
agulation and coagulopathy. According to the current ASRA
guidelines, some of the deeper peripheral nerve blocks
(paravertebral, sympathetic, lumbar plexus, and deep sciatic)
are considered by the authors to be of high enough risk that
they be treated with the same precautions as neuraxial pro-
cedures; however, this inclusion has generated controversy
[43, 44]. It may be most prudent to adhere as closely as
possible to the ASRA guidelines while simultaneously rec-
ognizing that they are not intended to be a cookbook for due to patients complaining of breakthrough pain despite a
patient care.
Buckenmaier et al. reported that 1 % incidence of catheter
site infection falls within the consistently reported range of
03 %. Catheter duration beyond 48 h is the greatest inde-
pendently associated risk factor for catheter-related infection.
Other identified risk factors include patients located in the
ICU, trauma patients, catheter insertion at femoral or axillary
sites, and lack of antibiotic prophylaxis [45].
In certain cases, patients may benefit from two or more
continuous catheter placements. Examples include patients
who have sustained injury to multiple extremities, simulta-
neous blockade of the femoral and sciatic components of an
injured lower extremity, or the use of bilateral paravertebral
catheters for rib fractures. Although local-anesthetic systemic
toxicity (LAST) is rare, it is a life-threatening complication
and must be taken seriously. In an American Society Anes-
thesiology (ASA) Closed Claim Analysis, LAST was asso-
ciated with 7 of 19 claims involving death or brain damage
[46]. Bleckner et al. evaluated serum ropivicaine concentra-
tions in patients receiving long-term continuous peripheral
nerve block catheter infusions and found the median ropivi-
caine blood concentration to be 0.11 mg/L [47]. Of note, two
patients had isolated serum ropivicaine levels of 0.63 mg/L
and 0.59 mg/L. Both of these measurements were obtained
24 h following a procedure during which the patients each
had their catheters bolused with a total of 60 ml of 0.5 %
ropivicaine. Neither of the patients demonstrated signs or
symptoms of LAST. In a study involving healthy volunteers,
a mean free plasma concentration of 0.6 mg/L was related to
the onset of CNS toxicity [48]. Strategies to reduce the risk
of toxicity associated with multiple catheters include reduc-
ing the concentration of infused ropivicaine (e.g., 0.1 or
0.15 %) and to transition from a continuous infusion to an
intermittent bolus delivery [40].
One major concern regarding the use of regional anes-
thesia in the setting of trauma is compartment syndrome
(CS). CS is a serious complication that occurs when the
interstitial pressure within an osteofascial compartment
increases to such a point that blood flow is impeded
resulting in tissue ischemia and, if left untreated, tissue
necrosis. Although CS usually occurs as the result of a high
energy injury, other reported causes include crush or
reperfusion injury, exercise, arterial puncture, tight dress-
ings and casts, burn, and snake bites. The two most com-
mon sites affected are the lower leg related to tibial
fractures and the forearm. Hesitation to place peripheral
nerve blocks in trauma patients stems from concern that the
block might mask the symptoms of disproportional pain
and paresthesia that are classically associated with CS.
However, the clinical signs and symptoms are routinely
unreliable. Furthermore, many case reports have noted that
the use of regional anesthesia facilitated earlier detection
previously functioning continuous catheter [40]. A recent
systematic review (Driscoll et al. unpublished) evaluated
28 case reports and 6 research articles stating that a reliable
conclusion regarding appropriate practice could not be
made based on the current evidence. For patients at risk of
CS who also have continuous catheters, it is probably
prudent to infuse a more dilute concentration of local
anesthetic in order to reduce the likelihood of masking
symptoms.
Central Neuraxial Techniques
Increased risk limits use of central neuraxial techniques
such as epidural analgesia in the polytrauma population.
Contraindications including hypovolemia, hypotension,
coagulopathy, head or spinal injury, and sepsis are all
relatively common among this patient population. Fur-
thermore, as these patients often have an altered level of
consciousness that limits their ability to provide reliable
neurological feedback, many practitioners are unwilling to
attempt placement out of concern for unrecognized spinal
cord or nerve root injury [49].
The most common application of epidural analgesia in
the setting of trauma is for management of pain related to
rib fractures. Evidence suggests that number of rib frac-
tures are directly related to increased morbidity and mor-
tality in both young and elderly patients [50, 51]. Adequate
pain management is a central tenant in the care of these
patients in order to achieve increased pulmonary excursion
and improved clearance of secretions. A recent systematic
review of the use of thoracic epidural analgesia for trau-
matic rib fracture failed to identify benefits toward mor-
tality, ICU length of stay (LOS), and hospital LOS over
other analgesic techniques. Although several studies eval-
uated in the review did indicate superior pain control, this
finding was unable to be assessed in the pooled analysis
123

due to missing information. Epidural catheters infused with
local-anesthetic-only solutions were found to significantly
reduce the duration of mechanical ventilation. Given the
lack of substantial benefit and the potentially increased risk
of placement in this population due to altered mental status
hindering adequate neurological assessment, the authors
were unable to recommend the routine use of epidural
analgesia for patients with rib fractures [52]. Paravertebral
catheters are considered by many to be safer alternatives
regarding the risks of bleeding, infection, and neurological
injury in the trauma population. For this reason, their use in
the management of rib fracture pain has become the
treatment modality of choice by many experts [53].
Gabapentinoids
The gabapentinoids, gabapentin, and pregabalin, have been
utilized in the treatment of neuropathic pain conditions such
as post-herpetic neuralgia and diabetic neuropathy for many
years. Their potential benefits when combined with their
relatively benign risk profiles have resulted in increased use
of these medications for more widespread pain conditions
such as fibromyalgia. More recently there has been growing
interest in the efficacy of these medications in the reduction
of acute postsurgical pain and, potentially, the development
of more chronic postsurgical pain states.
Gabapentinoids are believed to exert their analgesic
mechanism of action at the level of the dorsal horn by
inhibiting a2 - d1 calcium channels at the presynaptic
membrane. The subsequent reduction of the influx of cal-
cium presynaptically upon depolarization limits the release
of excitatory neurotransmitters into the synaptic cleft
blunting the synaptic transmission of nociceptive signals.
Such reduction in neuronal excitability may help prevent
central sensitization and the development of hyperalgesia
and allodynia. Indeed, gabapentin and pregabalin have both
been found to reduce postoperative pain; incidence of
chronic postsurgical pain has also been found in a combined
systematic review and meta-analysis of the literature [54].
It is worth noting that gabapentin and pregabalin have
both been shown to be effective in the management of
several types of post-traumatic neuropathic pain in ran-
domized controlled trials [55, 56]. A recent systematic
review found gabapentin and pregabalin to exhibit some
efficacy in the management of neuropathic pain following
SCI [57]. Gabapentin also may reduce phantom limb pain
in the intermediate period following amputation [58].
Pruritus, which is an almost universal complaint during the
acute phases of healing following burn injury, has also
been found to respond well to the gabapentinoids [59].
Most patients who receive gabapentinoids (around
80 %) report side effects including dizziness, somnolence,
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Curr Anesthesiol Rep
peripheral edema, gait or balance disturbance, and tremor.
However, serious adverse events are much less common
(around 8 % or lower) and are not significantly higher than
placebo [60]. Caution may be indicated regarding the use
of these medications in patients with heart failure [61].
Because they are eliminated through the kidneys, the dose
must be adjusted for patients with renal insufficiency.
Antidepressants
Antidepressants are commonly used in the treatment of
chronic pain, but their usefulness in acute pain has not been
thoroughly reviewed. In their systematic review, Wong
et al. concluded that although there is insufficient evidence
to support widespread use of antidepressants in acute pain,
there may be specific clinical conditions in which they are
indicated [62]. For the management of postmastectomy
pain, venlafaxine 37.5 mg ER was compared to placebo
and found to reduce the analgesic requirements in the
postoperative period, with exception for the first postop-
erative day. Furthermore, at 6 months there was a clinically
and statistically significant reduction in regards to the
neuropathic pain symptoms of burning, stabbing, and
pricking compared to placebo [63]. Although the role of
antidepressants in post-trauma pain has not been studied,
this reduction in neuropathic pain may prove beneficial and
future investigation would be useful.
NMDA-Receptor Antagonists
N-methyl-D-aspartic (NMDA) receptors are a subclass of
glutamate receptors that upon activation allows positively
charged ions (Na?, Ca2?, K?) to travel through the cell
membrane. Under normal conditions, this receptor is ton-
ically blocked by magnesium ions; however, when pro-
longed depolarization occurs, such as in the setting of
trauma-induced nociceptive afferent barrage, calcium dis-
placement of magnesium allows the ion channel to open.
The NMDA receptor is believed to be involved in the
processes of central sensitization, opioid tolerance, opioid-
induced hyperalgesia [64].
Ketamine, which was first described in the literature in
1965, was initially anticipated to be used as a sole anesthetic
or induction agent. However, investigation of its efficacy as
an analgesic has since become a key topic of interest for
many investigators. Ketamines most studied mechanism of
action involves inhibition of the NMDA receptor. However,
interaction with other receptors including opioid, sigma,
nicotinic, and serotonergic has also been recognized and
postulated to contribute to its analgesic efficacy. Ketamine
also suppresses the synthesis of pro-inflammatory cytokines
Curr Anesthesiol Rep
TNF-a and IL-6 which may contribute to longer-lasting
analgesic potential [65].
As an induction agent ketamine has many advantages. It
is rapid in onset. Spontaneous respiratory effort and pro-
tective reflexes of the airway are maintained. Although
ketamine is a direct myocardial depressant, in the setting of
trauma its sympathomimetic effects typically preserve
hemodynamic stability [66]. In fact, one study noted that
fentanyl was required in most patients to blunt any unwanted
hypertensive response to intubation [67]. Unlike etomidate,
ketamine does not cause adrenal suppression. Previous
concerns regarding the use of ketamine in patients with
traumatic brain injury are no longer supported in the liter-
ature [68]. Especially with larger doses, psychotomimetic
effects may occur; however, the incidence and severity of
this adverse effect can be significantly reduced with co-
administration of a benzodiazepine. Although further study
is warranted regarding effectiveness, use of ketamine as an
induction agent allows for early initiation of an opioid-
sparing multimodal regimen in a patient population for
which alternative options are often limited.
A Cochrane Analysis concluded that perioperative
ketamine reduced opioid consumption and postoperative
nausea and vomiting during the first 24 h. In their discus-
sion, the authors identified patients who were opioid tol-
erant and those who were more prone to experience opioid-
related adverse events such as the elderly might benefit the
most [69]. A review by De Kock et al. concluded that low
doses of ketamine (\1 mg/kg) not only demonstrated some
minor analgesic effects but, perhaps more importantly,
reduced the amount of hyperalgesia that developed from
surgical incision and opioid analgesia [70].
Infusion of magnesium, the natural inhibitor of the
NMDA receptor, has been shown to reduce pain and opioid
requirements for up to 48 h following surgery [71]. Fur-
thermore, there is some evidence in the setting of spinal
surgery that magnesium and ketamine infusions may be
synergistic [72].
Other medications including dextromethorphan,
memantine, and amantadine also possess NMDA-receptor
antagonist properties. Dextromethorphan is probably the
most studied. A systematic review of 28 studies concluded
that analgesic and opioid-sparing benefits were too incon-
sistently found for any recommendations to be made [73].
Carlsson et al. found that dextromethorphan produced
clinically significant analgesia for patients suffering from
neuropathic pain following traumatic injury; however, the
required doses were too large for many to tolerate due to
side effects and the study size was small [74]. A review by
Collins et al. was unable to offer any conclusions regarding
the effectiveness of any of the NMDA antagonists for
neuropathic pain [75].
a2 Agonists
a2 agonists exhibit analgesic and sedative properties that
could prove to be beneficial in the trauma setting. a2 ago-
nists are believed to exert most of their analgesic actions at
the level of the dorsal horn through inhibition of nociceptive
signaling at the level of the synapse; however, other
peripheral and supraspinal mechanisms of action may also
exist [76, 77]. Their ability to induce sedation is thought to
result from reduced norepinephrine release from the locus
ceruleus creating a hypnotic state that resembles sleep [78].
There is very little evidence regarding the efficacy of
these medications for the trauma population. Indeed, with
the two most common side effects of this class being
hypotension and bradycardia, this is not surprising; how-
ever, in adequately resuscitated and hemodynamically
stable patients these medications offer the potential for
opioid-sparing analgesia. In a meta-analysis of 1792
patients, use of perioperative systemic a2 agonists provided
superior analgesia while reducing opioid consumption and
incidence of postoperative nausea and vomiting [79]. These
medications can be continued as part of a multimodal
opioid-sparing analgesic regimen well into the recovery
period. Clonidine is available in both oral and transdermal
forms. Although the evidence is mixed, it may be an
effective long-term analgesic for some patients [80].
Tizanidine may also be an appropriate choice for patients
with ongoing pain needs, especially those suffering from
spasticity due to traumatic brain or spinal cord injury [81].
Lidocaine Infusions and Mexiletine
Lidocaine and the oral analog mexiletine can be adminis-
tered systemically and have been shown to decrease pain
and opioid requirements [82]. IV and topical lidocaine
improved pain control in burn patients. Mexiletine, in
conjunction with clonidine, was shown to improve pain
control in patients with phantom limb pain. Intravenous
lidocaine with or without ketamine did not improve func-
tional recovery, pain scores, or opioid consumption in
patients recovering from open abdominal hysterectomy
[83]. These mixed results may be related to the underlying
mechanisms of the pain, neuropathic or nociceptive, and
their relative contributions to the patients pain experience.
Alternative and Complimentary Modalities
Alternative and complimentary modalities may help reduce
the experience of pain and associated anxiety in the acutely
injured trauma patient. According to Matsota et al., music
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may provide some anxiolysis but is not effective when pain
is severe [84]. They do note, however, given that it is
inexpensive and lacking in side effects it may be useful in
individual patients. A randomized control trial of 58
inpatients with rib fractures demonstrated a statistically
significant improvement in cough, deep breathing, and
turning over in the acupuncture group, with the effect
lasting at least 6 h in most patients [85]. The military has
begun to utilize techniques such as acupuncture, virtual
reality, and yoga to assist the pain management of woun-
ded soldiers [86]. Neurofeedback has been demonstrated to
be effective in the treatment of both chronic as well as
acute pain [87].
Sedation in the ICU
Sedation of trauma patients in the ICU is a topic that is
beyond the scope of this article. However, several of the
analgesics discussed above are often incorporated into var-
ious sedation techniques. Opioids are frequently chosen
because of their duel analgesic and anxiolytic properties. All
opioids have the downside of respiratory depression, seda-
tion that precludes accurate neurological exam, and precip-
itation of withdrawal if suddenly discontinued. Fentanyl is
widely preferred because of its perceived short half-life
offering faster wake up times. In reality, though, because of
factors such as high protein binding, large volume of dis-
tribution, and reliance on hepatic metabolism, its context-
sensitive half-life can range from 3 to 25 h. Remifentanil,
because it is metabolized by non-specific tissue and plasma
esterases, maintains its half-life of 4 min despite prolonged
infusion, but there are concerns that it may cause opioid-
induced hyperalgesia to an extent that is greater than other
opioids. One study that compared fentanyl to remifentanil
for sedation of mechanically ventilated patients found no
differences in outcome between the two [88].
Ketamine has the potential to serve as a useful adjunct in
sedation regimens in order to capitalize on its opioid-sparing
effects; however, studies are needed. It has also been used as
a sole agent, especially for patients who were hemodynam-
ically unstable or in status asthmaticus [89]. A systematic
review noted that ketamines more favorable hemodynamic
profile may make it preferable for more unstable patients but
that further investigation was warranted [90].
Dexmedetomidine, with its analgesic and anxiolytic
properties that are not c-aminobutyric receptor mediated,
may allow it to help to avoid the withdrawal and emer-
gence delirium associated with some of the more tradi-
tional agents used for sedation such as opioids and
benzodiazepines [91]. In a study of 342 mechanically
ventilated patients in the neurointensive care unit,
dexmedetomidine was found to have a similar incidence of
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Curr Anesthesiol Rep
hypotension and bradycardia when compared to propofol
[92]. However, concerns regarding adverse effects of
tachyphylaxis and complications of respiratory failure,
acute respiratory distress syndrome, and agitation have
prompted to the United States Federal Drug Administration
to approve its use only for 24 h [93].
Ultimately, no sedation agent has been found to be clearly
superior, and instead sedation technique may play a more
important role in determining outcome. Repeated studies
have demonstrated that minimizing sedation for patients in
the ICU provides clinical benefit. Lighter sedation is asso-
ciated with decreased length of mechanical ventilation,
length of ICU stay, morbidity, and mortality. For a more
complete review of the topic please refer to Reade et al. [94].
Conclusion
Effective pain control is essential in the care and recovery
of the trauma patient. Inadequate pain treatment can con-
tribute to an increase in complications, prolonged recovery,
and even death. In addition, there is increasing evidence
that it may contribute to the development of chronic pain
and disability. Most pain practitioners favor the use of
multimodal therapy in the treatment of pain in the injured
patient to improve patient comfort and to limit develop-
ment of these acute and chronic sequelae.
Compliance with Ethics Guidelines
Conflict of Interest Roland Short and Ryan Almeida declare that
they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
References
Papers of particular interest, published recently, have been
highlighted as:
Of importance
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Curr Anesthesiol Rep (2016) 6:1621
DOI 10.1007/s40140-016-0150-0
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Anesthetic Management of the Burn Patient
Christian Diez1 Albert J. Varon1
Published online: 12 February 2016
 Springer Science + Business Media New York 2016
Abstract Burn victims are among the most challenging
patients to care for. Major burn patients require immediate
attention for airway management, evaluation of inhalation
injury, and fluid resuscitation. Patients with extensive burns
usually require multiple procedures and extended hospital
stays. In these patients, the evaluation of vascular access,
availability of blood products, and determining where to
place standard and advanced monitors are important in
planning. Lastly, postoperative pain management and
complications of prolonged mechanical ventilation are
challenging issues that constantly need to be addressed.
Keywords Burns
Electrical
Thermal
Chemical
Tube
exchange
Excision and grafting
Introduction
The number of burn patients seeking treatment in the
United States reaches 450,000 annually, with 40,000 hos-
pitalized and 3400 deaths [1]. Seventy-five percent of
deaths due to burns occur at the scene or on initial transport
[2]. Flame-related injuries account for 46 % of burn inju-
ries [2]. Severe burns, greater than 40 % total body surface
area (TBSA), occur in approximately 35,000 patients
annually [3]. Mortality from burn injuries correlates with
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Christian Diez
cdiez@miami.edu
1 there is no pain in the affected area. Excision and grafting
Division of Trauma Anesthesiology, University of Miami
Miller School of Medicine, P.O. Box 016370-M820, Miami,
FL 33101, USA
123
several risk factors including age greater than 60, more
than 40 % TBSA burns, and the presence of inhalation
injury [3]. The presence of all three risk factors carries a
mortality rate of 90 % [3]. Jeschke et al. attempted to find a
TBSA burn cutoff value in adults and pediatric patients
above which mortality and other complications greatly
increase. Results showed cutoff values of 60 and 40 %
of TBSA burns in pediatric (\16 years) and adult patients,
respectively [4]. In an editorial, Greenhalgh points out that
although these cutoff values provide some usefulness they
cannot be used to determine treatment, since the prognosis
of burn patients depends on numerous factors [5].
Burn Classification
Burn depths are classified by degrees. First-degree burns
are characterized by damage to the epidermis. These areas
are erythematous and painful. These minor burns usually
resolve within a week without scarring. First-degree burn
areas should not be factored into the calculation of TBSA
for fluid resuscitation, as it may lead to over resuscitation
[6]. Second-degree burns are divided into superficial and
deep. Superficial second-degree burns involve the outer
dermis and clinically can produce blistering and pain to
touch. These wounds usually heal within 21 days without
scarring. Deep second-degree burns involve the deep der-
mis and show blistering, reduced pain, and diminished
sensation to touch. Excision and grafting may be required.
Third degree, full-thickness burns involve the entire der-
mis. These wounds may appear leathery, white or red, and
although patients may feel pressure on deep palpation,
is usually required. It is important to note that patients
frequently have different degrees of burns throughout their
Curr Anesthesiol Rep (2016) 6:1621
body and therefore some areas may be insensible to pain
while other areas are extraordinarily painful.
Patients may present to the emergency department (ED)
or specialized burn center with injuries ranging from minor
burns to catastrophic injuries that may ultimately lead to
death. Thermal, electrical, and chemical are three common
types of burns found in the inpatient setting.
Causes of thermal burns include fire, steam, hot water or
oil, and other hot objects. Most thermal burns occur as a
result of fire in adults or as a result of scalding in children.
Electrical burn injuries vary from thermal injuries by the
fact that most tissue destruction may not be grossly visible.
As electricity travels through the body it causes tissue
destruction along its path. Entry sites may be small
depending on voltage and causing agent (e.g., power line,
electrical socket, lighting strike). Exit sites may be more
explosive and larger than entry sites.
Chemical burns can be caused by a myriad of sub-
stances. When these occur close to facial structures they
may cause swelling and edema leading to airway obstruc-
tion. If chemicals are ingested or aspirated they can cause
gastrointestinal or airway injuries. Most chemical burn
wounds are treated by irrigation with copious amounts of
water.
Inhalation injuries may result from exposure to flames,
smoke, or other gaseous products. Damage to upper and
lower airway structures occurs upon exposure and may
continue to progress when the patient arrives to the hospital
and during the first few hours. Heat can cause direct injury
to airway structures leading to inflammation and rapidly
progressing edema. Products of combustion (e.g., carbon
monoxide, soot, cyanide) can cause direct injury to the
airway, lungs, and ability to maintain oxyhemoglobin sat-
uration and ventilation. Signs of soot in the airway or the
presence of singed nasal hairs or facial burns should
increase suspicion of extensive airway exposure to the
inciting event. Patients suspected of having smoke
inhalation should be placed on a non-rebreather (NRB)
mask with flow rate at 15 LPM (up to 90 % FiO2) and have
an arterial blood specimen drawn for measurement of
carboxyhemoglobin (COHgb). Patients with COHgb values
greater than 20 % require tracheal intubation and
mechanical ventilatory support. Patients with values of
1020 % may be treated with a NRB mask if otherwise
stable.
Airway Management
Upon patients arrival, standard Advanced Trauma Life
Support (ATLS) indications for securing the airway apply.
These include Glasgow Coma Scale (GCS) score B8,
apnea, severe maxillofacial fractures, inadequate respira-
tory effort, hemodynamic instability, risk for aspiration,
17
closed head injury with need for hyperventilation, and risk
of obstruction [7]. Patients who require an immediate
definitive airway should undergo tracheal intubation.
Although some patients may not initially require airway
intervention, factors such as large fluid requirements, and
facial or upper torso burns may result in respiratory com-
promise at later stages. Securing the airway once interstitial
edema has worsened may decrease the success rate of
intubation. Therefore, early intubation should be consid-
ered in patients with a worsening airway and increased risk
for delayed respiratory compromise.
The administration of induction agents for airway
management in the ED or the operating room should be
guided by the patients hemodynamic condition. The
intubating dose for propofol may need to be reduced sig-
nificantly due to its vasodilatory effects. Burn patients,
either upon presentation or during hospitalization, may
have fluid deficits and a large dose of propofol may lead to
a significant decrease in blood pressure and cardiovascular
collapse. Etomidate remains the most frequently used
induction agent for rapid sequence induction and intubation
outside the operating room. It is commonly used for its
cardiac and hemodynamic stability. Although it is clearly
established that etomidate causes adrenal cortical sup-
pression via the inhibition of 11-beta hydroxylase, a single
dose has not been shown to increase morbidity or mortality
in burn patients. In contrast, etomidate has been reported to
increase mortality in the intensive care unit (ICU) when
used as a sedative infusion [8]. Therefore, the repeated use
of etomidate should be avoided. This is applicable to burn
patients, as recurrent operative procedures requiring
numerous anesthetics are common. Ketamine has several
properties that make it a popular selection for anesthesia
induction in burn patients. Two main features are its
analgesic properties and its potential for increasing or
maintaining blood pressure. However, one must keep in
mind that many burn patients are catecholamine depleted
and that a large dose of ketamine may uncover its
myocardial depressant effects and result in hypotension.
Muscle relaxation for emergent intubation is frequently
achieved by the use of succinylcholine or rocuronium.
Patients who have suffered thermal or chemical burns
should not receive a depolarizing muscle relaxant 2448 h
after injury. Upregulation of extrajunctional receptors may
lead to a hyperkalemic response after such period. Patients
with acute electrical burns differ from those with thermal
injury. The use of succinylcholine is discouraged even in
the immediate period of electrical injury because these
patients may have hyperkalemia from tissue and muscle
destruction. Therefore, even a small rise in extracellular
potassium may lead to deleterious effects. Rocuronium
(1.2 mg/kg) can be used for muscle relaxation during rapid
sequence induction in these patients.
123
18
Airway adjuncts such as supraglottic airways, video
laryngoscopes, and flexible intubation endoscopes are
valuable devices in patients with anticipated or unexpected
difficult airway. Video laryngoscopes have proven to be
useful in certain difficulty airways. Grade 3 or 4 laryngo-
scopic views are frequently improved with video laryngo-
scopes containing acute angle blades. Flexible intubating
endoscopes can also be very helpful in patients whose
tracheas are difficult to intubate and for diagnostic or
therapeutic intervention.
Common Surgical Procedures
Burn patients may undergo a variety of surgical proce-
dures. Four common procedures include escharotomy,
excision and grafting, extensive dressing changes, and
tracheostomy. These procedures may take place in a
warmed resuscitation area, operating room, or ICU.
Escharotomies are performed when dead tissue may
compromise perfusion or ventilation. Vascular compromise
may follow full-thickness circumferential burns, most
commonly in extremities; and large burns to the torso may
impede ventilation. In such cases, escharotomy should be
performed as soon as possible to avoid vascular, neuro-
logical, or ventilatory compromise.
Excision and grafting procedures are performed to
remove dead tissue from patients and replace with viable
skin. Operating rooms should be kept warm during the
operative procedure, as excision of large areas of skin
contributes to heat loss when exposed to cold ambient
temperature. Although electrical burn patients may not
suffer as large surface area burns as those with thermal or
chemical injuries, the same considerations apply regarding
heat loss. Skin grafts onto previously damaged areas are
usually performed with autologous or allogeneic grafts.
Epinephrine may be used on donor sites to reduce blood
loss. The topical application or subcutaneous infusion of
diluted epinephrine solutions have the potential to increase
heart rate and blood pressure. This is important to note as
an elevated blood pressure may give the clinician false
reassurance of a patients hemodynamic status.
Minor dressing changes are frequently performed at
patients bedside. Extensive dressing changes or those that
require significant patient movement can be extremely
painful. ICU patients on mechanical ventilation often receive
sufficient analgesia to tolerate large dressing changes.
Ketamines amnesic and analgesic properties along with
maintenance of blood pressure, airway reflexes, respiratory
rate, and tidal volume make it a good option for dressing
changes performed under monitored anesthesia care (MAC).
Securing the tracheal tube (TT) may present a challenge
in patients with face or upper torso burns. Commercial
products which aid in securing TTs or suturing them to
123
Curr Anesthesiol Rep (2016) 6:1621
patients teeth may be necessary. When TTs are secured
with tape, frequent checks are necessary to prevent
impairment of face venous drainage by circumferential
taping. Tracheostomy is often performed in patients with
extensive burns requiring prolonged mechanical ventila-
tion. However, the procedure may be difficult in certain
patients due to edema and difficulty in positioning.
Preoperative Management
During the preoperative evaluation of a burn patient several
areas need to be addressed. Although a comprehensive
preoperative exam is required, several key issues are
specific to burn patients. The patients vital signs and fluid
status are of upmost importance. As the TBSA of burns
increases and depth of burn varies, the amount of resusci-
tative fluid required is more difficult to quantify. Patients
are frequently over- or under-resuscitated. Heart rate, blood
pressure, urine output quantity and quality, and data from
invasive monitors such as systolic pressure variation
(SPV), pulse pressure variation (PPV), and stroke volume
variation (SVV) may help in the assessment of volume
status. Preoperative evaluation of electrolytes and renal
function is also important, as metabolic derangements may
occur during large burn procedures.
Thermal or chemical burn patients who otherwise do not
require an electrocardiogram (ECG) based on history do
not usually require one for the operating room. Patients
who suffer electrical burns routinely receive an ECG upon
presentation. Patients who have a normal ECG at presen-
tation do not require further cardiac monitoring regardless
of route of electrical current. Patients with abnormal ECG
(including sinus tachycardia) on presentation should
receive cardiac monitoring for 24 h after admission.
Because electrical burns may cause rhabdomyolysis, the
preoperative evaluation of these patients should include
knowledge of the burn, route, and estimation of muscle
damage. Measurement of enzymes such as CPK, SGOT,
SGPT, and LDH aid in evaluating the extent of muscle
destruction, along with urine analysis for the presence of
myoglobin.
Critically ill burn patients have high caloric demands
and require intravenous or enteral nutrition. These patients
also frequently undergo multiple surgical procedures that
would cause enteral feeds to be held due to fasting rules.
Because this may lead to multiple delays in nutrition,
fasting rules in certain burn patients have to be altered. The
riskbenefit analysis of attempting to avoid aspiration in
someone who already has a secure airway versus the
consequences of poor nutrition favors continuing feeds.
Therefore, enteral feeds should be continued in patients
with a secure airway if no airway intervention will take
place (e.g., TT exchange, tracheostomy).
Curr Anesthesiol Rep (2016) 6:1621
Obtaining consent for anesthesia is a frequent challenge
in burn patients, as these patients are frequently receiving
mechanical ventilation and sedation. Health care proxies
may not be immediately available to provide consent for
such frequent procedures. Fahy and associates reported that
the use of a single consent for serial anesthetics was an
effective way of decreasing time spent obtaining multiple
consents [9]. This may also remove the appearance of
inefficiency that health care surrogates perceive if they are
contacted repeatedly for consents on frequent but similar
procedures (e.g., grafting, dressing changes).
Intraoperative Management
The amount of damaged tissue in burn patients varies
greatly among surface and depth. In patients with large
TBSA damage, a large area may be prepped and exposed
for both excision and grafting. Frequently, one must
improvise when attempting to find the best method to apply
the American Society of Anesthesiologists (ASA) standard
monitors.
Pulse oximetry and a non-invasive blood pressure cuff
need to be placed on extremities that are not on the oper-
ative field. If this is not possible, specialized earlobe pulse
oximetry probes may be used. An arterial line for beat-to-
beat pressure monitoring and frequent blood sampling is
commonly used during extensive burn procedures. Arterial
lines may be prepped into the sterile field if a non-operative
site is unavailable. The concomitant use of a non-invasive
blood pressure cuff when an arterial line is in place is
recommended, as it will serve as back-up if the arterial line
malfunctions intraoperatively. Line placement through
burn sites is discouraged but sometimes impossible to
avoid. ECG leads should be placed as close as feasible to
their standard locations. The ability of electrodes to adhere
to burned tissue may not be adequate. In such instances,
stapling of electrodes may be necessary.
The crystalloid and colloid requirements for burn pro-
cedures can vary greatly. Therefore, the required IV access
for such procedures varies as well. Large-bore peripheral
access is frequently sufficient for administration of fluids.
Patients with large surface area burns often arrive to the
operating room with central access. Smaller sized triple-
lumen catheters (e.g., 7 Fr.) are commonly used in ICU
patients since they provide multiple ports for various
infusions and medications. These catheters also allow
access for blood sampling if an arterial line is not in place.
However, many of these central catheters are not sufficient,
and quite frankly inferior to large bore peripherals for
administering large amounts of blood products. The sub-
stantial length of these catheters adds a significant amount
of resistance. Larger single-lumen or multiple-lumen
catheters (e.g., 9 Fr.) allow for faster infusion rates of
19
crystalloids and blood products. Large area burn proce-
dures may frequently require the transfusion of copious
amount of products. The use of ultrasound for line insertion
may be beneficial, as landmarks may be obliterated due to
edema. Moreover, patients frequently have multiple lines
during prolonged stays and the evaluation of vessel patency
before attempts may increase cannulation success.
The pharmacokinetics of medications used in the
induction and maintenance of anesthesia may be affected in
burn patients. Factors such as changes in volume of dis-
tribution and protein drug-binding help explain the
unconventional behavior of medications in these patients
[1]. Sedatives and analgesics are commonly used as
continuous infusions in the ICU. Patients may have an
increased tolerance for such medications. High opioid
requirements are common in patients who received opioid
infusions throughout a prolonged ICU stay. Such patients,
even after extubation and in stable condition, may require
large doses of opioids to achieve analgesia after proce-
dures. Non-depolarizing neuromuscular blocking drug
(NMBD) requirements may be significantly increased to
achieve standard muscle relaxation. Upregulation of
acetylcholine receptors contributes as one of the reasons
for the increased requirements.
The development of hypothermia is a significant con-
cern when treating burn patients. Patients are susceptible to
hypothermia due to loss of the skin barrier, which increases
thermal loss and impairs thermoregulation. Ambient tem-
perature in the operating room should be increased to avoid
heat loss via all mechanisms, especially radiation. In
addition to increasing ambient temperature, forced-air
warming blankets should be used on non-sterile sites to
prevent cooling and help rewarm patients. In situations
where large TBSA burns and operative exposure do not
provide sufficient area to place a non-sterile forced-air
warming blanket, a sterile one can be used. Sterile forced-
air warming blankets may be placed on surgical fields that
are not being immediately worked upon and moved to
other parts of the body throughout the case. Fluid warmers
for administration of crystalloids and blood products
should also be used during burn procedures. Warmed fluid
administration of small volumes or at low flow rates is not
effective in warming a patient. Large fluid administration
through a fluid warmer, especially at high rates, can help
maintain or increase a patients temperature. Blood prod-
ucts, which are commonly kept in cold storage, should be
warmed before administering in patients who are suscep-
tible to hypothermia.
Fluid management is one of the most important aspects
of the care of the burn patient. Patients usually present to
the operating room after their initial fluid deficit has been
replenished. The use of albumin for initial resuscitation of
burn patients has been reviewed elsewhere [10, 11]. Some
123
20
suggest that although it may not decrease edema formation
in injured tissue, non-injured areas may experience less
edema [10]. Park et al. reported decreased mortality and
duration of mechanical ventilation in patients sustaining
more than 20 % TBSA burn who received albumin in the
first 24 h after injury [11]. After initial resuscitation, vitals
signs, urine output, and dynamic parameters such as SPV,
PPV, or SVV can help the clinician decide if a patient is
properly resuscitated. The most commonly used crystalloid
solutions include Lactated Ringers (LR) and 0.9 % sodium
chloride (NaCl). One caveat with large amounts of NaCl is
the development of hyperchloremic metabolic acidosis. For
this reason, LR or other equivalent solutions (e.g., isolyte,
plasmalyte) are preferentially used in these patients during
extensive procedures.
Type and cross-matched packed red bloods cells (PRBC)
should be available before procedures with anticipated blood
loss. Fresh frozen plasma (FFP) should also be included if
significant blood loss is expected. Although the preoperative
hemoglobin and hematocrit (H/H) may be useful, the inter-
pretation of these values depends on the patients volume
status. A patient who may be under-resuscitated in an attempt
to decrease edema may have a significant decrease in H/H
after fluid administration in the OR.
The use of tranexamic acid (TXA) in trauma patients
has increased within the past few years, especially since the
CRASH-2 study was released [12]. However, insufficient
data exist on the use of TXA in burn patients. These have
been limited to case reports and small studies [13, 14].
Further research is needed to determine if TXA reduces
blood transfusion requirements or mortality in burn
patients. If TXA is found to be beneficial, one interesting
issue to evaluate is how multiple administrations of TXA
through multiple burn procedures would affect outcome.
Glucose control in critically injured patients has proven
beneficial. Burn patients are in a catabolic state where
glucose control plays an important role. Patients often
receive continuous insulin infusion in the ICU and this can
be continued in the operating room [15]. One caveat of
glucose control has always been the risk of hypoglycemia.
Although prior studies in critically ill patients recom-
mended a glucose target range from 90 to 140 mg/dl,
recent studies in burn patients have suggested a range of
130150 mg/dl, as it may decrease morbidity and mortality
without the risk of hypoglycemia [16].
Postoperative Management
Postoperative pain is mostly managed by the use of sys-
temic opioids. Patient-controlled analgesia (PCA) can be
used in patients who can follow commands and have the
physical ability to utilize the IV administration remote.
Intraoperative administration of opioids allows patients to
123
Curr Anesthesiol Rep (2016) 6:1621
emerge from anesthesia with adequate pain relief. For
patients who will undergo tracheal extubation immediately
after the surgical procedure a regional anesthetic block is
an excellent adjunct. Regional anesthesia for postoperative
pain control, especially at skin donor sites, can significantly
decrease the amount of postoperative opioid consumption,
decrease postanesthesia care unit recovery time, and
increase patient satisfaction. Femoral or fascia iliaca blocks
are commonly utilized, as the anterior and lateral thigh are
common skin donor sites.
Patients who are to remain intubated postoperatively
also require postoperative analgesia. An opioid approach is
more commonly used than a combined approach. Patients
may receive intraoperative opioid boluses or infusions that
can be continued after surgery. Infusions of opioids in
mechanically ventilated patients provide analgesic effects
as well as sedative effects.
The transport of patients between the ICU and the OR
who require high levels of ventilatory support is best
achieved by the use of ICU mechanical ventilators. Patients
with low levels of support can be transported using bag-
valve ventilation. A positive end expiratory pressure
(PEEP) valve can be attached to the bag-valve device to
prevent atelectasis during transport.
Although it may not occur immediately, re-intubation or
TT exchange in ICU burn patients may be required. Inability
to drive adequate volumes is a common reason to be called
for evaluation of a TT. This can be due to a positive pressure
ventilation leak or high pressure from tube occlusion. When
low tidal volumes are being delivered due to a leak, one must
verify that the TT cuff has not migrated into a supraglottic
position. Advancement of the tube in such circumstances
should not be performed blindly. A variety of methods for TT
advancement include direct laryngoscopy, video laryn-
goscopy, or the use of a flexible endoscope through the TT.
Inserting an airway exchange catheter blindly carries the risk
of being inserted into the esophagus if the TT is supraglottic.
If the TT is to be advanced, it should be done under direct
vision to assure the softened tube is not coiling in the pos-
terior pharynx. The addition of a rigid catheter through the
TT as an adjunct increases the rigidity of the TT for easier
advancement.
TTs that are partially occluded with hardened secretions
may also need to be exchanged. Exchanging TTs in burn
patients may prove especially challenging once resuscitation
and edema has caused airway and facial swelling. The use of
video laryngoscopes and airway exchange catheters, where a
conduit to the airway is never lost, can be extremely
advantageous. One caveat of airway exchange catheters is
the possibility of pushing airway debris distally when the
catheter is inserted blindly through the TT. This can thrust a
significant amount of debris into the tracheobronchial tree or
form a hard plug in the distal portion of the TT causing total
Curr Anesthesiol Rep (2016) 6:1621
obstruction. One method to avoid this is to look through the
TT with a flexible endoscope for inspection before placing an
airway exchange catheter. If a high amount of debris is seen,
exchanging the airway via direct laryngoscopy or video
laryngoscopy represents better options.
Conclusion
Major burn patients present many challenges for airway
management, vascular access, and hemodynamic and pul-
monary support. Upon initial arrival, the severity of a
patients burns should be assessed along with the immediate
or impending need for a secure airway. A patients mental
status, hemodynamics, and urgency of airway intervention
are important factors when deciding how to best secure their
airway. After initial patient stabilization, severely injured
patients are frequently hospitalized for a prolonged period of
time and will require numerous operative procedures.
Escharotomies, excision and grafting, extensive dressing
changes, and tracheostomy are common operative proce-
dures performed. Attention must be given to the preoperative
assessment of each patient. Intraoperative concerns include
monitoring, crystalloid and blood management, and pre-
vention of hypothermia to name a few. Lastly, postoperative
analgesic requirements are frequently increased. Patients
may benefit from a multimodal approach to pain relief
including regional blocks. The ultimate goal is to provide
care that will lead to an optimal functional outcome.
Compliance with Ethics Guidelines
Conflict of Interest Christian Diez declares that he has no conflict
of interest. Albert J. Varon has received royalties from Cambridge
University Press for co-editing Essentials of Trauma Anesthesia
(textbook), and has received honoraria from the American Board of
Anesthesiology for serving as an Associate Examiner.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
References
Papers of particular interest, published recently, have been
highlighted as:
Of importance
Of major importance
21
1. Bittner EA, et al. Acute and perioperative care of the burn-injured
patient. Anesthesiology. 2015;122(2):44864. Recent publication
discussing the care of burns patients. Article is inclusive of
pathophysiology, operative care, and pain management.
2. Orgill DP. Excision and skin grafting of thermal burns. N Engl J
Med. 2009;360(9):893901.
3. Pierre EJ, Varon A. Anesthetic management of the burn patient.
In: Smith C, Varon AJ, editors. Essentials of trauma anesthesia.
Cambridge: Cambridge University Press; 2012. p. 25362.
4. Jeschke MG, et al. Morbidity and survival probability in burn
patients in modern burn care. Crit Care Med. 2015;43(4):80815.
5. Greenhalgh DG. Can we really predict morbidity and mortality in
burn patients? Crit Care Med. 2015;43(4):9189.
6. Yowler C. Burn injuries: critical care in severe burn injury. In:
Smith C, editor. Trauma anesthesia. Cambridge: Cambridge
University Press; 2015. p. 65765.
7. ATLS Subcommittee, American College of Surgeons Committee
on Trauma, A.W.G. International. Advanced trauma life support
(ATLS(R)): the ninth edition. J Trauma Acute Care Surg.
2013;74(5):13636.
8. Ledingham IM, Watt I. Influence of sedation on mortality in
critically ill multiple trauma patients. Lancet. 1983;1(8336):1270.
9. Fahy BG, et al. A single consent for serial anesthetics in burn
surgery. Anesth Analg. 2015;121(1):21922. Reports on consents
for burn patients. Article discusses the advantages of not
requiring multiple consents for the same procedures, for both the
clinicians and patients or proxies.
10. Cartotto R, Callum J. A review of the use of human albumin in
burn patients. J Burn Care Res. 2012;33(6):70217.
11. Park SH, Hemmila MR, Wahl WL. Early albumin use improves
mortality in difficult to resuscitate burn patients. J Trauma Acute
Care Surg. 2012;73(5):12947.
12. Roberts I, et al. The CRASH-2 trial: a randomised controlled trial
and economic evaluation of the effects of tranexamic acid on death,
vascular occlusive events and transfusion requirement in bleeding
trauma patients. Health Technol Assess. 2013;17(10):179.
13. Walsh K, Nikkhah D, Dheansa B. What is the evidence for
tranexamic acid in burns? Burns. 2014;40(5):10557.
14. Tang YM, Chapman TW, Brooks P. Use of tranexamic acid to
reduce bleeding in burns surgery. J Plast Reconstr Aesthet Surg.
2012;65(5):6846.
15. Ballian N, et al. Glucose metabolism in burn patients: the role of
insulin and other endocrine hormones. Burns. 2010;36(5):599605.
Discusses the role of glucose metabolism and glucose lowering
agents in bun patients. Moreover, describes how endogenous
mediators affect glucose regulation.
16. Jeschke MG. Clinical review: glucose control in severely
burned patientscurrent best practice. Crit Care. 2013;17(4):232.
Reviews publications observing tight glycemic control in burn
patients. Attempts to identify a range that increases glycemic
control without the dangers of hypoglycemia.
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Curr Anesthesiol Rep (2016) 6:2229
DOI 10.1007/s40140-016-0146-9

ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)

Trauma Anesthesia Contributions to the Acute Care

Anesthesiology Model and the Perioperative Surgical Home
Maureen McCunn1 Richard P. Dutton2 Catherine Heim3 Clarence E. Gilmore IV4

Jean-Francois Pittet5

Published online: 12 February 2016

 Springer Science + Business Media New York 2016

Abstract Emergency surgery is associated with increased
postoperative complications and mortality. Few patients
are more poorly prepared for surgery than those who come
to the operating room from the emergency department or
trauma bay, in need of an urgent operative procedure. The
physiology of these patients may be abnormal upon pre-
sentation due to multiple etiologies such as volume loss
(through hemorrhage, vomiting, diarrhea, or insensible
losses as seen with fever), tachycardia, tachypnea, and/or
hypotension. There is no time for prehabilitation, preop-
erative evaluation, or optimization of existing disease
states. The art of acute resuscitation now incorporates
multiple guidelines based on extensive scientific data. As
with other anesthesiology sub-specialties, maintaining the
knowledge and competence to treat the specialized field of
trauma and acute care requires experts who can either
manage these patients or serve as expert consultants to their
colleagues. Creating a perioperative surgical home (PSH)
model may improve patient-flow, inpatient care, and tran-
sition to rehabilitation or home, and contribute to improved
long-term outcomes.
Keywords Trauma
Resuscitation
Acute care
Introduction
Trauma is the leading cause of death and disability for
patients between the years of 1 and 46, eclipsing ischemic
heart disease, cerebrovascular disease, and HIV AIDS [1].
Worldwide, one in seven deaths is due to injury and this is
expected to rise to 1 in 5 in the next 15 years despite

This article is part of the Topical Collection on Anesthesia for

Trauma.

& Maureen McCunn 2

450 Las Olas Blvd, Fort Lauderdale, FL 33301, USA
mmccunn@anes.umm.edu 3
Service danesthesiologie, CHUV, Rue du Bugnon 46,
Richard P. Dutton BH-05.300, 1011 Lausanne, Switzerland
Richard.dutton@usap.com 4
Department of Anesthesiology, The University of Texas
Catherine Heim Medical School at Houston, 6431 Fannin Street, MSB 5.020,
Catherine.Heim@chuv.ch; Houston, TX 77030, USA
http://www.chuv.ch 5
Division of Critical Care and Perioperative Medicine,
Clarence E. Gilmore IV Department of Anesthesiology, University of Alabama at
Clarence.E.Gilmore@uth.tmc.edu Birmingham, 619 19th Street South, JT 926, Birmingham,
AL 35249, USA
Jean-Francois Pittet
jpittet@uabmc.edu
1
Department of Anesthesiology, R Adams Cowley Shock
Trauma Center, University of Maryland School of Medicine,
11 South Paca Street, Suite 300A, Baltimore, MD 21201,
USA

123
Curr Anesthesiol Rep (2016) 6:2229
continuing advances in resuscitation, trauma surgery, and
critical care [1]. The cost of trauma care is thus steadily
increasing. In fact, an estimated 20 % of the United States
(U.S.) gross domestic product will be devoted to healthcare
before the end of the current decade [2]. There is the need
to propose fundamental changes in healthcare delivery and
payment systems to prevent this dramatic increase in
healthcare costs without decreasing the quality of the ser-
vices provided to the patients. A few years ago, Berwick
and the Institute for Healthcare Improvement (IHI) pro-
posed the concept of the Triple Aim as a basic frame-
work for this needed overall healthcare reform [3]. The IHI
Triple Aim consists of three interdependent goals: (a) im-
proving the individual experience of care (patient cen-
teredness), (b) improving the health of defined populations,
and (c) reducing per capita costs of care, thus increasing
the value (quality/cost) of the care delivered to the
patients. Furthermore, the authors suggested that there is a
need for an integrator to optimize these three aims. In
particular, this integrator would be responsible for imple-
menting the IHI Triple Aim in a defined patient population
[3]. They also proposed that the patient-centered medical
home (PCMH) could be the integrator for primary care
services. This concept has been supported by recent data
that indicate that PCMH improves outcomes and while
decreasing the costs of treatment [3].
Surgical care accounts for more than half of the health
care costs in the U.S. There are several reasons that con-
tribute to these high costs: inefficiency and fragmentation of
care delivery, lack of focus on the value of the care delivered
to the surgical patients, and lack of alignment between the
stakeholders who deliver versus pay for this care. To address
these important shortcomings, the American Society of
Anesthesiologists has recently proposed the concept of
Perioperative Surgical Home (PSH) based on the PCMH
model for primary care. The PSH could be defined as a
patient-centered approach to the surgical patient that
emphasizes standardization, coordination, and value of care
throughout the perioperative continuum, including the post-
discharge phase, thus serving as an integrator for achieving
and leveraging the IHI Triple Aim for surgical patients [4].
Patients begin in a PCMH and transition into a PSH
when they pursue a surgical procedure. The implementa-
tion of the PSH for patients requires a physician team
leader who provides current best care practices to the
surgical patients while maintaining an active involvement
with patients, families, and other stakeholders involved in
the care of these patients. The surgeons have traditionally
performed that role as perioperative team leader. However,
the ability of surgeons to provide alone the full perioper-
ative care has recently become more challenging because
of increasing demands and productivity for surgical ser-
vices without a corresponding increase in newly trained
23
surgeons. Hospitalist internists have historically provided
perioperative services for some surgical patients and it is
likely that, in some settings, they will continue to play that
role in the future. However, anesthesiologists are in a
unique position to perform an important role as perioper-
ative physicians because of their ability to assess and
prepare patients with multiple co-morbidities for their
surgical procedure and their ability to manage these com-
plex co-morbidities intra- and postoperatively.
The Acute Care Anesthesiology Model
In 2003, the American College of Surgeons began a pro-
cess to evaluate the need for the practice of acute care
surgery (ACS)an evolving specialty with three essential
componentstrauma, critical care, and emergency
surgery. National data on demographics and outcomes for
patients following emergency operative procedures show
that morbidity and mortality are higher for patients who
require emergency surgery [5]. An overview of adverse
events recently presented by the Anesthesia Quality Insti-
tute (AQI) shows that patients with physical status (PS) [3
and those over the age of 50 years exhibit the highest
serious adverse event rate [6]. Hospitals are witnessing an
increase in volume and acuity of admissions, in addition to
more elders with co-existing diseases, while simultane-
ously dealing with declining resources and high demands
for improved clinical efficacy and quality care, patient
satisfaction, and financial efficiency [7]. Yet there is a
paucity of literature regarding the practice and impact of
anesthetic management of these patients from a systems
approach. As perioperative partners with surgeons in
trauma, intensive care, and during emergency general
surgery cases, we propose a parallel practice for acute care
anesthesiology adapting from the ACS model.
The physiology of trauma and emergency patients differs
from the physiology of patients undergoing elective surgeries,
and hence anesthesia and resuscitation strategies for elective
surgical cases differ markedly from those of emergency sur-
gery, due largely to the common presence of shock [8]. Con-
trary to elective cases in which large volume blood loss and
fluid shifts might be readily anticipated but yet not present,
bleeding or infection in emergency surgery patients often
results in substantial total body fluid deficit at the time of
presentation to the trauma bay/emergency department or to the
operating room. For surgical patients in acute shock, whether it
is due to hemorrhage, sepsis, tamponade, or other causes, rapid
clinical assessment, resuscitation, and surgical management
by a focused multidisciplinary team are key components to
optimal outcome. Early implication of an experienced anes-
thetist is crucial for timely access to surgical source-control
and initiation of goal-directed resuscitation strategies aiming
123
24
at rapid restoration of normal physiology. Anesthesia for the
shocked patient requires a thorough understanding of the
pathophysiology and treatment of shock and specific consid-
erations in the continuous assessment of the patients physi-
ologic reserves throughout the entire period of acute care.
Goal-directed hemostatic management has recently
gained a wide interest as being a major contributor to out-
come in bleeding patients. The liberal transfusion of allo-
genic blood products has been associated with adverse
effects such as infections, organ dysfunctions, and increased
mortality [911], while a liberal use of coagulation factors
may lead to pro-thrombotic complications and has
immunologic and economic issues. Several European
working groups have edited guidelines for the management
of massive bleeding [1214]. Both pre- and postoperative
administration of blood products needs specific risk assess-
ment integrating the perioperative condition and treatment
[15, 16]. A close collaboration between the anesthetists as
the perioperative coagulation manager and the surgical team
may help control for appropriate indications for transfusion
and reduce transfusion-related adverse events.
The American Association for the Surgery of Trauma
(AAST) is currently developing quality indicators for
hospital care of emergency surgery patients. Their panel of
experts has made recommendations on the preoperative
work-up and intraoperative monitoring that should be
performed by anesthesiologists during emergency surgery
cases. Only one anesthesiologist was a part of this process
and has provided inputs into the recommended guidelines,
which are being revised. There is, then, a critical oppor-
tunity for anesthesiologists to measure and to define the
value of our practice in the care of this patient population
for our own specialty rather than by another medical spe-
cialty. Although no data currently exist examining the
impact of the acute care anesthesiologist on outcomes in
this patient population, it is not unreasonable to believe that
a model similar to that for the acute care surgeon would
contribute to better patient care. Thus, we need to explore
the added value of anesthesiologists providing care in the
data from the care provided by acute care surgeons. The
ACS model is associated with better patient outcomes
and supports the efficacy, as well as efficiency, of this
model in management of surgical emergencies. Does this
make sense for anesthetic emergencies?
Acute care anesthesiology extends the (ideal) preoperative
management of medical co-morbidities and the science of
resuscitation skills forward into the emergency department,
trauma bay, and operating room, where resuscitation care may
differ from the postoperative care. An acute care-trained
anesthesiologist can staff an OR for emergency and trauma
cases, an ICU, orwhere the model existsalso participate in
emergency department airway, vascular access, and resusci-
tation efforts. The acute care anesthesiologist with additional
123
Curr Anesthesiol Rep (2016) 6:2229
fellowship training would serve as an expert resource in the
most up-to-date techniques and research in these fields. This
concept has recently been introduced into the anesthesiology
literature as a white paper [17].
The concept of a Trauma Surgical Home has been
extensively tested at the busiest trauma hospital in the United
States, the R Adams Cowley Shock Trauma Center (STC) of
the University of Maryland [1820]. The STC is a freestanding
hospital dedicated to caring for severely injured trauma and
emergency general surgery patients, positioned at the top of an
organized statewide intake and triage system. The multidis-
ciplinary care model at the STC has always included anes-
thesiologists in every step of the chain of survival from training
prehospital providers to initial assessment and resuscitation to
operative anesthesia to critical care to acute and chronic pain
management. The studies cited show both the economic gains
available in a coordinated care model and the collateral benefit
to outcomes [18, 21]. Specialists in trauma anesthesiology
should seek to emulate this example, by involving themselves
as deeply in the overall care of the patient as possible. This is an
underdeveloped area of anesthesia practice, but one where a
modest contribution can make a large difference (Figs. 1, 2).
These data refer to studies that introduced a daily discharge
rounds process for all patients cared for at the trauma center.
This interdisciplinary process decreased readmission rates and
patient returns to clinic.
The Acute Care Surgical Home
While trauma and acute care might seem like an odd fit for
the PSH model of coordinated care, in fact this is a concept
well worth exploring. Trauma care suffers from high frag-
mentation. Patients are often uninsured, hospitals are under-
funded, and care is provided by dozens of individuals from
different medical and therapeutic services. Care is uncoor-
dinated, patient experience is unsatisfying, and the cost is
Fig. 1 Unexpected readmission. Data are expressed as the rate per
100 live discharges. There was a significant decrease in readmission
rate in the fourth year of the study (p \ 0.02). From [18], with
permission from Wolters Kluwer Health
Curr Anesthesiol Rep (2016) 6:2229
Fig. 2 Clinic calls and walk-in visits. Patients are instructed to call or
to walk into the STC clinic with any problems or questions arising
after discharge. The decrease in call volume in the third year is
significant (p = 0.001). The decrease in both calls and walk-ins in the
fourth year is significant (p = 0.001 and 0.03, respectively). From
[18], with permission from Wolters Kluwer Health
high. Most surgical patients chose their surgeon and their
hospital, and then schedule their surgery at a convenient
time. The patient admitted after trauma or for an emergency
procedure has their life interrupted and disrupted in a
moment, with few choices. While there is scant opportunity
to influence care before the patient is injured, there is a
substantial opportunity thereafter. There are few areas of
anesthesia practice where care coordination is so critical and
the potential for improvement in safety and efficiency so
high. This is an area ripe for process re-design.
Care coordination in emergency-admission patients can
occur during both the acute phase (diagnosis of injuries and
life-saving care) and during the sub-acute phase (critical
care, scheduling of follow-on procedures, pain management,
transition to rehabilitation). Anesthesiology presence at the
time of acute care admission can facilitate emergency air-
way management and initial resuscitation; availability of
monitored deep sedation services in the Emergency
Department improves both patient comfort and operational
efficiency. In the operating room, the anesthesiologist should
participate in conversations about the sequence and extent of
planned procedures. For example, an understanding of the
patients physiologic stability gleaned from the response to
fluid therapy and medication administration might be critical
to determining whether to perform a definitive or a dam-
age-control procedure.
Following initial resuscitation, there is also an important
role for the anesthesiologist. Every trauma patient will have
pain; managing this in the most effective and efficient
fashion is a core expertise. Prioritization of future surgeries
is another consideration, both in terms of OR logistics (when
can the schedule best accommodate the patient) and man-
agement of physiology (when will this patient be best pre-
pared). As we lead in understanding the science of
25
inflammatory response after trauma [22], our input into
surgical scheduling should increase. Is the patient at bed rest
with an unstable cervical spine better served by earlier sur-
gery, even if somewhat under-resuscitated, or a delay to
improve hemodynamics at the expense of deteriorating
pulmonary function? Beyond required surgeries, though
there is a role for anesthesiologist leaders in overall case
management, we speak the language of all of the services
involved, and can play a role in facilitating communications
between trauma general surgeons, orthopedic surgeons,
neurosurgeons, physical therapists, and even case managers.
Acute Care Anesthesia: The European Vision
In Western Europe, anesthetists have long been key players
in the team of specialists caring for acute care, critically ill
patients. With the progressing sub-specialization in medi-
cal specialties, there is a recognized risk of fragmentation
of care pathways and a lack of transversal coordinators
within the various disciplines involved. Critically ill
patients may therefore be taken care of by various spe-
cialties. In the perioperative setting, often the anesthetist is
together with the ICU physicianthe person who will see
and follow these patients most extensively. S/he is impli-
cated in their pathway from the arrival in the shockroom
throughout the OR and to the handover to ICU, and will be
in charge for postoperative pain control and the frequent
retakes to the OR.
The growing tendency to create priority care pathways
for diseases, where time to specialist care plays a crucial
role as in acute coronary events, stroke, burns, sepsis, and
trauma, has led to an increasing demand of immediate
availability of anesthesia specialists 24/7. The ambition of a
University hospital to deliverat all timethe highest
level of care by providing the most experienced specialists
for each domain leads further to the call for anesthetists
participating in in-house resuscitation teams, for bedside
procedures, or for intubations in the ICU. Such situations
are often challenging not only because of the patients
critical state, but additionally due to the lack of a proper
preoperative work-up, taking place in unfamiliar locations
and often with the need to coordinate multiple teams
simultaneously. In these settings, we suggest that experi-
enced anesthetists, who are at ease in unpredictable, un-
standardized situations, will be able to provide optimal care.
Training in intensive care is in most European countries
mandatory for the anesthesia specialty title. Despite the
separation of the anesthesia and intensive care curriculum,
the surgical ICU is in many hospitals still covered by
anesthetists allowing for a smooth overlap from OR to
ICU, with optimal information flow and the continuum of
carestrategies during the frequent take backs. As in the
123
26
U.S., European/UK ICUs are often chronically overbooked
and the post-anesthesia care unit may be used as a buffer
zone for prolonged stays of postoperative critically ill
patients, sometimes for an extended period. Dealing with
the unique needs of the critically ill postsurgical patient
requires anesthetists to be specifically trained, as postop-
erative adverse events are known to be often a greater
determinant of survival than pre-existing comorbidity or
intraoperative complications [23]. Further, the creation of
an intermediate care unit has shown to be associated with
improved ICU utilization [24]. In many places, anes-
thetists are in charge of intermediate care units on surgical
wards; thus, they understand the needs for postoperative
care or pre-anesthesia preparations and investigations.
Acute Care Anesthesia in Europe and the UK
In the face of this increasing need for anesthetists providing
support for critically ill patients outside the standard frame
of the elective OR, acute care anesthesia is subject of
extensive discussions. The creation of a specific curriculum
implementing a formal training program is discussed in
many places. The British Royal College of Anaesthetists
offers with the Acute Care Common Stem a 2-year a high volume of trauma cases occurring during time periods
training program combining acute care anesthesia, acute
internal medicine, emergency medicine, and intensive care
medicine as a possible entry path into anesthesia [25]. In
France, several departments offer a University diploma in
Trauma Anesthesia [26] or in clinical hemostasis for
anesthetists [27]. In the UK, senior anesthetists being part
of the in-hospital cardiopulmonary resuscitation team has
become a defined quality standard [28].
In the University Hospital in Lausanne, the second
biggest hospital in Switzerland (1100 beds), this recent
evolution has led to the creation of an ACA team, con-
sisting of a fully trained senior anesthetist and a certified
anesthesia nurse, additionally to the actual on-call team.
The aim of the ACA team is to contribute to deliver the
best possible pre-, intra-, and postoperative care to criti-
cally ill patients presenting with an immediately life-
threatening condition. Supported by specific demands of
partner departments, the anesthesia service has obtained the
funding to create this supplementary line 24/7.
The ACA team is in charge of level-0 emergencies as
for stroke, severe trauma, or burn patients and acts as a
support for teams facing a massive perioperative hemor-
rhage. On demand, it will provide intubation and anesthesia
for bedside procedures in the ICU and is part of the in-
hospital cardiac arrest team. Further, the ACA team is in
charge of patients in the post-anesthesia care unit who were
operated on the emergency list, allowing the on-call team
to focus on anesthesia of the following emergency list.
When the ACA team is not deployed for one of the defined
123
Curr Anesthesiol Rep (2016) 6:2229
tasks, it will assist the on-call team for standard emergency
surgery procedures allowing for a timelier work-up of the
emergency list.
While data are yet to be analyzed, the ACA team is seen
as a welcomed contribution for enhanced quality of care in
critical situations. Thanks to the large translational contacts
and knowledge of key players in all specialties involved,
the ACA team creates the optimal platform for multidis-
ciplinary interaction and exchange of information. We
expect to demonstrate that this will lead to a sensitive
reduction of time to treatment for critically ill patients.
The PSH in Practice: A Model in Orthopedics
and Trauma
The Texas Trauma Institute at Memorial Hermann Hospi-
talTexas Medical Center (MHH-TMC) is one of the
busiest Level I trauma centers in the United States and is
affiliated with The University of Texas Medical School at
Houston. In 2011, orthopedic trauma admissions at MHH-
TMC numbered more than 3900. Of those admissions,
approximately two-thirds occurred on weekends. With such
when the operating room staffing was minimal, many of the
non-emergent orthopedic cases were delayed or bumped
by those at immediate risk for loss of life, limb, or eyesight.
This led to significant delays in the average time to surgery
for trauma-related orthopedic cases as well as overbooking
of such cases early in the workweek. A compounding factor
was the lack of additional dedicated operating room (OR)
times for these cases as MHH-TMC has a robust elective
surgical schedule 5 days per week that caters to both aca-
demic and private surgeons. Regularly, some of these
already-delayed orthopedic surgeries from weekend trauma
admissions would be posted on the OR schedule for a
Monday or Tuesday as an additional case (add-on). At some
point, usually late in the day or evening, the anesthesiolo-
gist-in-charge would have to inform the surgeon of addi-
tional delays or an inability to proceed with these add-on
cases as the priority in the evening had now shifted back to
major trauma and emergency surgeries. Additional setbacks
included case cancelations due to lack of patient optimiza-
tion, inadequate preoperative work-up, lack of communica-
tion with the primary physicians or surgeons, and
inconsistencies among the anesthesiologists themselves
regarding patient optimization in relation to the non-elective
nature of the cases. At times, this created an antagonistic
relationship between anesthesiologists and orthopedic sur-
geons. More importantly, patients also suffered from sig-
nificant delays to necessary surgery, ongoing NPO status,
and disruptions in their lives as their cases were moved to
subsequent days. These situations left the patients and their
Curr Anesthesiol Rep (2016) 6:2229
families frequently upset or disappointed as expectations,
plans, and hopes in anticipation of surgery on the stated day
were altered.
The often non-elective nature of these surgeries presented
a challenge to the Departments of Anesthesiology and
Orthopedic Surgery at UT Houston and the administration of
MHH-TMC. Time from trauma admission to the operating
room had to be improved. Through the collaboration of
orthopedic surgeons, anesthesiologists, hospitalists, and
hospital administrators, the MHH-TMC Orthopedic Trauma
Surgical Home was founded. The goals in using the Peri-
operative Surgical Home (PSH) model for trauma cases
were decreased patient length of stay, improved case time
efficiency, and improved OR utilization, thus achieving the
secondary goals of decreased cost, improved patient out-
comes, and improved patient and provider satisfaction.
Prior to the establishment of a surgical home model (see
Fig. 3), the disproportionate weekend (Saturday/Sunday)
surgical caseload distribution was addressed. As more ded-
icated OR times were unavailable during the workweek with
any consistency, additional staffing on the weekends during
the daytime became a solution. These consisted of one to
two additional OR teams (anesthesiologist, nurse, and sur-
gical technician) who were available and dedicated to the
orthopedic service on Saturdays and Sundays. The addi-
tional staffing resulted in a more predictable distribution of
orthopedic trauma surgeries throughout the entire week.
This singular maneuver laid the foundation for and was
crucial to the success of subsequent efficiency measures and
the PSH.
Fig. 3 Example of a PSH model of work-flow for orthopedic patients
27
Conditions generally improved; however, case delays and
cancelations continued to be an ongoing problem and
occurred due to a variety of reasons. One reason was due to
a lack of communication and/or coordination of care
between orthopedic surgeons, trauma surgeons, neurosur-
geons, anesthesiologists, intensivists, hospitalists, various
specialists, operative staff, floor/emergency staff, and resi-
dents/fellows of various specialties. This was addressed by
creating two positions: an Orthopedic Trauma Surgical
Home Coordinator (PSH coordinator) who is a full-time
Registered Nurse (RN)/Nurse Practitioner (NP/APRN) and
an Orthopedic Anesthesia Team Leader (OTL) consisting of
an anesthesiologist rotated from a core group of orthopedic
anesthesiologists. In our model, these two positions are now
the central points of communication and coordination for all
the various teams taking part in a patients care as it relates
to orthopedic surgery during the admission.
The PSH coordinator role at MHH-TMC acts as a liaison
between all the services, gathers relevant patient informa-
tion, and communicates/coordinates care with the OTL and
other services. Additionally, the coordinator may expedite
the processes by ordering appropriate diagnostic and labo-
ratory tests if they have the appropriate privileges. When
potential issues arise regarding patient care or delays, the
coordinator is usually the first to know and will then com-
municate with the OTL and pertinent parties. This nursing or
mid-level position is critical to the success of our PSH
model and their day begins at 05:00 with the collection of
patient anesthesia preoperative evaluations (if performed),
and all additional relevant information and test results. At
123
28
06:00, the PSH coordinator and OTL attend the Orthopedic
Trauma morning report where the services admissions from
the previous 24 h are presented and discussed. During this
report, the OTL reviews patient information for all of the
days anticipated cases as well as those being presented that
may require surgery on following days. The OTL dispenses
recommendations for action to the PSH coordinator and also
communicates with the orthopedic surgeons any potential
delays, their basis, and potential solutions or plans. Fol-
lowing the morning report, the OTL begins their usual
clinical day as an anesthesiologist (supervising one to two
operating rooms) with the additional responsibility of com-
municating pertinent patient and case information with the
other anesthesiologists assigned to orthopedic rooms that
day. Throughout the day, the OTL is in near constant
communication with the PSH coordinator and maintains
contact with the acute pain management service (APS/
APMS) and regional anesthesia service in addition to pre-
viously mentioned parties. Sh/e is also readily available for
physician-to-physician level communications or higher if
necessary. There is some intentional overlap in the respon-
sibilities between the PSH coordinator and OTL that helps
prevent loss of key information or lack of communication.
Another position, which we have found necessary for the
implementation of the PSH in our setting, is the Orthopedic
Anesthesia Director. This anesthesiologist is the leader of a
specific team of dedicated orthopedic/trauma anesthesiolo-
gists, many with regional anesthesia skills, for utilization
within the orthopedic section of the operating suites. This
individual also creates the OTL schedule, helps develop,
mentor, and recruit fellow anesthesiologists for the team,
and addresses problems within the section and the PSH.
Preliminary indicators have demonstrated improvements
in preoperative length of stay (Pre-op LOS), average length
of stay (ALOS), and case cancelation rate. Secondary
benefits remain to be determined; however, surgeon satis-
faction and in turn hospital administrator satisfaction have
dramatically improved leading to a noticeably healthier and
happier working relationships between anesthesiologists
and orthopedic surgeons.
Conclusion
The PSH has the opportunity to achieve the Triple Aim in
the surgical setting, and the management of acute care/-
trauma and emergency patients is a need that is currently
not being met. Anesthesiologists are uniquely qualified to
care for patients who have no preoperative optimization
(prehabilitation) into and following their surgical proce-
dures, through their intensive care unit stay, and prior to
hospital discharge. Our expertise in resuscitation strategies,
in critical care, in acute and chronic pain management, and
123
Curr Anesthesiol Rep (2016) 6:2229
in integration of complex medical conditions may improve
long-term patient outcomes. Success of the PSH requires
the continued close clinical collaboration of anesthesiolo-
gists, hospitalists, primary care physicians, and surgeons,
working closely with nurses, pharmacists, rehabilitation
specialists, and social workers. Incorporating existing
models within the U.S. and in Europe may provide estab-
lished models with proven outcomes.
Acknowledgment Dr. Pittet is supported by the National Institutes
of Health R01 GM86416.
Compliance with Ethics Guidelines
Conflict of Interest Maureen McCunn, Richard P. Dutton, Cather-
ine Heim, Clarence E. Gilmore IV, and Jean-Francois Pittet declare
that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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Curr Anesthesiol Rep
DOI 10.1007/s40140-016-0143-z
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Changing Paradigms in Hemostatic Resuscitation: Timing,
Extent, Economic Impact, and the Role of Factor Concentrates
Roman Dudaryk1 Nadav Sheffy2 John R. Hess3,4
 Springer Science + Business Media New York 2016
Abstract Damage-controlled hemostatic resuscitation
has become a standard of care for critically injured
patients. Recently completed PROPRR trial demonstrated
hemostatic benefits of 1:1:1 Platelets:FFP:RBC transfusion
approach, although overall mortality did not decrease.
Improved logistics of resuscitation (decreased crystalloid
administration), optimization of blood product delivery
with adoption of massive transfusion protocols (short time
to first unit of plasma transfused), and better early post-
MTP management are the factors that contributed to lower
than expected mortality in this study. Liquid plasma and
pre-thawed Type A fresh frozen plasma (FFP) are safe
alternatives to universal donor Type AB FFP and have
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Roman Dudaryk
RDudaryk@med.miami.edu
Nadav Sheffy
nadavs1@gmail.com
John R. Hess
hessj3@uw.edu
1
Division of Trauma Anesthesiology/Critical Care Medicine,
Jackson Memorial Hospital, Department of Anesthesiology,
University of Miami, Miami, FL, USA
2
Department of Critical Care, Rabin Medical Center,
Beilinson Hospital, Petah Tikva, Israel
3
Laboratory Medicine and Hematology, University of
Washington, Seattle, WA, USA
4
Transfusion Service, Harborview Medical Center, University
of Washington, Seattle, WA, USA
been adopted by few trauma centers in North America due
to shortage of AB FFP supply.
Keywords Damage-controlled resuscitation
Massive
transfusion
1:1:1 Ratio
Liquid plasma
Factor
concentrates in trauma
Goal-directed coagulopathy
management
Introduction
Damage control resuscitation (DCR) is an approach to
managing critically injured and massively hemorrhaging
patients, that emerged from military practice. It has been
rapidly adopted by civilian trauma centers in North
America and Europe. Historically, DCR consisted of two
main components: hypotensive resuscitation and hemo-
static resuscitation. Hypotensive resuscitation was used to
limit crystalloid and artificial colloid administration with
their potential for hemodilution, hypothermia, and platelet
dysfunction. Hemostatic resuscitation with blood products
was aimed at prevention and correction of dilutional
coagulopathy. As resuscitation science has advanced with
earlier deployment of blood products, hemostatic resusci-
tation has become the main thrust.
The concept of hemostatic resuscitation became a corner-
stone of trauma care in the last decade since the discovery of
trauma-induced coagulopathy (TIC). Numerous retrospective
studies, initially in military and later in civilian settings,
demonstrated a probable survival benefit from administering
high ratios of units of fresh frozen plasma (FFP) and platelets
to red blood cells (RBCs). This pattern of resuscitation was
rapidly adopted by North American and European trauma
centers. Academic societies guiding trauma care also
advanced this changing practice in newly issued guidelines.
123

