The trauma anesthetic begins long before the patient’s injury. One or more operating rooms (ORs) must be immediately available for the trauma-to-come. These rooms should either be rapidly warmed (upon notification of a trauma) or prewarmed, should be immediately adjacent to the emergency department (ED), trauma burns intensive care unit (TBICU), interventional radiology, and the required sterile gear, and staffed by experienced personnel well known to the rest of the trauma team.

Trauma rooms should be set up with the basic gear to begin an anesthetic. The anesthesia machine should be on and the checkout completed, physiologic monitors should be on with electrodes attached, a variety of airway equipment ready to use, intravenous (IV) setups immediately available, in addition to having suction and drugs ready. The drugs that must be ready include sedative hypnotics (often etomidate or ketamine is preferable to the standard propofol or sodium thiopental) and succinylcholine as well as a nondepolarizing muscle relaxant (often rocuronium), lidocaine, and basic vasopressors such as ephedrine, phenylephrine, and epinephrine. In addition, scopolamine should be stocked to be given for amnesia if the patient is unable to tolerate any anesthetic, insulin and D50 should be available for treatment of hypo- or hyperglycemia, and mannitol and furosemide in stock for treatment of intracranial hypertension. Other vasopressors such as dopamine and norepinephrine should also be available, as well as vasopressin and hydrocortisone. Narcotics should be checked out ahead of time to the anesthesia trauma team and either be carried on their persons in the hospital during call or kept in a locked location immediately available to the trauma ORs. Multiple sizes of catheters-IV, arterial, central venous, introducer sheath-and pulmonary artery catheters (PACs) should all be in the room, along with the gowns, gloves, and sterile drapes for inserting these catheters if time permits. High-volume fluid warmers should be in the room or immediately outside, and it is usually preferable to prestage bagged kits of the required disposables for the warmers along with instructions (with pictures) of the setup steps. These can be left indefinitely if not opened but minimize the time required to set up the fluid warmer in a crisis. Crash carts must be immediately available to the trauma OR and checked daily.

Unfortunately we must address the issue of OR security. After hours trauma ORs must be locked, must be within a secured operating suite, or must be under constant observation according to Centers for Medicare and Medicaid Services (CMS) regulations.¹ This is primarily to allow prepared drugs to be left on top of the anesthesia carts rather
than locked up in the cart itself. Unfortunately, a properly set up trauma OR is also a magnet for other hospital personnel who need gear and may elect to scavenge it from the OR, thereby making their life easier but potentially compromising the care of the acutely injured patient. Proper room security can help avoid this situation.

Aside from the trauma OR setup, there are several other preparations that can be made, which help smooth the anesthetic care of the trauma patient. Of primary importance is a rapid and reliable communication system, which integrates the anesthesiology team into the hospital trauma response. It is not practical for the trauma team to find a phone or computer, look up an anesthesia pager number, transmit an informative message, and await a response all the while engaging in the ED stabilization of a critical patient. A designated anesthesia walkie-talkie or cell phone should be linked to the trauma system’s announcement of patient acquisition, arrival, and immediate disposition. In addition, this device should allow the trauma team to transmit anesthesia-specific information rapidly and with prompt acknowledgement of receipt. This is particularly critical if an anesthesiologist is not part of the ED trauma response team in your institution.

Another preparation that can pay big dividends is mobile airway equipment in the form of an airway bag, tackle box, or “airway cart.” When responding to an airway crisis in the ED, radiology suite, or TBICU, a well-equipped airway box can be a lifesaver. The contents of the airway box will depend on the favored airway interventions in your institution but may include a variety of blades for direct laryngoscopy (DL), assistive stylets such as the gum elastic bougie, laryngeal mask airways (LMAs) and/or intubating LMAs, a portable flexible fiber optic bronchoscope, a portable rigid fiber optic laryngoscope such as a Bullard, and percutaneous cricothyrotomy kits. The immediate availability of a variety of airway devices that are familiar to all department personnel can keep an unpleasant airway situation from deteriorating into frank disaster.

