Introduction
Trauma is a severe injury caused by some external stimulus, and injury by trauma directly injures the tissues. It is the leading cause of mortality nowadays. It can include multiple organ damage. So, caring for traumatic patients requires various specialists to collaborate and work as a team on the traumatic injury-suffering patient. They have to manage many works together like airways, blood, fluid, coagulopathy, pain, and hypothermia; it requires a whole team to handle the complex cases.
What Is a Traumatic Injury?
Any injury with a sudden onset whose severity depends upon tissues damaged by it and requires immediate medical attention is a traumatic injury. Trauma is a complex disease and a leading cause of death in people of nearly 45 to 50 age groups. Traumatic injuries include traumatic brain injury, spinal cord injury, spine fractures, facial trauma, a broken bone, skull fractures, burns, and cuts and vary from minor isolated wounds to complex injuries involving organs. Major injuries like traumatic brain and spinal cord injury require anesthesia to manage these cases; that anesthesia is called traumatic anesthesia.
How Are Major Traumatic Injury Cases Managed?
Major traumatic injuries require a lot of cooperation to manage. The main motive of doctors is resuscitation (to prevent the patient from dying). Initially, an assessment of the injured parts and stabilization of the patient is made in an emergency. Here are the following points on the management of traumatic injuries:
-
The initial assessment involves the airways, breathing, and circulation.
-
A simple conversation with the patient can give an idea about neurological status. The Glasgow coma scale also checks neurological status.
-
Accordingly, other body parts are also checked for any harm or injury.
-
Other parameters involving anemia and hypotension are also noted before going for cases of surgery and anesthesia.
-
Airway management is maintained in major traumatic injuries by tracheal intubation or cricothyrotomy. Tracheal intubation is set before the anesthesia or surgery. New techniques for airways are also developed, like glidescope video laryngoscopy, which passes tracheal tubes through the glottis. Nasal intubation is prohibited in cases of skull fractures or facial fractures.
-
Now the anesthesia is given. The choice of anesthesia should be made appropriately for better airway management. Intravenous or inhalation methods are mostly preferred.
-
Further, ventilation is adjusted for oxygen maintenance and gas exchange after inspecting the chest and checking the breathing rate. If required, a chest radiograph should also be taken.
-
After the airway and breathing maintenance, circulation should be checked by palpating the pulse, and going for a blood test is recommended for the patient's blood group.
-
Blood pressure is monitored. If the blood pressure is relatively low and bleeding is also present, management steps are taken by intravenous fluid transfusion.
-
If bleeding is present anywhere, it should be managed; if it is superficial, it is stopped by pressing directly on the injured part.
-
After managing the ABC (airway, breathing, circulation), other parameters are observed, like anemia (when the hemoglobin level is less than 10 g/dl) requires a blood transfusion. And cases related to disorders related to blood coagulation and decreased sugar levels are managed by giving factor VII medicine and insulin therapy, respectively.
-
Even the other remaining screening tests, like electrocardiogram (ECG), computerized tomography, and radiographs related to the injured area, are done as per requirements.
How Is Induction of Anesthesia Done?
The goal of anesthesia is to provide optimal surgical conditions for surgery and adequate analgesia. After the patient is identified for surgery, his vital signs (blood pressure, temperature, respiratory rate) are noted. Then, the induction of the anesthesia is done. Sedative hypnotics are used. Anesthesia is maintained by inhalation of volatile or intravenous agents; doses should be enough to work as sedation and analgesia. But these cases should use a lower dose than the standard dosages.
Ketamine, Propofol, Midazolam, and Fentanyl are commonly used at lower doses. In addition, a neuromuscular relaxant is used to facilitate endotracheal intubation. Succinylcholine takes nearly 45 seconds to work on muscles for endotracheal intubation.
It can induce drugs like Rocuronium instead of Succinylcholine, which cannot work. Using endotracheal intubation for induction of anesthesia can be risky. Rapid sequence induction with direct laryngoscopy is a much safer way to secure the airway. Soon after that operation proceeds.
What Is Resuscitation?
Resuscitation is the state or action done to revive someone from apparent death. In cases of major traumatic injuries, resuscitation is the doctor's motive. For resuscitation in traumatic injuries, the following steps are taken:
-
Tranexamic acid (TXA) medicine is used as an anti-fibrinolytic (to treat bleedings). Administration of TXA (1 gm) for ten minutes within three hours of injury has improved the patient's health.
-
Hydrocortisone, 100 gms given during the state of shock, has proven helpful.
-
Hypocalcemia and hypotension are corrected by 1 gm of calcium chloride use.
-
Antibiotics used during the treatment can also prevent post-infection rates.
-
Blood transfusion in cases of anemia becomes essential.
-
Isotonic solutions or saline can also be given on requirement.
-
For coagulopathies, factor VII is given.
-
Mannitol, 0.25 to 1 g/kg body weight for lowering the increased intracranial pressure.
-
Insulin therapy for hypoglycemics.
What Are the Key Points to Keep In Mind During Traumatic Injury Management?
The key points are:
-
Airways obstruction is a major cause of death immediately after trauma.
-
Tracheal intubation in trauma should be done early, but in some cases, it can lead to swelling and distortion of the airway.
-
After airway establishment, it is essential to secure it well.
-
Small pneumothorax can be missed in chest radiographs.
-
Hemorrhages can be the most common preventable cause of mortality in trauma patients.
-
Brain traumatic injuries have a high chance of death when hypotension accompanies them.
Conclusion:
The necessity for resuscitation during induction and anesthesia altogether complicates management. The topic gives views on the concept of anesthesia used during traumatic injuries for patient resuscitation. Although these all make it very complicated. But as per the injured patient's necessity, different resuscitation methods are used. It is not in the hands of one doctor; it requires a whole set of specialized doctors and nurses to operate on an injured patient.
