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KEY POINTS

KEY POINTS

  • Anesthesia in trauma care is the practice of perioperative resuscitation.

  • Anesthesiologists, surgeons, and emergency medicine and critical care physicians must communicate and collaborate effectively to provide comprehensive continuous trauma care.

  • Anesthesiologists blend clinical pharmacology expertise and advanced physiologic monitoring to optimize resuscitative outcomes in trauma patients.

  • Standard anesthetic objectives of anxiolysis, analgesia, hypnosis/amnesia, and immobility often require creative modification to accommodate trauma physiology.

  • Regional anesthesia techniques should be incorporated earlier in trauma care to facilitate patient comfort, assessment, procedural care, and transport without impairing cognitive function.

  • Multimodal analgesia techniques are proving increasingly valuable in reducing the harmful impacts of opioid use, both in the acute hospitalized trauma patient and in the immediate postdischarge phase.

Anesthesiologists are perioperative physicians who are responsible for preoperative evaluation and preparation, intraoperative anesthetic and critical care medicine, and acute postoperative care.1 Whereas elective surgical patients benefit from comprehensive preoperative evaluation, medical optimization, and a multitude of safe and comfortable anesthetic options, management of the acute trauma patient can be remarkably different. Limited planning time, unknown patient variables, and rapidly changing patient and surgical conditions demand a more adaptive approach. The trauma patient’s physiologic instability from ongoing hemorrhage and multiorgan injury demands the prioritization of resuscitative medicine and may require significant adaptations of traditional anesthetic approaches. These patients require a dynamic balance of perioperative goals with consideration of type and depth of anesthesia, medication selection and dosing adjustments, airway management techniques, continuous resuscitative assessment and treatment, and postoperative disposition and pain management. With unique challenges in trauma anesthesia care, this chapter highlights the key considerations and modifications to standard anesthetic practice for each phase of care in the acute trauma patient.

PREOPERATIVE ASSESSMENT AND MANAGEMENT

Anesthetic planning begins preoperatively and must consider preoperative, intraoperative, and postoperative objectives. Information about a patient’s current medical and surgical condition is gathered to appraise risk at the organ-system level, predict likely changes from evolving injury, and formulate a dynamic anesthetic prescription (and contingency plans) to manage perioperative risks. In busy trauma centers, anesthesiology presence at the initial phases of care allows for direct participation in early resuscitation and helps allocate resources (eg, staff, space, time, equipment, blood availability) to facilitate emergent surgical interventions; this is particularly crucial when triaging multiple-casualty incidents.2 For trauma patients without immediate surgical needs, early anesthesiology assessment remains a valuable opportunity to document future anesthetic options and discuss medical optimization with other providers. Finally, trauma patients with complex pain management requirements can also be identified at the onset and offered regional anesthesia techniques to ameliorate the need for large-dose opioids or other sedative medications.3

General Principles of Preoperative Evaluation

Standard preoperative anesthesia evaluation involves a focused history, physical examination, and review of laboratory and radiology tests, if available. Particular attention is given to planned surgical procedure and urgency; comorbidities; previous medical and surgical histories; previous ...

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