Trauma, Volume 40, No. 3 of International Anesthesiology Clinics R. P. Dutton and S. R. Sharrar, eds.
Philadelphia, Pennsylvania: Lippincott Williams & Wilkins, 2002. ISBN 0020-5907. 126 pp., $83.00 or $225.00 annual subscription.
Trauma is the leading cause of death among Americans younger than age 45 and the fourth leading cause of death overall. Anesthesiologists have been integral to the successful resuscitation, intraoperative management, and postoperative care of trauma victims for the last century. However, this important topic has been underrepresented in anesthesiology publications.
This edition of Clinics takes a significant step toward filling the knowledge gap regarding trauma management principles published in the anesthesiology literature. Each of the seven chapters is authored by physicians who know the literature as well as their way around the inside of the operating room and resuscitation suites. Indeed, the authors are clinician scientists from two of our nation’s most prestigious trauma centers: the R Adams Cowley Shock Trauma Center in Baltimore and Harborview Hospital in Seattle. Although a single edition of Clinics could not possibly review the entire gamut of trauma care, the editors have selected seven subjects that will be of interest to all anesthesiologists involved in trauma management.
The first chapter is written by a trauma surgeon, intensivist, and leader in promoting trauma management based on clinical evidence. This chapter summarizes the literature underpinning several of the most important advances in trauma care over the last decade. Important developments in the evaluation process (ultrasound in blunt abdominal or penetrating trauma, and helical CT scan of the chest in the diagnosis of traumatic aortic injury) are reviewed. Three additional topics are covered in this first chapter (Nonoperative management of blunt solid visceral injury, damage control, and geriatric trauma). The author describes why blunt liver injury is successfully managed nonoperatively. Selective embolization is described as a new technique, which may increase the splenic salvage rate toward 90%. The concept of damage control, which has become the pillar of American trauma principles over the last decade, is described in terms of five phases: Phase 1: initial resuscitation (concomitant with identification of areas of rapid exsanguinating hemorrhage); Phase 2: operative exploration and control of major hemorrhage, expendable organs (e.g., spleen) are resected rather than repaired, GI contamination is controlled by stapling, etc., all nonbleeding injuries are temporized (but usually not definitively repaired); Phase 3: secondary resuscitation (occurs in the ICU and typically lasts 24–48 hours); Phase 4: take back for definitive surgery; and Phase 5: reconstruction. A review of geriatric trauma argues that the elderly, having less physiologic reserve, may benefit from higher initial resuscitation pressures, earlier use of PRBCs, and increased used of invasive monitors.
In Chapter 2, a masterful review of the controversial topic of low-pressure resuscitation from hemorrhagic shock is reviewed, highlighting the history and science surrounding the subject, including the work of Bikell et al., who sparked the controversy (N Engl J Med 1994) and a recently completed follow-up study. Dutton posits a logical set of resuscitation guidelines for acute hemorrhage. His initial strategy emphasizes conservative fluid administration until bleeding sites have been controlled (although data supporting this approach remains controversial). After bleeding control has been established, blood pressure and other measures of perfusion are restored toward normal values (except for hematocrit, which is allowed to fall further, and cardiac output, which may remain on the elevated side). These recommendations are balanced by cautioning that certain patients (elderly, those with CNS trauma) should be managed with higher perfusion pressures from the beginning. However, guidance for other possible exception populations is not clearly articulated (e.g., younger patients with coronary artery disease, hypertension, or renal insufficiency).
The third chapter covers perioperative head injury management of the multiply injured trauma patient and provides a comprehensive review of both preoperative resuscitation guidelines and intraoperative management of traumatic brain injury (TBI). Evaluation and treatment priorities are well developed. However, management principles for one important TBI-trauma conundrum is not covered, that of concomitant massive abdominal or thoracic trauma in a patient that has obvious TBI requiring decompression, but is so hemodynamically unstable that operative management must proceed prior to head CT. On the other hand, the topic of surgical timing for non-life threatening injuries in the TBI patient is quite well covered.
Chapter 4 describes the sedation, analgesia, and anesthetic techniques for acute trauma patients requiring diagnostic and therapeutic procedures outside of the operating room. This chapter provides sage guidance on a very important (and controversial) topic. Because of increasing demands on operating room resources, and the reluctance of third party payers to provide financial compensation for anesthesiologists outside the OR, many of these procedures are being conducted by nurses using “conscious sedation guidelines.” However, backup by fully trained and immediately available anesthesiologists able to take over when the patient deteriorates or becomes oversedated is essential for patient safety. The authors also argue that all ASA3 or higher patients should universally receive a consultation by an anesthesiologist prior to administration of sedatives or analgesics.
Pediatric traumatic brain injury, chapter 5, emphasizes several important differences between the pediatric and adult patient with TBI (including patterns of injury, incidence of increased ICP, differences in brain maturity). The optimal perfusion pressure is unknown in children.
Chapter 6 provides a review of the pathophysiology of acute lung injury (ALI) and adult respiratory distress syndrome (ARDS) following acute trauma, and the role of airway pressure release ventilation (APRV) in this population.
It is unclear to this reviewer why APRV was singled out by the authors as the one mode of ventilation to focus upon given that so many other ventilation techniques and strategies are employed nationally in ARDS patients. Indeed, APRV is a technique that is used at only a few centers. First popularized by John Downs in the late 80s, APRV does continue to be promoted by some. However, very few of the references in the chapter covering APRV were of studies published in the past 5 years. Having said that, the authors do a very professional job of discussing the basic concepts of APRV and management techniques. They also do a nice job of touching on the principles underlying lung protective ventilation strategies for ARDS and make strong arguments that APRV is superior to alternative modes of ventilation, in the one circumstance of the spontaneous breathing patient with ALI or ARDS.
Chapter 7 covers the anesthetic management of spinal cord injury, and along with chapters 1 and 2, is the most comprehensive and useful chapter in the edition. The anatomy, mechanism of injury, and pathophysiology of injury are covered first, followed by early supportive care, diagnosis, and intraoperative management. The final section reviews new investigational therapies.
An obvious missing section in this issue is the topic of airway management for trauma. Trauma airway management is the single trauma-related topic that has been extensively reviewed by anesthesiologists and would have nicely completed the offerings included. Furthermore, there have been advances and changes in emphasis in trauma airway management over the last 10 years (ASA Difficult airway algorithm, advent of the laryngeal mask airway, increased emphasis on airway evaluation, awake intubation, and confirmation of tube position with capnography.
Overall, this edition of Clinicson Trauma provides updated reviews on many of the most important topics of interest to anesthesiologists. The chapter are well organized and authoritatively written by distinguished experts. Additionally, there is appropriate use of figures and tables to accompany the very well written text throughout. This reviewer will recommend this edition of Clinics to his staff and residents, as each chapter contains clinically relevant material that is both readable and current.