PROPPR TrialWhat Does It Mean for Your
Practice
Despite many retrospective studies and a prospective
observational study demonstrating benefit from high FFP-to-
RBC ratios, no data existed from a randomized prospective
clinical trial addressing the optimal ratios of FFP to RBC that
might improve hemostasis without increasing the incidence
of transfusion-related complications. The Pragmatic Ran-
domized Optimal Platelet and Plasma Ratios (PROPPR) trial
was designed and executed to answer these questions [1].
This multicenter clinical trial compared outcomes from the
two most common transfusion ratios of PLT, FFP, and RBC,
1:1:1 versus 1:1:2. The key points from this landmark study
are important to understand:
Patients in the 1:1:1 ratio group had significantly de-
creased mortality due to exsanguination (difference,
-5.4 % [95 % CI, -10.4 % to -0.5 %], P = .03), demon-
strating that better hemostasis was indeed achieved with
higher FFP ratios.
While overall (all cause) mortality was not different
between two groups (Fig. 1), the study was underpowered
for this endpoint, which was in part attributable to lower-
than-expected mortality in the control group. This fact
leads to another very important observation: both arms of
the study received good-quality resuscitation consistent
with DCR principals. Timely initiation of MTP and median
time to the first batch of blood product was 8 min. Both
groups received minimal crystalloids with median volume
of 6 l over first 24 h after admission. At 24 h, cumulative
ratios of blood products in both groups were similar,
Fig. 1 PROPRR trial: KaplanMeier curves for mortality at 24 h and
30 days. The colored areas indicate 95 % confidence bands. For 24-h
mortality, the Cox proportional hazards regression model, adjusted for
site as a random effect, produced a hazard ratio (HR) of 0.72 (95 %
CI 0.491.07). For 30-day mortality, the Cox proportional hazards
123
Curr Anesthesiol Rep
approaching 1:1 ratio. It appears that after termination of
MTP and initiation of local standard of care patients in the
1:2 group received more FFP, achieving ratios close to
intervention group but at later time (Fig. 2).
Since the wide adoption of early empiric high ratio FFP
transfusion for trauma, there has been a concern regarding
transfusion related complications (TRALI, sepsis, respira-
tory failure). Pre-specified analysis of complications in high
and low FFP ratio group showed no difference, confirming
that a 1:1 ratio appears to have the same safety profile as a
1:2 ratio. This noteworthy observation likely was related to
the endothelium preserving properties of FFP and the lim-
ited volume of crystalloids in both study groups.
The 1:1:1 study arm received platelets early during
resuscitation. According to the study protocol, platelets
were transfused first when new batch of blood products was
delivered in this group, whereas in the lower ratio group, it
was the 13th product administered. Nevertheless, most
patients in both groups received platelets. It is not clear if
this sequence conferred a benefit, or that the use of platelets
was partially responsible for decreased overall mortality in
the study comparing to the common practice of adminis-
tering PRBC and FFP first during MTP.
Logistical and Economical Challenges for Blood
Banks in Massive Transfusion Era
Wide adoption of massive transfusion protocols is leading
to increased demand for FFP. The American College of
Surgeons requires adoption and practical implementation
regression model, adjusted for site as a random effect, produced an
HR of 0.83 (95 % CI 0.611.12). From Holcomb et al. [1], with
permission of the American Medical Association. Copyright 2015
American Medical Association. All rights reserved (Color
figure online)
Curr Anesthesiol Rep
Fig. 2 PROPRR trial: distribution of blood product amounts within
period up to 24 h after admission. The lower and upper edges of the
boxes are the 25th and 75th percentiles, the whiskers extend to 1.5
9 the interquartile range, and the points outside are the outliers. The
thick lines inside the box represent the median, and the circles
of a MTP as a fundamental requirement for ACS trauma
center accreditation in the United States. MTPs per se have
been shown to decrease utilization and wastage of blood
products overall [2].
Demand for FFP, especially the universal donor AB FFP,
that has been traditionally used in initial stages of hemostatic
resuscitation has increased, putting additional strain on
already limited pool of donors (AB donors are only 4 % of US
population) and is overwhelming the supply capacity with
increased utilization of 27 % between 2006 and 2001 [3]. One
common MTP requirement is maintenance of a limited supply
of pre-thawed universal donor plasma in case of MTP acti-
vation, as obtaining an ABO blood type typically takes 25 min
and thawing type specific plasma typically takes 25 min more.
Thawed FFP units have a limited shelf life of only 5 days and,
if not utilized for trauma, have to be withdrawn for general
use, which will lead to thawing another batch and repeating
this cycle. This can lead to increased utilization and wastage
especially in smaller hospitals and less busy trauma centers
where the frequency of MTP activations is low. In order to
alleviate this shortage and minimize wastage several strate-
gies have been proposed and tested recently [4].
Liquid (never frozen) AB plasma (LQP) has been pro-
posed as an alternative to thawed AB FFP. It has a shelf life
of 26 days, giving an obvious advantage in response time
[5]. Limited in vitro and in vivo experience with this
product has been favorable so far [6, 7].
Another alternative is to use a thawed male Group A
plasma for the initial stages of the MTP. The safety of this
approach has been studied recently [8]. Transfusion reac-
tions due to anti-B antibody were not observed, and several
small safety studies suggested that group A FFP is generally
a safe option for emergent transfusion [8, 9]. Furthermore,
transfusion of Group O apheresis platelets with potentially
higher antibody load (anti-A and anti-B antibody) has been
accepted as a generally safe practice and became routine.
represent the mean. Five or 6 U pools of whole blood-derived
platelets were considered equivalent to 1 U of apheresis platelets
(e.g., an adult dose of platelets). From Holcomb et al. [1], with
permission of the American Medical Association. Copyright 2015
American Medical Association. All rights reserved
Pre-hospital Plasma Transfusion: Current
Experience and Challenges of Implementation
The pathophysiological basis of coagulopathy and bleeding
following injury is believed to be an interplay of hypo-
perfusion, endothelial injury, and an inflammatory response
and starts immediately after the injury, independent of
hypothermia, bleeding, and coagulation factor dilution.
Within the framework of DCR, major improvements have
been achieved in the last decade with regard to delivery
time of plasma products to bleeding trauma patients after
hospital admission [10, 11]. The next logical step would
be treatment of coagulopathy as early as the pre-hospital
setting. While pre-hospital transfusion of plasma and
plasma products had been conducted in military cam-
paigns, little evidence of outcome improvement has been
shown [1214].
A recent retrospective study done in Houston compared
trauma patient receiving pre-hospital transfusionRBCs
and plasma during aeromedical transportwith those
receiving only in-hospital transfusion. The pre-hospital
group had some evidence of better outcomes such as
improved acidbase status on admission, decreased use of
blood over 24 h, and some reduction in 6-h mortality for a
subset of the most critically injured. However, no 24-h or
30-day mortality benefit was noted [15].
Distributing plasma to pre-hospital services, whether
ground or air platforms, creates logistical difficulties for
transfusion services and necessitates a rigorous process of
training and quality control [16]; plasma products used in
military milieus, such as freeze-dried plasma (FDP), can
serve as potential alternative to liquid plasma products [13,
17]. FDP has also been shown to be feasible for use in
civilian setting in a pre-hospital environment in Norway
[18]. Another approach, which is logistically appealing, is
administration of fibrinogen concentrate. There is some
123

evidence for improved outcomes in combat casualties
receiving higher ratios of fibrinogen to RBCs [19]. This
approach is supported by some European authors, who
have wider experience in using fibrinogen concentrate for
trauma patients and is currently undergoing prospective
investigation in the Fibrinogen in Trauma Induced Coag-
ulopathy (FIinTIC) study [20, 21].
There are currently three Department of Defense funded
randomized prospective trials underway meant to compare
efficacy and utility of air and ground pre-hospital plasma
transfusion as compared to standard crystalloid infusion:
Prehospital Air Medical Plasma (PAMPer), Control of
Major Bleeding after Trauma (COMBAT), and Prehospital
use of Plasma for Traumatic Hemorrhage (PUPTH) [22
24]. It is hoped that the studies will provide the necessary
evidence to justify the emerging concept of early pre-
hospital plasma transfusion.
Goal-Directed Coagulopathy Management Versus
Predetermine Ratios: Theory and Practice
Currently, three main approaches to massive blood
transfusion in trauma are described. These are the blind
use of a predetermined blood component ratio, a labo-
ratory-directed goal-directed approach, and the use of
bedside or laboratory-based viscoelastic testing to direct
variation from a standard resuscitation strategy. In fact,
most groups start with ratio-based approach and move to
a laboratory or viscoelastic guided strategy as soon as
data are available.
Following the implementation of DCR, major differ-
ences arose between most North American trauma centers
and some European centers in the approach to treating
massively bleeding trauma patients. The predetermined
approach, known as the 1:1:1 approach, has become experts make an argument not to wait for a perfect study
very popular, mainly in the US, and has several appealing
aspects to it. It enables the clinician to treat massive
hemorrhage rapidly, while supplying the patient with
coagulation factors and much needed volume at the same
time, mitigating the need to use crystalloid or colloids. It
has been studied extensively in the military and civilian
setting, with over 30 studies culminating in the afore-
mentioned randomized PROPRR study, showing, with
different degrees of significance and methodological
robustness, mortality, and morbidity advantage over giving
a lower ratio of plasma and platelets [25, 26].
The Central European goal-directed approach relies
heavily on viscoelastic testing which attempts to identify
specific deficiencies in the coagulation system and assigns
specific coagulation products such as fibrinogen concen-
trate, prothrombin complex concentrate (PCC), and
123
Curr Anesthesiol Rep
tranexamic acid. Proponents of this approach site higher
potency of PCC over FFP, decreased danger of exposure to
allogeneic blood products, and decreased waste of blood
products [27, 28, 29]. A randomized control study com-
paring the two approaches has never been conducted, and
given regulatory obstacles is highly unlikely to be done.
However, these two approaches are not mutually exclusive,
and indeed many centers are combining the use of the
proportional ratio system in the acute massive exsan-
guination phase, transitioning into a goal directed therapy
as soon as the patients clinical situation allows [30].
Role of Plasma and Fibrinogen Concentrates
Contrary to North American and British teachings, in
Europe, management of trauma-induced hemorrhage relies
mainly of administration of fibrinogen and 4-factor con-
centrates and is commonly guided by viscoelastic testing of
coagulation (ROTEM or Rapid TEG)a goal-directed
approach to coagulation therapy. Proponents of this
approach claim that viscoelastic testing can identify
specific coagulation deficiencies in the settings of trauma
such as decreased fibrinogen or platelet function and
hyperfibrinolysis and deliver targeted individualized ther-
apy in form of factor concentrates. Such therapy claims to
address three major derangements of coagulation cascade
related to trauma: improvement in clot stability (fibrinol-
ysis), clot strength, and thrombin generation. There are a
few reports published describing this approach with visu-
ally appealing algorithms, but except for a handful of case
reports, there are no prospective trials confirming efficacy
or superiority of this method. Even if performed, such a
study is likely to be underpowered for primary outcome
and definition of control group will be challenging. Some
but to adapt individualized approach on the basis of
existing evidence from trauma, basic science, and other
clinical situations where it has been showed to be of benefit
(cardiothoracic surgery and liver transplantation) [31]. In
general, if adopted, TEG tends to encourage giving more
plasma, more platelets, and more fibrinogen, just like for-
mula-based resuscitation. More importantly, there is
emerging evidence that high plasma ratio DCR may not
have significant influence on coagulation abnormalities
diagnosed by viscoelastic testing during massive transfu-
sion protocols [32]. In this prospective multicenter obser-
vational study, viscoelastic markers of coagulation did not
change significantly with administration of high ratio of
FFP, except cases when, in addition to plasma and plate-
lets, cryoprecipitate was administered boosting fibrinogen
levels (in excess of 4 g/l total fibrinogen transfused).
Curr Anesthesiol Rep
The 2013 European guidelines for management of
bleeding and coagulopathy following major trauma strongly
recommends using PCC for the emergency reversal of
vitamin-K antagonists (VKA) as well as suggest using PCC
and fibrinogen concentrate-based goal-directed therapy
[33]. Evidence for the use of PCC in reversal of warfarin
induced VKA are present, mainly in neurosurgical trauma
[34, 35]. For bleeding trauma patients with unsuspected
VKA influence using PCC under viscoelastic testing, goal-
directed approach is widely practiced in some European
centers, mainly for its thrombin generation capabilities and
the theoretical reduction in exposure risk to allogeneic blood
products. Evidence for this approachs utility is mainly
observational in nature and might not be generalized to
different patient population [36, 37, 38]. A 4-complex
concentrate (Kcentra) was only approved in April 2013 by
the US Food and Drug Administration for use in emergency
reversal of VKA in the bleeding patient, and most of its use
for trauma patients in the US has been reported in connec-
tion with head injury, sometimes in addition to FFP [3941].
There have been some studies conducted in the US on the
perioperative use of PCC in patients with elevated INR, both
trauma and non-trauma, irrespective of VKA use [42, 43].
Conclusions
Hemostatic resuscitation of injured patients with high
fixed ratios of PRBC, FFP, and PLTs is becoming a
standard of trauma care in North America. High demand
for plasma in initial stages of resuscitation prompted
introduction of liquid plasma and group A FFP as safe
and viable alternatives to a universal donor AB FFP. Pre-
hospital plasma administration is a next frontier of
hemostatic resuscitation with few ongoing studies evalu-
ating efficacy and safety of this approach. Goal-directed
hemostatic resuscitation with aid of viscoelastic testing is
more valuable in later stages, when hemodynamic sta-
bility is achieved. Administration of PCC and fibrinogen
concentrate guided by viscoelastic testing has been
strongly recommended by European Guidelines on Man-
agement of Bleeding and Coagulopathy but has not been
adopted in the United States as it is based primarily on
small observational studies.
Compliance with Ethics Guidelines
Conflict of Interest Roman Dudaryk, Nadav Sheffy, and John R.
Hess declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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Papers of particular interest, published recently, have been
highlighted as:
Of importance
Of major importance
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view of the evidence advocation pre-hospital use of TXA and
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2014;18(6):637. Good review of goal-directed coagulation
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This document also recommends to use factor concentrates
(PCCs) and fibrinogen concentrate as a primary modality to
correct trauma-induced coagulopthy.
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anticoagulant reversal in neurosurgical emergencies. Br J Neu-
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Curr Anesthesiol Rep
DOI 10.1007/s40140-016-0149-6

ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)

Anesthetic Considerations and Ventilation Strategies

in Cardiothoracic Trauma
Craig S. Jabaley1 Roman Dudaryk2 Charles E. Smith3

 Springer Science + Business Media New York 2016

Abstract Cardiothoracic trauma represents a significant
challenge for the anesthesiologist, and little robust
investigational evidence exists to guide management
decisions. Injury patterns are potentially diverse and often
severe, and mortality rates are second only to those of
traumatic brain injury. As such, anesthesiologists must be
familiar both with the fundamentals of trauma patient care
and considerations unique to cardiothoracic injury.
Herein, we discuss anesthetic considerations related to
traumatic injury of the heart, great vessels, conducting
airways, and lungs. As the rate of respiratory failure and
acute respiratory distress syndrome (ARDS) exceeds that
of the general trauma population, we then review the
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Craig S. Jabaley
csjabaley@emory.edu
Roman Dudaryk
rdudaryk@med.miami.edu
Charles E. Smith
csmith@metrohealth.org
1
Division of Critical Care Medicine, Department of
Anesthesiology, Emory University Hospital, 1364 Clifton
Road, NE, Atlanta, GA 30322, USA
2
Department of Anesthesiology, Perioperative Medicine, and
Pain Management, University of Miami/Jackson Memorial
Hospital Ryder Trauma Center, 1611 NW 12th Avenue
(C-301), Miami, FL 33136, USA
3 conducting airways. We then conclude with a review of
Department of Anesthesiology, MetroHealth Medical Center,
Case Western Reserve University School of Medicine,
2500 MetroHealth Drive, Cleveland, OH 44144, USA
relevant fundamental aspects of mechanical ventilation
and treatment of ARDS.
Keywords Thoracic trauma
Trauma anesthesia

Thoracic aortic injury
Blunt cardiac injury
Airway
trauma
Pulmonary contusion
Introduction
The management of blunt thoracic trauma from both
the anesthetic and surgical standpoints is complex
owing to the unique challenges of certain injury pat-
terns and the diverse nature of traumatic injury. Dis-
cussion regarding the perioperative management of
these patients has been limited in the literature and is
further constrained by a narrow foundation of investi-
gational evidence. Thoracic trauma often involves
inherent challenges that require high levels of expertise
in the realms of airway management, interdisciplinary
communication, perioperative mechanical ventilation,
lung isolation, recognition and diagnosis of occult
injuries, and treatment of obstructive shock. As such,
the management of these patients involves concepts
that extend beyond the conventional core trauma
anesthesia topics of resuscitation, transfusion, and cor-
rection of coagulopathy. Mortality associated with
thoracic trauma is second only to that caused by trau-
matic brain injury and is a leading preventable con-
tributor to post-traumatic death [1]. To simplify the
discussion, injuries to the heart and major vessels will
be discussed separately from those to the lungs and
mechanical ventilation and acute respiratory distress
syndrome (ARDS).

123

Vascular and Cardiac Trauma
Thoracic Aortic Injury
While penetrating injury may affect any segment of the
thoracic aorta, blunt trauma most commonly occurs distal
to the takeoff of the left subclavian artery where the
proximal descending aorta is anchored by the ligamentum
arteriosum at the aortic isthmus [2]. This relatively
immobile segment is therefore susceptible to injury from
abrupt deceleration. Blunt trauma can also manifest as
injury throughout the entire continuum of the aorta. The
incidence of blunt thoracic aortic injury is approximately
2 % of all patients who sustain thoracic trauma with the
majority (80 %) being caused by motor vehicle collisions
[3, 4]. Patients who sustain thoracic aortic injury after blunt
trauma are typically severely injured owing to the high
energies involved [5]. As demonstrated in one prospective
series, operative repair has historically carried a high rate
of mortality (31 %) and paraplegia (8.7 %); however,
mortality in patients managed non-operatively was even
greater at 55 % [6].
Initial excitement regarding the role of TEE in the
diagnosis of acute aortic injury has subsided, and multi-
detector computed tomography (CT) has emerged as the
most common diagnostic modality. The sensitivity and
specificity of CT with regard to the diagnosis of aortic
injury approaches 100 % throughout the entire aorta. Fur-
ther, CT is a critical tool to detect and catalog traumatic
burden and reduces the likelihood of occult injury over-
looked during clinical examination. The addition of intra-
venous contrast to facilitate CT angiography is easily
accomplished and can be performed and interpreted rapidly
at any time of the day. In contrast, TEE requires the
presence of an experienced operator, and many institutions
cannot support the continuous availability of a TEE ser-
vice. Furthermore, it is often impractical to perform TEE in
the resuscitation bay or emergency department, and TEE is
ill-suited to rule out the gamut of potential non-vascular
injuries. Compared to CT, TEE cannot visualize all por-
tions of the ascending aorta due to the interposed air-filled
distal trachea and left bronchi. Lastly, TEE is relatively
contraindicated in the setting of unstable cervical spine
injuries, severe craniofacial trauma, and suspected eso-
phageal injury. Despite these shortcomings, TEE remains
an invaluable intraoperative tool when cardiac or major
vascular injury is suspected in patients brought emergently
to the OR without previous CT imaging. Use of TEE in this
scenario may quickly yield a potentially life-saving intra-
operative diagnosis.
In addition to greater diagnostic accuracy, CT imaging
also facilitates patient triage. This damage control
123
Curr Anesthesiol Rep
radiology approach uses CT to identify sites of bleeding
and facilitate triage to either non-operative management,
operative intervention, or hemorrhage control by inter-
ventional radiology [7, 8]. While current guidelines suggest
that patients with intimal tears can be managed non-oper-
atively, those with intramural hematomas, pseudoa-
neurysms, or contained rupture (periaortic hematoma) will
likely require intervention [9]. Given the potential for high
morbidity in the severely injured patient, surgical inter-
vention can be delayed when the risk of rupture is low
(e.g., no evidence of pseudoaneurysm) [10]. Numerous
approaches to the open repair of thoracic aortic injuries
have been described [11]. Over the last decade, the man-
agement of trauma to the great vessels has shifted from
open to endovascular approaches such that open repair of
aortic injury is becoming increasingly rare. Endovascular
repair has been associated with lower mortality, decreased
incidence of paraplegia, and reduced need for blood
transfusion when compared with open approaches [12, 13].
The principles of anesthetic management for patients
undergoing post-traumatic thoracic aortic repair are similar
to those for associated elective procedures. Systemic blood
pressure must be maintained within a narrow range to
avoid worsened hemorrhage or extension of injury. In the
absence of head injury, a systolic blood pressure of less
than 100 mmHg is typically targeted. Although easily
titratable agents (e.g., clevidipine, nicardipine, sevoflurane,
and/or remifentanil) can be employed for elective cases,
the hemorrhaging trauma patient may require only close
attention to hemodynamics during perioperative resuscita-
tion. Likewise, beta blockade has long been a cornerstone
of aortic injury management, as reduction in both the
chronotropic and inotropic state of the heart is thought to
reduce shear forces (i.e., the rate pressure product) and
protect the site of injury. Esmolol has a favorable phar-
macokinetic profile that affords a relative margin of safety
in the compromised trauma patient. Periods of controlled
hypotension, with mean arterial pressures of 5055 mmHg,
are sometimes required during endovascular stent deploy-
ment; however, the development of low-profiles stents has
largely obviated this need. The relative merits of controlled
hypotension must be weighed against the risks when con-
comitant traumatic brain injury is known or suspected [14].
Open repairs of the aortic arch and ascending aorta
typically require cardiopulmonary bypass and may require
a period of circulatory arrest. On the other hand, open
repair of the descending aorta requires one-lung ventilation
(OLV) to facilitate exposure of the descending thoracic
aorta. Placement of a single-lumen endotracheal tube
(ETT) affords the greatest chance of timely first-pass suc-
cess when a definitive airway is required emergently either
in the resuscitation bay or operating room (Table 1). The
Curr Anesthesiol Rep

placement of a double-lumen tube may be challenging in
the trauma patient due to cervical spine immobilization,
airway contamination, and risk of aspiration. Moreover,
tracheal anatomy may be distorted or externally com-
pressed by a periaortic hematoma, which can complicate
tube exchange and positioning. Furthermore, ETT
exchange is typically ill-advised in the trauma patient as
coagulopathy, airway edema, and limited pulmonary
reserve are common. As such, a bronchial blocker is often
the most expeditious and safest means by which to
accomplish lung separation and OLV under emergent
conditions after placement of a single-lumen ETT.
Blunt Cardiac Injury and Commotio Cordis
Blunt cardiac injury (BCI) should be suspected in patients
with a decelerating mechanism of injury. Its overall inci-
dence following thoracic trauma is difficult to discern
owing to inconsistent diagnostic criteria over the years;
however, it is likely between 10 and 25 % with a propor-
tional increase in likelihood that parallels injury severity
[15, 16]. The diagnosis of BCI is challenging, and its
sequelae can vary substantially. The spectrum of BCI can
include cardiac contusion (with cardiac enzyme elevation
and wall motion abnormalities), arrhythmia, acute coronary
syndrome, valvular disruption, cardiogenic shock, and
potentially catastrophic structural damage (Table 2).
Comprehensive screening guidelines for BCI are available
from the Eastern Association for the Surgery of Trauma
(EAST) [17]. EAST guidelines recommend an admission
EKG for all patients with suspicion of BCI. However, a
normal EKG does not exclude BCI as was demonstrated in
one study wherein 41 % of patients with abnormal
echocardiographic findings had a normal EKG [18]. The
addition of normal troponin I levels to an unremarkable
EKG confers a negative predictive value of almost 100 %

Table 1 Advantages and disadvantages of selected lung isolation techniques

Options Advantages Disadvantages

Double-lumen tubes Quickest to place successfully under elective Size selection more difficult
conditions Challenging to place in the context of a difficult
Repositioning rarely required airway or abnormal trachea
Facilitates bronchoscopy and suction of the isolated Non-optimal postoperative two-lung ventilation
lung Risk of bronchial and/or laryngeal trauma
CPAP easily added
Can alternate OLV to either lung easily
Placement still possible if bronchoscopy not
available
Bronchial blockers Size selection rarely an issue More time needed for positioning
1. Arndt Easily added to regular ETT Repositioning needed more often
2. Cohen Allows ventilation during placement Bronchoscope essential for positioning
3. Fuji Easier placement in patients with difficult airways Non-optimal right lung isolation due to RUL
and in children anatomy
4. EZ Blocker Bilateral blocker balloons allow for sequential lung Limited availability and practical experience at
isolation without repositioning some centers
Univent Same as for bronchial blockers Same as for bronchial blockers
Less repositioning than with bronchial blockers Higher air flow resistance than regular ETT
Larger diameter than regular ETT
Endobronchial tubes Like regular ETTs, easier placement in patients with Bronchoscopy necessary for placement
difficult airways Does not allow for bronchoscopy, suctioning, or
Longer than regular ETT CPAP to isolated lung
Short cuff designed for lung isolation Difficult right lung OLV
Tube is reinforced
Endotracheal tube advanced into Easier placement in patients with difficult airways Does not allow for bronchoscopy, suctioning, or
mainstem bronchus CPAP to isolated lung
Cuff not designed for lung isolation
Difficult right lung OLV
Modified from [124] with permission from Cambridge University Press. 2015 Cambridge University Press, NY
CPAP continuous positive air pressure, ETT endotracheal tube, RUL right upper lobe, OLV one-lung ventilation

123

[19]. Contrary to previous beliefs, sternal fractures have
not been reliably associated with BCI, and their presence or
absence is not incorporated in current screening schema.
Management of BCI depends largely on the exact
manifestations of injury. Patients with a concerning
mechanism of injury, hemodynamic instability, and a
positive FAST examination suggestive of tamponade will
undergo immediate operative exploration. Formal
echocardiography has been shown to have limited screen-
ing utility and is typically reserved for patients with
hemodynamic compromise and arrhythmia [17]. Patients
with BCI may come to the attention of an anesthesiologist
during preoperative evaluation. Heighted perioperative
mortality has been described for patients with BCI on an
inconsistent basis in the literature; however, mortality was
typically due to non-cardiac causes [2022]. The ideal
length of time, if any, to delay non-emergent surgery is
unclear from the existing evidence and should rely on
patient-specific factors and clinical judgement. In any case,
the anesthesiologist must be vigilant as both arrhythmias
and pump dysfunction with cardiogenic shock are known
sequelae of BCI [21]. At a minimum, the anesthesiologist
must be prepared to treat arrhythmias, such as ventricular
tachycardia, ventricular fibrillation, atrial fibrillation with
rapid ventricular response, conduction blocks, and heart
failure. A defibrillator should be immediately available,
and prophylactic placement of transcutaneous electrodes
(i.e., pads) may be prudent. Non-emergent surgery should
be delayed in the setting of clinically significant arrhyth-
mias and/or heart failure.
Commotio cordis describes the development of malig-
nant (e.g., ventricular) arrhythmia and cardiac arrest
Table 2 Clinical manifestations of blunt cardiac injury
Arrhythmias
Sinus tachycardia
Sinus bradycardia
Conduction blocks (e.g., right bundle branch block, third degree
block)
Atrial fibrillation
Premature ventricular contractions
Ventricular tachycardia or fibrillation
Decreased cardiac function
Heart failure
Cardiogenic shock
Pericardial effusion and tamponade
Wall motion abnormalities
Valvular disruption
Cardiac chamber rupture
Elevated cardiac troponins
Modified from [125] with permission from Cambridge University
Press. 2008 Cambridge University Press, NY
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Curr Anesthesiol Rep
following forceful impact to the precordium. The classic
scenario involves young athletes injured while playing
contact sports. Mechanical energy imparted to the myo-
cardium during repolarization is thought to be the under-
lying mechanism; however, specific risk factors have not
been fully elucidated [23]. The only intervention that has
been associated with favorable outcomes is the immediate
initiation of CPR and defibrillation [24]. Adverse legal
consequences are not uncommon for involved parties and
in instances of delayed diagnosis and treatment [25].
Considerations for Resuscitative Thoracotomy
Resuscitative thoracotomy (RT) in the ED and aortic cross-
clamping are maneuvers that can be potentially life-saving
for certain patients. However, efforts to establish evidence-
based indications for this dramatic procedure have been
frustrated by significant heterogeneity and limitations in
the existing literature. The best available evidence supports
the use of RT for patients who present to the ED with signs
of life followed by rapid deterioration or cardiac arrest,
especially for those with thoracic penetrating trauma or
likely cardiac injury and tamponade [26, 27]. The use of
RT following either out of hospital witnessed arrest and
CPR, or CPR immediately on arrival by EMS, is more
controversial [28]. However, Western Trauma Association
guidelines argue that rapid transport may confer increased
survivability in certain scenarios [29]. On this basis, the
guidelines state that RT is potentially indicated following
blunt trauma with less than 10 min of prehospital CPR,
penetrating torso trauma with less than 15 min of prehos-
pital CPR, and penetrating neck or extremity trauma with
less than 5 min of prehospital CPR. In keeping with these
findings, a recent review concluded that the RT is likely
most beneficial for pulseless patients with signs of life after
penetrating thoracic injury (e.g., likely tamponade) and
least likely to be beneficial or pulseless patients without
signs of life following blunt trauma [30].
RT is typically accomplished via a left anterolateral
approach. For the anesthesiologist, endotracheal intubation
is frequently performed concurrently. Visualization of lung
expansion is a valuable means by which to confirm correct
placement of the ETT as typical indicators (e.g., end-tidal
carbon dioxide) will be unreliable. As patients are mori-
bund, attention to analgesia and amnesia can be delayed
initially. In the event that RT is successful in restoring
signs of life, immediate preparations should be undertaken
to facilitate ongoing resuscitation and prepare the operative
suite. Temporary cannulation of the right atrial appendage
and descending thoracic aorta have both been described as
means by which to facilitate fluid resuscitation following
RT when standard methods of vascular access prove to be
impossible [31, 32].
Curr Anesthesiol Rep
Anesthetic Considerations for Damage Control
Strategies
Damage control was originally used to describe the acceptance as the most expeditious means by which to
immediate but temporary correction of damage sustained
by naval vessels to prevent loss of the ship through simple
practical maneuvers. The term was first applied to trauma
patients in the context of damage control laparotomy,
whereby generous exposure was obtained, packs were
placed to abate hemorrhage, and a temporary closure was
effected [33]. Thereafter, the patient would be admitted to
the ICU for resuscitation, correction of coagulopathy, and
further optimization prior to definitive surgical interven-
tion. A similar approach has been described for penetrating
thoracic trauma, although mortality remains high
(2340 %) even at experienced centers [3436]. A related
concept is that of damage control resuscitation (DCR),
which emphasizes means by which to facilitate early
hemostasis. In addition to early surgical control of bleed-
ing, the cornerstones of DCR are initial deliberate
hypotension; resuscitation with transfusion of blood prod-
ucts rather than crystalloid fluids; avoidance and treatment
of coagulopathy, acidosis, and hypothermia; and goal-di-
rected delayed resuscitation [3739].
One recently developed technique for hemorrhage con-
trol is resuscitative endovascular balloon occlusion of the
aorta (REBOA), which acts as an endovascular aortic cross-
clamp equivalent [40]. REBOA can be employed as a tem-
porizing and life-saving measure in severely injured patients
who continue to manifest profound hemodynamic instability
and impending cardiac arrest despite aggressive resuscita-
tion. Conceptually, deployment of a REBOA catheter will
allow time to catch up with resuscitation while making
arrangements for definitive hemorrhage control or further
diagnostic studies. The success of this approach is likely
patient and operator-dependent, and a recent prospective
multicenter observational study demonstrated an increased
risk of death in patients who underwent REBOA [41]. It has
been argued that REBOA is likely contraindicated in the
setting of thoracic hemorrhage as it could exacerbate
bleeding from the great vessels [42]. Further experience and
research is needed to better define the role of this technique
for patients with thoracic injuries [43].
Pulmonary and Airway Trauma
Pneumothorax and Parenchymal Injury
The diagnosis of pneumothorax is typically made during
the primary survey owing to obvious clinical signs or fol-
lowing radiographic studies as an element of the secondary
survey. Occult pneumothorax that is not detected by plain
chest radiography, but is evident on CT scan, occurs in up
to 16 % of all trauma patients and in 30 % of blunt chest
trauma [44]. Point of care ultrasound is gaining increasing
diagnose pneumothorax in the prehospital and hospital
settings with higher sensitivity and specificity than a plain
chest radiograph [45, 46]. Similarly, ultrasound can facil-
itate intraoperative detection of pneumothorax by anes-
thesiologists [47]. The conventional approach of tube
thoracostomy following the detection of even a small (e.g.,
less than 1.5 cm at the 3rd rib) or occult pneumothorax has
been challenged as evidence mounts that patients with a
small unilateral asymptomatic pneumothorax can be man-
aged expectantly even in the setting of positive pressure
ventilation [4850]. However, this approach may prove to
be inadvisable in the polytrauma patient slated to undergo
emergent operative intervention. The frenetic intraopera-
tive environment may lead to delayed appreciation of
worsening pneumothorax on the basis of increased airway
pressures (during volume-controlled ventilation [VCV]),
reduced tidal volumes (during pressure-controlled ventila-
tion [PCV]), impaired gas exchange, or hemodynamic
compromise. As such, pre- or intraoperative tube thora-
costomy is often the safest option in this circumstance.
Bleeding from the peripheral low-pressure pulmonary
circulation resulting in hemothorax is typically self-limited.
Tube thoracostomy in this setting is both therapeutic and
diagnostic as the hemothorax can be evacuated and further
bleeding monitored through suction of the pleural space.
While bleeding from the lung parenchyma is often modest,
intercostal, internal mammary, or hilar injury can result in
brisk hemorrhage. The vast majority of pulmonary injury
from blunt thoracic trauma is managed conservatively with
tube thoracostomy, and less than 10 % of injuries require
intervention [51]. Patients are typically taken to the oper-
ating room due to a massive air leak or uncontrolled
bleeding, which is defined as a chest tube output exceeding
1500 ml/24 h or 3 consecutive hours of output [200 ml/h
[52]. For the anesthesiologist, it is important to monitor
chest tube output in the trauma patient who is undergoing
repair of other coexisting injuries and alert the trauma team
should the output exceed these thresholds.
Tracheobronchial Injury
Tracheal injury is rare but exceedingly challenging to
manage both from a surgical and anesthetic perspective. As
is frequently noted, the true incidence of such injuries is
difficult to discern as many patients die promptly at the
scene. Penetrating neck trauma typically entails injury to the
cervical portion of the trachea as this segment is relatively
poorly protected anatomically. Conversely, blunt injury
typically entails either injury within 2 cm of the carina
123