The last preparation that should be undertaken is the establishment of a protocol for massive transfusion between the blood bank, the trauma service, and the anesthesia service. When a trauma patient requires massive transfusion, it is helpful for everyone to have agreed in advance how rapidly blood will be available, what kind of blood will be released under what circumstances, and when and how rapidly factors and platelets will accompany the packed cells. This helps to avoid arguments during resuscitation over product availability and allows providers to focus on the patient instead.²

The hallmark of the typical anesthetic is a careful preoperative evaluation, which thoroughly explores the patient’s history and current condition, thereby leading to a carefully considered anesthetic plan with appropriately chosen monitoring and carefully titrated anesthetic dosing. In the trauma situation this often goes out the window; under the worst of circumstances you may receive a page that the patient is already in the OR! Therefore, the trauma preoperative evaluation must focus on the essential areas of immediate relevance to the performance of a limited anesthetic, is often obtained from an emergency medical technician (EMT), ED nurse, or surgical resident, and is usually incomplete. Laboratory or radiologic studies or professional consultations, which under other circumstances might be essential, may have to be deferred to the intraoperative or postoperative period. Even basic necessities such as IV access may have to be performed in the OR in concert with surgical preparation and/or activity.

Time for a history can often be obtained by meeting the patient in the ED trauma bay. Even if the patient is unconscious and undergoing multiple procedures, it is often possible to get the relevant history by listening to the ED “chatter” and asking targeted questions. This also places the anesthesia team in a position to assist with airway or access procedures as needed. Alternatively, with the increasing importance of interventional radiology in the treatment of the trauma patient with abdominal or pelvic bleeding, it may be possible for a member of the anesthesia crew to be present in angiography to assist with patient management if necessary and to obtain a more complete history with the benefit of a little breathing room.

A useful mnemonic for the emergency history is “AAM-PLE”: (A = allergies, A = age, M = medications, P = past medical history, L = last meal, E = events up to the trauma). However, even this much history is often unknown or known imperfectly. Allergies are useful to know for obvious reasons, but are often completely unknown and in the event that resuscitation is proceeding poorly, anaphylaxis should be kept as part of the differential diagnosis. Age is important in broad ranges. Although adolescent and young adult males are most likely to be involved in trauma, physiologically they are most able to tolerate it.³ The very young and the very old are most susceptible to trauma and its associated complications. Questions about medications should focus on those of immediate relevance to the anesthetic-cardiovascular medications (β-blockers, calcium channel blockers, and particularly angiotensin-converting enzyme [ACE] inhibitors), pulmonary medications (bronchodilators), neurologic medications (anticonvulsants, antipsychotics, and antidepressants), analgesics, and recreational drugs (alcohol and other depressants, opiates, and sympathomimetics such as cocaine and methamphetamine). Past medical history likewise focuses on areas of immediate relevance to the anesthetic and may often, to some extent, be inferred from the medication list if known. A history of coronary artery disease or congestive heart failure, neurologic disease,⁴ asthma or chronic obstructive pulmonary disease (COPD), renal disease, diabetes, psychiatric disorder, or recreational drug
abuse will immediately impact the conduct of the anesthetic, the physiologic targets for therapy, and postoperative management. Events leading to the trauma help to focus attention on the most life-threatening conditions, while also triggering a targeted search for possible associated injuries.

It is often important to know the general details of the out-of-hospital management: What was the time of injury, what was the mechanism of injury, what injuries were noted at the scene and what was the patient’s neurologic status, and what treatment was given at the scene and en route? Most important in many cases is what airway management occurred: Did the patient need to be intubated, if so was the attempt successful, and if not what was used as a rescue airway?

It is also useful to know the results of any diagnostic studies done as part of the trauma workup. Did the focused abdominal sonography for trauma (FAST) show abdominal or pelvic fluid? What were the results of the chest and abdominal plain films? Were any bone studies done? Was angiography performed and what were the results? Were any bleeding vessels embolized? Was head, neck, thoracic, or abdominal computed tomography (CT) or magnetic resonance imaging (MRI) done; if so, are the results available and what were they?

