Joshua M. Tobin

Review article: update in trauma anesthesiology: perioperative resuscitation management.

The management of trauma patients has matured significantly since a systematic approach to trauma care was introduced nearly a half century ago. The resuscitation continuum emphasizes the effect that initial therapy has on the outcome of the trauma patient. The initiation of this continuum begins with prompt field medical care and efficient transportation to designated trauma centers, where lifesaving procedures are immediately undertaken. Resuscitation with packed red blood cells and plasma, in parallel with surgical or interventional radiologic source control of bleeding, are the cornerstones of trauma management. Adjunctive pharmacologic therapy can assist with resuscitation. Tranexamic acid is used in Europe with good results, but the drug is slowly being added to the pharmacy formulary of trauma centers in United States. Recombinant factor VIIa can correct abnormal coagulation values, but its outcome benefit is less clear. Vasopressin shows promise in animal studies and case reports, but has not been subjected to a large clinical trial. The concept of “early goal-directed therapy” used in sepsis may be applicable in trauma as well. An early, appropriately aggressive resuscitation with blood products, as well as adjunctive pharmacologic therapy, may attenuate the systemic inflammatory response of trauma. Future investigations will need to determine whether this approach offers a similar survival benefit.

Factor concentrates in trauma

Purpose of review Recent advances in the understanding of transfusion practices during hemorrhagic shock in trauma have led to early administration of thawed plasma in increased ratios to packed red blood cells and have improved survival in the most severely injured patients. As an appreciation for the sequelae of massive transfusion continues to mature, it is becoming apparent that a more targeted approach to coagulation deficiencies may offer an advantage. Recent findings Factor concentrate therapy offers the advantage of smaller volumes of resuscitative fluids directed at specific phases of coagulation identified by alternative laboratory assays (e.g., viscoelastic testing). Case reports, animal studies, and retrospective reviews offer encouraging data on the ability of factor concentrates to reverse coagulopathy and reduce blood product usage. Summary The use of factor concentrates to target specific phases of coagulation may offer benefit over blood product ratio-driven transfusion. The outcome benefit of factor concentrates, however, has not yet been demonstrated in well powered prospective trials.

A Hemodynamic Profile for Consciousness During Cardiopulmonary Resuscitation

We report the quantification of a hemodynamic profile sufficient to support consciousness during cardiopulmonary resuscitation. A 62-yr-old man experienced cardiac arrest while being evaluated for heart failure after heart transplantation. During the emergency, hemodynamic data were obtained from bedside monitors and reviewed at regular intervals. His mean arterial blood pressure and heart rate were correlated with consciousness during cardiopulmonary resuscitation. A mean arterial blood pressure of 50 mm Hg with a heart rate of 100 bpm supported consciousness during cardiac arrest. This case helps to validate the recent emphasis on hard, fast, basic life support.

Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning

BACKGROUND Cardiac arrest associated with drowning is a major public health concern with limited research available on outcome. This investigation aims to define the population at risk, and identify factors associated with neurologically favourable survival. METHODS The Cardiac Arrest Registry for Enhanced Survival (CARES) database was queried for patients who had suffered cardiac arrest following drowning between January 1, 2013 and December 31, 2015. The primary outcomes of interest were for favourable or unfavourable neurological outcome at hospital discharge, as defined by Cerebral Performance Category (CPC). RESULTS A total of 919 drowning patients were identified. Neurological outcome data was available in 908 patients. Neurologically favourable survival was significantly associated with bystander CPR (Odds Ratio (OR)=2.94; 95% Confidence Interval (CI) 1.86-4.64; p<0.001), witnessed drowning (OR=2.6; 95% CI 1.69-4.01; p<0.001) and younger age (OR=0.97, 95% CI 0.96-0.98; p<0.001). Public location of drowning (OR=1.17; 95% CI 0.77-1.79; p=0.47), male gender (OR=0.9, 95% CI 0.57-1.43; p=0.66), and shockable rhythm (OR=1.54; 95% CI 0.76-3.12; p=0.23), were not associated with favourable neurological survival. AED application prior to EMS was associated with a decreased likelihood of favourable neurological outcome (OR=0.38; 95% CI 0.28-0.66; p<0.001). In multivariate analysis, bystander CPR (adjusted OR 3.02, 95% CI 1.85-4.92, p<0.001), witnessed drowning (adjusted OR 3.27, 95% CI 2.0-5.36, p<0.001) and younger age (adjusted OR 0.97, 95% CI 0.96-0.98, p<0.001) remained associated with neurologically favourable survival. CONCLUSIONS Neurologically favourable survival after drowning remains low but is improved by bystander CPR. Shockable rhythms were uncommon and not associated with improved outcomes.

The Ryder Cognitive Aid Checklist for Trauma Anesthesia

Despite mixed results regarding the clinical utility of checklists, the anesthesia community is increasingly interested in advancing research around this important topic. Although several checklists have been developed to address routine perioperative care, few checklists in the anesthesia literature specifically target the management of trauma patients. We adapted a recently published “trauma and emergency checklist” for the initial phase of resuscitation and anesthesia of critically ill trauma patients into an applicable perioperative cognitive aid in the form of a pictogram that can be downloaded by the medical community. The Ryder Cognitive Aid Checklist for Trauma Anesthesia is a letter-sized, full-color document consisting of 2 pages and 5 sections. This cognitive aid describes the essential steps to be performed: before patient arrival to the hospital, on patient arrival to the hospital, during the initial assessment and management, during the resuscitation phase, and for postoperative care. A brief online survey is also presented to obtain feedback for improvement of this tool. The variability in utility of cognitive aids may be because of the specific clinical task being performed, the skill level of the individuals using the cognitive aid, overall quality of the cognitive aid, or organizational challenges. Once optimized, future research should be focused at ensuring successful implementation and customization of this tool.