(80 %) or at the laryngotracheal junction (20 %) as these
two segments are vulnerable to crush injury by overlying
osseous structures or barotrauma with a closed glottis,
respectively [53]. In an otherwise stable patient, tracheal
injury may present as unexplained dyspnea and subcuta-
neous emphysema (Table 3). Clinical suspicion should be
further heightened when pneumothorax or pneumomedi-
astinum is refractory to conventional management.
Patients with tracheobronchial injuries often require
intubation due to hemodynamic instability and concomitant
injuries before a diagnosis can be made. Care is warranted
while inserting the ETT as intubation can either exacerbate
the injury or create a false lumen. As such, when reason-
able clinical suspicion for a tracheobronchial injury exists,
fiberoptic bronchoscopy (FOB) should be performed at the
time of intubation. Pre-loading an ETT onto the broncho-
scope facilitates both an examination of the airway prior to
intubation as well as insertion of an ETT into the trachea.
This technique requires not only a skilled operator but also
the aid of several trained assistants in a coordinated fash-
ion. Simultaneous direct laryngoscopy (or videolaryn-
goscopy) by a separate provider allows for more complete
visualization of the supraglottic airway and speeds inser-
tion of the FOB into the trachea. Management of the
traumatized airway has been recently reviewed in greater
detail for interested readers [126].
Significant injury to the post-carinal conducting airways
will typically manifest as a pneumothorax. Continued air leak
from a chest tube is highly suggestive of a bronchopleural
fistula (BPF) related to either a bronchial tear or disruption.
A BPF may lead to impaired gas exchange due to compro-
mised lung expansion, loss of tidal volume, or the inability to
provision positive end-expiratory pressure (PEEP) during
mechanical ventilation. In such instances, it is preferable to
preserve spontaneous ventilation unless respiratory failure
develops. Otherwise, endotracheal intubation and emergent
lung isolation can be used as a salvage maneuver until sur-
gical intervention can be completed. If lung isolation cannot
be accomplished, minimization of mean airway pressures
during mechanical ventilation will reduce the pressure gra-
dient across the fistula and minimize any associated air leak.
Less obvious bronchial injuries may go unnoticed as radio-
graphic and clinical findings can be subtle. Persistent
atelectasis, otherwise unexplained consolidation, or seg-
mental collapse should heighten clinical suspicion [54].
While discreet bronchial injuries can typically be repaired
primarily, the operative approach to more complex injuries
most often involves some degree of pulmonary resection.
Rib Fractures and Flail Chest
Rib fractures are the most common manifestation of blunt
thoracic trauma. Rib fractures themselves are typically not
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Curr Anesthesiol Rep
directly threatening and rarely require operative manage-
ment aside from tube thoracostomy to manage associated
pneumo- or hemothorax. However, they are painful and
promote the development of splinting, ineffective airway
clearance, progressive atelectasis, hypoxemia, and eventual
respiratory failure. The incidence of respiratory complica-
tions has been estimated at up to one-third of patients with
rib fractures [55]. As such, analgesia is an important ele-
ment of management. Anesthesiologists are frequently
asked to consider thoracic epidural (or paravertebral)
analgesia as anecdotal evidence of its efficacy is prevalent.
However, a clear role for epidural analgesia has not been
borne out in the literature as evidenced by a recent sys-
tematic review and meta-analysis that did not demonstrate
a benefit [56]. As increasing age and number of fractures
confer a higher risk of mortality, epidural placement is
more likely to be beneficial among those who are over
55 years of age and sustain multiple fractures [57].
Flail chest describes the fracture of adjacent ribs at
multiple points thus resulting in a freely mobile segment.
Paradoxical expansion of the segment during exhalation
and retraction during inspiration is commonly observed
[58]. Patients with a flail segment are at an increased risk
for respiratory failure compared to those with less threat-
ening rib fracture patterns, and concomitant pulmonary
contusion further increases the risk [59, 60]. Conservative
management without positive pressure ventilation is pos-
sible in a subset of patients without polytrauma when
coupled with judicious fluid administration, close attention
to airway clearance, and multimodal analgesia [61].
However, such an approach is likely impractical in the
severely injured patient with a flail segment as evidenced in
a recent retrospective series, which identified that
mechanical ventilation (59 %) and ICU admission (82 %)
were often required [62].
Pulmonary Contusion
The recognition of pulmonary contusion as a clinical entity
began largely as a result of battlefield blast injuries after
which pulmonary hemorrhage was evident on autopsy
despite the absence of external trauma [63]. Following
energy transmission to the thorax, three mechanisms of
lung injury have been identified: shearing forces at gas
liquid interfaces, inertial injury between relatively fixed
hilar structures and more mobile peripheral alveolar tissue,
and expansion of gas in the wake of a pressure wave [64].
Disruption of the alveolocapillary membrane leads to loss
of plasma and blood into the alveoli, which contributes to
reduced compliance in conjunction with alveolar septal
inflammation [65, 66]. These changes worsen the shunt
fraction with resultant hypoxemia, and it has been postu-
lated that increased pulmonary vascular resistance
Curr Anesthesiol Rep
Table 3 Selected findings in laryngeal and tracheobronchial trauma
Signs and symptoms:
Subcutaneous emphysema, crepitus, air escape, external bleeding and bruising, ecchymosis, hematoma, dyspnea, stridor, wheezing, cough,
dysphonia, hoarseness, pain with phonation, hemoptysis, tracheal deviation
Bronchoscopic findings:
Tear, edema, hematoma, abnormality of vocal cords, compression or distortion of airway
Tracheal injury may be exterior to the visible mucosa, and evidence of injury may not be visible during fiberoptic bronchoscopy
Computed tomography findings:
Compression or distortion of airway and surrounding structures, fracture, tear, edema, hematoma, abnormal air pockets, pneumothorax,
pneumomediastinum
Modified from [126], with permission from Wolters Kluwer Health
develops as a compensatory mechanism [67]. Patients who
suffer significant contusions may go on to develop fibrosis
and sequelae of chronic lung disease [68].
Diagnosis relies initially on clinical suspicion in the
setting of an appropriate mechanism of injury with
impaired gas exchange. The development of infiltrates on a
plain chest radiograph is often delayed, and radiographic
findings typically worsen over the first 24 h [69]. As is the
case with many injury patterns, CT offers heightened
diagnostic sensitivity [70, 71]. Retrospective evidence
suggest that patients with a GCS[13, B4 rib fractures, and
pulmonary contusions totaling \1/3 of the total lung fields
as assessed by CT scan are unlikely to deteriorate [72].
However, patients with polytrauma or extensive contusions
evident on admission are a high risk for respiratory failure
and progression to frank ARDS [73]. The evidence avail-
able to guide decision making for patients with pulmonary
contusions is heterogeneous and of a limited quality; as
such, the relevant EAST guidelines lack level 1 recom-
mendations [61]. Common interventions supported by
EAST guidelines include limitation of fluid administration,
administration of diuretics, and management of respiratory
failure with positive pressure ventilation. The preferential
use of colloids over crystalloids is not supported for this, or
any other, subsegment of trauma patients [74]. Poor com-
pliance of respiratory system often complicates mechanical
ventilation as high inspiratory pressures may be needed.
Inattention to ventilator parameters can lead to ventilator-
induced lung injury, as is discussed subsequently.
Management of Mechanical Ventilation
Mechanisms of Lung Injury in Trauma
Traumatic injury initiates a complex neurohormonal
inflammatory cascade that acts in concert with shock,
surgical stress, sepsis, aspiration, and iatrogenic influences
to produce pulmonary dysfunction [75]. The association
between trauma, resuscitation, the development of
pulmonary infiltrates, and resultant poor gas exchange was
first made during World War II [76]. Subsequent experi-
ence has shown this entity to be ARDS [77]. Current
ARDS diagnostic criteria were established in 2012 and are
outlined in Table 4 [78]. ARDS can develop after either
direct (e.g., pulmonary contusion) or indirect (e.g., sys-
temic inflammatory response to trauma) insults to the lung
[79]. The common theme underlying both mechanisms is
the development of a pro-inflammatory pulmonary milieu
that either causes or worsens existing parenchymal injury
[80].
Lung-Protective Mechanical Ventilation
and Prevention of Lung Injury
ARDS frequently complicates the course of recovery after
traumatic insult and represents a major source of morbidity
and mortality in this patient population [81]. However, its
incidence and associated mortality have significantly
declined over the past decade in nosocomial settings, and a
similar trend has been identified among trauma patients
[82, 83]. These gains can be attributed largely to the
widespread adoption of low tidal volume mechanical
ventilation after publication of a landmark trial in 2000
[84]. Key aspects of this so-called lung-protective
strategy are highlighted in Table 5. Critically, the appli-
cation of these principles not only improves outcomes of
patients with ARDS but also protects against the devel-
opment of ARDS in at-risk patients [8587]. As such, lung-
protective strategies are now considered a standard of care
in the ICU environment.
Unfortunately, these advances have not been universally
adopted with regard to intraoperative mechanical ventila-
tion, and the delivery of potentially injurious ventilation in
the operating room remains common. In one recent retro-
spective study, 61 % of patients undergoing non-cardiac
surgery received tidal volumes C8 ml/kg predicted body
weight (PBW), and 39 % did not receive PEEP [88]. (See
Table 5 for calculation of PBW.) Multiple trials have
assessed the relationship between intraoperative lung-
123

protective ventilation and postoperative pulmonary out-
comes. When subjected to individual patient data meta-
analysis, findings from relevant randomized controlled
trials suggest that intraoperative delivery of tidal volumes
in excess of 8-10 ml/kg PBW is associated with postop-
erative pulmonary complications [89].
However, it is conceivable that patients undergoing
short, elective procedures will be less vulnerable to venti-
lator-induced lung injury and can thus tolerate larger tidal
volumes and greater degrees of atelectasis. As such, it has
been argued that the most sensible approach to intraoper-
ative ventilation is an individualized one in which lung-
protective strategies are more stringently applied to
patients with either a high likelihood of, or known, lung
injury [90]. With that in mind, nearly all trauma patients
are at a high risk for the development of ARDS, and the
risk is further increased in patients with thoracic trauma.
This point was well-elucidated during the development of a
highly cited lung injury predictive score (LIPS) [91, 92].
Shock, aspiration, traumatic brain injury, smoke inhalation,
pulmonary contusion, fractures, abdominal surgery, aortic
surgery, and acidosis were among the identified risk factors
(Table 6). Using a LIPS score cutoff of 4, the negative
predictive value was 97 %; however, a positive predictive
value of only 18 % likely limits its clinical utility [92].
Therefore, the authors feel it prudent to apply stringent
perioperative lung-protective ventilation strategies to every
trauma patient in an effort to reduce the risk of lung injury
and ARDS.
Other ARDS Interventions
In an effort to standardize the care of patients enrolled in
trials examining therapies for ARDS, a checklist for lung
injury prevention has been developed as outlined in
Table 7. Elements of the checklist are largely directed at
avoidance of secondary lung injury through prevention of
additional insults, such as unchecked septic shock or
aspiration. Aside from appropriate mechanical ventilation,
only two other interventions have been proven helpful in
randomized trials to treat ARDS: prone positioning and
neuromuscular blockade. Prone positioning allows for
Table 4 Acute respiratory distress syndrome diagnostic criteria [78]
Feature
Onset within one week of a known insult or newly worsening respiratory symptoms
Bilateral opacities on chest imaging in the absence of another etiology
Pulmonary edema without heart failure or fluid overload
Impaired oxygenation (with PEEP C5 cm H2O)
PaO2 partial pressure of oxygen, FiO2 fraction of inspired oxygen, PEEP positive end-expiratory pressure
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Curr Anesthesiol Rep
dorsal lung recruitment and homogenization of ventilation,
thus distributing the forces associated with positive pres-
sure lung insufflation more uniformly [93]. The benefit to
prone sessions has been demonstrated in patients with
varying degrees of ARDS and is likely to be increasingly
impactful as disease severity worsens [9496]. However,
placing critically ill patients prone is challenging under the
best circumstances. The impact of fractures, injury burden,
surgical wounds, body habitus, and hemodynamic insta-
bility must be weighed when considering the prone posi-
tion for a trauma patient as various complications have
been described [97]. The effects of neuromuscular block-
ade on ARDS outcomes were highlighted in a multicenter
randomized control trial wherein patients who received a
48-h infusion of cisatracurium demonstrated reduced
barotrauma and adjusted mortality rates [98]. Neuromus-
cular blocking drugs may serve to reduce ventilator asyn-
chrony; however, their prolonged use contributes to the
development of neuromuscular weakness and impaired
airway clearance. These factors in addition to method-
ological criticisms have led some to argue that the benefit
of neuromuscular blockade is not yet entirely convincing
[99].
Practical Aspects of Intraoperative Ventilation
for the Trauma Patient
VCV is the most common modality of intraoperative
mechanical ventilation and thus is the most familiar to
anesthesiologists [100]. Peak inspiratory pressure alarms
are a common feature of anesthesia machine ventilators
and are typically set to 40 cm H2O. Driving pressures in
excess of this value lead to cessation of inspiration on most
modern ventilators and can result in hypoventilation. Peak
airway pressures correspond to dynamic compliance and
are affected by airway resistance. The ability to add an
inspiratory pause during VCV is typically available but not
always selected by default. An inspiratory pause allows
determination of plateau pressures, which are unaffected by
airway resistance and thus correspond to static respiratory
system compliance (i.e., lung compliance plus chest wall
compliance). A large difference between peak and plateau
Mild 200 mmHg \ PaO2/FiO2 B300 mmHg
Moderate 100 mmHg \ PaO2/FiO2 B200 mmHg
Severe PaO2/FiO2 B100 mmHg
Curr Anesthesiol Rep

Table 5 Principles of lung-protective ventilation for patients with acute respiratory distress syndrome
Parameter Considerations

Calculation of predicted body weight Males PBW = 50 ? 0.91 9 (height in CM 152.4) kg

Females PBW = 45.5 ? 0.91 9 (height in CM 152.4) kg
Tidal volume 46 ml/kg PBW
Positive end-expiratory pressure C5 cm H2O for PaO2 5580 mmHg, SpO2 8895 %
Peak airway pressures Pplat \30 cm H2O (via 0.5 s inspiratory pause where applicable)
Respiratory rate Ideally B35/min (for pH C7.30)
PBW predicted body weight, Pplat plateau pressure

Table 6 Lung injury prediction score calculation worksheet

Predisposing conditions Risk modifiers
Condition Points Modifier Points

Shock 2 Alcohol abuse 1

Aspiration 2 Obesity (BMI [30) 1
Sepsis 1 Hypoalbuminemia 1
Pneumonia 1.5 Chemotherapy 1
High-risk surgery FiO2 [0.35 2
Emergency surgery 1.5 Tachypnea (RR [30) 1.5
Orthopedic spine 1 SpO2 \95 % 1
Acute abdomen 2 Acidosis (pH \7.35) 1.5
Cardiac 2.5 Diabetes mellitus with sepsis -1
Aortic vascular 3.5
High-risk trauma
Traumatic brain injury 2
Smoke inhalation 2
Near drowning 2
Lung contusion 1.5
Multiple fractures 1.5
Reprinted with permission of the American Thoracic Society. Copyright  2015 American Thoracic Society. From [92]
BMI body mass index, RR respiratory rate

pressures suggests increased airway resistance, whereas
elevations in both values without a large delta suggest poor
compliance of the respiratory system. The addition of an
inspiratory pause is not only a valuable diagnostic
maneuver but also allows for careful monitoring of plateau
pressures in accordance with the principles of lung-pro-
tective ventilation. Elevated plateau pressures are indica-
tive of impaired static respiratory system compliance,
which can be due either to changes in lung or chest wall
compliance.
Many anesthesiologists transition to PCV when peak
airway pressures during VCV are encountered. Although
this may ultimately be advisable, efforts should first be
directed at ruling out an easily remedied cause. Elevation of
peak pressure during VCV in excess of plateau pressure
suggests increased airway resistance: secretions, bron-
chospasm, and circuit obstruction should be ruled out.
Elevation of both peak and plateau pressures with a narrow
or absent delta suggests decreased compliance of the respi-
ratory system, which could be due to endobronchial intu-
bation, pneumothorax, ventilator asynchrony, or inadequate
neuromuscular blockade. When these potentially reversible
causes of elevated airway pressures have been excluded,
common causes of respiratory system compliance impair-
ment among trauma patients should then be considered:
abdominal compartment syndrome, surgical retractors, pul-
monary contusion or edema, and ARDS. In these instances,
efforts should be made to limit plateau pressures to less than
30 cm H2O. PCV offers more precise control over airway
pressures; however, tidal volume becomes a dependent
variable and must be monitored closely. The authors rec-
ommend tight expired tidal volume and minute ventilation
alarm settings for this reason when using PCV to avoid
hypo- or hyperventilation related to changes in respiratory

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Table 7 Lung injury prevention checklist

Checklist elements Definition

Lung-protective mechanical ventilation Vt 46 ml/kg PBW, Pplat \30 cm H2O, PEEP C5 mmHg
Aspiration precautions RSI by experienced providers, elevate HOB, oral care with chlorhexidine, gastric acid
neutralization in the absence of enteral feeding
Adequate empiric antimicrobial treatment Guided by suspected site, likelihood of nosocomial pathogens, and immune suppression status
and source control
Limiting fluid overload Early fluid resuscitation in septic shock followed by goal-directed therapy
Restrictive transfusion Hb target [7 g/dl in the absence of active bleeding and/or ischemia
Appropriate patient handoff Structured ICU handoff that covers checklist elements for duration of stay
Adapted from [127] with permission from BMJ Publishing Group Ltd
Vt tidal volume, PBW predicted body weight, Pplat plateau pressure, PEEP positive end-expiratory pressure, RSI rapid sequence intubation,
HOB head of bed, Hb hemoglobin, ICU intensive care unit

system compliance. Outcome differences between VCV and
PCV have not been established; as such, provider familiarity
and expertise should be considered when choosing intraop-
erative ventilation modes [101].
When elevated airway pressures limit ventilation, per-
missive hypercapnia should be considered. Bedside and
investigational evidence both suggest that modest degrees of
respiratory acidosis are relatively well-tolerated by most
trauma patients [102, 103]. However, hypercapnia should be
avoided in patients with traumatic brain injury as cerebral
vasodilation may lead to elevated intracranial pressures. The
adequacy of ventilation should be based on assessment of
PaCO2 by arterial blood gas (ABG) analysis instead of end-
tidal carbon dioxide (EtCO2). The absolute value of, and
trends in, EtCO2 often poorly correlate with PaCO2 in
trauma patients owing to increased alveolar dead space in
the setting of hypovolemia, shock, and regional pulmonary
ventilation/perfusion mismatch [104]. However, trends in
EtCO2 when minute ventilation is held constant can be a
useful surrogate marker of cardiac output and adequacy of
resuscitation [105, 106]. Efforts to increase minute venti-
lation when the respiratory system compliance is poor by
manipulation of the respiratory rate can lead to incomplete
exhalation, dynamic hyperinflation (i.e., auto-PEEP),
increased intrathoracic pressures, decreased venous return,
and cardiovascular collapse [107109]. Similarly, vigorous
ventilation via bag valve mask (BVM) devices must be
avoided. Patients who prove difficult to ventilate intraoper-
atively or require high levels of PEEP should be transported
with a mechanical ventilator (instead of BVM) and EtCO2
monitor to reduce the risk of complications [110].
Considerations Related to One-Lung Ventilation
Management of OLV can be challenging even during elec-
tive operations, and these challenges are compounded fol-
lowing traumatic injury. Under normal circumstances, the
shunt fraction induced by OLV is reduced from the expected
50 to 2030 % by virtue of hypoxic pulmonary vasocon-
striction, improved perfusion matching by lateral position-
ing, and manipulation of the operative lung [111]. Tolerance
of OLV is generally much reduced in trauma patients owing
to hypovolemia and either primary or secondary lung injury.
Pulmonary contusions affecting the non-operative lung may
make tolerance of OLV impossible owing to superimposed
baseline shunt and poor compliance. As such, non-emergent
procedures requiring OLV may require delay until gas
exchange and pulmonary mechanics improve. Little defini-
tive evidence exists to guide management of mechanical
ventilation during OLV; however, lower tidal volumes
(45 ml/kg PBW) have been associated with reduced
inflammatory biomarkers and are likely most appropriate
[112, 113]. When low tidal volumes are employed, higher
levels of PEEP applied to the ventilated lung (averaging
10 cm H2O) are needed to maximize recruitment and reduce
lung strain [114]. Application of CPAP to the non-ventilated
lung is often avoided during elective procedures such as
video-assisted thoracoscopy (VATS) but may not necessar-
ily interfere with emergent resection during open thoraco-
tomy. CPAP not only minimizes shunt fraction but also
prevents dense atelectasis that can be difficult to overcome
postoperatively [115].
Advanced Ventilation Strategies
Airway pressure release ventilation (APRV [also known as
bi-level ventilation]) provides high inspiratory pressures
(Phigh) for a set time period (Thigh) with brief releases to a
lower pressure (Plow) for a set time (Tlow). APRV differs
from PCV with an inverse I:E ratio in that it allows for
spontaneous breathing throughout the respiratory cycle,
and mean airway pressures are typically higher. A clear
consensus has not been developed regarding the optimal
approach to initial settings [116]. However, typical empiric
settings entail a Phigh of 2030 cm H2O, Plow 05 cm H2O,
Thigh 5 s, and Tlow 0.5 s. Hypoventilation requires a greater

123
Curr Anesthesiol Rep
pressure gradient or total proportion of the respiratory
cycle spent at Plow. Hypoxemia requires either a greater
inspired fraction of oxygen or higher mean airway pres-
sure, which is dependent upon Phigh and Thigh. The hypo-
thetical benefit of APRV is that it maximizes and maintains
alveolar recruitment while avoiding collapse on exhalation.
Although APRV has been studied in trauma patients,
insufficient evidence exists to recommend its routine use,
especially in centers without extensive experience [117,
118]. Similarly, excitement about the application of high-
frequency oscillatory ventilation (HFOV) has been tem-
pered by the publication of two large prospective trials in
which mortality was either not improved or worsened in
patients who received HFOV [119, 120].
Asymmetric or unilateral pulmonary contusions cause
reduced compliance of the more injured lung, over-dis-
tention of the healthier lung during conventional mechan-
ical ventilation, and ventilator-induced lung injury.
Similarly, the applied PEEP may not be sufficient to recruit
the injured lung. On this basis, independent lung ventila-
tion (also known as differential ventilation) has been
advocated as one means by which to manage patients with
this challenging condition [121]. Lung isolation is typically
best accomplished with a double-lumen ETT in this sce-
nario. No difference in outcomes has been established
regarding synchronous versus asynchronous ventilation,
and an asynchronous strategy with two ventilators is typi-
cally less technically complex [122, 123].
Conclusion
The management of cardiothoracic trauma often requires a
high degree of ingenuity and expertise owing to the diversity
and severity of possible injuries. Anesthesiologists must
understand the rationale underlying surgical management
decisions and the operative approach to injuries in order to
facilitate appropriate preparation. Unfortunately, there is a
paucity of high-quality investigational evidence specifically
related to thoracic trauma to help guide the anesthesiologist.
As such, conclusions must be extrapolated from relevant
literature concerning general trauma and critically ill adults.
All trauma patients are at an increased risk of ARDS, and
these risks are compounded in the setting of thoracic injury.
Attention to appropriate mechanical ventilation not only
helps limit the severity of ARDS, but also helps prevent its
development in at-risk patients.
Compliance with Ethics Guidelines
Conflict of Interest Craig S. Jabaley, Roman Dudaryk, and Charles
E. Smith declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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Curr Anesthesiol Rep
DOI 10.1007/s40140-016-0148-7
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Initial Evaluation and Triage of the Injured Patient: Mechanisms
of Injury and Triggers for Operating Room Versus Emergency
Department Stabilization
Samuel M. Galvagno Jr.1 Robert A. Sikorski1 Christopher Stephens2
Thomas E. Grissom1
 Springer Science + Business Media New York 2016
Abstract Trauma anesthesiologists are uniquely juxta-
posed with the multidisciplinary trauma team, serving both
an administrative role in preparing the operating room
(OR) and allocating resources for resuscitation, and a direct
patient care role, providing definitive airway management
and advanced resuscitation. Trauma anesthesiologists must
have an intimate understanding regarding mechanisms of
injury, appropriate diagnostic modalities, and current
practices regarding OR versus emergency department or
radiology suite (IR) resuscitation. In this review, current
practices regarding assessment and triage, mechanisms of
injury, and the concepts of surgical, orthopedic, and radi-
ology damage control approaches to the severely injured
trauma patient are discussed.
Keywords Triage
Trauma anesthesiology
Damage
control orthopedics
Damage control resuscitation

Damage control radiology
Mechanism of injury
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Samuel M. Galvagno Jr.
sgalvagno@anes.umm.edu
1
Department of Anesthesiology, Divisions of Trauma
Anesthesiology and Critical Care Medicine, Program in
Trauma, R Adams Cowley Shock Trauma Center, University
of Maryland School of Medicine, Baltimore, MD 21201,
USA
2
Department of Anesthesiology, University of Texas Health
Science Center at Houston, Houston, TX, USA
Introduction
Trauma anesthesiologists are uniquely juxtaposed with the
multidisciplinary trauma team, serving both an adminis-
trative role in preparing the operating room (OR) and
allocating resources for resuscitation, and providing direct
patient care through definitive airway management and
advanced resuscitation. Both patient assessment and diag-
nosis are time-dependent processes, and trauma anesthe-
siologists must have an intimate understanding regarding
mechanisms of injury, appropriate diagnostic modalities,
and current practices regarding OR versus emergency
department (ED) or radiology suite (IR) resuscitation. In
this review, current practices regarding assessment and
triage, mechanisms of injury, and the concepts of surgical,
orthopedic, and radiology damage control are discussed.
Mechanisms of Injury Prompting Urgent
Intervention
Pre-hospital triage of the seriously injured trauma patient
begins in the field and is fraught with difficulty. Estimations of
blood loss are woefully imprecise and classically taught shock
classifications are commonly confounded by extremes of age
and variations in physiological reserve [1]. In 2011, the
Centers for Disease Control and Prevention (CDC) along with
the National Highway Traffic Safety Administration
(NHTSA) collaborated with the American College of Sur-
geons Committee on Trauma (ACS-COT) to revise previous
field triage decision schemes in order to reduce over triage of
patients with non-life threatening injuries, and to help direct
patients in most need of lifesaving interventions to appropriate
trauma centers [2]. Current guidelines recommend a four-step
assessment to assist pre-hospital providers with making
decisions about which patients are most in need of transport to
123

a trauma center. Briefly summarized, the four steps for
assessing the need for trauma center referral are (1) physio-
logical considerations, including systolic blood pressure
\90 mmHg, Glasgow Coma Scale B13, respiratory rate\10
or[29 (or need for ventilatory support); (2) anatomical con-
siderations, to include any penetrating injury to the head, neck,
torso, and extremities (proximal to the elbow or knee), chest
wall instability/deformity, amputation proximal to the wrist or
ankle, pelvic fracture, open/depressed skull fracture, and
paralysis; (3) mechanisms of injury (discussed in the section
that follows); and (4) special patient or system considerations
such as age[55 years, children, patients on anticoagulants, or
with bleeding disorders, burns (to be triaged to designated
burn centers), and pregnancy[20 weeks.
Traditionally, mechanism of injury has been referred to as
blunt versus penetrating trauma, with no further delineation
as to how much energy was imparted, or information
regarding anatomical and physiological insults. Some stud-
ies have suggested that mechanism of injury alone is a poor
predictor for trauma center referral [3, 4]. Others have
demonstrated that distinct mechanisms, such as ejection
from a vehicle or prolonged extrication time, clearly warrant
trauma center team activation [5, 6]. In a study by Lerner
et al., the ACS Field Triage Decision scheme was examined,
and interviews conducted with emergency medical techni-
cians who transported patients to trauma centers based on
mechanism alone [7]. Only three mechanisms of injury
reliably predicted the need for referral to a trauma center
when patients did not meet anatomical or physiological
injury criteria: death of an occupant in the vehicle, fall
greater than 20 feet, and extrication time greater than 20 min
[7]. Additional studies have justified mechanism of injury as
a parameter that helps reduce inappropriate transport of
patients with major trauma to non-trauma centers [8, 9].
Blunt and penetrating injuries are regularly disparate in
presentation but may share similarities in terms of extent of
injury [10]. Penetrating injuries are identified as ballistic and
non-ballistic. The point of injury in the patient with pene-
trating trauma may be utterly discernibleeven to the
inexpert providerbut the extent of tissue damage and
depth of shock may be less detectible compared to the
patient suffering from a blunt traumatic injury [10]. Con-
versely, the patient with penetrating trauma will lose blood
volume externally together with loss into body cavities,
whereas the patient with blunt trauma may present in
hemorrhagic shock with no obvious signs of hemorrhage.
Multiple blunt traumatic insults, bleeding into compartments
(e.g., unstable long bone fractures), retroperitoneal hemor-
rhage (e.g., pelvic fractures, major vascular injury, and solid
organ damage) and bleeding into other body cavities may
present as indolent hemorrhagic shock [11, 12].
The performance of a thorough patient assessment,
application of rapid diagnostic tests, and early activation of
123
Curr Anesthesiol Rep
resources is vital for ensuring optimal outcomes in patients
with severe traumatic injuries [13]. Primary assessment,
use of Focused Assessment with Sonography in Trauma
(FAST) exam, initial radiographic studies and computed
tomography (CT) scanshemodynamic stability permit-
tingwill specify a definitive diagnosis of injury and plan
of treatment [11, 14].
Who Should Go Directly to the OR?
In selected cases with obvious, imminent exsanguination,
patients should be directly admitted to the operating room,
bypassing the ED, and radiology suite. Historically, it has been
shown that up to a third of preventable trauma deaths may be
caused by delays getting to the OR; in one registry study,
mortality was increased by 1 % for every 3 min of delay to
laparotomy among hypotensive patients with abdominal
injuries [1517]. Steele et al. were among the first to describe a
direct to the OR approach in San Diego, reporting data
gathered over a 10-year period [18]. Patients with traumatic
cardiac arrest, systolic blood pressure persistently \100
mmHg, amputation, or uncontrolled external hemorrhage,
were admitted directly to the OR for resuscitation, regardless
of mechanism of injury. These triage criteria had poor sensi-
tivity (24.1 %) but high specificity (98 %) in identifying
patients truly in need of immediate surgery. Observed com-
pared to predicted survival was significantly higher in this
observational study. In another 10-year retrospective analysis
from Portland, Oregon, Martin et al. used the same triage
criteria as Steele et al., with the addition of the following
indications for unstable patients requiring direct-to-OR
admission: patients with a chest injury; acute abdomen; crush
injury to the torso, or evisceration of abdominal contents;
penetrating injuries to the neck, chest, abdomen or pelvis;
impaled objects in the neck, chest, abdomen, or pelvis; or
massive blood loss on scene or en route [19]. From 2000 to
2009, 1407 patients were admitted directly to the OR (5 % of
all admissions). After excluding patients who died on arrival
(8 %), 3.6 % died in the OR, and overall observed (5 %)
mortality was significantly lower than predicted (10 %).
Emergent surgical procedures were started within 30 min of
arrival in 77 % of patients and within 60 min in 92 %.
Not every seriously injured patient requires direct
admission to the OR. In the sections that follow, damage
control concepts are briefly discussed, as well as the
evolving role of less invasive techniques.
Damage Control Resuscitation
If hemorrhagic shock is present, damage control surgery
(DCS) and damage control resuscitation (DCR) should
immediately follow the primary survey and FAST exam [20
22]. A term originally coined by the US Navy in reference to
Curr Anesthesiol Rep
preventing a badly damaged vessel from sinking by imple-
menting procedures to stabilize the ship, the principle of
damage control has now been applied to trauma care [23].
Tenets of DCS and DCR include compressible hemorrhage
control; hypotensive resuscitation; rapid surgical control of
bleeding; avoidance of the overuse of crystalloids and col-
loids; prevention or correction of acidosis, hypothermia, and
hypocalcemia; and hemostatic resuscitation with the early
use of a balanced amount of red blood cells, plasma, and
platelets [24, 25]. DCR and DCS have been associated with
higher successful non-operative management rates and sur-
vival in patients with a variety of injuries, including severe
blunt liver injuries [22] and severe thoracic injuries [26].
While an in-depth discussion of DCS and DCR is beyond the
scope of this report, the reader is referred to several excellent
reviews on the topic [24, 25, 27, 28].
Patients with non-compressible hemorrhage ought to be
taken immediately to the operating room for DCS as well
as DCR [29]. However, with the advent of rapid diagnostic
tests and therapeutic interventions, alternative resuscitation
strategies continue to evolve, serving as temporizing
measures en route to the OR or radiology suite. One such
modality is the Resuscitative Endovascular Balloon
Occlusion of the Aorta (REBOA) for non-compressible
torso hemorrhage. This procedure involves placing a bal-
loon occlusion catheter into the common femoral artery in
order to reach the proximal descending thoracic aorta
where the balloon is deployed to occlude blood flow [30,
31]. When employed by knowledgeable and skilled pro-
viders, the REBOA has been associated with positive
outcomes thus far in selected patients for whom the pro-
cedure is clearly indicated [32, 33]. Additional mechanical
(i.e., bandages impregnated with zeolite, kaolin, chitosan,
etc.) and injectable hemostatic adjuncts (e.g., tranexemic
acid and prothrombin complex concentrates) represent
early DCR measures that can be utilized in the pre-hospital
arena, addressing the lethal triad of acidosis, hypothermia,
and coagulopathy, and providing physiological support for
the patient requiring definitive repair of injuries [25, 34].
Damage Control Orthopedics
Fractures and soft tissue injuries are injuries frequently
encountered with polytrauma patients [23]. Ideally, defini-
tive repair of fractures in the OR (i.e., early total care)
saves costs, improves mobilization, and allows for more
efficient utilization of OR staff and orthopedic surgeons [23].
However, in patients with multiple injuries, a staged strategy
is employed to reduce serious complications. This strategy is
called damage control orthopedics (DCO) (Table 1).
The decision to use DCO is based on the status of the
severely injured patient. Four classes of patients have been
described by Pape et al. [35].
DCO consists of four phases [36]. In the first phase,
lifesaving interventions are performed according to ATLS.
In the second phase, measures are taken to control hem-
orrhage and temporarily stabilize major skeletal fractures.
External fixation and traction techniques are often used
during this phase [37]. Phase three consists of intensive
care unit management and stabilization of additional inju-
ries (i.e., pulmonary contusions, fluid shifts, and immuno-
logical changes). In the final phase, fractures are
definitively repaired. In general, definitive fixation usually
occurs between the 5th and 10th days post-injury [23, 38].
During days 24, definitive orthopedic repair is not advised
due to ongoing immunological changes, tissue edema, and
fluid shifts; patients undergoing definitive repair during this
timeframe have been observed to have a higher risk for
multiple organ dysfunction syndrome and other complica-
tions, such as acute respiratory distress syndrome (ARDS)
[39, 40]. A DCO strategy is preferred for femur fractures in
patients with multiple injuries based upon this rationale
[4042].
Pelvic ring injuries are relatively rare, but associated with
a poor prognosis, particularly when associated with hemor-
rhagic shock. The pelvis can accommodate up to 4 l of blood
before the pressure from a hematoma tamponades bleeding
vessels [43]. 90 % of all bleeding in pelvic fractures origi-
nates from venous disruption; arterial bleeding is less com-
mon [23]. Hence, selective angiographic embolization is
frequently utilized to achieve hemodynamic stability (dis-
cussed in the section below) [44]. The care of these patients
requires a unique multidisciplinary approach since the deci-
sion to take the patient to the OR for a laparotomy and pelvic
packing is only prudent for hemodynamically unstable pa-
tients [23, 44, 45]. The overall strategy for managing patients
with radiologically confirmed or suspected pelvic fractures is
described in Fig. 1.
The ideal timing of spine fracture internal fixation in
patients with multiple severe injuries remains controversial
[46]. Some have proposed that delayed fixation of thora-
columbar fractures may help avoid lethal complications, as
has been shown with femur fractures [46]. There is cur-
rently no consensus on the ideal timing and modality of
spine fracture fixation in multiply injured patients, and
prospective multicenter trials are indicated to provide
clarification on which groups of patients might benefit from
DCO.
Damage Control Radiology
The decision to take a patient to the OR for the manage-
ment of life-threatening hemorrhage presupposes that
operative intervention is the best method of controlling
active hemorrhage. For example, the finding of free fluid in
the abdomen during a FAST exam in the setting of
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 Curr Anesthesiol Rep

Table 1 Indications for damage control orthopedics (DCO)

Parameter Stable (grade I) Borderline (grade II)a Unstable (grade III) Extremis (grade IV)

Shock
Blood pressure (mmHg) C100 80100 6090 \5060
Lactate (mmol/L) 02 28 515 [15
No. of PRBCs (2 h) Normal &2.5 [2.5 Severe acidosis
Base excess (mmol/L) Normal [618
ATLS classification I IIIII IIIIV IV
Urine output (mL/h) [150 50150 \100 \50
Coagulation
Platelet count (mcg/mL) [110,000 90,000110,000 \70,00090,000 \70,000
Factor II & V (%) 90100 7080 5070 \50
Fibrinogen (g/dL) [1 &1 \1 DIC
D-Dimer Normal Abnormal Abnormal DIC
Temperature
(C) [35 3335 3032 B30
Soft tissue injuries
PaO2/FiO2 ratio [350 300 200300 \200
Chest AIS AIS I or II AIS C 2 AIS C 2 AIS C 3
Thoracic trauma score O III IIIII IV
Abdominal trauma score BII BIII III CIII
Pelvic trauma (AO) A B or C C C (crush, rollover with
abdominal trauma)
Extremity AIS AIS I or II AIS IIIII AIS IIIIV Crush, rollover (with
extremity injuries)
Patients meeting criteria in grades IIIV should have a DCO approach
Adapted from Pape et al. [35], with permission from Wolters Kluwer Health
Pelvic trauma modified Muller AO classification-A, posterior arch intact; B, rotationally unstable/vertically unstable/incomplete disruption of the
posterior arch; C, rotationally and vertically unstable/complete disruption of the posterior arch. (From Muller [65]). (I) DIC-disseminated
intravascular coagulation, abdominal trauma score, (II) any injury to common hepatic artery, splenic artery or vein, right/left gastric arteries,
gastroduodenal artery, inferior mesenteric vessel; (III) any injury to superior mesenteric vessels, iliac vessels, hypogastric vessel, infrarenal vena
cava; (IV) any injury to superior mesenteric vessels, celiac axis, suprarenal, or infrahepatic aorta; (V) portal vein, retrohepatic/duprahepatic vena
cava, and suprarenal/subdiaphragmatic aorta. AIS-abbreviated injury scoreaAdditional factors to consider in borderline patients: Injury
severity score[20 with additional thoracic trauma (AIS 2), polytrauma with abdominal/pelvic trauma and hemodynamic shock, ISS 40 or above
in the absence of additional thoracic injury, bilateral lung contusions on radiographic studies

penetrating trauma will almost always necessitate an
operative exploration without the need for further evalua-
tion [47]. In the setting of blunt trauma, however, the
operative decision tree can be more complex, even in the
unstable patient. In the setting of blunt abdominal trauma,
the utility of the FAST exam has been questioned and more
importance placed on the whole-body CT scan, particularly
in the hemodynamically stable patient [48]. The hemody-
namically unstable blunt trauma patient has been more of a
challenge with a positive FAST exam typically leading to
an exploratory laparotomy [48]. Recent changes in radio-
logic technology may alter future management strategies in
the hemodynamically unstable patient with blunt and
penetrating trauma where non-operative options such as
endovascular stenting or transarterial catheter embolization
(TAE) may be a preferred management strategy. The
anesthesiologist managing the traumatically injured patient
should understand the evolving practice of Damage Con-
trol Radiology (DCRad) and how this interacts with their
role in the perioperative management of these patients.
The concept of DCRad was described by Gay and Miles
in their review of imaging used in trauma decision making
for wartime casualty management [49]. The aims of
DCRad are listed in Table 2.
To achieve these aims, imaging studies must be fast,
accurate, and sufficiently detailed if they are to be of value
in the decision making process while not unduly delaying
definitive care. Traditional imaging such as digital chest
radiographs immediately available for review at the point
of resuscitation and the FAST exam are routinely used in
the primary survey although each of these has limitations in
selected settings. With DCRad, more importance is placed
on whole-body CT scans with the use of contrast although
questions remain about the appropriate sequencing and