Anesthetic management of the trauma patient focuses on the immediate and most life-threatening priorities. Generally these are (i) intravascular volume, access, and resuscitation; (ii) airway management; (iii) establishing necessary monitoring; and (iv) provision of whatever anesthetic the patient will tolerate. These priorities are somewhat fluid and must often be done simultaneously. The presence of a trauma anesthesia team contributes materially to successful outcomes. By dividing up the responsibilities for airway management, access, fluid management, monitor placement, drug administration, record keeping, and overall direction among multiple people, each team member can successfully focus on discrete tasks. Note that the “anesthetic” portion of the anesthetic is low on the list of priorities. The time-honored axiom that the trauma patient must “earn” the anesthetic is due to the cardiovascular collapse sometimes seen with even small doses of anesthetics.

Usually, but not always, this process has started before arrival in the OR; either in the field or in the ED. A minimum standard should be two free-flowing short large bore (16 or 14 gauge) peripheral IVs, and more as necessary. Short peripheral lines in general have higher flow rates and are preferred for acute resuscitation.⁵,⁶ Sometimes peripheral IVs have been started but may be antecubital and/or of inadequate caliber. Small antecubital catheters can be changed over a wire to a “rapid infusion catheter (RIC)” or short single lumen central venous pressure (CVP) catheter, but the existing antecubital must be at least 20 gauge for this to work, and the vein has to be large enough to accept the larger catheter. The saphenous vein is often large, readily accessible, and provides a direct route to the inferior vena cava (IVC); minor problems such as long-term infection rate offset by ease of access and remoteness from surgical sites. However, use caution in the potential presence of venous bleeding below the diaphragm or you may merely contribute your resuscitation fluid to the ongoing hemorrhage. Central venous catheters are started more rapidly than a peripheral cut down and should be obtained if peripheral catheters cannotbe quickly started, or after the initial resuscitation to obtain secure IV access and to facilitate operative and postoperative management. Massive transfusion may require multiple introducer sheaths in the central circulation.

At this point, there is no outcome data to support the choice of a particular fluid to be used in the initial resuscitation. There is likewise no data to support the use of colloid over crystalloid in the initial resuscitation of a trauma patient.⁷,⁸ The particular crystalloid used does not appear to be very important. There is no outcome data to support the use of one crystalloid over another; therefore, the choice of crystalloid will depend upon secondary indicators. Lactated Ringers (LR) is the most common fluid used in anesthesia and OR resuscitation. It is balanced and buffered and can be given in large volumes with little effect on acid-base status but is slightly hypoosmolar, at least transiently decreases serum osmolarity,⁹ and is incompatible with blood transfusion. Normal saline (NS) is readily available, slightly hyperosmolar, and compatible with transfusions and medications; however, it is associated with a hyperchloremic acidosis when given rapidly.¹⁰ Hypertonic saline has been studied for decades but there is no clearly established role for it that changes outcome,⁸ with the possible exception of patients with head trauma. Other solutions are available such as Normosol, which is also balanced, is isoosmolar, and is buffered with acetate. These types of solutions may prove to be better for volume resuscitation; however, there is again no outcome data to support this notion.

Like hypertonic saline, colloids have been extensively studied in resuscitation for decades, and as yet there is no clinically established role for them. Colloids studies include human albumin and various synthetic colloids such as dextran and hydroxyethyl starch. Although colloids are more efficient at expanding intravascular volume, increase indices of tissue perfusion, and may decrease peripheral edema, they have also been associated with brain and lung edema and the synthetic colloids have a significant incidence of anaphylactic reaction.⁸ They are also substantially more expensive than crystalloids
and in the case of albumin, sometimes in short supply. In summary, although colloids are often mixed with crystalloids during trauma resuscitation, there is at present no clear justification for their use or expense.

None of the crystalloid or colloid solutions provide what is often most needed in the trauma patient-oxygen carrying capacity. In the continued absence of a non-human blood oxygen carrier, only red blood cells (RBCs) can augment oxygen uptake and delivery. A requirement for transfusion is associated with increased mortality from trauma, but it is not clear whether this is due to adverse effects of transfusion or due to the greater acuity of trauma patients who require transfusion.¹¹ Indications for transfusion will depend on the patient and the situation, but include evidence of end-organ ischemia, increasing base deficit (lactic acidosis), a hematocrit measurement below which it is dangerous for the patient (approximately 20 to 25 in young previously healthy patients to 30 or higher for older patients with systemic diseases), or ongoing hemorrhage.

