Anesthesia Student Survival Guide
Jesse Ehrenfeld, Richard Urman, and Scott Segal, editors
© 2010 Springer Science and Business Media
CASE STUDY
Chapter 25: Anesthesia for Trauma and Orthopedic Surgery
A 23 year-old male was an unrestrained driver in an automobile crash in an older car
without airbags. He and his friends had recently left a party where he had consumed
“a couple of beers.” He hit the steering wheel on impact and has multiple contusions
on his chest and complains of chest pain with respiration. His left shoulder is
dislocated. He also has a broken tibia and is suspected of having a splenic injury. He
did not lose consciousness at the scene. His breath smells of alcohol and he is snoring
loudly. He awakens with vigorous shouting and is somewhat combative and
confused. He complains of pain in the affected injured area when examined and can
move all four extremities on command. He is an otherwise previously healthy college
student.
What is his Glasgow Coma Scale score?
The GCS is calculated as 3 for eye opening + 4 for best verbal response + 6 for best motor
response=13.
The patient arrives from the emergency department with two upper extremity peripheral IVs in
place infusing room temperature lactated Ringer’s. Do you need additional access? How will
you modify the resuscitation strategy in the OR?
You probably have enough iv access for induction of anesthesia. You may want central
access for postoperative care, given the possibility of chest trauma and lung contusion
and to have “one above and one below” the injuries. You will start warming all
intravenous fluids. You will send (or check if already sent) laboratory studies to
determine red cell, clotting factor, and platelet needs. You will consider pre-lab
administration of blood products per trauma protocols derived from the experience of
military trauma resuscitation in Iraq. This protocol, still controversial in civilian trauma,
particularly blunt trauma, dictates use of early RBC, FFP, and platelet transfusions in a
1:1:1 ratio until laboratory studies have returned.
Studies of the aorta have led the surgeons to observe rather than operate for this injury. The
cervical spine was found free of fractures or dislocations on head and neck CT scan. The patient
is still wearing a cervical collar placed at the scene. He does not complain of neck pain. Can you
now remove it prior to facilitate management of the airway?
No. The cervical spine is not cleared yet. First, soft tissue injury is not ruled out because
CT does not image soft tissues adequately. Furthermore, the patient’s intoxication and
Anesthesia Student Survival Guide
Jesse Ehrenfeld, Richard Urman, and Scott Segal, editors
© 2010 Springer Science and Business Media
other injuries make the verbal response that his neck does not hurt unreliable. You will
need to manage the patient as having a potentially unstable spine. You can remove the
anterior portion of the collar after induction to facilitate intubation with manual inline
stabilization.
The patient has not consumed solid food for eight hours and last drank liquids more than 2 hours
ago. How will you induce anesthesia and secure the airway?
Examine the airway first! Trauma patients are sometimes quite difficult to intubate,
and inline stabilization has been shown to make even easy airways more difficult to
manage. Awake intubation may be required if the airway appears challenging, and at
any rate you may wish to have additional personnel and equipment available.
Assuming you believe the airway exam to be reassuring, you will remove the anterior
portion of the collar as anesthesia is induced, and a second experienced operator will
provide manual inline stabilization of the cervical spine to prevent anterior motion with
laryngoscopy. In any trauma patient, you should consider having surgical backup to
provide an emergency surgical airway if you encounter difficulty. You will treat the
patient as a “full stomach” because of the history of trauma, despite the patient’s NPO
status. Indeed, the single highest risk group for pulmonary aspiration of gastric
contents is trauma patients; some evidence suggests the incidence may be as high as
30%. A rapid sequence intubation with cricoid pressure, generally with thiopental or
ketamine and succinylcholine, and placement of a cuffed endotracheal tube without
mask ventilation, is customary. Although still considered the standard of care, there are
now substantial controversies regarding the efficacy of both inline stabilization and
cricoid pressure. The former has been shown to increase the force required to perform
laryngoscopy and to actually increase subluxation of the injured spine in cadaver
models. The latter has been shown in imaging studies not to occlude the esophagus in
the majority of cases, but instead to displace the esophagus laterally.
What other goals will you have during anesthesia for the case?
In trauma, you hope to avoid the so-called lethal triad of hypothermia, coagulopathy,
and hypovolemia. You will keep the patient warm by increasing the room temperature,
using convective warmers during the case, even if you have to rearrange them
periodically during the procedure, use fluid warmers, and use a passive humidifier in
the breathing circuit. You will treat hypovolemia and acidosis with crystalloids,
possibly colloids, and blood products. You will also probably place an arterial line and
check ABGs periodically. You will check coagulation studies frequently and treat
coagulopathy with plasma, cryoprecipitate (for fibrinogen) and platelets as needed.
Recombinant factor VIIa (rFVIIa) has been used in cases of refractory coagulopathy with
some success (and great expense). Depending on the intraoperative course, you may
Anesthesia Student Survival Guide
Jesse Ehrenfeld, Richard Urman, and Scott Segal, editors
© 2010 Springer Science and Business Media
consider postoperative intubation if fluid shifts are extreme and you suspect airway
edema, if ventilation or oxygenation is difficult, if there is ongoing hemodynamic
instability, or if there are signs of lung contusion or ARDS at the end of the case.