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Curr Anesthesiol Rep
Fig. 1 Algorithm for management of pelvic fractures in the patient with multiple severe injuries. EFAST extended focused assessment
sonography for trauma, CT computerized tomography, Ex-Fix external fixation. From Nicola [23]. 2013 Ratto Nicola
interpretation of these studies in the unstable patient.
Expanding on the role of DCRad as a diagnostic tool, early
involvement with interventional radiology can also be very
useful in the management of the bleeding trauma patient.
One of the longstanding arguments for not routinely
obtaining CT evaluation of the unstable trauma patient is the
delay in care caused by movement to and from the scanner
combined with the study acquisition and interpretation time.
It has been suggested that the philosophy of care that the
unstable patients should not be taken to the CT scanner is
widely accepted but not based on any evidence [50]. With
the positioning of multidetector CT scanners in close prox-
imity to trauma resuscitation units and EDs, it is now fea-
sible to rapidly obtain a non-contrast head CT scan followed
by a dual-phase contrast injection for the neck and trunk to
identify injuries requiring the most urgent management
including any active bleeding or solid organ laceration
[50]. Typically these scans can be completed in less than 3
min in addition to the transport and patient positioning time.
With rapid review of the results by trained radiologists, the
trauma surgeon and resuscitation team can more quickly
define specific injury patterns compared to traditional
assessment methods [51].
Several studies have suggested that CT scans can be
accomplished without increased mortality in hypotensive
patients provided they are obtained quickly and with ongoing
resuscitation [52, 53]. Wada et al. examined the impact of
obtaining a CT scan prior to interventions in a retrospective
blunt trauma patient population that subsequently required
emergency bleeding control [52]. In a multivariate analysis,
obtaining a CT scan was an independent predictor for
probability of increased 28-day survival. In a subgroup
analysis of patients with more severe trauma (Trauma and
Injury Severity Score Probable Survival, TRISS Ps \50 %)
and shock index [1 before CT scan, they observed a better
survival rate for CT scan patients than that predicted by the
TRISS method. Additionally, there was no difference in
survival rate of non-CT scan patients suggesting that whole-
body CT scans performed in the most seriously injured and
unstable blunt trauma patients may be associated with
improved survival. Looking at a retrospective population of
909 blunt trauma patients, Fu and colleagues identified 91
(10 %) patients who remained hypotensive (systolic blood
pressure, SBP \90 mmHg) after their initial resuscitation
[53]. Fifty-eight (63.7 %) of the hypotensive patients
underwent full body CT scan before receiving definitive
123

Table 2 Aims of damage control radiology
Identification
Life-threatening injuries
Need for emergent thoracic or abdominal surgery
Traumatic brain or spinal cord injury in multi-trauma patient requiring
additional monitoring or therapeutic interventions
Adapted from Gay and Miles [49], with permission from BMJ Publishing Group Ltd
treatment compared to 68.8 % of the non-hypotensive
patients. There was no difference in mortality or the time to
definitive hemostasis with surgery or angiography with
embolization for either group suggesting the CT scan did not
alter the treatment timeline. During the review period, the
authors also noted that the percentage of hypotensive
patients getting a CT scan increased from 26 % in 2008 to
88 % by 2013.
In the only published randomized trial comparing the
effects of early CT scans obtained immediately in the
resuscitation room compared to CT scans obtained at a
more remote location, the authors found no improvement
on clinical outcomes with only trends toward decreased
mortality with earlier CT scans despite faster completion of
the CT scan [54]. Unfortunately, this study was done in two
different facilities with all patients in each arm of the study
coming from a different institution introducing potential
treatment bias into the results. A follow-on study to this
work, the Randomized Study of Early Assessment by CT
Scanning in Trauma Patients-2 (REACT-2) trial, is a
multicenter randomized clinical trial comparing whole-
body CT scan during the primary survey to local conven-
tional trauma imaging protocols supplemented by selective
CT scans [55]. The results of this study should help clarify
the role of early whole-body CT scans in both the
stable and hypotensive blunt trauma patient.
With an increased usage of early whole-body CT scans
in the actively bleeding patient, the anatomical knowledge
gained from these studies allows greater choice between
open and endovascular control of hemorrhage in several
clinical scenarios. Increasingly, personnel involved in the
initial management of the severely traumatized patient,
including surgeons, emergency medicine physicians, and
anesthesiologists, will need to interface with IR to control
active bleeding prior to an operative intervention, sec-
ondary control after an operative procedure, or as the pri-
mary means of hemorrhage control in order to avoid a trip
to the OR. While many of these procedures are handled
outside of the traditional OR, the advent of hybrid ORs
with combined operative and IR support has brought these
patients more into the perioperative environment. The
123
Curr Anesthesiol Rep
Interventions
Provide control of ongoing bleeding through interventional
radiology techniques including:
Temporary balloon arterial occlusion
Embolization to occlude arteries
Stent grafting to repair injured vessels
Refinement of surgical and therapeutic options
anesthesiologist should be familiar with triage decisions in
these patients to better prepare for support of ongoing
resuscitation during IR treatment or to anticipate subse-
quent operative requirements. Common scenarios that have
both open and IR management options include: splenic,
liver, and pelvic hemorrhage.
Splenic injury is a common finding after blunt trauma and
has largely become a non-operative diagnosis except in the
setting of hypotension or peritoneal signs where emergent
laparotomy is used to make the diagnosis. The increase in
non-operative management, however, does show significant
institutional variation with an early operative rate between 7
and 67 % in the United States in 2005 [56]. Need for
angiographic evaluation and possible TAE is now largely
limited to patients with Grade IV or V injury, presence of
contrast blush or pseudoaneurysm on CT scan, moderate
hemoperitoneum, or evidence of ongoing splenic bleeding
(unexplained decline in hemoglobin over time) [57, 58]. In
the most recent multicenter prospective observational study
of non-operative management of blunt splenic injuries not
requiring operative management within the first 24 h, Zar-
zaur et al. noted that 70 of 383 patients (18.3 %) underwent
angiography on admission with 61 (15.9 %) also undergoing
TAE [59]. Interestingly, the likelihood of subsequently
requiring splenectomy after TAE (2.8 %) was not statisti-
cally different than those patients not undergoing TAE.
Similarly, in a recent single-center study comparing proto-
colized TAE for all patients with Grade III or higher injuries,
a 5 % failure rate was observed compared to a historical
failure rate of 15 % with non-operative management with
less use of TAE [60]. With the increasing availability of
hybrid ORs and vascular surgeons taking on more respon-
sibility for trauma-related angiography/TAE cases, these
patients will be increasingly seen by anesthesiologists in the
perioperative environment.
Severe blunt liver injury has similarly shifted to a more
non-operative management strategy in the stable patient.
Current recommendations from the Eastern Association for
Surgical Trauma (EAST) for blunt liver injury in the setting
of hemodynamic instability or diffuse peritonitis remain the
same as those for splenic injuries with emergent exploratory
Curr Anesthesiol Rep
laparotomy being a Level 1 recommendation. In a recent
review of blunt hepatic injury management, Melloul and
colleagues reviewed studies covering 4946 patients [61].
They noted that a median of 66 % of patients were managed
non-operatively and only 3 % required TAE with a 93 %
success rate. Despite the reportedly high success rate,
930 % of patients ultimately required a laparotomy. More
importantly, of the 31 % requiring initial operative man-
agement, 1228 % of these patients went on to get sec-
ondary TAE in the setting of recurrent or uncontrolled
hepatic bleeding. Current recommendations suggest that the
patients with blush on CT scan or who fail non-operative
management should be considered for TAE [61, 62].
A final group of patients that may also require early
TAE with or without operative requirements are those with
pelvic fractures and associated hemorrhage. This group of
patients, unlike those with solid organ injuries, may benefit
from earlier TAE rather than operative interventions since
surgical control of retroperitoneal hemorrhage is difficult if
not impossible in many patients. Of note, much of the
hemorrhage may come from the venous plexus or bleeding
cancellous bone making control through TAE difficult.
Current EAST guidelines recommend that patients with
pelvic fractures and hemodynamic instability or signs of
ongoing hemorrhage should be considered for pelvic
angiography and TAE with avoidance of an exploratory
laparotomy if possible [48]. The timing for embolization
remains a question since many institutional protocols strive
for external pelvic fixation prior to TAE, whereas others
pursue embolization as the first priority [36, 63, 64].
There is some evidence that earlier embolization may
affect survival. Tanizaki et al. performed a retrospective
review of 140 patients with pelvic ring fractures with 68
(49 %) undergoing angiography and TAE [64]. They found
that patients embolized within 60 min of arrival had a sig-
nificantly lower mortality rate (16 vs 64 %) than those with a
longer time to embolization (average time to embolization
was 76 min). A pelvic binder was placed if hypotension was
present but angiography was not delayed for external fixation.
Not all studies have shown a benefit to earlier TAE in
the patient with unstable pelvic fractures. Thorson et al.
reported on their experience over a 12-year period from
1999 to 2011 with 2922 patients with pelvic fractures [45].
Of those patients, only 183 (6 %) underwent angiography.
When looking at the sequencing, 49 (27 %) went to the OR
before angiography and the remainder went to angiography
first. The rate of TAE was similar between groups (71 vs
62 %) with no difference in mortality or length of stay. In a
recent Italian consensus conference, the participants felt
that the current level of evidence did not support the use of
angiography and TAE as the initial treatment strategy and
recommended preperitoneal pelvic packing and external
fixation as the first line of therapy.
Conclusion
In summary, there appears to be a trend toward a more
damage control approach in the early management of the
severely injured patient for both diagnosis and therapeutic
interventions. When combined with the advent of hybrid
ORs and surgeons trained in interventional radiology
approaches, it is clear that the anesthesiologist participating
in the care of these patients should have an understanding
of the triage approach for both operative and non-operative
management. Decisions regarding ongoing resuscitation,
transfers for imaging, and whether IR or surgery is the
appropriate approach to manage bleeding are complex in
this heterogeneous population and should include the
anesthesiologist participating in the perioperative man-
agement of the patient.
Compliance with Ethics Guidelines
Conflict of Interest Samuel M. Galvagno Jr., Robert A. Sikorski,
Christopher Stephens, and Thomas E. Grissom declare that they have
no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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Papers of particular interest, published recently, have been
highlighted as:
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Curr Anesthesiol Rep
DOI 10.1007/s40140-015-0130-9
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
The Anesthesiology/Emergency Medicine Combined Residency:
Defining a New Future for Trauma Resuscitation
Joshua M. Tobin1 Philip D. Lumb2
 Springer Science + Business Media New York 2015
Abstract As management of patients in extremis
becomes increasingly complex, the need for a resuscitation
consultant is apparent. This physician must be able to
provide and/or coordinate care for the acutely ill and
injured patient across the continuum of care; from pre-
sentation to definitive care to disposition. The resuscitation
consultant produced by a residency in anesthesiology and
emergency medicine will capitalize on the complementary
strengths of both programs; a 60-month residency will offer
board eligibility in both specialties. The first (PGY-1) year
will be spent as an intern on the emergency medicine
service and the second (PGY-2) year will be spent on the
anesthesiology service as a clinical anesthesiology-1 resi-
dent. The remaining 3 years will be split into 18 months
each of anesthesiology and emergency medicine. Approval
of the program in anesthesiology and emergency medicine
by appropriate governing bodies is a pre-requisite for
program establishment. While medical students will
determine the success of the program in anesthesiology and
emergency medicine (for it is they who are the prospective
applicants to the program), it is the patient who will be the
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Joshua M. Tobin
joshua.tobin@med.usc.edu
Philip D. Lumb
lumb@med.usc.edu
1
Trauma Anesthesiology, Keck School of Medicine of
University of Southern California, 1520 San Pablo Street,
Suite 3451, Los Angeles, CA 90033, USA
2 Anesthesiology combines a thorough understanding of the
Department of Anesthesiology, Keck School of Medicine of
University of Southern California, 1520 San Pablo Street,
HCT 3451, Los Angeles, CA 90033, USA
beneficiary of a uniquely trained resuscitation consultant. A
physician who is at ease diagnosing undifferentiated dis-
ease, managing resuscitation in the operating room or
interventional radiology suite and managing the critically
ill patient throughout the care continuum will define the
future specialty.
Keywords Trauma
Resuscitation
Residency

Simulation
Anesthesiology
Emergency medicine
Introduction
The role that resuscitation plays in the care of the injured
patient has become more apparent as the management of
trauma matures in the context of lessons learned from the
past decade of conflict in Iraq and Afghanistan. The prompt
application of basic medical technologies like tourniquets
have saved many lives on the modern battlefield, just as
they did on battlefields of the past [1]. Refinements of
trusted therapies like blood transfusion have improved
outcomes, and rigorous investigations continue to define
the margins for improvement in trauma resuscitation [24].
A perfect surgery performed on a poorly resuscitated
patient is of no benefit. Similarly, aggressive resuscitation
without equally effective surgery is also a failure. The role
of the anesthesiologist in resuscitation defines the trauma
anesthesiologist. Procedural fluency, while required for the
anesthesiologist, should not limit the specialty to a purely
technical role. Anesthesiology is no more defined by (or
limited to) endotracheal intubation than the specialty of
critical care is defined by ventilator management. Trauma
pathophysiology of acute illness with the interplay of
anesthetics during an on-going resuscitation; there is no
123

currently available physician specialist training program
that incorporates the appropriate elements to accomplish
this goal.
The emergency physician understands the challenges
inherent in the diagnosis of undifferentiated disease and the
pathophysiology of the critically ill patient under physio-
logic stress (e.g., trauma, sepsis). The emergency physi-
cians intervention as the first physician responder for
many trauma patients is integral to the continuum of care
for these patients; appropriate primary care defines the
subsequent hospital course and outcome.
A combined residency in anesthesiology and emergency
medicine can incorporate and supplement the strengths of
these two specialties to manage patients along the contin-
uum of resuscitative and definitive care. As medical prac-
tice continues to find more resources outside traditional
medical constructs (e.g., mid-level providers, on-line
resources), physician consultants must provide a value
added commodity. The resuscitation expert will consult
on patients in the emergency department, manage their
medical care in the OR/IR suite, and coordinate their
ongoing management in the ICU. The future of physicians
in hospital-based practices will be defined by their capacity
to rescue, manage, and coordinate care across a wide
spectrum of diseases and environments of care.
Combined Programs
The concept of a combined anesthesiology and emergency
medicine program is not without precedent. Both anes-
thesiology and emergency medicine offer programs of
combined study with internal medicine. The objective of
these programs is to develop physicians who integrate the
similarities of specialties with significant didactic and
clinical overlap while amplifying the unique contributions
of each in the final curriculum. Physicians with combined
training offer a sophisticated perspective on complex
clinical problems (e.g., a patient with significant chronic
medical issues who presents for a complex anesthetic, or a
patient who presents repeatedly to the emergency depart-
ment with multiple co-morbidities). These combined pro-
grams offer a template for an anesthesiology
emergency/trauma medicine program; a description of the
anesthesiology/internal medicine and internal medicine/
emergency medicine programs bears consideration.
The combined anesthesiology/internal medicine resi-
dency, established in 2012, requires 5 year for completion
[5, 6]. When taken as separate courses of study, the
anesthesiology and internal medicine programs would
require 6 years to complete. To be eligible for board cer-
tification in both fields, a resident must complete a
60-month combined program. This represents a 12-month
123
Curr Anesthesiol Rep
reduction in training time that is possible due to the overlap
of curricula in each specialty. The American Board of
Internal Medicine (ABIM) requirement of 36 months of
training time is met by 30 months of training in internal
medicine; and supplemented with 6 months of training
appropriate to internal medicine accomplished during the
anesthesiology curriculum. The American Board of Anes-
thesiology (ABA) requirement of 48 months of training is
met by the first year of internal medicine internship com-
bined with 30 months of training in anesthesiology, and
supplemented by 6 months of anesthesiology-related
experience in the internal medicine program.
The first year (PGY-1) is the internship in internal
medicine. The second year (PGY-2) is devoted to
12 months of training in anesthesiology. In the remaining
3 years, residents must spend 6 months in each specialty
per annum, typically divided into 3-month blocks.
Specific requirements throughout the 30-month internal
medicine program include:
20 months of internal medicine inpatient and outpatient
rotations, to include geriatrics (at least 1/3 of rotations
must be inpatient and at least 1/3 of rotation must be
outpatient)
A 4-week experience in the emergency department
during the PGY-1 year
Four months of medical critical care, and 1 month of
surgical critical care
An ambulatory experience with a minimum of 130
half-day outpatient sessions
Specific requirement throughout the 30 months of
anesthesiology training include:
Two single-month rotations in obstetric, pediatric,
neuro-, and cardiothoracic anesthesia
One month of critical care during each of the last
3 years
Three months of pain medicine, typically divided into
chronic pain, acute pain, and regional anesthesia
rotations
One month in the pre-operative clinic
Two weeks in the post-anesthesia care unit
Requirements for procedural proficiency must be met in
both fields. In-training exams, continuing clinical (faculty
on resident/resident of faculty/resident on program)
assessments, and participation in regular conferences in
both disciplines must be attended throughout the
60 months. Documentation of ACGME core competencies
must be tracked throughout the training period.
In 1989, the American Boards of Internal Medicine and
Emergency Medicine began to offer dual certification for
candidates who had completed combined residency pro-
grams in internal medicine and emergency medicine [7].
Curr Anesthesiol Rep
The program is 60 months in length, similar to the anes-
thesiology/IM combined program; with 30 months of
training each devoted to internal medicine and emergency
medicine.
Requirements specific to IM include:
20 of the 30 months in internal medicine must include
direct management of patients within the domain of
internal medicine
Three months of critical care
Seven months of non-intensive care inpatient rotations
Four months of IM subspecialty experience
Two months of ambulatory medicine
A maximum of 3 months of emergency medicine
A continuity experience in which residents attend a
one-half day per week continuity care clinic
Geriatric and general medical consultant service
experience
At least 1/3 of the 30 months must involve outpatient
rotations
Significant exposure to cardiology, psychiatry, and
neurology
Requirements specific to EM include:
3 % of the patient population must present with critical
illness
Pediatric patients should account for 16 % of all
emergency department encounters; or 4 months of full
time experience caring for infants and children, of
which 2 months must be in the emergency department.
Two months of critical care from the IM program may
be credited to the EM curriculum
Clinical experience in emergency medical services and
trauma management
Competency
Ultimately, any curriculum must develop physicians with
documented competency in the care of acutely ill and
injured patients. Competency, however, is often difficult to
define. The Accreditation Council for Graduate Medical
Education (ACGME) has defined competency in six areas;
knowledge, patient care, professionalism, communication
& interpersonal skills, practice-based learning &
improvement, and system-based practice. Their focus is on
development of clinical competency rather than a system
based primarily on time in training.
Recently the Accreditation Council for Graduate Med-
ical Education and the American Board of Anesthesiology
introduced a joint initiative entitled the Anesthesiology
Milestone Project [8]. The Milestone Project provides a
template for semi-annual review of resident performance
along a spectrum of identified benchmarks. While not
intended to be assess the entirety of the six domains of
physician competency, the Milestones provide a frame-
work in which to assess development of resident knowl-
edge, skills, attitudes and other attributes from program
entry to graduation. Five distinct levels evaluate trainees
from post-graduate year 1 (level 1) to a few exceptional
residents who exceed expectations of new residency
graduates (level 5).
In a similar effort to quantify competency, Millers
model of competence describes several levels of under-
standing (i.e., knows, knows how, shows how, does) [9]. At
the basic level, one knows the material at the knowledge
level. One knows how a process works at the next higher
level, followed by one who meets expectations and shows
how to perform a task. Finally, a trainee acts indepen-
dently (i.e., the does level). Competency has also been
described as a continuum from unconscious-incompetence
to unconscious-competence. The unconsciously incompe-
tent physician doesnt know what they dont know; they
are dangerous. A consciously incompetent physician is
aware of their limitations, but is not able to perform
without supervision (e.g., junior residents). A consciously
competent physician is safe and capable (e.g., senior trai-
nee or program graduate). Unconscious-competence
defines mastery of the specialty. Rarely, senior physicians
will achieve this distinction. Unfortunately, the uncon-
sciously incompetent individual is difficult to distinguish
from those who are unconsciously competent, drawing
attention to the need to evaluate competency.
Learning Styles
Individual learning styles are an important consideration in
competency determination. Flemings VAK/VARK model
divides learning into visual, auditory, reading, and kines-
thetic/tactile styles [10]. Visual learners conceptualize
ideas visually and use cognitive aids. Auditory learners use
speech and hearing to place concepts within a familiar
construct. They may prefer background music while
studying and sometimes like to talk out a problem. They
tend to benefit from podcasts, lectures, and other auditory
formats. Reading learners prefer to assimilate information
from a well-referenced text. Tactile learners, or kinesthetic
learners, use touch and movement to assimilate concepts;
and benefit from active experimentation. Ultimately,
learners have some component of all learning styles and
may benefit from a multi-disciplinary approach.
As noted above, defining competence in medical prac-
tice is an elusive goal, and different learning styles have
not been prospectively associated with performance [11,
12]
123

Evaluation of Learning
The fundamental knowledge base of any specialty is pro-
vided by comprehension of basic concepts in that subject.
Standardized testing with multiple choice questions screens
for a basic level of understanding. While these exam for-
mats can efficiently evaluate large numbers at a funda-
mental level, there are significant limitations to their ability
to demonstrate mastery of subject matter.
An American medical schools first 2 year curriculum
was evaluated using Moores expanded outcomes frame-
work [13]. Questions were categorized as those requiring
rote memorization (level 3A), questions requiring appli-
cation of knowledge (level 3B), and questions evaluating
competence by requiring [showing] how to do what the
educational activity intended them to be able to do (level
4). The authors noted that some level 3A questions could
even be answered without reading the entire question.
The first year of medical school focuses on acquisition
of facts, with nearly 90 % of exams testing what is
essentially recall. Procedural (application) questions
accounted for 14 % of exam content. The second year of
medical school did demonstrate an increase in procedural
questions, with nearly 90 % of exams evaluating knowl-
edge application. No exams contained competence level
questions. Allied health education offers a similar educa-
tional style [14].
Acquisition of a knowledge base set is an undeniable
component of education; however, these evaluation for-
mats are often focused on recall. Competence in tactile
procedures (e.g., endotracheal intubation, suturing, bron-
choscopy), mastery of concepts (e.g., pathophysiology,
pharmacology), and analytical synthesis (e.g., development
of treatment plans) are all part of medical education.
Simulation
In simulation, idealized scenarios are presented in which
potentially dangerous situations are evaluated. Creation of
a training team environment, without risking the safety of
actual patients, offers one of the great advantages of sim-
ulation. Leadership styles can be critiqued and communi-
cation can be improved.
Abrahamson introduced computerized evaluation of
anesthesiology residents ability to intubate in the 1960s.
Gaba subsequently recreated the training environment with
more advanced anesthesia simulators [15]. A tactile oper-
ating room simulation experience was created in a safe
(off site) environment utilizing appropriate equipment and
actors and/or other trainees from relevant disciplines
schooled with appropriate scripts necessary to complete
123
Curr Anesthesiol Rep
the simulated experience. Simulation sessions were con-
ducted using the pre-designed scripts (unknown to the test
subject) and directed by simulation staff. Test subjects
participated in scenarios and feedback questionnaires were
evaluated. Simulation was identified as a realistic training
tool for potentially risky procedures.
While simulation can improve communication and
adherence to protocols, there has been little data to
demonstrate improvement in outcome [16]. Nevertheless,
simulation has been incorporated in graduate medical
education, and even board certification. Ziv described the
use of simulation in an Objective Structures Clinical
Examination (OSCE), in anesthesiology board certification
[17]. Ziv concludes; there is no doubt that incorporating
simulation and OSCE for testing and evaluation should
play a formative (training) and a summative (testing) role,
involving the anesthesiology board.
Simulation offers the opportunity to practice procedures
before attempting them on a patient, and the ability to
simulate emergencies like cardiovascular collapse or
malignant hyperthermia. Facilitator monitored video replay
analysis offers further valuable feedback. While simulation
offers a valuable lesson in reinforcing procedural skills
necessary for medical practice, the evaluator must appre-
ciate the limitations of simulation.
The Program in Anesthesiology and Emergency
Medicine
Qualification in anesthesiology has undergone significant
change recently. Anesthesiology board certification cur-
rently involves a basic sciences examination at the con-
clusion of the introductory anesthesia year, followed by a
clinical sciences examination at the completion of the
program. A combined oral exam and procedural skills
demonstration, similar to well-known simulation sessions,
will replace the traditional oral exam with no procedural
component. The emergency medicine board certification
process also involves written and oral exam formats. This
evaluative system will capitalize upon a range of educa-
tional platforms (e.g., lectures, clinical rotations, individual
study). As specialties across the practice of medicine
debate the ideal method to train for and to maintain pro-
ficiency in an increasingly complex medical landscape,
educational constructs that share similarities across spe-
cialties can be leveraged to refine resident education and
board preparation.
The combined residency in anesthesiology and emer-
gency medicine will be patterned after other combined
programs; and will capitalize on similarities in both pro-
grams. A 60-month residency will offer board eligibility in
Curr Anesthesiol Rep
Table 1 The program in anesthesiology and emergency medicine
PGY-1 PGY-2 PGY-3
Emergency Anesthesiology 2 months CCM
medicine CA-1 general OR 2 months Anes Peds
PGY-1 internship 2 months EM Peds
1 month Anes OB
1 month EM OB
2 months Anes general OR
2 months EM non-acute ED
PGY post-graduate year, CA clinical anesthesia, CCM critical care medicine, Anes anesthesiology, Peds pediatrics, EM emergency medicine, OB
obstetrics, OR operating room, ED emergency department, Neuro neurosurgery, EMS emergency medical services
both specialties. The first (PGY-1) year will be spent as an
intern on the emergency medicine service. The second
(PGY-2) year will be spent on the anesthesiology service as
a clinical anesthesiology-1 (CA-1) resident. Initial intro-
duction to both specialties with a year of uninterrupted
study will immerse the resident in the clinical approach to
undifferentiated disease (i.e., emergency medicine) as well
as to the management of the perioperative patient (i.e.,
anesthesiology).
While appreciation for the pathophysiology of disease is
the foundation of all physician education, the curricula in
anesthesiology and emergency medicine also emphasize
mastery of procedures (e.g., endotracheal intubation,
placement of vascular access). Procedures specific to
anesthesiology (e.g., transoesophageal echocardiography,
epidural placement) and emergency medicine (e.g.,
transthoracic echocardiography, fracture reduction) can be
learned in the periods of instruction specific to those spe-
cialties. Rotations in critical care will benefit both spe-
cialties and serve to consolidate several months of training
time.
The remaining 3 years will be split into 18 months of
anesthesiology and emergency medicine each (Table 1).
This will accommodate the required rotations in anesthe-
siology (i.e., 2 months of obstetric, pediatric, neuro-, and
cardiothoracic anesthesia, 3 months of pain medicine,
1 month in the pre-operative clinic, and 2 weeks in the
post-anesthesia care unit); as well as emergency medicine
(i.e., 4 months of pediatrics, 2 weeks of obstetrics, a clin-
ical experience in emergency medical services and trauma
management, and a broad clinical experience in the
emergency department).
Specific education in trauma anesthesiology has recently
drawn attention, due in part to the American College of
Surgeons requirement that Level 1 Trauma Centers desig-
nate directors of trauma anesthesiology. A growing body of
literature has emphasized the role of the anesthesiologist as
PGY-4 PGY-5
1 month CCM 1 month Anes cardiothoracic
2 months Peds EM 1 month Anes Neuro
1 month Anes OB 1 month Anes pain
1 month Anes cardiothoracic 2 months Anes general OR
1 month Anes Neuro 4 months EM acute care ED
2 months Anes Pain 2 months EM non-acute ED
1 month Anes pre-op clinic 2 weeks EMS ? 2 weeks Anes
1 month EM non-acute ED PACU
2 months EM acute care ED
resuscitation consultant, and a curriculum for trauma
anesthesiology has been suggested by the Committee for
Trauma and Emergency Preparedness (COTEP) of the
American Society of Anesthesiologists [18, 19].
The similarity in clinical approach and procedural skill
sets of anesthesiology and emergency medicine has been
noted during the past decade of conflict. Anesthesiologists
and emergency physicians have provided forward resusci-
tative care aboard military evacuation platforms such as
American Critical Care Air Transport and British Medical
Emergency Response Teams [20]. The complementary
training of these specialties in the acute care of hemody-
namically unstable patients offers an opportunity to con-
solidate educational objectives in order to develop a
physician uniquely qualified to care for the patient while in
extremis and throughout the care continuum. The com-
bined program in anesthesiology and emergency medicine
provides a mechanism for formalized training of these
unique physicians.
Conclusion
The resuscitation consultant produced by a residency in
anesthesiology and emergency medicine will be able to
care for the acutely ill and injured patient across the con-
tinuum of care; from presentation, during definitive care
through disposition. This new type of physician must be
comfortable filling an important, yet somewhat standard-
ized, role during critical times in a patients hospitalization.
This may seem to be at odds with the more traditional,
individualized role of physician as artisan; however, it is
a realistic acknowledgment of the changing healthcare
environment.
Appropriate oversight and approval by the ACGME and
Residency Review Committees (RRC) for Anesthesiology
and Emergency Medicine are pre-requisites for program
123

establishment. Ultimately, it is medical students who will
determine the success of the program in anesthesiology and
emergency medicine, for it is they who are the prospective
applicants to the program. Finally and most importantly, it
is the patient who will be the beneficiary of a uniquely
trained resuscitation consultant who is at ease diagnosing
undifferentiated disease, managing resuscitation in the
operating room or interventional radiology suite and
moving along the continuum of care with the critically ill
and injured patients.
Compliance with Ethics Guidelines
Conflict of Interest Joshua M. Tobin and Philip D. Lumb declare
that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
References
Papers of particular interest, published recently, have been
highlighted as:
Of importance
Of major importance
1. Butler FK Jr, Hagmann J, Butler EG. Tactical combat casualty
care in special operations. Mil Med. 1996;161(Suppl):316.
2. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Pod-
bielski JM, et al. Transfusion of plasma, platelets, and red blood
cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with
severe trauma: the PROPPR randomized clinical trial. JAMA.
2015;313(5):47182. doi:10.1001/jama.2015.12.
3. Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine
T, Beekley AC, et al. The ratio of blood products transfused
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1097/TA.0b013e3181271ba3.
4. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal
LA, Schreiber MA, et al. Increased plasma and platelet to red
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5. American Board of Anesthesiology. Guidelines for combined
training in internal medicine and anesthesiology. In: Combined
training. 2015. http://www.theaba.org/PDFs/Internal-Medicine/
CombinedTrainingRequirementsInternalMed. Accessed 15 Apr
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0/pfassets/programrequirements/040_anesthesiology_07012014.
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program in anesthesiology and internal medicine.
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combinedim/comem.aspx-guidelines. Accessed 15 Apr 2015.
Defines specifications for combined program in internal medicine
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8. Culley DCN, Hall S, Kuhn C, Lewis L, Mason L, Nestler SP,
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medical education and american board of anesthesiology. 2013.
http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/
AnesthesiologyMilestones.pdf. Accessed 4 May 2015. Describes
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Verst AL. Assessment of multiple-choice questions in selected
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training. Anesthesiology. 1988;69(3):38794.
16. Okuda Y, Bryson EO, DeMaria S Jr, Jacobson L, Quinones J,
Shen B, et al. The utility of simulation in medical education: what
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1002/msj.20127.
17. Ziv A, Rubin O, Sidi A, Berkenstadt H. Credentialing and cer-
tifying with simulation. Anesthesiol Clin. 2007;25(2):2619.
doi:10.1016/j.anclin.2007.03.002.
18. Committee for Trauma and Emergnecy Preparedness (COTEP).
Curriculum for CA-1 and CA-2 residents. 2013. http://www.
asahq.org/For-Members/About-ASA/ASA-Committees/
Committee-on-Trauma-and-Emergency-Preparedness.aspx.
Accessed 19 July 2013.
19. Committee for Trauma and Emergnecy Preparedness (COTEP).
Curriculum for CA-3 residents. 2013. http://www.asahq.org/For-
Members/About-ASA/ASA-Committees/Committee-on-Trauma-
and-Emergency-Preparedness.aspx. Accessed 19 July 2013.
20. Kehoe A, Jones A, Marcus S, Nordmann G, Pope C, Reavley P,
et al. Current controversies in military pre-hospital critical care.
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Curr Anesthesiol Rep (2016) 6:6571
DOI 10.1007/s40140-016-0142-0
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Trauma Hand-Offs: Moving Patients Through Multiple Phases
and Locations of Care
George W. Williams II1 Christopher T. Stephens1 Carin Hagberg1
Published online: 19 February 2016
 Springer Science + Business Media New York 2016
Abstract Hand-off reports in hospitals have recently
gained attention as a potential safety issue regarding
overall patient care. This has been a particular concern in
the acutely injured patient. There is a paucity of research
regarding patient care hand-offs in a trauma center envi-
ronment and as a result, little has been done to change this
global problem. Hand-offs of trauma patients begin in the
emergency department between pre-hospital providers and
trauma center staff, and continue to the operating room,
ICU, as well as other locations. As a result, patient
assessment and critical information get lost along the way.
After reviewing the literature, we have identified some
important references and recommendations to improve
trauma patient hand-offs.
Keywords Emergency department hand-offs
Operating
room hand-offs
Trauma care communication