The specific kind of RBC will depend on the urgency of the transfusion. When time permits (usually about an hour), transfusion should be performed with blood that has been typed and crossed. This procedure performs a blood typing (including Rh), performs a minor cross match testing donor plasma against the recipient’s RBCs as well as a major cross match of donor RBC against recipient plasma, and tests for antibodies against Kell, Kidd, and Duffy antigens. This testing decreases the chance of any transfusion reaction to approximately 1:50,000. If time is short, typed and screened blood can be administered, which omits the major and minor cross matches and has approximately a 1:10,000 incidence of allergic or nonallergic transfusion reaction. Unfortunately, this only saves a few minutes of processing time, hence it is generally not recommended to use type and screen over type and cross. Type-specific blood, on the other hand, only tests for ABO and Rh type and can be available in 10 minutes. Type-specific blood carries a 1:1,000 incidence of transfusion reaction and therefore should be avoided except when necessary. If there is no time to wait, then prestaged universal donor (O-) blood should be available in the ORs for immediate transfusion requirements. If more than four units of O- blood are used, then transfusion should be continued with O− blood to avoid graft versus host type reactions. O+ blood can also be used unless the patient is a woman of child-bearing age.

Cell salvage techniques may be life saving during massive hemorrhage. Blood can be suctioned from the field, and the red cells washed, concentrated, and retransfused. While the washed red cells do not contain any clotting factors and can contain traces of anticoagulant, nevertheless blood can often be processed faster than it can be obtained from the blood bank, and by recycling hemorrhaged blood transfusion requirements can be decreased.

There is some evidence that supports modest improvements in outcome if patients are allowed to have lower than normal blood pressure and intravascular volume up to the time that major hemorrhage is controlled.¹² Although this has been controversial, there is general agreement that once major hemorrhage has been controlled resuscitation should be aggressive but not excessive. End points for resuscitation will be addressed in the section on later stages of the anesthetic.

Often concurrently with resuscitation for the anesthesiologist comes the necessity of airway management. A definitive airway may have been placed before arrival in the OR; otherwise rapid decisions must be made regarding airway management.

There must be a very low threshold for endotracheal intubation: Airways rarely improve during trauma treatment and the airway that is manageable now may be unobtainable later. If the airway has been secured already, either in the field or in the ED, the anesthesiologist must verify that the existing airway is secure, properly placed, and appropriate for further hospital care. An endotracheal tube (ETT) placed in the field may be esophageal (with the patient spontaneously ventilating around it), may be endobronchial, or may be of inadequate size for the anesthetic or for subsequent critical care.

Most trauma anesthetics will be general anesthetics, necessitating a secure, properly placed ETT. Regional anesthetics or monitored anesthesia care (MAC) cases will be the minority and reserved for more minor trauma and surgery. Although these anesthetics have the wonderful attributes of facilitating neurologic examination and potentially avoiding airway management, in practice the intoxication or lack of cooperation on the part of the patient, the extent of the surgery, presence (or possibility) of coagulopathy, or hemodynamic instability usually prevent the use of awake anesthetic techniques. The airway is best secured early and electively; attempting to avoid a difficult intubation in the trauma patient invites disaster later when the airway worsens or the surgery takes a turn for the worse. If an awake anesthetic is chosen to avoid immediate airway management, there must be several options planned and prepared to quickly manage the airway later should that become necessary.

Airway assessment is done in the usual manner except that the patient may not be cooperative with the airway examination. Particular attention is paid to signs of airway trauma: external trauma to the neck, swelling (symmetric or asymmetric), coughing, or breathing through secretions or blood, or stridor. As always, the anterior neck is examined for the feasibility of a surgical airway should that be necessary. A high index of suspicion is necessary for airway injuries, as airway injuries may be markedly greater than suspected based on the external examination.