Usage and efficacy of airway adjuncts in an emergency intubation kit.

Dear Editor, Although endotracheal intubation outside of the operating theatre and even outside of the hospital environment can be safe, such intubations are associated with oesophageal intubation, pulmonary aspiration and death. An organized approach to these critically ill patients is required to effectively manage the airway in this complex, dynamic environment. Part of such an approach is a well-prepared and adequately supplied emergency airway kit. Although some difficult airway carts include a wider variety of more complex equipment, their use is associated with complications and alternative devices are infrequently used. A smaller set of more frequently used equipment is more helpful in an emergency. Many of the difficult airway carts referenced in the literature recommend the inclusion of intubating laryngeal mask airways (LMAs) and a surgical airway capability. Additionally, the gum elastic bougie has recently been included in the Advanced Trauma Life Support guidelines for airway management in the trauma patient. Equipment needed to secure the airway, including the difficult airway, must be anticipated in the emergency airway kit. Medications necessary to safely induce the critically ill patient, as well as medications needed to treat potential haemodynamic instability after induction must also be included (Please see Table 1). Over 12 month period the number of intubations outside of the operating room at a level I trauma centre with 40 adult intensive care unit beds was examined. A laryngoscope with several blades, along with a variety of differently sized endotracheal tubes, was used in the majority of cases in this series. Direct visualization of the vocal cords with a laryngoscope and intubation with an endotracheal tube was successful in 46 of 49 cases. In the event that direct visualization of the vocal cords was not possible, several airway adjuncts were immediately available. A gum elastic bougie is recommended in the most recent Advanced Trauma Life Support guidelines and was used twice in this series. Several sizes of regular LMAs were included in the kit; however, they were not used. The intubating LMA provides a means of blindly advancing an endotracheal tube into the trachea through the lumen of a specially designed LMA with the assistance of a bougie. This device was used once when direct visualization of the vocal cords was not possible and the gum elastic bougie was unsuccessful. In the event of a ‘can’t intubate, can’t ventilate’ situation, a scalpel and a 14 gauge angiocatheter were available for establishment of a surgical airway. Thankfully, these were not needed. The development of an emergency airway kit resulted in successful intubation each time it was carried to an emergency. Direct laryngoscopy was successful in the majority of cases (46/49). Alternative airway adjuncts were used in the remaining 6% (3/49) of cases; the gum elastic bougie was used twice (2/49) and the intubating LMA was used once (1/49). This modest communication quantifies the use of airway adjuncts in out-of-operating room intubations at

Developing a trauma curriculum for anesthesiology residents and fellows.

Purpose of review The board certification process for qualification by the American Board of Anesthesiology is undergoing significant review. A basic sciences examination has been added to the process and the traditional oral examination is evolving into a combined oral interview and practical skills assessment. These recent developments, as well as the growing body of evidence regarding the resuscitation of trauma patients, call for a revision in the curriculum beyond the documentation of participation in the anesthetics of 20 trauma patients. Recent findings The implications of the 80-h work week are beginning to be appreciated. The development of a new trauma curriculum must take this significant change in residency training into account while incorporating modern educational theory (e.g. simulation) and new data on the resuscitation of trauma patients. Summary Currently, the curriculum for trauma anesthesia requires only that residents participate in the anesthetics of 20 trauma patients. There is no plan for, and little literature regarding, a more extensive educational program. This offers a unique opportunity to innovate a novel curriculum in the anesthesiology residency. The American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness has designed a curriculum that can serve as a template for this important step forward in anesthesiology education.

Damage Control Anesthesia

The role of the anesthesiologist in damage control trauma care is that of resuscitation consultant. Damage control anesthesia must occur in concert with damage control resuscitation and surgery to optimize the physiology of the shocked patient, while ensuring adequate surgical conditions for the operative team. Damage control anesthesia encompasses a variety of procedural skills, from the induction of anesthesia to advanced airway management techniques and to the full spectrum of vascular access options. Beyond providing only procedural assistance in the resuscitation, the anesthesiologist offers the unique perspective of a physician who spends each day monitoring and correcting deranged physiology in the operating room.

Airway Management for Trauma Patients

Trauma airway management is a critical skill for medical providers supporting combat casualties since it is an integral component of damage control resuscitation and surgery. This clinical practice guideline presents methods for optimizing the airway management of patients with traumatic injury in the operational medical treatment facility environment. The guidelines represent the knowledge and experience of 10 co-authors from 3 allied countries representing Emergency Medicine, Surgery and Anesthesia.

Anesthesia for Trauma Patients

An improved understanding of the pathophysiology of combat trauma has evolved over the past decade and has helped guide the anesthetic care of the trauma patient requiring surgical intervention. Trauma anesthesia begins before patient arrival with warming of the operating room, preparation of anesthetic medications and routine anesthetic machine checks. Induction of anesthesia must account for potential hemodynamic instability and intubation must consider airway trauma. Maintenance of anesthesia is accomplished with anesthetic gas, intravenous infusions or a combination of both. Resuscitation must precede or be ongoing with the maintenance of anesthesia. Blood product transfusion, antibiotic administration, and use of pharmacologic adjuncts (e.g., tranexamic acid, calcium) all occur simultaneously. Ventilatory strategies to mitigate lung injury can be initiated in the operating room, and resuscitation must be effectively transitioned to the intensive care setting after the case. Good communication is vital to efficient patient movement along the continuum of care. The resuscitation that is undertaken before, during and after operative management must incorporate important changes in care of the trauma patient. This Clinical Practice Guideline hopes to provide a template for care of this patient population. It outlines a method of anesthesia that incorporates the induction and maintenance of anesthesia into an ongoing resuscitation during surgery for a trauma patient in extremis.