Intraoperative hand-off
Intensive care unit hand-off

SBAR
Introduction
Hand-offs affect nearly every medical specialty to some
degree. The term hand-off has multiple synonyms com-
monly applied in medical texts and literature. Some of the
This article is part of the Topical Collection on Anesthesia for
Trauma.
& George W. Williams II
george.w.williams@uth.tmc.edu
1
University of Texas Medical School at Houston, 6431 Fannin
Street, MSB Suite 5.020, Houston, TX 77030, USA
terms include transitions of/in care, handover, and signout
[1]. In either case, a patient hand-off is the transfer of
information and professional responsibility from one pro-
vider to another while a patient is admitted to a hospital or
a facility.
Pre-hospital (EMS) to Emergency Department
(ED)/Trauma Center Hand-Off
Handing off (sign out) of patients has been a cornerstone
of healthcare services since the inception of clinics and
hospitals. Unfortunately, as our healthcare system has
become more advanced and burdened with increased
numbers of patient admissions, there has been little pro-
gress made with respect to improved hand-off commu-
nication between pre-hospital providers and emergency
department (ED) staff. The hand-off (transfer of patient
care) from one healthcare provider to another is arguably
the most important skill during the care of the seriously ill
or injured patient [2, 3].
Anyone who has worked in a busy ED or trauma center
has witnessed the communication breakdown between
EMS and hospital receiving staff. The following scenario is
what typically occurs during this critical phase of patient
care:
Emergency medical services (EMS) roll into the trauma
bay with a critically injured patient where chaos ensues as
the medics attempt to move the patient from their stretcher
to the trauma room bed: Intravenous catheters get acci-
dentally pulled out during transfer, monitor cables get
tangled around the patient and beds, EMS providers
attempt to move their stretcher out of the way as nurses,
medical students, interns, residents, fellows, and physicians
bump into each other all trying to simultaneously assist
123
66
in evaluating and treating the patient.throughout this
organized chaos, the EMS providers are attempting to
communicate a patient field report on what has been
witnessed and the care that was performed prior to patient
arrival at the ED/Trauma Center. One of the nurses or
residents may hear part of what the medic is saying but in
reality, much of the EMS hand-off is lost in translation
and goes in one ear and out the other of the ED/Trauma
Center staff. The disgruntled medics then leave to prepare
for another call and a short time later, the attending
physician makes inquiry as to what drugs were adminis-
tered in the field, how much fluid patient received, and if
the vitals were unstable. No one really knows the answers
to these questions, as the medics have already departed and
the nurses have been too busy to chart anything that EMS
stated in their report. With any luck, a carbon copy of the
EMS run report may be left behind for someone to try
and interpret the scribbled notes, usually with minimal
success. After all, most EMS field patient care reports are
now electronic and a copy is unable to be accessed until
long after the patient has been treated and moved off to
other locations in the hospital, with multiple hand-offs
occurring throughout the process.
We can learn from these all too common experiences, as
we have tackled this problem in the operating room (OR)
through a very specific time-out checklist. This checklist
has essentially solved the problem of hand-off commu-
nication breakdown, as the patient is rolled to the OR to be
placed under anesthesia for a surgical procedure. A big
difference between the field/ED/trauma bay is that this
checklist is performed under a controlled setting in the OR,
with plenty of time to communicate any issues that need to
be addressed, such as antibiotic administration, correct
surgical procedure, appropriate consents. Often times, there
is a moribund patient in the trauma bay where a controlled
hand-off is very difficult for EMS providers to complete
in a timely fashion. In fact, studies have demonstrated that
ED staff recall less than half of the information that EMS
providers report during verbal hand-offs [46].
Unfortunately, hand-offs between EMS providers and
the ED/Trauma Center staff is a largely unstudied area of
health care. There are few reports in the literature with
respect to medic hand-offs to hospital staff. A review of
EMS safety by Bigham et al. showed that only 4 of 88
studies included in the review addressed EMS hand-offs
[7]. The primary reason for this is that there are very few
pre-hospital studies compared to hospital-based research.
Thus, studies involving hand-offs from the EMS providers
viewpoint are lacking, leading to slow advancement in this
important area of research.
A recent report by Meisel et al. attempted to address this
issue of EMS providers perspective during hospital hand-
offs. The goal of their study was to identify factors and
123
Curr Anesthesiol Rep (2016) 6:6571
issues involving the EMS hand-off process that occurs on a
regular basis, and attempt to address these issues in order to
streamline the process into a safer, more efficient, and
higher-quality patient-centered practice [8]. This study
demonstrated that EMS providers recommend the follow-
ing changes to the current hand-off process: communicat-
ing directly with the physician who will be responsible for
patient care, ED staff familiarity of EMS protocols and
field environment, as well as a standardized approach to the
hand-off report to include all critical aspects of field
assessment and care that occurred prior to arrival. Fur-
thermore, it was suggested that current technology be uti-
lized to bridge the gap between information exchanges [9].
The results of this study bolster previous research, which
demonstrated that EMS hand-off reports are variable in
content and organization, and that the majority of patient
information is delivered to clinicians not ultimately
responsible for the care of the patient [911].
Another well-organized study by Carter et al. attempted
to identify and utilize a trauma hand-off checklist of 16
key data elements in an urban academic trauma system.
The focus of the study was to identify these key data
elements that were actually transmitted (verbal deliv-
ery) to the trauma team staff by EMS providers yet not
received (documented by trauma team). The results of
this elegant study demonstrated that only 72.9 % of data
elements transmitted by EMS were received by the
trauma team. The most common transmitted data elements
were mechanism of injury, anatomic location of injury, and
age. One significant limitation of this study was that the
16-data-element list is not applicable to every trauma
patient (blunt vs penetrating) [12]. Further work on this
important topic included an observational study by Sarce-
vic and Burd on EMS patient report hand-off to trauma
team members [13]. This group examined the character-
istics of information handover between EMS and trauma
team members during trauma resuscitations. The results of
this observational study suggested that a significant number
of pre-hospital hand-off reports are incomplete, thus trig-
gering a barrage of questions from the trauma team, some
of what may or may not be important at the time and likely
will not be recalled by team members. This study group
further suggests that problems occur when EMS reports are
disorganized, lack key information, such as procedures/
treatments performed at the scene and en route, as well as
response to those treatments. In addition, electronic com-
plete field reports take time to complete after the fact and
are usually not easily accessible to the ED/Trauma Center
staff [13].
It is evident from the few well-designed studies
involving EMS hand-offs to ED/Trauma Center staff that
there are several potential pitfalls that occur with each
patient hand-off encounter. In general, the EMS providers
Curr Anesthesiol Rep (2016) 6:6571
do not give the key data information points within a
certain time frame to the receiving trauma team in an
organized concise fashion that is understandable and to the
point. Secondly, the responsible clinician is not paying
attention to the verbal hand-off and is left with many
unanswered questions during the initial care of the patient,
as the EMS providers leave the trauma bay. Furthermore,
the recording representative (typically the trauma nurse)
fails to receive, inquire, and chart the key EMS data points
that need to be included in the patients medical record.
Emergency Department (ED) to Anesthesiology
(Operating Room) Hand-Off
Once the EMS hand-off has occurred, the trauma team
quickly assesses and performs any indicated life-saving
interventions, such as intubation, vascular access, chest
tube placement, and ultrasound FAST exam in the trauma
bay. If a surgical procedure is indicated, the attending
trauma surgeon typically says to post the case with
Anesthesia and call the OR charge nurse. A short time
later, the patient arrives to the OR and a very brief hand-
off occurs between the trauma nurse who transported the
patient and/or the intern, surgical resident or fellow, and
least likely the attending trauma surgeon to the anesthesi-
ology resident, advanced care practitioner, or least likely
the Anesthesiology attending. This hand-off typically
describes the mechanism of injury and blood product
administration in the ED/trauma bay. There may be a brief
discussion of vascular access and whether the patient was
intubated in the ED or field. The nurse then departs quickly
back to the busy ED, while the attending Anesthesiologist
attempts to decipher the tangle of monitors, vascular lines,
and a quick survey of the airway or oxygenation/ventila-
tion, if the patient is already intubated. Much of this hand-
off may have been watered down from the anesthesia operating room has essentially been overlooked in the lit-
resident or advanced care practitioner caring for the patient
under the medical oversight of the Anesthesiology
attending.
As peri-operative specialists, Anesthesiologists are
expected to quickly gather a patient history, perform a brief
focused physical exam, and prepare to anesthetize a criti-
cally injured trauma patient in a matter of minutes on
arrival to the OR. The end result is a potentially critically
ill patient with little, if anything, known regarding key
elements relevant to care (patient history, vascular access
and its functionality, blood product administration, medi-
cation administration, physiological responses, airway
difficulties and details of airway management, results of
chest X-rays, CT scans and FAST exams if performed, and
pre-hospital EMS reports). In reality, most of this critical
information is never filtered down to the attending
67
Anesthesiologist, who is responsible for the care of this
critically injured patient. It is up to that physician to seek
out this information from their surgical colleagues and
hope that they recall much of what has been performed in
the care of the patient up to this point. One can now see
how the major gaps in patient hand-off can and do take
place and that this is ultimately detrimental to definitive
patient care.
At The University of Maryland R Adams Cowley Shock
Trauma Center, attending trauma Anesthesiologists are
present for every trauma admission in the Trauma Resus-
citation Unit (TRU), which is located adjacent to the
trauma operating rooms. Thus, the attending trauma
Anesthesiologist is present for the EMS provider hand-off
report from the field care given by the EMTs/paramedics.
Furthermore, the Anesthesiologist is present to manage the
airway/ventilation, initiate resuscitation with the attending
surgeon, perform any indicated procedures, such as vas-
cular access or chest decompression, and is ready to per-
form a direct seamless transition to the trauma OR,
obviating the need for yet another hand-off from the trauma
team. Thus, this institution is one of the few in the United
States where an attending trauma Anesthesiologist is pre-
sent from the delivery of the patient to the trauma bay
through all peri-operative phases of care. This has mini-
mized hand-off errors and allows the responsible
physician to communicate directly with EMS providers,
nursing staff, and other peri-operative colleagues.
There is a paucity of literature with respect to hand-offs
occurring between the ED/Trauma Center staff and Anes-
thesiology personnel for patients requiring operative
intervention. In a recent report by Evans et al., of the 500
articles reviewed in 2012 regarding the best practice peri-
operative hand-offs, all of these reports focused on OR to
intensive care unit (ICU) hand-offs [14, 15]. It appears that
the hand-off process on delivering a critical patient to the
erature. Evans et al. decided to perform an important recent
literature search involving all peri-operative/peri-anesthe-
sia hand-offs. Of the 80 articles identified, none addressed
the hand-off of patients to the OR. This was an unexpected
finding and is, indeed, concerning. The reverse hand-off
as the authors call it from the ICU (or ED for trauma) to the
OR is potentially even more important than from OR to
ICU because ICU to OR transfers often occur in unsta-
ble patients scheduled for emergent or urgent surgical
procedures and magnify the potential risk to patient safety
[14]. The authors conclude that an ICU to OR checklist
may have some merit in terms of decrease in the number of
adverse events that occur in critical care patients being
taken to the OR for an urgent procedure [14].
So what can we as trauma professionals learn from this
hand-off pitfall in both the trauma bay and operating
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68
room? Going back to our OR time-out policy that has
become the standard of care for all hospital operating
rooms, we as peri-operative specialists must take lessons
learned from this time-out process and begin to utilize a
similar approach to handing off a critically injured/ill
patient. Much as a pilot of an aircraft does when he or she
prepares to depart on a flight, a checklist is performed prior
to take-off on every single flight so nothing crucial is
missed. Should physicians be held to the same standards as
FAA licensed pilots?
After reviewing the current literature, it is evident that
we, as peri-operative physician professionals, need to
perform a much better job at enforcing a hand-off process
that is unique to the critically injured patient who is
arriving to the trauma center and ultimately to the OR for
definitive resuscitative care. One approach may be to have
a standing time-out style checklist that will work for
both EMS providers in the trauma bay and for ED staff
delivering a critical patient to the OR. This checklist does
not need to be exhaustive and time consuming but should
have several bullet points that are crucial to hand-off
information exchange. The following are examples of
hand-off checklists that can be placed on the wall of the
trauma bay and trauma operating room:
Trauma bay Trauma OR
Mechanism of injury Mechanism of injury
Pertinent medical history Airway interventions
GCS in field Vascular access
Last recorded vital signs LSIs performed
Life-Saving Interventions Blood products/massive transfusion
(LSIs) en route protocol activation
Response to LSIs Medications (paralytics, antibiotics,
etc.)
Drugs and doses given Recent vital signs
Field estimated blood loss Results of radiological studies
Any concerns by EMS Brief EMS report
Lab results (rTEG, ABG, toxicology
screen)
Any concerns from ED staff
Intraoperative Hand-Offs
Transitions of care in the operating theater are unique
among all other types of care transitions that will be dis-
cussed in this chapter for several reasons: (1) they are more
frequent; (2) they may occur with various, and sometimes
unpredictable, levels of complexity; and (3) the principal
diagnosis/purpose of surgery may be extremely broad. The
frequency of intraoperative hand-offs is very high sec-
ondary to the principal fact that the provider ratio for
123
Curr Anesthesiol Rep (2016) 6:6571
anesthetic care is 1:1. Even in the ICU environment, a
hand-off is not necessarily required to facilitate a nurse
going to the bathroom, for example. As such, the OR is the
highest level of care in the hospital from a provider
standpoint, regardless of the type of case. This level of
acuity is reflected in the fact that intraoperative hand-offs
have a dose- dependent effect on mortality [15]. As such,
while various standardized systems, such as SBAR, may be
generally effective, important information may be omitted.
The potential complexity of anesthetic management needed
to facilitate a surgical intervention is vast. As the reader
likely knows, the medical challenges for a MAC upper
gastrointestinal endoscopy are quite different from double
lumen intubation, single lung ventilation, and video-as-
sisted thoracoscopic surgery (VATS). The degree of con-
tent required and the systems affected are quite different
for these two hypothetical cases.
Finally, the anesthesia team may be requested to care for
patients with an unlimited variety of surgical interventions,
diagnoses, and co-morbidities. As such, the standardization
of hand-offs poses a unique challenge in that it may be
more difficult to standardize a hand-off according to ser-
vice line or specialty type. In tertiary centers, however,
where anesthesiology teams are highly specialized, a
structured hand-off that addresses subspecialty issues may
not only be possible, but necessary for the implementation
of protocols and quality improvement strategies.
The prevailing theme thus far with regard to intraoper-
ative hand-offs is that in order for a hand-off tool to be
universally applied in an institution, all systems would
need to be included and such hand-offs would need to take
place consistently. In order to achieve adoption of a hand-
off tool, buy-in is required by all stakeholders and a
cultural change must take place. Cultural change, while
being the most obvious, may be the most difficult to
implement in a group or a hospital. Nonetheless, it has been
stated that the difference between a good hospital and a
great hospital is culture. When trainees are involved in the
hand-off process, early educational intervention through
simulation or coaching may be useful in maximizing suc-
cess of such cultural modification. Multiple tools have been
developed by multiple institutions to facilitate hand-offs,
though many institutions create their own hand-off tool
[16].
Out of necessity, secondary to the 80-h work-week or
due to patient safety concerns, the ACGME requires that
hand-off education be included in resident education [17].
Furthermore, the Center for Medicare and Medicaid Ser-
vices (CMS) may require hand-off documentation as an
Anesthesiology quality metric in the near future. While
paper is more common and potentially easier to implement
in the OR, electronic hand-off tools have been demon-
strated to facilitate increased retention of the information
Curr Anesthesiol Rep (2016) 6:6571 69

Fig. 1 Sample consistent hand-off at transfer tool (CHATT) form currently used at the Memorial Hermann Hospital

contained within a hand-off in the intraoperative environ- patients admitted during these time frames is increased
ment [18]. [19]. Mechanisms proposed for this increased mortality
Hand-off policy adherence may be even more important include the tendency for a less well-staffed and more ju-
on weekends and at night, as the 30-day mortality for nior team staffing patients during this time.

123
70
Operating Room to Post Anesthesia Care Unit
(PACU)/Intensive Care Unit (ICU) Transfers
Improving hand-offs from the Anesthesiology team to the
PACU/ICU team are an opportunity to improve patient
safety in the hospital. While not the same level of care as
the OR, the frequency of hand-offs required because of
patients leaving the ICU for a procedure or surgery lends
itself to complications arising. This risk is especially
prominent when hand-offs occur between different teams
instead of between members of the same team [19].
Additionally, 72 % of patients transported from an ICU to
another location experience hypotension, arrhythmias,
hypoxemia, or cardiac arrest [20]. Additionally, ICU per-
sonnel use information provided from the transporting
team to direct their therapy, especially when it is their first
time assessing the patient [21]. At the authors institution,
the Anesthesiology team is encouraged to outline and
report concerns for impending pathophysiology, if appli-
cable. See Fig. 1 to review examples of the form, called
consistent hand-off at transfer tool (CHATT), one for the
pre-operative report from the ICU team to the anesthesi-
ology team, and vice versa. This form is required whether
the patient is brought to the PACU or ICU.
Ideally, any hand-off tool should be structured so that
there is no information documented that is fully redundant
to the chart, as this will likely serve to reduce compliance
with tool completion by medical team stakeholders.
Additionally, an effective hand-off tool serves as a mech-
anism to assist the person covering key recalling items to
discuss with the receiving provider, similar to a checklist.
In some instances, Anesthesiology-oriented checklists are
compared to aviation checklists but this approach may be
faulty. This is illustrated by the fact that a pilot is at equal
risk as the passengers on any aircraft if the checklist is not
followed (the pilot would go down with the passengers). In
the OR or ICU, the Anesthesiologist is not at personal
mortal risk if the checklist is not followed. Therefore,
special care must be taken to ensure checklist compliance.
By the time all transfers of care are completed during an
inpatient hospitalization, dozens of medical providers need
to know the same content of information to appropriately
care for a given patient [21]. Utilizing a structured hand-off
based on medical systems in lieu of a SOAP format not
only ensures all information is covered but also fosters
more accurate communication between caregivers [22]. As
such, the importance of the OR to PACU/ICU hand-off
should be treated with the same urgency as an intraopera-
tive hand-off.
In future iterations of hand-off tools, integration and/or
standardization based on information contained in the elec-
tronic health record (EHR) will likely take place. The
123
Curr Anesthesiol Rep (2016) 6:6571
benefits of this may be reduced cost and time required for
hand-offs overall across a service line, especially consider-
ing that 46 % of information in nursing and physician hand-
offs overlaps in terms of the content discussed [23]. As
trends in healthcare converge on the goal of zero compli-
cations, hand-off integrity is essential in achieving this goal.
Conclusion
Hand-off reports between multiple healthcare providers
with differing backgrounds is a challenge in todays busy
healthcare system. As a result, patient safety is a concern,
particularly with respect to the critically injured patient
arriving to a trauma center. As trauma professionals, we
need to bridge this gap in communication by implementing
novel strategies for patient information hand-off between
multiple hospital locations. Checklists are one way that we
can simplify and streamline this process so that critical
information is not lost in translation. Further research is
needed in this important aspect of patient care, particularly
with pre-hospital to ED hand-offs, as well as ICU to OR
hand-offs.
Compliance with Ethics Guidelines
Conflict of Interest Christopher T. Stephens, George W. Williams,
II, and Carin Hagberg declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
References
Papers of particular interest, published recently, have been
highlighted as:
Of major importance
1. Abraham J, Kannampallil TG, Patel VL. Bridging gaps in
handoffs: a continuity of care based approach. J Biomed Inform.
2012;45(2):24054.
2. Solet D, Norvell J, Rutan G, et al. Lost in translation: challenges
and opportunities in physician-to-physician communication dur-
ing patient hand-offs. Acad Med. 2005;80(12):10949.
3. Koenig G, Galvagno S. Effective communication between pro-
viders & physicians improves patient hand-offs. http://www.jems.
com/articles/2012/04/effective-communication-between-provider.
html (2012). Accessed 16 Dec 2015.
4. Talbot R, Bleetman A. Retention of information by emergency
department staff at ambulance handover: do standardized
approaches work? Emerg Med J. 2007;24(8):53942.
5. Bhabra G, Mackeith S, Monteiro P, et al. An experimental
comparison of handover methods. Ann R Coll Surg Engl.
2007;89(3):298300.
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6. Pothier D, Monteiro P, Mooktiar M, et al. Pilot study to show the
loss of important data in nursing handover. Br J Nurs.
2005;14(20):10903.
7. Bigham BL, Buick JE, Brooks SC, et al. Patient safety in
emergency medical services: a systematic review of the literature.
Prehosp Emerg Care. 2012;16:2035. Bigham et al. performed a
12 year literature review in order to identify EMS related threats
to patient safety. Multiple factors negatively impacting patient
safety included adverse events and medication errors, clinical
judgment, communication, ground vehicle safety, aircraft safety,
interfacility transport, and intubation. The authors suggest that
interventions to modify behavior and provide closed-loop com-
munication training reduced misunderstandings and encouraged
staff to communicate concerns more readily.
8. Meisel ZF, Shea JA, Peacock NJ, et al. Optimizing the patient
handoff between emergency medical services and the emergency
department. Ann Emerg Med. 2015;65(3):3107. Meisel et al.
conducted 7 nationally oriented focus group (at 3 national and
regional conferences) of EMS providers in order to determine
their perspective on ways to improve handoffs. 4 potential ways
to improve handoffs were determined, including 1) direct com-
munication from EMS to the ED provider, 2) increased feedback
and transparency, 3) handoff standardization and 4) use tech-
nology to close communication gaps.
9. Carter AJ, Davis KA, Evans LV, et al. Information loss in
emergency medical services handover of trauma patients. Pre-
hosp Emerg Care. 2009;13:2805.
10. Evans SM, Murray A, Patrick I, et al. Assessing clinical handover
between paramedics and the trauma team. Injury. 2010;41:4604.
11. Fairbanks RJ, Bisantz AM, Sunm M. Emergency department
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2007;50:396406.
12. Sarcevic A, Burd R. Information handover in time-critical work.
In: Group09 proceedings of the ACM 2009 international con-
ference on supporting group work. New York: Association for
Computing Machinery; 2009. p. 30110.
13. Evans AS, Yee M, Hogue CW. Often overlooked problems
with handoffs: from the intensive care unit to the operating room.
Anesth Analg. 2014;118(3):6879. Evans et al. submits a letter to
the editor discussing OR to ICU handoffs and the particular
opportunities for improvement by presenting examples and dis-
cussing successful systems for this process. Additionally, barriers
to optimizing such handoffs are reviewed in general.
71
14. Segall N, Bonifacio AS, Schroeder RA, et al. Durham VA patient
safety center of inquiry. Can we make postoperative patient
handovers safer? A systematic review of the literature. Anesth
Analg. 2012;115:10215.
15. Lane-Fall M, Gutsche JT, Augoustides JG. Are intraoperative
anesthesia handovers associated with harm? Getting to the heart
of the matter in cardiac surgery: the search for the hat-trick of
quality, safety, and continuous improvement. J Cardiothorac
Vasc Anesth. 2015;29(1):810.
16. McCrory MC, Aboumatar H, Custer JW, Yang CP, Hunt EA.
ABC-SBAR training improves simulated critical patient hand-
off by pediatric interns. Pediatr Emerg Care. 2012;28(6):53843.
17. Lane-Fall MB, Brooks AK, Wilkins SA, Davis JJ, Riesenberg
LA. Addressing the mandate for hand-off education: a focused
review and recommendations for anesthesia resident curriculum
development and evaluation. Anesthesiology. 2014;120(1):
21829. Lane-Fall et al. discussed handoffs role in health care
quality and the Accreditation Council for Graduate Medical
Educations (ACGME) interest in facilitating handoff education
in order to prepare residents for practice in the emerging
healthcare environment. Definitions of handoffs, elements of a
successful handoff, a general history of handoff curricula and
assessment techniques are reviewed.
18. Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch G. An
electronic checklist improves transfer and retention of critical
information at intraoperative handoff of care. Anesth Analg.
2015;120(1):96104.
19. Filichia L, Halan S, Blackwelder E, Rossen B, Lok B, Korn-
dorffer J, Cendan J. Description of web-enhanced virtual char-
acter simulation system to standardize patient hand-offs. J Surg
Res. 2011;166(2):17681.
20. Shields J, Overstreet M, Krau SD. Nurse knowledge of intra-
hospital transport. Nurs Clin N Am. 2015;50(2):293314.
21. Black-Schaffer RM. Communication among levels of care for
stroke patients. Top Stroke Rehabil. 2002;9(3):2638.
22. Abraham J, Kannampallil TG, Almoosa KF, Patel B, Patel VL.
Comparative evaluation of the content and structure of commu-
nication using two handoff tools: implications for patient safety.
J Crit Care. 2014;29(2):311.e17.
23. Collins SA, Stein DM, Vawdrey DK, Stetson PD, Bakken S.
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Curr Anesthesiol Rep
DOI 10.1007/s40140-016-0145-x
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Damage Control Resuscitation: More Than Just Transfusion
Strategies
Catherine Heim1 Marc P. Steurer2 Karim Brohi3
 Springer Science + Business Media New York 2016
Abstract Trauma hemorrhage continues to carry a high
mortality worldwide. The contemporary damage control
resuscitation (DCR) paradigm supports actively bleeding
trauma patients until hemorrhage control is achieved. The
principles of DCR center on early hemorrhage control and
limiting ongoing blood loss by adopting strategies limiting
fluid administration, reducing blood pressure targets, and
maintaining hemostasis through balanced transfusion
strategies. Application of DCR strategies has dramatically
reduced mortality from trauma hemorrhage and also seems
to reduce the incidence and severity of complications such
as organ failure and infection. While much of the discus-
sion around DCR focuses on control of coagulopathy and
the delivery of a balanced transfusion, the other principles
are at least as important. Avoiding clear fluids solutions,
especially at the most critical timepoints, require experi-
ence and a coordinated, practiced, multidisciplinary
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Catherine Heim
Catherine.Heim@chuv.ch
Marc P. Steurer
marc.steurer@ucsf.edu
Karim Brohi
k.brohi@qmul.ac.uk
1
Anesthesia Department, Centre Hospitalier Universitaire
Vaudois (CHUV), Rue du Bugnon 46, 1011 Lausanne,
Switzerland
2 through to the operating room and intensive care unit. The
Department of Anesthesia and Perioperative Care, San
Francisco General Hospital, UCSF, 1001 Potrero Ave, Room
3C-38, San Francisco, CA 94110, USA
3
Centre for Trauma Sciences, Queen Mary University of
London, 2 Newark St, London E1 2AT, UK
approach. The anesthesiologist therefore has a central role
to play in the successful delivery of DCR, and periopera-
tive management of fluid administration and the patients
cardiovascular status can make all the difference between a
good and bad outcome. In this article, we discuss the
principles of DCR with a focus on areas of trauma anes-
thesiology management.
Keywords Trauma
Hemorrhage
Damage control
resuscitation
Trauma anesthesiology
Anesthesia

Hemostatic resuscitation
Blood
Plasma
Crystalloids

Permissive hypotension
Introduction
Hemorrhage remains a leading cause of death in the
severely injured. Management of the massively bleeding
trauma patient has significantly changed over the last two
decades with the emergence of the Damage Control
paradigm. The original principle of damage control surgery
(DCS) was the planned temporary sacrifice of normal
anatomy to preserve vital physiology [1]. This use of
abbreviated surgical procedures, focusing on rapid
hemostasis rather than anatomic repair, led to improve-
ments in survival for the most severely injured [1]. Damage
control resuscitation (DCR) is a more recent development
of the DCS concept. DCR describes the extension of the
damage control principles beyond surgery, including
resuscitation strategies spanning the pre-hospital care
principle aim of DCR is to define a systematic approach to
major trauma in order to minimize blood loss and ulti-
mately optimize outcome [2]. DCR strategies are applica-
ble to patients who are actively bleeding and focus on
123

maintaining hemostatic competence and central perfusion
while hemorrhage control is achieved.
Often, DCR is simplified as DCS in combination with a
formula-guided blood transfusion strategy. However,
recent efforts in resuscitation focus on minimizing the
coagulopathic response to trauma and preservation of
endothelial integrity, as well as maintenance of circulating
volume [3, 4]. Anesthesia for the severely injured,
bleeding patient plays a central role in achieving good
outcomes and requires specific considerations and carefully
assessment of hemostatic and physiologic reserves. Goals
and limits often differ from those used in elective settings
and a close collaborative approach between the surgical,
anesthesia and ICU team is required. The aim of this
publication is to describe the principles of the anesthetic
considerations of the DCR concept. We focus on the
principles required to support rapid hemostasis while lim-
iting inflammatory dysfunction and thus improving sur-
vival and reducing subsequent complications such as organ
failure and infection.
Indication for DCR
The DCR approach applies to patients who are actively
bleeding. The aim is to protect hemostatic competence and
maintain core perfusion such that physiologic reserves are
maintained as far as possible. Patient selection is critical
and no single parameter for identification has been deter-
mined. The critical decision is whether a patient is actively
bleeding or not. Patients who are in hemorrhagic shock but
are not actively bleeding (that is they have bled but this has
now stopped) require standard resuscitation to restore
systemic perfusion. In contrast, it is impossible to nor-
malize systemic perfusion in actively bleeding patients and
thus the paradigm changes to a DCR approach.
Patients with signs of severe hemorrhagic shock and
active bleeding should be included into the damage control
pathway. Active bleeding is best recognized as a poor
dynamic response to initial attempts at volume resuscita-
tion. Rapid identification of patients in compensated
hemorrhagic shock warrants an experienced clinician,
integrating the mechanism of trauma and potential injuries
and the hemodynamic response to a fluid challenge. More
sensitive measures for volume status as invasive monitor-
ing are difficult to establish during the phase of ongoing
bleeding and are not recommended as inferring unneces-
sary delay to surgical hemostasis. Blood gas values such as
lactate and base deficit provide an indication of the depth
of shock [5] but do not in themselves describe whether
bleeding is ongoing or not. They may be of use in patients
who initially appear well but who are at the limit of
hemodynamic compensation for the blood loss. Similarly
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Curr Anesthesiol Rep
the presence of coagulopathy implies significant trauma
and depth of shock but does not in itself specify that
bleeding is still ongoing.
Factors that may further trigger a damage control
approach are hypothermia, metabolic acidosis, an inac-
cessible major vascular injury or the need for time-con-
suming procedures in a patient with suboptimal response to
resuscitation [6, 7, 8]. In most civilian trauma centers,
less than 10 % of the trauma population qualifies for this
approach. Patients must be selected carefully as inappro-
priate application of DCR can lead to significant morbidity,
wasting of blood products, and hospital resource use.
The Principles of Damage Control Resuscitation
Together with DCS, the following strategies can be sum-
marized as the three conceptual pillars of DCR:
Limited fluid administration
Permissive hypotension
Hemostatic resuscitation
Limited Fluid Administration
Aggressive fluid resuscitation to restore normal blood
pressure and systemic perfusion has been the mainstay of
the approach for hemorrhagic shock for a long time. It is
now recognized that aggressive crystalloid resuscitation in
the actively bleeding patient leads to increased bleeding
and dilutional coagulopathy. Crystalloid resuscitation dur-
ing hemorrhage may temporarily increase blood pressure
but counteracts local vasoconstriction and the innate pri-
mary hemostasis, causing more hemorrhage and re-bleed-
ing from spontaneously clotted vessels [9, 10]. The term
bloody vicious cycle had been coined, describing the
sequence of hypotension, fluid bolus, re-bleeding, and
deeper hypotension. This cyclical crystalloid resuscitation
rapidly leads to a severe dilutional coagulopathy. Large
volumes of crystalloids may also have adverse immuno-
logical and inflammatory effects (Fig. 1). Large shifts in
extracellular volume and osmolarity can lead to cellular
swelling, impairing enzyme function vital to intracellular
signaling mechanisms and ultimately to organ function
[11].
Crystalloid-based resuscitation leads to increased con-
centration of circulating pro-inflammatory cytokines,
potentiating the inflammatory mediators [12]. Inducing
shedding of the endothelial glycocalyx high volumes of
crystalloids may increase reperfusion injury, all of which
may subsequently contribute to infectious complications
and organ failure. Further, high volumes of crystalloids in
hemorrhagic shock have also been associated with cardiac
Curr Anesthesiol Rep
Fig. 1 The consequences of aggressive crystalloid resuscitation
dysfunction, decreased cardiac output, and higher mortality
as compared to blood-based resuscitation. Stroke volume
may be reduced by 20 % despite adequate filling pressures,
if volume restoration was achieved by crystalloid loading
[13, 14].
Synthetic colloids such as gelatines, dextran solutions,
and hydroxyethyl starches have no benefit over crystalloids
and have their own specific complications. In the situation
of shock with inflammatory widening of the endothelial
cell gap, macromolecular solutions will further leak into
the interstitial space, contributing to additional intravas-
cular dehydration through osmosis. Synthetic colloidal
solutions induce or enhance established coagulopathy by
impairing fibrin polymerization and blockade of the fib-
rinogen receptor GIIb-IIIa, impairing platelet function [15].
A set of large RCTs in critically ill patients has further
shown a correlation of starches with adverse outcome [16
19]. It is therefore recommended that during ongoing sur-
gical bleeding, clear fluids should be limited to minimal
amounts until definitive control of hemorrhage has been
achieved.
Permissive Hypotension
Reducing blood pressure targets is a key method of
reducing fluid administration during active hemorrhage.
Permissive hypotension (PH) is a strategy to reduce blood
loss by limiting blood pressure temporarily to a vital
minimum. In massively bleeding patients, raising blood
pressure to normal levels before achieving surgical
hemostasis has been shown to increase bleeding by
displacing clots formed during the bodys attempt of pri-
mary hemostasis [9].
The specific blood pressure targets remain unclear and
probably vary from patient to patient and at different
phases of an individual patients care. Theres a known
lack of correlation between the hemodynamics of the
macrocirculation and end-organ perfusion, indicating that
systolic blood pressure (SBP) is of limited value for the
assessment of organ perfusion. The often used cut-off of a
SBP of 90 mmHg as marker of shock has been based on
expert opinion. In animal models re-bleeding occurred
when SBP was raised to above 8090 mmHg and a sig-
nificant correlation between the blood pressure at the ini-
tiation of resuscitation and the re-bleeding pressure was
demonstrated [9, 20]. Similarly there is no hard data sup-
porting that a mean arterial pressure (MAP) of 60 mmHg is
required to preserve heart and brain perfusion. Animal
studies have also shown that PH aiming at values of 60 %
of baseline MAP does not reduce regional organ perfusion
as compared to normotensive resuscitation but resulted
ultimately in less bleeding [21]. In the actively hemor-
rhaging patient, such targets will most likely lead to over-
resuscitation, increasing bleeding and ultimately worsening
tissue perfusion.
Without high-grade evidence, the European Guidelines
for trauma resuscitation recommend aiming at a SBP of
80 mm Hg during ongoing hemorrhage [6]. However, it
should be emphasized that such low pressures should be
maintained for the shortest possible time in order to limit
further exacerbation of hypoperfusion and the inflamma-
tory response. The importance of early surgical hemostasis
123

and the need for the DCR concept being applied as a whole
has to be underlined.
In the exsanguinating patient, even lower than normal
blood pressures are often difficult to achieve. The use of
vasopressors for hemodynamic support during resuscitation
after injury, however, is controversial. Arterial hypotension is
the bodys attempt to improve microcirculation by opening
maximally the capillary bed. Vasopressors will significantly
further decrease perfusion of microcirculation via their alpha-
receptor-mediated action [22]. A prospective multicenter
study on blunt trauma patients indicated an increased mor-
tality with early vasopressors, regardless of the drug used
[23]. Interestingly, research in septic shock failed to improve
sublingual microcirculation with increasing doses of Nora-
drenaline [24]. Hemorrhagic shock should therefore be treated
primarily by surgical hemostasis and volume replacement.
Hemostatic Resuscitation
Preserving hemostatic competence is the central tenet of
the DCR approach. Coagulopathy is common in trauma
patients and has two principle originsan endogenous
coagulopathy due to the injury pathophysiology, and a
dilutional coagulopathy due to volume resuscitation (with
fluid or red blood cells).
The recognition of the early endogenous coagulation
disorder of severely injured patients in hemorrhagic shock
has significantly contributed to the change in resuscitation
paradigms over the last decade. The presence of this acute
traumatic coagulopathy (ATC) has been identified as a
surrogate marker of the extent and severity of tissue trauma
and hypoperfusion. It correlates with transfusion require-
ments, incidence of organ failure, and increased mortality
[25]. Up to 30 % of injured patients present with impaired
coagulation at their arrival to the care facility, even before
the onset of hypothermia, acidosis or a dilution of coagu-
lation factors occurs [26, 27]. Trauma itself induces an
endogenous coagulopathic state as part of a maladaptive
response to tissue destruction and shock. ATC can be seen
as an imbalance of the dynamic equilibrium between pro-
and anticoagulant factors, platelets, endothelium, and fib-
rinolysis. Exposed tissue factor, released from the injured
subendothelium, fibrin, and activated platelets serve as
catalyzer for a massive stimulation of thrombin generation,
fibrinogen depletion, and the activation of fibrinolytic
processes [2628]. Thrombin is a key element for con-
version of fibrin to fibrinogen and platelet activation.
Additionally, it is a potent stimulator of endothelial t-PA,
activating fibrinolysis; another key feature of ATC [29].
Hypoperfusion and cellular hypoxia play a crucial role in
the pathogenesis of ATC, leading to systemic anticoagu-
lation via activated protein C [29] . Activated protein C
plays a key role in the cleavage of factor Va and VIIIa. It
123
Curr Anesthesiol Rep
activates fibrinolysis by binding PAI-1 and reduces the
inhibition of t-PA [3033]. During resuscitation efforts,
ATC is secondarily exacerbated by iatrogenic dilution of
coagulation factors and worsening hypothermia and aci-
dosis, combining to the multifactorial trauma induced
coagulopathy (TIC) [34].
Early identification of patients with ATC may be of
value for the timely initiation of hemostatic resuscitation.
Early blood product-based resuscitation, tackling coagula-
tion disorders, has shown to reduce the overall need of
blood products, the incidence of posttraumatic multi-organ
failure and in return shorten the length of hospital stay and
improve patients survival [3538]. To date, none of the
vast array of published clinical scoring systems has proven
reliable in identifying patients at risk of ATC. Standard
plasma-based coagulation tests are not useful in the setting
of acute trauma-related hemorrhage because of the absence
of assessment of the cellular components of coagulation,
the interaction with the cellular phospholipid surfaces as
well as the lack of identification of fibrinolysis. Further,
long turn-around times invalidate these tests as point-of-
care assays in the rapidly changing setting of massive
bleeding. Point-of-care viscoelastic tests as thromboelas-
tometry (ROTEM or TEG) have been useful in early
detection of ATC with moderately or severely injured
patients exhibiting typical features [39, 40]. In the absence
of timely laboratory assessment, in patients with evidence
of impaired end-organ perfusion, expressed as base deficit
and in combination with extensive tissue trauma, initiation
of hemostatic resuscitation may be indicated even before
biologic or viscoelastic confirmation of ATC.
Balanced resuscitation with high-dose plasma adminis-
tration appears to reduce the severity of dilutional coagu-
lopathy and may also have anti-inflammatory properties
and the potential to restore the shed glycocalyx [41, 42].
Most centers therefore currently follow a resuscitation
strategy centered on the balanced administration of blood
products. There is an ongoing debate about the optimal
transfusion ratios of fresh frozen plasma (FFP) and plate-
lets that should be administered alongside packed red blood
cells (PRBCS). In the recent multicenter RCT PROPPR, a
ratio of 1:1:1 FFP:PLT:PRBC has shown a relative risk
reduction for mortality of 25 % as compared to 1:1:2 [43].
This difference, however, did not reach statistical signifi-
cance and the optimal ratio of products remains unclear.
Many recommend switching to a goal directed approach as
soon as possible, ideally guided by viscoelastic tests [6].
Although validated treatment algorithms are lacking, this
strategy is supported by a decreased risk of infection and
mortality when applying a restrictive, targeted transfusion
strategy [44]. A plasma-free resuscitation approach has
been described, based on crystalloids in combination with
factor concentrates [45]. While the latter might provide
Curr Anesthesiol Rep
advantages in terms of readiness of products and safety
issues, data suggest that plasma-based resuscitation is
better at preserving endothelial integrity when compared to
the crystalloid-based approach.
Fibrinogen, the final key component in the coagulation
cascade acts as ligand for platelet aggregation, ensuring
effective clotting and platelet function [46, 47]. During
resuscitation of hemorrhagic shock, fibrinogen is the first
coagulation factor to critically deplete and low fibrinogen
levels are associated with poor outcome [4850]. Plasma-
based volume resuscitation provides approximately
500 mg of fibrinogen per unit FFP and has proven to be
insufficient in adequately rising plasmatic fibrinogen
levels [49]. Viscoelastometry-guided substitution of fib-
rinogen during hemostatic resuscitation has shown to
increase survival and reduce the need for blood products
[36].
Fibrinolysis is a key feature of ATC and is induced by
inhibition of plasmin via the thrombin-activated fibrinoly-
sis inhibitor (TAFI) and PAI-1. Hyperfibrinolysis occurs
within the first hour after trauma and is associated with a
mortality rates as high as 90 % [51, 52, 53]. The CRASH
2 trial, a large multicenter RCT including over 20,000
patients, showed a significant mortality reduction from
bleeding after the administration of tranexamic acid (TXA)
in trauma patients at risk of major hemorrhage [54]. Ben-
efits have been maximal if administrated within 1 h after
the injury without any increase in thromboembolic events.
Early administration of TXA to severely bleeding trauma
patients constitutes a key element in many pre-hospital
treatment algorithms today.
Hypothermia impairs coagulation mainly by inhibition
of platelet adhesion and aggregation, inhibition of thrombin
generation, and fibrinogen synthesis [55]. At lower levels,
altered enzyme activity will act aggravatingly. Addition-
ally, hypothermia impairs the oxidative killing function of
neutrophils via activation of the autonomic nervous system.
During DCR aggressive measures should be taken to pre-
vent further heat loss, aiming at a core body temperature
above 35 C. Acidosis is a surrogate marker of the sys-
temic hypoperfusion of the microcirculation. A low pH
decreases cardiac contractility, attenuates adrenergic
receptor responsiveness, and impairs kidney perfusion.
Further, acidosis impairs coagulation by reducing thrombin
generation and accelerating fibrinogen degradation, leading
ultimately to a reduced availability of fibrinogen. Addi-
tionally, acidosis weakens the interplay of coagulation
factors with activated platelets. Administration of bicar-
bonate has not proven to be efficacious to reverse the
acidosis-induced coagulation impairments. Restoration of
the microcirculatory perfusion appears to be the only
valuable strategy [55]. Early and consistent application of
DCR principles to patients should reduced the depth and
duration of hypothermia and acidosis experienced by
bleeding trauma patients.
Tissue oxygen delivery is directly dependant on the
hemoglobin concentration. Compensatory mechanisms,
including changes in flow in macro- and microcirculation,
can compensate for acute anemia. Erythrocytes also con-
tribute to hemostasis via a rheological effect on platelet
margination and by supporting thrombin generation [46].
However, the ideal threshold for hemoglobin during and
after traumatic hemorrhage to sustain optimal tissue oxy-
genation and hemostasis is unknown. Rapid administration
of high amounts of blood products raises logistic chal-
lenges. The implementation of a major hemorrhage pro-
tocol (MHP) is recommended, which allows for a rapid and
consistent availability of blood products [6]. The insti-
tution of a MHP has shown to be associated with a
reduction of organ failure and improved 30-day-survival
after severe trauma.
Post-operative Critical Care
Principles of damage control aim at rapid hemostatic pro-
cedures of as short as possible duration, allowing for
bringing patients early to the less aggressing and more
controlled environment of ICU. Therefore, patients in the
damage control pathway are expected to arrive in the ICU
in a critical and under-resuscitated state. The goal of the
initial treatment in ICU is to reverse the sequela inherent to
damage control principles. Rapid restoration of optimal
organ oxygen delivery by normalization of microcircula-
tion, correction of coagulopathy, and rewarming are key
for optimal outcome. Speed of lactate clearance is a vali-
dated marker of outcome in this stage [56].
Early and optimal flow of information about the situa-
tion and specific needs between the surgical, anesthetic and
ICU teams is key for the optimal follow-up management.
Therefore, trauma resuscitation requires prolonged collab-
oration in a multidisciplinary resuscitation strategy, starting
in the pre-hospital setting and continuing through emer-
gency departments and operating theaters to the ICU.
Conclusion
For the actively bleeding injured patient, the primary goal
is the early control of hemorrhage. The conduct of anes-
thesia and resuscitation is central to the maintenance of
hemostatic competence and therefore the ability to
achieve hemorrhage control. DCR provides a framework
to support central circulation and coagulation during this
critical phase. The delivery of the principles of limited
fluid administration, PH, and hemostatic resuscitation are
123

challenging and require an experienced and practiced
team working to agreed procedures and guidelines. The
principles and practice of DCR continue to evolve as we
improve our understanding of the pathophysiology of the
bleeding trauma patient.
Compliance with Ethics Guidelines
Conflict of Interest Catherine Heim, Marc P. Steurer, and Karim
Brohi declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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Curr Anesthesiol Rep
DOI 10.1007/s40140-016-0147-8
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Radiographic Imaging and Ultrasound in Early Trauma
Management: Damage Control Radiology for the Anesthesiologist
Thomas E. Grissom1 Bert Pierce2
 Springer Science + Business Media New York 2016
Abstract The role of radiographic imaging and ultra-
sound (US) in decision-making during the early manage-
ment of the polytrauma patient has increased significantly
in the last decade based on technological advancements
and ongoing research. With the introduction of faster and
more capable computed tomography scanners as well as
portable US machines, individuals responsible for the care
of the trauma patient have more information than ever to
guide perioperative care and operative decisions. This has
led to the implementation of Damage Control Radiol-
ogy (DCRad) in the early resuscitation and treatment of
these patients. In this review, we focus on the current lit-
erature surrounding applications of US and other radio-
graphic imaging in the early management of the trauma
patient. This includes reviews of the Focused Assessment
with Sonography in Trauma (FAST) and Extended-FAST
(E-FAST) exams with an emphasis on their applicability,
sensitivity, and specificity in the setting of blunt and pen-
etrating trauma as well as their ability to predict the need
for an operative intervention. Additionally, we will briefly
review the role of US for airway management, and vascular
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Thomas E. Grissom
tgrissom@umm.edu
Bert Pierce
bpierce@uab.edu
1
Department of Anesthesiology, R Adams Cowley Shock
Trauma Center, University of Maryland School of Medicine,
22 S. Greene St., T1R77, Baltimore, MD 21201, USA
2 patient can be addressed through radiographic and US
Department of Anesthesiology and Perioperative Medicine,
University of Alabama at Birmingham, 804 Jefferson Tower,
619 South 19th Street, Birmingham, AL 35249-6810, USA
access. Relevant to anesthesiologists managing patients
with potential cervical spine injury, we will also review
recommendations regarding radiographic clearance of the
cervical spine in the obtunded patient. Finally, we will
discuss early detection and management of patients with
blunt cerebrovascular injury in the early perioperative
period.
Keywords Ultrasound
Central venous catheterization

Trauma
Airway management
Cervical spine injury

Blunt cerebrovascular injury
Introduction
The early evaluation of the traumatically injured patient
increasing relies on imaging to guide early management
and operative decisions. Through an understanding of the
integration of radiologic studies, including ultrasound
(US), into the decision-making process, the anesthesiolo-
gist involved in the resuscitation and perioperative care of
the trauma patient can better participate in their treatment.
This includes the concept of damage control radiology
(DCRad). Originally described in the military setting, the
goals of DCRad include (1) rapid identification of life-
threatening injuries including active hemorrhage, (2)
identification or exclusion of significant head or spinal
injuries, and (3) rapid triage of patients with thoracic or
abdominal injuries to the operating room or interventional
radiology suite as appropriate [1].
From the anesthesiologists perspective, several issues
surrounding the perioperative management of the trauma
imaging including the concepts outlined in DCRad. These
issues include the following:
123

(1) Identification of life-threatening injuries such as
massive hemothorax, pneumothorax, or pelvic frac-
ture during the primary survey with the combined
clinical exam and radiographic imaging (portable dig-
ital chest and pelvic radiographs);
(2) Identification of free abdominal fluid or pericardial
tamponade on the Focused Assessment with Sonog-
raphy in Trauma (FAST) US scan that might neces-
sitate an operative intervention;
(3) Evaluation for other unidentified or suspected injuries
with multi-slice ([64) whole-body computed tomog-
raphy (CT) scan;
(a) Radiographic clearance for the presence of
cervical spine injuries or presence of traumatic
brain injury;
(b) Identification of solid organ injury or retroperi-
toneal hemorrhage in the setting of blunt
trauma;
(c) Early identification of blunt cerebrovascular
injury (BCVI);
(4) Establishment of intravenous access guided by US;
(5) Evaluation of ongoing resuscitation through a focused
transthoracic US cardiac assessment.
In this review, we focus on the current literature sur-
rounding applications of US and other radiographic imag-
ing in the early management of the trauma patient. This
includes reviews of the FAST and Extended-FAST (E-
FAST) scans with a focus on their applicability, sensitivity,
and specificity in the setting of blunt and penetrating
trauma as well as their ability to predict the need for an
operative intervention. Additionally, we will briefly review
the use of US for airway evaluation and vascular access.
Relevant to anesthesiologists managing patients with
potential cervical spine injury, we will also review rec-
ommendations regarding radiographic clearance of the
cervical spine in the obtunded patient. Finally, we will
discuss early detection and management of patients with
BCVI in the early perioperative period.
Point-of-Care US in Trauma
Screening, or focused US examination, of trauma patients
has been performed for nearly thirty years, first gaining
widespread acceptance in Europe then in the United States
[2]. US examinations of specific, high yield areas of the
abdomen, pelvis, and heart has become the basis of the
classic FAST exam. More recently, a wider examination of
the thorax was included to become the E-FAST exam.
Beyond the trauma-specific aspects of the FAST and
123
Curr Anesthesiol Rep
E-FAST exams, US has been used to perform intracranial
pressure assessments, cardiac evaluations, hemodynamic
measurements, regional anesthesia, endotracheal tube
placement confirmation, and vascular access. All of these
clinical applications have direct applicability to the prac-
tice of anesthesiology, particularly in the perioperative
management of the traumatically injured patient. As
demonstrated by Ramsingh and colleagues at the Univer-
sity of California, Irvine, these skills can be acquired
during residency training and their application in the
perioperative setting can affect clinical management in a
significant percentage of patients [3].
FAST Exam
The classic FAST exam is essentially a search for trauma-
induced blood/fluid collections. It includes views of both
flanks, the pelvis and the heart. The perisplenic, perihepatic
and pelvic retrocystic/retrouterine areas are examined with
a 35 MHz curved, phased array probe as these are the
typical sites for intraperitoneal fluid collections observable
by US. The focused cardiac examination readily shows the
presence of pericardial effusions that, in the setting of
trauma, and especially in the hemodynamically unsta-
ble patient, should be considered blood.
The right flank examination proceeds with the probe
placed laterally along the midaxillary line in the 8th to 10th
intercostal space, parallel to the long axis of the body. The
US beam is then directed through the liver towards the
right kidney to identify perihepatic fluid collections such as
that seen in Fig. 1. Gradual movements to the mid-clav-
icular line provide scanning of the area between the dome
of the liver and the right hemidiaphragm, Morisons pouch
and the right perinephric area. In order to minimize rib
shadowing, the probe may be rotated in a counterclockwise
fashion to fit more readily between the adjacent ribs where
needed.
The left flank examination mirrors the right and is
directed through the spleen towards the left kidney. Scan-
ning of this area allows detection of infradiaphragmatic,
perisplenic, and perinephric fluid collections. Identification
of the diaphragm helps ensure correct identification of the
spleen as well.
The pelvic portion of the examination is performed with
the probe placed perpendicular to the skin in the midline
just above the pubic symphysis, with the beam parallel to
the long axis of the body. A full bladder facilitates this
exam by providing a readily recognized, fluid-filled ana-
tomic structure that acts as an excellent US window. Fluid
collections are sought behind the bladder and/or uterus
(pouch of Douglas).
The cardiac examination is typically performed from the
subxiphoid area (Fig. 2). This is an excellent view to
Curr Anesthesiol Rep
Fig. 1 Ultrasound image of intraperitoneal fluid beneath the liver
during FAST exam
Fig. 2 Subxiphoid image of the heart, utilizing the liver as an
acoustic window. Left atrium (LA), left ventricle (LV), right atrium
(RA), and right ventricle (RV)
evaluate pericardial effusions for signs of cardiac tam-
ponade and the cardiac structures. The probe is placed just
below the xiphoid process and aimed towards the left
posterior shoulder/scapula with the plane of the beam
nearly parallel to the sternum. From this point, scanning
movements can provide images of the heart, the pericardial
space, the inferior vena cava, and the liver. Significant
pressure may be required to visualize the heart and peri-
cardial space and may not be tolerated by the patient with
abdominal tenderness. In this case, the left parasternal
views are utilized. The probe is placed perpendicular to the
skin at the left sternal border in the 4th6th intercostal
space. The probe marker is then directed towards the right
shoulder for a long axis view of the heart. The probe is then
rotated 90 clockwise for a short axis view with the scan
proceeding from cardiac base to apex. The apical
4-chamber view may also be utilized by placing the probe
just lateral to the point of maximal impulse aimed towards
the right scapula and shoulder with the beam perpendicular
to the bed.
Clinical Application of FAST
The FAST or E-FAST exam is typically performed on all
polytrauma patients during the primary survey to address
potential life-threatening injuries. When performed as
described above, it can be accomplished rapidly with a
high degree of specificity and sensitivity for detecting free
fluid in the abdomen [4]. In the context of trauma, the
finding of free fluid in the abdomen with penetrating
trauma will almost always necessitate operative explo-
ration without the need for further evaluation. In a recent
review of US examination in penetrating trauma, Quinn
et al. found the FAST exam had a high specificity
(94.1100 %) but lower sensitivity (28.1100 %) for
diagnosing intraperitoneal or pericardial fluid collections
when compared to CT, local wound exploration, diagnostic
peritoneal lavage, or exploratory laparotomy [5]. They
concluded that a positive FAST exam associated with
penetrating trauma should prompt exploratory laparotomy,
whereas a negative FAST exam should proceed to further
evaluation. Proceeding in this manner allows a more rapid
progression to definitive care while at the same time
decreasing radiation exposure which is significant in
trauma patients with high Injury Severity Scores.
In the setting of blunt trauma, however, the operative
decision tree can be more complexeven in the unsta-
ble patient. In the setting of blunt abdominal trauma, the
utility of the FAST exam has been questioned and more
importance placed on the whole-body computed tomogra-
phy (CT) scan, particularly in the hemodynamically
stable patient [6, 7]. The hemodynamically unstable blunt
trauma patient has been more of a challenge with a positive
FAST exam typically leading to an exploratory laparotomy
[7]. Recent changes in radiology support, however, may
alter future management strategies in the hemodynamically
unstable patient with blunt and penetrating trauma where
non-operative options such as endovascular stenting or
transarterial catheter embolization may be a preferred
management strategy. This triage consideration is dis-
cussed in more detail here [8].
US examination in the setting of blunt abdominal trauma
(BAT) carries the concern of missing intra-abdominal
injuries that do not produce a significant amount of free
fluid [9]. With good specificity and positive predictive
value (99 and 98 %, respectively), addition of US contrast
to this examination has been shown to improve the sensi-
tivity and negative predictive values significantly from 59
123

and 83 % to 96 and 98 %, respectively, increasing the
overall accuracy from 86 to 98 % [10]. It is important to
note that in this study, CT was utilized as the gold standard
for diagnosis of intra-abdominal injury in BAT.
The cardiac portion of the FAST has been shown to
reduce time to operative care and improve survival for
penetrating trauma [11]. If an adequate acoustic window is
found, the presence of pericardial fluid is readily identified.
Studies have shown it to be extremely sensitive and
specific for this diagnosis in trauma [12, 13]. The rate of
incidental or insignificant effusion, however, makes the
simple presence of fluid a diagnostic dilemma when
deciding which patients require intervention [14].
Fig. 3 Two-dimensional and M-mode lung images demonstrating the
beach sign. The waves are the relatively constant layers of the chest
wall where the constantly moving lung produces the granular pattern
of the beach. Seen in real time, the two-dimensional image shows
lung sliding at the pleural interface
Fig. 4 a Lung point. In the two-dimensional image at the top, the
separation of the visceral and parietal pleura is seen. This separation
intermittently causes the beach sign to be lost as seen in the M-mode
image at the bottom. b Absent beach sign. The granular beach is not
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Curr Anesthesiol Rep
E-FAST Exam
A high-frequency, near-field, linear array or a small foot-
print convex 35 MHz probe is typically recommended for
the thoracic examination portion of the E-FAST exam.
Each hemithorax can be evaluated beginning in the mid-
clavicular line proceeding laterally along two or three
intercostal spaces. The probe should be perpendicular to
the skin and the beam parallel to the long axis of the body.
This allows verification of lung sliding seen as the vis-
ceral and parietal pleurae move against each other during
the respiratory cycle (Fig. 3). The artifact known as B-
lines or comet tails, appearing as fan-like rays of
sunlight shining through a small opening in the clouds,
should be identified as well. The absence of these signs,
and especially identification of the lung point (a single
image where the visceral and parietal surfaces are seen
separating) are highly associated with the presence of a
pneumothorax (Fig. 4a). Additional US modes have been
utilized as well, most typically M-mode looking for the
absence of the beach sign which would also indicate a
pneumothorax (Fig. 4b).
The supradiaphragmatic, dependent areas of the chest
should be evaluated for fluid collections as a sign of
hemothorax as well. In this case, the US signal is able to
penetrate through the fluid collection and allow visualiza-
tion of lung away from the inner chest wall.
Clinical Application of E-FAST
In application, the E-FAST exam has been determined to
be much more sensitive for detection of pneumothorax than
chest radiographs in trauma with near 100 % specificity
[1517]. It also provides results sooner than the chest
seen because the sound waves echo off of the highly reflective pleura/
air interface creating a reverberation artifact and continuation of
waves
Curr Anesthesiol Rep
radiograph. It is now considered to be the best modality for
rapid diagnosis and treatment of pneumothorax in trauma.
High-frequency, linear probes, typically used to establish
central venous access, provide better resolution and greater
accuracy in identifying lung sliding and are often readily
available [18].
Hyacinthe et al. evaluated 119 patients admitted with
chest trauma comparing clinical exam and chest radiograph
(CXR) to clinical exam and thoracic US for the detection of
hemothorax, pneumothorax, and lung contusion [15].
When compared to follow-up CT exam, they found clinical
exam and US to be significantly better than clinical exam
and CXR for both pneumothorax and lung contusion
evaluation with no significant difference between the two
for hemothorax evaluation. For hemothorax detection, the
sensitivity and specificity for clinical exam and CXR were
17 and 94 %, respectively, compared to 37 and 96 % with
clinical exam and thoracic US. This highlights the diffi-
culty in evaluating the dependent/posterior aspect of the
chest in a patient who is secured in a supine position for
spine precautions. While this arrangement works nicely for
evaluating a pneumothorax with US due to the air
migrating anteriorly, the opposite is true of fluid
collections.
US of the Airway
Bedside US is commonly available for central line place-
ment and performance of regional nerve blocks. Its appli-
cation has rapidly expanded into more perioperative
clinical scenarios as we become more familiar with its use.
One such advancement involves its use to evaluate and
assist with airway management [19]. US evaluation of the
anterior cervical area allows accurate location of important
structures. Superficially, the hyoid bone, thyroid and cri-
coid cartilages, tracheal rings, and the cricothyroid mem-
brane can be easily identified. The deeper structures of the
epiglottis and vocal cords can often be identified as well.
The traumatized patient occasionally requires an emer-
gent surgical airway. The ability to quickly and accurately
identify the cricothyroid membrane and tracheal rings for
emergent airway procedures is not a simple task in some of
these patients (Fig. 5). In patients where a thick, burned or
irradiated neck would otherwise make this an extremely
difficult task, these US skills show tremendous benefit [20].
The US can help determine the inner diameter of the
subglottic trachea, allowing selection of an appropriate
endotracheal tube size [21].
Trauma patients may also develop or present in car-
diopulmonary arrest. In these situations, US can be helpful
in determining endotracheal versus esophageal intubation
and is recommended as an adjunct to capnography, espe-
cially in patients that may have little or no end-tidal CO2
Fig. 5 Cricothyroid membrane. The thyroid and cricoid cartilages are
typically easy to identify with a high-resolution (high-frequency)
probe. The hyperechoic cricothyroid membrane is located between
the two structures
[22, 23]. Later, at the point of extubation, US examination
may also be helpful in predicting post-extubation stridor as
well [24].
US for Central Venous Access
Real-time, dynamic US has changed the way we perform
central venous access. In the trauma setting with the ready
availability of US equipment, the competing issues of
space and urgency must be balanced against improved first
attempt success and a decreased complication rate for most
venous access sites. Despite die hard opponents to its
becoming the standard of care, the use of US for venous
access procedures continues to be advocated by many as
the preferred techniqueat least in the non-emergent set-
ting. Improved first stick success and decreased accidental
arterial puncture rates have been readily shown with the
use of US [25]. Other benefits include painless evaluation
of patency and anatomy of intended target vessels and
confirmation of intravenous guide wire placement prior to
dilation (Fig. 6). Many specialty societies that were ini-
tially hesitant to promote US guidance as the standard of
care are now including it in their recommendations. The
2012 American Society of Anesthesiology (ASA) Practice
Guidelines for Central Venous Access recommend that US
be utilized for pre-procedural evaluation of the vascular
anatomy and that real-time US should be used to guide
placement of internal jugular lines in elective situations
[26]. That same year, the American Society of Echocar-
diography (ASE) and the Society of Cardiovascular
Anesthesiologists (SCA) published their joint recommen-
dations regarding US use for vascular cannulation. In this
they recommend that properly trained clinicians use real-
time US for IJ cannulation whenever possible. [27] In a
123

Fig. 6 Guidewire in the internal jugular vein (IJ) in short axis (out of plane) on left and long axis (in plane) on right
more recent systematic review of real-time US-guided
subclavian vein catheterization, Lalu and colleagues found
that US-guided techniques resulted in fewer adverse events
(arterial puncture, pneumothorax) with an increased suc-
cess rate compared to landmark-based techniques [28].
A high-frequency ([7 MHz) linear probe is recom-
mended for vascular access due to its high resolution of
superficial structures. The ASE/SCA recommendations and
a more recent review article by Weiner et al. provide
excellent descriptions of the in-plane and out-of-plane
techniques [25, 29].
Cervical Spine Clearance in the Obtunded Patient
With an incidence in the range of 2.8 % in alert patients
and 7.7 % in obtunded patients, injuries to the cervical
spine are frequently found in those who sustain blunt
trauma [30]. As a result, many blunt trauma patients are
placed in a cervical collar for protection either prior to
admission or immediately upon arrival. Perioperative
clearance of the cervical spine and removal of the cervical
collar in the traumatically injured patient can be difficult,
but helpful to the anesthesiologist. For example, airway
management can be made easier and safer by cervical spine
clearance since manual in-line stabilization and the need to
avoid excessive neck movement can be avoided [31].
Unfortunately, clearance is not always straightforward and
can be impaired by the patients concomitant injuries, the
chaotic environment of the emergency setting, the need for
analgesics, and the performance of life- and limb-saving
interventions. In the alert and cooperative patient, clear-
ance can generally be accomplished by following estab-
lished, non-radiologic criteria such as the National
Emergency X-Radiography Utilization Study (NEXUS) or
Canadian C-Spine Rule for Radiography (CCRR) low-risk
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Curr Anesthesiol Rep
criteria [32, 33]. There is significantly more controversy in
how and when to perform cervical spine clearance in the
obtunded patient which relies more on radiographic
assessments in the absence of a clinical exam.
There is general agreement that modern CT is adequate
for detection of bony injuries and malalignment of the
cervical spine following trauma [34]. Controversy still
exists, however, regarding whether a normal cervical CT
scan in the obtunded patient without evidence of neuro-
logic deficit is adequate to prompt removal of the cervical
collar. The decision to remove the collar and other cervical
spine precautions must be balanced against the risk of
prolonged immobilization such as pressure ulcers and
missed occult injures. To identify potentially unsta-
ble ligamentous injury, magnetic resonance imaging (MRI)
has been recommended as a follow-up study in the
obtunded patient with a negative CT scan (Fig. 7).
Several recent studies have addressed issues related to
this controversy. Satahoo and colleagues retrospectively
reviewed the records of 309 patients with altered mental
status (Glasgow Coma Scale, GCS, score B13 undergoing
both CT and MRI scans of the cervical spine during their
trauma admission [35]. A total of 107 patients were found
to have a negative CT scan prior to their MRI. Of these
patients, 7 (7 %) were found to have positive findings on
MRI including two patients who subsequently underwent
surgery. In one case, the initial CT noted mention of
unfused bone that probably represented a piece of
fractured bone and the other had a repeat CT that noted
subluxation of occipital condyles on C1 initiating the fol-
low-up MRI. The other MRI findings included stable liga-
mentous injuries and questionable injuries not requiring
surgery. The authors concluded that the addition of MRI
does not appear to alter management in this patient
population with the two surgical cases having other indi-
cations for obtaining an MRI.
Curr Anesthesiol Rep
Fig. 7 a Sagittal reconstruction of cervical spine shortly after motor vehicle accident with no evidence of bony injury or malalignment on
computed tomography. b Magnetic resonance imaging (MRI) of same patient showing disruption of posterior longitudinal ligament and acute
disk extrusion (arrow). c Patient later found to have subluxation at level of injury likely related to missed findings on MRI
In a similar retrospective review, Tan et al. identified 83
trauma patients with altered mental status (GCS B 14) in
whom both cervical CT and MRI scans were obtained after
admission [36]. Of the 55 patients with negative CT scans,
4 (7 %) were found to have an abnormal MRI scan. All
four patients had an intramedullary T2 hyper-intensity
signal consistent with possible spinal cord injury although
none of these patients were felt to have an unstable fracture
or ligamentous injury. Although not explicitly stated in the
study, the patients clinical exams were apparently con-
sistent with central cord syndrome and all underwent sur-
gical decompression during their admission. The authors
concluded that CT was highly sensitive in detecting
unstable injuries in this patient population. In the setting of
focal neurological deficit unexplained by intracranial
injury, they recommend MRI to evaluate for intrinsic spinal
cord injuries, but did not believe this precluded clearance
of the cervical spine and discontinuation of a cervical
collar.
These studies support the current recommendations
from the Eastern Association for Surgical Trauma (EAST)
that state cervical collar removal can be accomplished
after a high-quality C-spine CT scan result alone in the
obtunded patient [37]. Based on their analysis of five
studies with a total of 1017 included subjects, they noted
that no neurologic changes (paraplegia or quadriplegia)
were found after cervical collar removal. In a broader
review of 11 studies with 1718 subjects, they found a
worst-case 9 % incidence of stable injuries and a 91 %
negative predictive value of no injury after a high-quality
CT scan (CT axial thickness \3 mm) coupled with
magnetic resonance imaging (MRI), flexionextension CT
scan, upright X-rays, and/or clinical follow-up. Many other
recent meta-analyses, systematic reviews, and studies have
offered the same recommendation with varying degrees of
enthusiasm [3841] although some continue to recommend
MRI evaluation even with no CT evidence of injury [34,
42, 43].
Current practice appears to reflect this controversy. In a
recent survey of Level 1 trauma centers in the United
States, thirteen different clinical pathways were identified
for cervical spine clearance. Given the large degree of
variability at Level 1 centers, anesthesiologists managing
patients at all levels of care should be familiar with their
institutional policies and guidelines regarding clearance.
An effort should be made to determine whether their
patient meets those criteria prior to going to the OR or
undergoing airway management procedures since cervical
collar removal could be helpful in the perioperative setting.
Blunt Cerebrovascular Injuries (BCVI)
BCVI includes injury to both carotid and vertebral arteries
and occurs in approximately 12 % of patients with poly-
trauma [44, 45]. With stroke and mortality rates up to 67
and 38 %, respectively, in unrecognized and/or untreated
BCVI, early identification may significantly improve out-
comes [46, 47]. Depending on severity and location of
injury, patients with BCVI may need surgical intervention,
endovascular therapy, or medical management with anti-
platelet therapy or anticoagulation. For the
123

Table 1 Denver screening criteria for BCVI
Signs and symptoms of BCVI Risk factors for BCVI present
present with high-energy transfer
mechanism
Arterial hemorrhage Ischemic stroke on secondary
CT scan
Cervical bruit Lefort II or III fracture
Expanding neck hematoma Cervical spine fracture patterns
including subluxation,
fractures of C1C3, fractures
extending into transverse
foramen
Focal neurological deficit or Diffuse axonal injury with
neurologic exam not consistent GCS B 6
with CT scan
Basilar skull fracture
Near hanging with anoxic brain
injury
From [45], with permission from the American Medical Association.
2004 American Medical Association. All rights reserved
anesthesiologist, the presence of a BCVI may add addi-
tional risk in the perioperative setting during the manage-
ment of concurrent injuries or during treatment for the
BCVI itself.
Although 4-artery digital subtraction angiography
(DSA) remains the reference-standard for BCVI detection,
it has largely been supplanted by the CT angiogram (CTA)
as the primary radiographic BCVI screening tool [48, 49].
CTA allows for a more rapid time to diagnosis compared to
DSA as well as reduction in costs [46]. In the setting of
blunt trauma, screening criteria (Table 1) serve as the
trigger for DSA or CTA evaluations [45]. The concern with
screening-based criteria is that many injuries can still be
missed. Increasingly more liberalized screening is done
using a whole-body CT (WBCT) scan protocol for the
initial evaluation of the polytrauma patient [44, 50]. With
the placement of multi-slice CT scanners in close prox-
imity to trauma resuscitation units and emergency depart-
ments, it is now feasible to rapidly obtain a non-contrast
head CT scan followed by a WBCT with dual-phase con-
trast injection for the neck and trunk to identify injuries
requiring the most urgent management including BCVI,
any active bleeding, or solid organ laceration [51]. A
dedicated head and neck CTA with or without perfusion
imaging can then be obtained within 24 h to better define
the injury.
Bruns and colleagues retrospectively reviewed 16,026
trauma admissions over a 4-year period to identify those
with BCVI [44]. During the study period, 256 (1.6 %) were
diagnosed with BCVI. Of those 256, 185 (72 %) were
diagnosed after a WBCT protocol scan, with the other 71
either arriving via transfer from an outside facility with the
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Curr Anesthesiol Rep
diagnosis or being diagnosed with a dedicated diagnostic
procedure (CTA or DSA). The majority of those diagnosed
by WBCT had at least one of the expanded screening cri-
teria for BCVI but 56 patients (30 %) had no radiographic
or clinical risk factors based on BCVI screening criteria.
After confirmatory CTA, 35 patients with a total of 45
injured vessels were identified for further follow-up and
treatment. Six patients did not have a follow-up study and
two patients underwent dedicated neck magnetic resonance
angiography with one patient identified as having a per-
sistent injury. While use of WBCT scan protocol may not
replace dedicated CTA of the neck in all patients, it does
have utility in picking up injuries that would be otherwise
missed based on current screening criteria.
In a follow-up study from the same group looking only
at those patients getting the initial WBCT and diagnostic
CTA, overall sensitivity for WBCT was 92 % (91 % for
carotid injury and 94 % for vertebral injury) [50]. There
were 319 injuries identified in 227 patients. Of the 319
injuries, 58 (18 %) were classified as indeterminate with 13
of these injuries being reclassified to no injury on the
CTA. Only 20 (6.3 %) of the 319 injuries were not seen on
WBCT but identified on subsequent CTA necessitated by
the presence of an injury in another vessel.
Given the increasing use of early WBCT for evaluation
of the trauma patient, it can be anticipated that the number
of patients with identified BCVI may increase in the peri-
operative period. For the anesthesiologist, this may have
perioperative implications. Patient with BCVI may be
considered for early anti-platelet therapy or anticoagula-
tion; however, the presence of intracranial hemorrhage
frequently serves as a relative contraindication and requires
a riskbenefit analysis. The presence of stroke may require
tighter management of blood pressure. Additionally, the
presence of BCVI may require operative intervention or
endovascular therapy with anesthesia support.
Conclusion
In this review, we have introduced the concept of DCRad
and some of the implications for the anesthesiologist
managing the traumatically injured patient. The ready
availability of US equipment and training programs has
introduced a number of new diagnostic and patient man-
agement options which are being readily incorporated by
surgeons, emergency medicine physicians, and anesthesi-
ologists into the early care of the trauma patient. In order to
optimize the perioperative care of these patients, the
anesthesiologist must be familiar with the techniques,
decision-making implications, and risks of incorporating
the DCRad aims into their practice.
Curr Anesthesiol Rep
Compliance with Ethics Guidelines
Conflict of Interest Thomas E. Grissom and Bert Pierce declare
that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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Curr Anesthesiol Rep
DOI 10.1007/s40140-015-0132-7
ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)
Anesthetic Management and Challenges in the Pregnant Patient
Tiffany Sun Moon1 Joshua Sappenfield2
 Springer Science + Business Media New York 2015
Abstract Trauma during pregnancy is the leading cause
of non-obstetric morbidity and mortality and presents a
unique set of challenges to the anesthesiologist, as there are
inherently two patients to care for. The best treatment for
the fetus is expeditious evaluation and resuscitation of the
mother. Evaluation of the fetus by an obstetrician should be
part of the secondary survey, including fetal heart rate
monitoring for pregnancies exceeding 20 weeks gestation.
The duration of fetal heart rate monitoring should be gui-
ded by the severity and mechanism of injury, as well as by
maternal and fetal responses. Pregnancy brings about a
multitude of physiologic changes that must be considered
when evaluating and treating the pregnant trauma patient.
The anesthesiologist may have more familiarity with the
physiology of pregnancy and can play an important role in
resuscitation. The initial goals of resuscitation are main-
tenance of adequate ventilation and oxygenation, volume
replacement, and avoidance of aortocaval compression.
Keywords Anesthesia
Pregnancy
Trauma
Placental
abruption
Motor vehicle crash
Resuscitation
Fetal
monitoring
Perimortem C-section
Burn injury
This article is part of the Topical Collection on Anesthesia for
Trauma.
& Tiffany Sun Moon
tiffany.moon@utsouthwestern.edu
Joshua Sappenfield
jsappenfield@anest.ufl.edu
1 during pregnancy due to mechanical effects of the enlarg-
Department of Anesthesiology and Pain Management,
University of Texas Southwestern Medical Center, 5323
Harry Hines Boulevard, Dallas, TX 75390-9068, USA
2
Department of Anesthesiology, University of Florida,
Gainesville, FL 32610, USA
Introduction
Trauma is the primary cause of maternal or fetal demise,
with an incidence of approximately 78 % of all pregnancies
in the United States [1, 2, 3]. Almost one-quarter to one-
third of patients who are hospitalized for traumatic injuries
will deliver their child during their hospital stay [1, 4].
There are several known risk factors for experiencing trauma
during pregnancy, including a history of abuse, unintended
pregnancy, unmarried status, race, substance abuse, low
maternal education level, and lower socioeconomic status
[1, 4]. The three most common significant causes of trauma
to the pregnant female include motor vehicle accidents,
which account for 50 % of all traumas, falls, and intentional
trauma [1, 2, 4]. Intentional trauma, otherwise known as
intimate partner and domestic violence, accounts for 22 % of
all traumatically injured pregnant women [2]. Even rela-
tively minor trauma during pregnancy increases the risk of
preterm premature rupture of membranes, placental abrup-
tion, uterine rupture, and maternal and fetal death [1, 35].
The increased risk to the fetus does not end after stabilization
of the mother and discharge from the hospital. Patients who
sustain trauma during pregnancy are at an increased risk of
having an abruption, premature delivery, or babies with a
low birth weight [4].
Physiologic Changes of Pregnancy
Numerous changes take place in almost all organ systems
ing uterus, hormonal changes, and increased metabolic
demands (Table 1). Maternal blood volume increases 45 %
but the increase in red blood cell mass is not proportional,
resulting in a relative anemia [6]. By the end of the third
123

trimester, hematocrit is typically 3034 %. Resting heart
rate is 1520 beats per minute more in the third trimester,
with an increase in cardiac output of 3050 %. Blood
pressure decreases about 15 mmHg in the second trimester
and gradually increases toward pre-pregnancy levels by the
end of the third trimester [7]. After 20 weeks, the gravid
uterus can cause significant aortocaval compression in the
supine position; patients who are 20 weeks or more preg-
nant should be placed in the left lateral decubitus position.
The respiratory system also undergoes many changes
during pregnancy. Oxygen consumption increases
1520 % to compensate for the increased metabolic
demand and oxygen delivery to the fetus. Respiratory rate
is increased, causing a relative respiratory alkalosis
(PaCO2, 2732 mmHg) with compensatory metabolic aci-
dosis (kidneys increase bicarbonate excretion) [7]. Thus,
mechanically ventilated patients will need their minute
ventilation increased to target a PaCO2 between 27 and
32 mmHg. Tidal volumes are increased by 40 %, but
residual volume is decreased due to the gravid uterus,
resulting in 2025 % decrease in functional residual
capacity. This decrease in functional residual capacity,
coupled with increased oxygen consumption, predisposes
the pregnant patient to quicker desaturation and less tol-
erance for apnea [8].
During pregnancy, the effects of estrogen and increased
blood volume can cause the airway to be edematous and
friable. Capillary engorgement of the mucosa can cause
edema of the pharynx, larynx, and trachea, which may
necessitate a smaller size endotracheal tube [9]. If airway
obstruction is present, nasopharyngeal airways should be
used with caution due to the risk of bleeding. A short
laryngoscope handle may be helpful to avoid abutting the
larger breasts that frequently accompany pregnancy. The
incidence of a difficult airway with pregnancy is signifi-
cantly higher than in the general population [10, 11]. A
difficult airway cart should be readily available, as well [14]. Uterine blood flow is directly related to maternal cardiac
Table 1 Key physiologic changes during pregnancy
Physiology Change during pregnancy
Mean arterial pressure Decreases by 515 mmHg
Cardiac output Increases 3050 %
Heart rate Increases by 1015 bpm
Hematocrit Decreases due to more increase in blood volume than red blood cells, HCT 3034 % at term
Tidal volume Increases 40 %
Function residual capacity Decreases 20 %
PaCO2 Decreases to 2732 mmHg
Gastrointestinal tract Delayed emptying, decreased lower esophageal sphincter tone
Airway Increased edema, difficult ventilation/intubation
123
Curr Anesthesiol Rep
as providers who are trained in using adjunct airway
equipment and advanced techniques [12]. Additionally,
for patients who have cervical spine trauma, fiberoptic
intubation should be considered because of the desire to
prevent worsening of neurologic injury in the setting of a
higher incidence of difficulty with intubation [13]. Algo-
rithms for difficult ventilation and intubation in obstetric
anesthesia have previously been described [9].
Pregnant patients also have an increased risk for aspi-
ration due to relaxation of the lower esophageal sphincter
and displacement of the stomach cephalad by the gravid
uterus. Progesterone also slows gastric emptying, and thus,
pregnant women should be considered full stomach and
should undergo a rapid sequence induction.
Evaluation and Resuscitation of the Pregnant
Trauma Patient
The Eastern Association for Surgery and Trauma states the
best initial treatment for the fetus is the provision of optimum
resuscitation of the mother and the early assessment of the
fetus [2]. Pregnant patients who are traumatically injured
should be brought to the hospital and treated similarly to other
patients. At term, the gravid uterus can weigh up to 5 kg;
patients in the supine position can have a 30 % decrease in
cardiac output, compromising blood flow to vital organs. All
efforts should be made to displace the uterus off the inferior
vena cava with a wedge or rolled up towels. Patients who are
in C-spine precautions should not be moved, but a wedge can
be placed under the backboard or providers can manually
deflect the uterus to improve venous return.
The primary survey should be carried out expediently and
should not differ from that of a non-pregnant patient. All
pregnant women suffering from trauma should receive sup-
plemental oxygen, as the fetus is sensitive to maternal hypoxia
Curr Anesthesiol Rep
output because uterine circulation is not autoregulated.
Because systemic blood pressure is dependent on circulating
intravascular volume and systemic vascular resistance, ade-
quate volume replacement in the mother is necessary for
sufficient uteroplacental blood flow. Patients who are
[20 weeks pregnant should have a 50 % increase in the
volume of fluids given their increase in plasma volume [14].
The success of maternal resuscitation is the greatest factor
in determining fetal outcome. The average estimated blood
loss for term vaginal delivery and C-section are 500 and
1000 mL, respectively. Due to the hypervolemic adaptations
of pregnant women, this amount of hemorrhage may not
result in a significant change in vital signs. Signs of maternal
distress such as tachycardia and hypotension may not occur
until hemorrhage of 15002000 mL [7]. Thus, the absence
of maternal tachycardia or hypotension does not mean that
significant hemorrhage has not occurred.
The secondary survey should include a complete history,
including obstetrical history and evaluation of the fetus.
The gestational age of the fetus should be determined,
either from the patients history, ultrasound, or measure-
ment of the fundal height. Roughly, a fundal height at the
umbilicus indicates a pregnancy of 20 weeks gestation.
Neonatal specialists should be given advance warning if
delivery of the fetus is a possibility. A vaginal examination
should take place to look for blood or amniotic fluid. If
vaginal bleeding is present and the patient is past the first
trimester, placenta previa should be ruled out before cer-
vical examination to look for dilation and effacement [14].
Fetal heart rate monitoring can be useful to guide fluid
resuscitation because the fetal heart rate is sensitive to
maternal hypovolemia. As part of the complete assessment,
the Eastern Society for Surgery and Trauma has made
Level II recommendations that fetal monitoring should be
performed for all pregnancies at greater than 20 weeks
gestational age for 6 h [2]. (See Table 2 for indications for
fetal monitoring longer than 6 h.) Fetal monitoring will
help assess fetal well-being but should not interfere with
the care of the mother [1]. Laboratory analysis should
include a KleihauerBetke test in all gravid patients more
than 12 weeks gestational age [2]. Trauma care providers
should also consider an obstetric consult.
The pregnant patient may need a trip to the operating
room for surgical treatment of injuries sustained or to deliver
the fetus. Ideally, an anesthesiologist familiar with trauma
and obstetrical anesthesia should be available. Adequate
venous access consisting of two large-bore intravenous lines
should be attained for resuscitative measures. It should be
noted that pregnancy decreases the amount of volatile
anesthetic necessary during general anesthesia.
Even minor trauma can lead to injuries specific to
pregnant patients that should be excluded during evalua-
tion. The most concerning and leading cause of fetal death
is placental abruption [5]. Risk factors for placental
abruption include a positive KleihauerBetke test, frequent
uterine contractions, vaginal bleeding, abdominal or uter-
ine tenderness, postural hypotension, and fetal heart rate
abnormalities [2, 3]. Other obstetric-related complications
include preterm premature rupture of membranes, prema-
ture labor, premature delivery, uterine rupture, dissemi-
nated intravascular coagulation, fetal distress, fetal
hypoxia, and fetal death [1, 35]. Significant factors
affecting fetal demise are younger gestational age and a
higher injury severity to the mother [4, 5].
Amniotic fluid embolism is a rare event that can occur
with trauma [15, 16]. The signs and symptoms are non-
specific and include fever, chills, nausea, headache, con-
fusion, agitation, altered mental status, bronchospasm,
hypoxia, cyanosis, pulmonary edema, cardiac arrhythmias,
ventricular dysfunction, hypotension, coagulopathy from
disseminated intravascular coagulation, seizures, fetal dis-
tress, and shock [15]. Supportive treatment of these signs
and symptoms is the limit of current therapy [15, 16].
Cardiac Arrest in Pregnancy
Management of cardiac arrest in pregnant patients should
follow standard advanced cardiac life support guidelines.
Medications and their dosages should not be changed in
pregnancy, and defibrillation should be performed at the
usually recommended doses [17]. In cases of maternal
cardiac arrest, a perimortem C-section may be performed.
By definition, a perimortem C-section is one that occurs
concurrent with maternal cardiopulmonary resuscitation
[18, 19]. The physiological rationale for a perimortem
C-section is that by delivering the fetus, venous return is
improved and chest compressions will be more effective.
There are many reports of return of spontaneous circu-
lation or improvement in maternal hemodynamic status
occurring after delivery of the fetus [18, 19]. The American
College of Obstetricians and Gynecologists recommends
that the decision to perform a perimortem C-section should
be made within 4 min of arrest, as outcomes correlate
inversely with time from maternal arrest [18]. Other indi-
cations for emergency Cesarean delivery include a stable
mother with a viable fetus in distress and traumatic uterine
rupture [20].
Fetal Considerations
In the absence of clinical signs and symptoms of significant
trauma, there is reluctance to obtain imaging, which causes
ionizing radiation that can be harmful to the fetus [21, 22].
Ultrasound by itself is not sensitive enough to rule out
123

Table 2 Reasons for continued fetal monitoring beyond 6 h
[1, 2, 32]
Mechanism includes
Ejection from a vehicle
Motorcycle crash
Pedestrian collision
Time between contractions is less than 10 min
Concerning signs on the fetal tracing (tachycardia,
bradycardia, decelerations)
Maternal abdominal pain or discomfort
Vaginal bleeding
Rupture of amniotic membranes
Maternal heart rate greater than 110
Concern for maternal cardiopulmonary status
Glasgow Coma Score less than 10
Injury Severity Score greater than 9
Trauma requiring general anesthesia
injury, having a sensitivity of only 6183 % [1, 22, 23]. injury itself, but also from the pre-existing airway edema
Ultrasound is also not sensitive enough to rule out placental
abruption, and repeat ultrasounds days later may be nec-
essary to detect placental abruption [1, 3]. Although it is
important to be judicious when using imaging associated
with ionizing radiation during pregnancy, it is most
important that the mother undergo imaging that is clinically
indicated following a traumatic incident [2]. The typical
imaging for trauma patients will result in less than half the
100 mGy threshold thought to cause growth retardation,
intellectual deficiencies, and neural defects [24]. Although
the increase in radiation exposure from a CT scan does
place the fetus at a 0.20.8 % increased risk for developing
cancer [5, 24], additional precautions can be taken to
reduce the fetal exposure, including limiting the radio-
graphic exposure, z-axis modulation, and changing the scan
pitch [22]. Providers should consider discussing with a
radiologist how to minimize exposure and consolidate
studies if multiple scans are indicated based on the
patients injuries.
During surgery for the traumatically injured, the
risks to the fetus can be placed in three categories:
hypoxemia, teratogenic exposure, and preterm delivery
[25]. The etiologies of hypoxemia include reduction of
uterine blood flow, problems with maternal gas
exchange, and depressants to the fetal cardiovascular,
or nervous system [25]. Inhalational anesthetics have
not been shown to be teratogenic in clinical concen-
trations. Commonly used anesthetic medications also do
not seem to carry teratogenic potential, including ben-
zodiazepines [5, 25]. Fetal heart rate monitoring should
be considered for all surgeries where the surgical site
allows for monitoring and the expertise is available for
accurate interpretation [5]. An obstetrician should also
123
Curr Anesthesiol Rep
be readily available, should an emergency C-section be
necessary. When large hemodynamic changes are
anticipated, fetal monitoring should be utilized to help
assess the adequacy of placental perfusion. During an
operation, administration of medications and hypother-
mia can cause loss of heart rate variability; however,
decelerations should raise concern for possible fetal
distress [25].
The Pregnant Burn Patient
About 7 % of women of childbearing age who have burn
injuries are pregnant [26]. Burns during pregnancy pose a
major threat to the mother and fetus. In general, treatment
is not changed significantly by pregnancy and specific
guidelines for the management of pregnant burn patients
are lacking. A pregnant patient with facial burn injuries is
at high risk of airway compromise not only from the burn
that accompanies pregnancy. Patients with signs of
inhalational injury (hoarseness, stridor, soot in airway,
singed nasal hairs) may require close vigilance and early
tracheal intubation because post-injury edema may turn a
previously uncomplicated airway into a complicated or
difficult one.
Using the rule of nines, the total body surface area
(TBSA) burned can be estimated. Morbidity and mor-
tality are correlated with the extent of the burn injury. In
one series, both maternal and fetal mortality approached
100 % when TBSA [40 % [27]. Fluid resuscitation in
burn patients is traditionally guided by the Parkland
formula: TBSA (%) 9 4 mL 9 wt (kg). However,
pregnant burn patients have an increase in intravascular
volume so that the Parkland formula can lead to under-
resuscitation [28]. Thus, volume resuscitation should be
guided by clinical signs such as maternal vital signs,
urine output, and fetal heart rate and variability, rather
than by formula alone.
Burn injury can cause the release of prostaglandins,
which can cause preterm labor [14]. The risk of preterm
labor increases as TBSA increases. The use of tocolytics
may be indicated when TBSA is less than 30 % and
gestational age is between 24 and 32 weeks, as long as
fetal monitoring is reassuring [27]. Carbon monoxide
(CO) poisoning can occur in the fetus because CO
crosses the placenta and fetal hemoglobin has a higher
affinity for CO. Detection must be with a co-oximeter, as
a pulse oximeter will not detect CO poisoning. Treat-
ment is with 100 % oxygen. Electrical burns during
pregnancy are rare and the severity depends on the
strength of the voltage exposure and the path of the
current; fetal demise is common [29].
Curr Anesthesiol Rep
Neuroanesthesia in the Pregnant Patient
Nevelle et al. [30] have recommended that a multidisci-
plinary care team should be used to care for pregnant
patients that sustain neurotrauma. Although there is a
theoretical concern for dehydration in the fetus with the
administration of mannitol, administering 100 g of man-
nitol, raising the maternal osmolarity to 320 mOsmol/kg,
appears to be safe for the fetus [31]. Another concern is
that hyperventilation, when used to reduce intracranial
pressure, can reduce blood flow to the uterus [31].
Conclusion
Obstetric patients who experience even minor trauma are at a
high risk of having a complication related to their pregnancy.
This risk follows them even if they are rapidly stabilized,
treated, and discharged without delivering their child during
their hospitalization. Providers not only need to familiarize
themselves with the physiologic changes that accompany
pregnancy, but will need to adjust their management
accordingly. The best outcomes occur when the team caring
for the patient is adequately prepared and has the available
resources to care for the injured pregnant patient.
Compliance with Ethics Guidelines
Conflict of Interest Tiffany Sun Moon and Joshua Sappenfield
declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects per-
formed by any of the authors.
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Curr Anesthesiol Rep
DOI 10.1007/s40140-016-0141-1

ANESTHESIA FOR TRAUMA (JW SIMMONS, SECTION EDITOR)

Trauma Anesthesia for Traumatic Brain Injury

Bianca Conti1 M. Karla Villacin1 Jeffrey W. Simmons2

 Springer Science + Business Media New York 2016

Abstract Traumatic brain injury is a dynamic condition
with varying severities, classifications, and periods.
Treatments and interventions through these periods can
dramatically affect its morbidity. Anesthesiologists have a
unique opportunity to be involved in the care of traumatic
brain injury patients from their admission, through the
operative period, and into postoperative intensive care. In
this article, we will review current treatment, standards for
monitoring, and goals for resuscitation, both intraopera-
tively and postoperatively. Co-morbidities that affect
resuscitation will also be discussed.
This article is part of the Topical Collection on Anesthesia for
Trauma.
Keywords Traumatic brain injury
Intracranial
monitoring
Mannitol
Hypertonic saline
Decompressive
craniectomy
Intracranial hypertension
Introduction
In the United States, incidence of hospital visits and hos-
pitalizations attributed to traumatic brain injury (TBI) have
continued to increase over the past decade; however,
mortality has decreased. Overall, more than 1.7 million
people are affected annually [1]. Traumatic brain injury is
normally the result of acceleration or deceleration of the
brain by assault, motor vehicle accidents, or falls. Conse-
quences of TBI are classified as cognitive, functional,
neuro-electrical, behavioral, and social. The treatment of
TBI focuses on reducing morbidity and reducing the neu-
rological consequences for patients. This article reviews
the anesthesiologists role in caring for the traumatic brain
injury patient.

& Bianca Conti

bconti@umm.edu Injury Types
M. Karla Villacin
mvillacin@anes.umm.edu The pathophysiology of traumatic brain injury is dynamic
Jeffrey W. Simmons
and classified into two distinct periods, primary and sec-
jwsimmons@uabmc.edu ondary. Primary injury is due to force transmitted to the
brain immediately following trauma. A list of primary
1
Division of Trauma Anesthesiology, Department of injury types can be found in Table 1 [2].
Anesthesiology, R Adams Cowley Shock Trauma Center,
Secondary brain injuries are caused by systemic
University of Maryland School of Medicine, Baltimore,
MD 21201, USA derangements, increase morbidity of the primary injury,
2 and are potentially preventable. The major determinants
Section of Trauma and Acute Care Anesthesia, Department
of Anesthesiology and Perioperative Medicine, University of contributing to secondary brain injury include hypotension,
Alabama at Birmingham, Birmingham, AL 35249, USA hypoxemia, and hypercarbia that result in changes to the

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 Curr Anesthesiol Rep

Table 1 Primary brain injuries

Primary injury types Example

Parenchymal injury Diffuse axonal injury (DAI) caused by shearing due to accelerating and bleeding
Epidural hematoma Usually in the temporal or temporal-parietal region as a result of a tear in the
middle meningeal artery causing extradural blood to accumulate
Subdural hematoma Resulting from tearing of bridging veins
Post-traumatic subarachnoid hemorrhage Vascular injury due to penetrating trauma and intracerebral hemorrhage

Table 2 Sequelae of secondary brain injury
Cerebral edema
Hematoma
Hydrocephalus
Intracranial hypertension
Cerebral vasospasm
Metabolic derangement
Coagulopathy
Calcium ion toxicity
Infection
Seizure
deposition of amyloid protein
Apoptosis
intracerebral environment. Table 2 lists sequelae of sec-
ondary brain injury [3, 4, 5].
Initial Treatment
Diagnosis
Initial Glasgow Coma Score (GCS) is commonly used to
classify TBI, as it is easy to use and has interobserver
reliability [6]. A score of 1315 is considered mild, 912 is
considered moderate, and less than 9 is considered severe.
Rapid GCS assessment is often obtained before intubation
so that immobility secondary to the administration of
neuromuscular blocking agents does not become a concern.
Computed tomography (CT) scan is most often utilized to
formally diagnose traumatic brain injury.
Invasive Monitors
After diagnosis of TBI, consideration should turn toward
monitoring. The Monro-Kellie doctrine summarizes that
the cranial compartment is incompressible with a fixed
volume. Therefore, any increase in volume of one of the
cranial constituents must be compensated by a decrease in
volume of another to maintain equilibrium. For example,
brain swelling will result in reduced blood flow, potentially
worsening ischemia and resulting in infarct. Morbidity with
TBI is linked to elevated intracranial pressure (ICP);
therefore, monitoring ICP becomes paramount. When GCS
is 8 or less or the patient cannot follow serial neurological
exams, an ICP monitor is often utilized.
Current guidelines recommend an ICP less than
20 mmHg and cerebral perfusion pressure (CPP) greater
than 60 mmHg; however, patient-specific variability exists
and has been identified [7]. As a result, a targeted approach
using patient-specific cerebral autoregulation has been sug-
gested. Averaged values of ICP and mean arterial pressure
(MAP) result in a pressure reactivity index (PRx). Plotting
PRx against CPP produces a U-shaped curve, with the two
ends demonstrating hypoperfusion or low CPP and hyper-
perfusion or high CPP; both associated with worse cere-
brovascular reactivity. The lowest part of the curve is the
bottom of the U and is designated the optimal CPP. Factors
that may render this measurement unusable include the use
of vasoactive medication, high-dose sedation, neuromuscu-
lar blockade usage, and decompressive craniectomy that
makes the cerebral pressurevolume curve artificially flat
[8]. When direct ICP measurements are not yet available, a
mean arterial pressure of 80 mmHg or greater is recom-
mended based on the assumption of an ICP or 20 mmHg.
As an ICP monitor, ventriculostomies are both diag-
nostic and therapeutic. A ventriculostomy provides the
ability to both drain cerebrospinal fluid and measure ICP.
Placing a ventriculostomy involves cannulating the ven-
tricle via a durotomy and is the most commonly used ICP
monitor in trauma. Ventriculostomies have the highest risk
of intracerebral hemorrhage. Another ICP monitor, the
Richmond bolt, is seated adjacent to the dura. This device
does not penetrate brain tissue, and is diagnostic only.
Richmond bolts have been associated with infection,
epidural bleeding, and focal seizures. Additionally, epidu-
ral intracranial pressure monitors use pneumatic switches
that deform as the dura changes; however, these can be
difficult to place, calibrate, and can cause bleeding. Finally,
the Integra Camino monitor (Plainsboro, NJ, USA), an
intraparenchymal intracranial pressure monitor, is a can-
nula that is inserted directly into the cortical gray matter
and directly measures tissue pressure. Camino monitors
have a low risk of infection or leak and occlusion of the
catheter is rare; however, after placement there is no way to

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recalibrate the cannula [9]. In addition to measuring ICP,
cerebral perfusion pressure (CPP), cerebral blood flow
from cortical blood flow, and brain tissue PO2 can be
measured with a variety of instruments. The multimodal
approach versus the single approach of ICP measurement
may result in superior outcome [10].
Ventilation
Early management of traumatic brain injury hinges on the
avoidance of secondary insult. Hypoxia is well established to
worsen the outcome of TBI. As a result, rapid sequence
intubation (RSI) in the field was common practice. Recent
studies, however, demonstrated increased mortality with
paramedic intubation of brain-injured patients, possibly due to
increased transport times, transient hypoxia during the pro-
cedure, and inadvertent hyperventilation [11]. Accordingly,
patients are transported directly to a trauma center when
feasible, aka scoop and run. If there is airway compromise
in route, patients will divert to a local hospital to obtain a
definitive airway and then continue to a suitable trauma
center. Patients with severe TBI should be directed to a Level
I or II trauma center even if that hospital is not the closest [12].
If not intubated in the field, patients are often intubated
after arrival to the trauma center once initial GCS is
established. They remain intubated and mechanically
ventilated for the intraoperative and postoperative period.
After intubation, hyperventilation should be avoided
because it causes vasoconstriction of the cerebral circula-
tion and should only be used in short duration for
impending herniation. A PaCO2 of less than 25 mmHg is
not recommended. A decrease in PaCO2 can reduce ICP by
cerebral vasoconstriction; however, it also increases the
volume of severely hypoperfused tissue in the injured
ischemic brain tissue and results in more ischemia. Pro-
tective low tidal volumes and moderate positive end-ex-
piratory pressure (PEEP) can prevent acute lung injury
(ALI) that can accompany TBI. In euvolemic patients with
previously healthy lungs, PEEP up to 15 cm H2O does not
significantly affect intracranial pressures, but the lowest
PEEP to maintain open alveoli and avoid hypoxemia
should be utilized [4].
Hemodynamics
Hemodynamic goals for the patient with TBI should be
weighed against the effects on other injuries. Cerebral
perfusion pressure can be used to guide resuscitation.
A CPP below 50 mmHg can lead to cerebral infarction in
the injured brain and above 70 mmHg is also not recom-
mended [13]. Traumatic brain injury rarely occurs in iso-
lation, requiring the anesthesiologist to have a whole
patient approach to resuscitation. Increasing the arterial
blood pressure to gain an increase in CPP may have a
deleterious effect on the patients other injuries and a
multimodal approach to monitoring is recommended.
Temperature
Therapeutic hypothermia is controversial. If the patient has
not suffered a cardiac arrest, patients are rarely cooled. In
select populations, studies have shown that hypothermia
applied over 48 h can improve outcome; however, the
success may be dependent on timing of onset, temperature
at admission, rewarming rate which can cause rebound
intracranial hypertension, and target temperature. There-
fore, the use of hypothermia remains optional [1416].
Medical Management
Increased ICP can be managed medically and surgically. In
a 2010 survey of 295 practitioners by the Neurocritical
Care Society, about 90 % reported the use of osmotically
active agents to decrease ICP [17].
Mannitol
Mannitol, an osmotically active derivative of mannose, is
frequently used in the treatment of elevated ICP since its
introduction in the 1960s. It is a level II recommendation at
doses of 0.25 gm/kg to 1 g/kg body weight. Its osmotic load
establishes a gradient that results in the movement of water
from the brain and into the circulation, effectively decreasing
brain volume and ultimately leading to a decrease in ICP.
Additionally, it improves rheology within minutes of its
administration by volume expansion, decreasing blood vis-
cosity and increasing the deformability of red blood cells,
and ultimately improving CBF [16, 18, 19]. Despite these
positive influences on ICP, mannitol can result in a rebound
increase in ICP when the therapy is discontinued since it can
penetrate the injured BBB and reside within the injured
brain. Mannitol can also lead to complications such as
hemolysis, hypotension from its action as an osmotic
diuretic, renal failure, CHF and pulmonary edema, and
electrolyte imbalances with hyponatremia first from volume
expansion and then hypernatremia from hypovolemia [19].
Hypertonic Saline
The use of hypertonic saline (HTS) has steadily increased
since its introduction in the early 1990s. A 1995 survey
showed 83 % of centers in the US used mannitol to treat
increased ICP; however, by 2010 there was a narrowing
margin of preference with 55 % preferring HTS and 45 %
preferring mannitol [17, 20]. Reasons for increased
123

preference of HTS include less rebound edema, longer
lasting effect, and fewer systemic side effects.
HTS is formulated in concentrations of 2, 3, 7.5, 23.4 %.
HTS is one of the first line therapies included in the
armamentarium at the R Adams Cowley Shock Trauma
Center in Baltimore. It is administered readily to those
patients who have suffered polytrauma including head
trauma with a high concern for elevated ICP. A patient who
arrives with head trauma and signs and symptoms indica-
tive of elevated ICPs will receive 500 ml of 3 % HTS in
addition to other appropriate interventions. HTS, by
restoring circulating blood volume, improves cardiac out-
put, perfusion and MAP in hypovolemic trauma patients,
improving CBF while minimizing the risk of increasing
cerebral edema through the administration of large vol-
umes of NS or other crystalloids.
With the goal of preserving CPP by decreasing ICP and
elevating MAP, further secondary injury due to ischemia
may be minimized. Therefore, HTS has been compared to
mannitol in numerous studies. Elevations of ICP greater than
20 mmHg treated with equimolar doses of 20 % mannitol
and 15 % HTS administered as a bolus have shown a mean
decrease in ICP of 7.96 versus 8.43 mmHg, respectively,
with HTS producing a longer duration of the reduction [21].
In patients with severe ICP elevation, generally greater than
30 mmHg, HTS has been shown to generate more significant
reductions in ICP [22]. Cumulative ICP burden is defined as
the total number of days in which patients had an elevation of
ICP greater than or equal to 25 mmHg from the total number
of days in which ICP was monitored. A recent retrospective
analysis showed that patients who received HTS had a sig-
nificantly lower cumulative ICP burden and a statistically
significant decrease in the daily ICP burden than those
receiving mannitol [23].
When HTS is used, serum sodium and serum osmolality
should be followed. Generally, serum Na? should be main-
tained less than 162 mOsm/L and serum osmolality under
382 mOsm/L [22]. Complications associated with HTS are
renal failure, coagulopathy, pulmonary edema, hyperna-
tremia, hyperkalemia, central pontine myelinolysis, hyper-
chloremic metabolic acidosis, hyperoncotic hemolysis, vein
sclerosis if high concentrations are administered through a
peripheral vein, and rebound intracranial hypertension
although this is less than the risk with mannitol [17, 22].
Albumin
Whether a patient suffering from both traumatic brain injury
and hypovolemic shock should receive albumin has not yet
been completely elicited. According to the SAFE trial, TBI
patients receiving 4 % albumin had a significantly higher
risk of death compared to those receiving saline in the ICU.
Patients with severe TBI receiving 4 % albumin have a 1.6
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Curr Anesthesiol Rep
relative higher risk of death at 24 months compared to
patients receiving saline, despite the lack of differences in
hemodynamic resuscitation end points; however, the albu-
min group did have higher initial intracranial pressure.
Possible explanation is that the use of albumin could lead to
worsening of cytotoxic or vasogenic cerebral edema [24].
4 % Albumin has a calculated osmolarity of 274.5 mOsml/L
and a measured osmolality of 266 mOsm/kgH2O, and iso-
tonic saline has an osmolarity of 308 mOsm/L with a mea-
sured osmolality of 285 mOsm/kg H2O. Therefore, the
relative hypotonicity of 4 % albumin could contribute
vasogenic edema [25]. The sulfhydryl group on albumin can
interact with nitrous oxide and limit its breakdown, ulti-
mately decreasing cerebral vasodilation [26]. With con-
flicting data, there is no definitive guideline for the use of
albumin in polytrauma TBI patients.
Pentobarbital
In addition to the therapies discussed above, pentobarbital
coma can also be induced in patients suffering from
intractable intracranial HTN.
Seizure Prophylaxis
The traumatized brain is also at high risk for developing
seizures. In those who suffer mild TBI, the relative risk of
developing seizures is double to those without TBI. In
those who suffer intracranial hypertension or brain contu-
sion, the risks rise by 5- to 6-fold. For those who suffer a
combination of intracranial hypertension and contusion, a
43-fold increase in post-traumatic seizures can be seen.
[27]. Levetiracetam is commonly used for seizure sup-
pression along with phenytoin. Anti-seizure medications
are maintained for at least 7 days after severe traumatic
brain injury [28].
Surgical Management
Decompressive Craniectomy
Management of TBI hinges on controlling ICP. Patients who
require surgical intervention due to refractory intracranial
hypertension despite medical treatment often undergo
emergency decompressive craniectomy that involves
releasing the pressure by removing a part of the skull.
Patients with a higher GCS score on admission have better
outcomes after decompressive craniectomy, have a shorter
ICU stay, and require the ventilator for shorter periods [29,
30]. Early decompressive craniectomy, utilized commonly at
R Adams Cowley Shock Trauma, has been shown to have
good functional outcomes in patients with severe TBI [31,
Curr Anesthesiol Rep
32]. Some indications used to indicate the need for a
decompressive craniectomy include unilateral or bilateral
cerebral edema, midline shift greater than 5 mm with a GCS
of 8 or less, worsening neurological exam, bilateral fixed
pupils with intact brainstem reflex, intractable intracranial
HTN with ICP greater than 25 mmHg, and cerebral edema
despite hematoma evacuation [33].
Intraoperative management of patients undergoing
emergency decompression includes obtaining large bore
intravenous access for blood and possible vasopressor
administration. Commonly 16- or 14-gauge intravenous
catheters are placed. Rapid infuser catheters or central access
can also be established. An arterial catheter is placed for
constant blood pressure monitoring. Patients usually arrive to
the operating room with intracranial monitors already
established, since this is one indicator for the need of the
operation. As a result, an arterial line and ICP monitor allow
CPP to be calculated and followed. Blood products should be
readily available, including fresh frozen plasma, cryopre-
cipitate, and possibly prothrombin complex concentrate
(PCC) to reverse chemical anticoagulation and trauma-in-
duced coagulopathy. There is some uncertainty on the utility
of tranexamic acid (TXA) in patients with traumatic brain
injury. It has been suggested that TXA decreases the pro-
gression of intracranial hemorrhage and reduces, although
not significantly, the clinical outcome of TBI patients [34].
There was no increase in mortality with its use and can be
administered when bleeding cannot be controlled or a
thromboelastogram demonstrates fibrinolysis [35].
Decompressive Laparotomy
Despite all other medical and surgical interventions, some
patients continue to have an elevated ICP. For those patients
who have failed aggressive medical and surgical interven-
tion, including a decompressive craniectomy, a study at the R
Adams Cowley Shock Trauma Center showed a decom-
pressive laparotomy which resulted in a 65 % survival rate
[36]. Intracranial, intrathoracic, and intra-abdominal com-
partments are not isolated and inherently affect one another
by transmission of pressures through the venous system.
Elevations in the intra-abdominal compartment especially
after massive resuscitation in multiply injured trauma
patients can result in elevation of ICP and release of the
abdominal pressure can lead to drastic and significant
reductions in ICP [36, 37].
Co-morbid Conditions Associated with TBI
Aside from surgical complications, TBI carries the risk of
many complications. In addition to post-traumatic seizures,
the risk of developing hydrocephalus, spasticity, gait
abnormalities, agitation, and gastrointestinal and geni-
tourinary disorders are high. A myriad of immediate sys-
temic complications including cardiovascular, pulmonary,
hematologic, immunologic, and endocrinologic dysfunc-
tion can occur [38].
Cardiopulmonary
Abnormalities in cardiac conduction include tachycardia, ST
segment changes with and without elevated cardiac tro-
ponins, QTc prolongation, abnormal T waves, and U waves.
Wall motion abnormalities can also be seen, including
Takotsubo cardiomyopathy or broken heart syndrome char-
acterized by paradoxical septal and posterior wall motion
between mid-left ventricle and apex on echocardiogram [38].
Recognition of the high risk of developing these cardiovas-
cular abnormalities is crucial in the management of TBI
patients. Pulmonary complications including aspiration
pneumonitis, lower respiratory tract infections, acute respi-
ratory distress syndrome (ARDS), ventilator-induced lung
injury (VILI), and neurogenic pulmonary edema can develop
and make intraoperative and postoperative management of
respiratory status difficult [38]. Using ICU ventilators, with a
greater variety of ventilator modes, for transport and intra-
operatively, is a common strategy to reducing or managing
the pulmonary complications. Recognizing these complica-
tions and being prepared to address them are key in opti-
mizing oxygenation and ventilation.
Hematologic and Immunologic
Pathophysiologic mechanisms for hematologic abnormalities
associated with TBI are not well understood and can present as
fibrinolysis, disseminated intravascular coagulation (DIC),
platelet dysfunction, thrombocytopenia, and hypercoagulabil-
ity. These derangements can result in an increased incidence of
deep vein thrombosis, microthrombosis, and ischemia. One
mechanism for the development of coagulopathy is associated
with the massive release of tissue factor from the injured brain
leading to overactivation of the extrinsic pathway for coagu-
lation, ultimately resulting in a consumptive coagulopathy [38
40]. The risk of having such abnormalities is very high within
the first 24 h of injury, but it can persist for 3 or more days
thereafter [39]. Recognition of this is important in the intra-
operative management and postoperative management of these
patients since many TBI patients return for multiple surgical
procedures during their admission.
TBI patients are at higher risk of acquiring nosocomial
infections due to an increased activity of immunosuppres-
sive cytokines (IL 4, IL 10, transforming growth factor b)
compared to pro-inflammatory activity [41]. Maintaining
any perioperative antibiotics chosen by the ICU or infectious
disease specialists must be prioritized in such patients.
123

Neuroendocrinologic
SIADH is a well-known complication of TBI and presents as
euvolemic hyponatremia with hypoosmolar serum and
hyperosmolar urine. It is treated with fluid restriction,
hypertonic saline, and fludrocortisone to a goal of sodium
correction 0.51 mmol/l per hour. Post-traumatic diabetes
insipidus, seen in approximately 351 % of patients, is seen
within the first few days following brain injury and is
commonly seen as hypotonic, voluminous urine of[200 ml/
h for 2 consecutive hours or [5 ml/kg/h in a hypovolemic,
hypernatremic patient [41]. It is usually transient, lasting for
a few days to a few weeks. Intraoperative and postoperative
recognition of these issues is important and should be
communicated with the intensivist.
Conclusions
Traumatic brain injury is a complex and evolving entity. It
requires knowledge of underlying processes such as mech-
anism of injury and the requirements to prevent or limit a
potentially devastating secondary injury. Multiple modalities
exist to facilitate return to function after traumatic brain
injury including initial treatment such as diagnosis, blood
pressure control, and intracranial pressure monitoring and
control; medical management with mannitol and hypertonic
saline; surgical control through decompressive craniotomy
or laparotomy; and postoperative management including
seizure prophylaxis. Patient-specific techniques, new moni-
tors, labs, and drugs continue to evolve to decrease the
morbidity and mortality of traumatic brain injury.
Compliance with Ethics Guidelines
Conflict of Interest Bianca Conti, M. Karla Villacin, and Jeffrey
W. Simmons declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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