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Trauma anaesthesia
Current Anaesthesia and Critical Care (1996) 7, 113-114
© 1996 Pearson Professional Ltd
Editorial
Trauma anaesthesia
L. H. D. J. Booij
In the ideal situation, anaesthetic care for trauma patients begins at the site of trauma and continues during transportation of the patient to the hospital. With proper treatment during that period there is a better guarantee of the prevention of future harm to the patient, and a better final outcome. This contributes considerably to the decrease in morbidity and mortality in trauma victims. In many countries anaesthesiologists staff trauma teams which provide life-support at the trauma site. In the hospital more diagnostic and treatment possibilities are available, the application of which should start in the emergency room and be continued in the operating theatre and in the intensive care unit. Here also anaesthesiologists play an important role in life-support and in facilitating diagnostic and treatment procedures by other specialists. Over the years trauma anaesthesia has developed. Its objectives are:
Trauma is one of the major causes of death in people below the age of 40 years. In the countries of the European Union approximately 75 000 persons die from road accidents alone. About 2 million persons are seriously injured. The overall cost of trauma (for example initial and later medical care, disability and the resulting disability benefits) is enormous, and in Europe is estimated to be more than 70 billion ECUs. However, road accidents only represent about 40% of all fatal accidents, another 40% occur at home, about 5% at work and about 15% during sports. Figures on non-fatal accidents are less reliable, but indicate that they are most frequent at home, followed by sports, work, and finally in traffic. All over the world there is a rapid increase in assault as the origin of trauma. Prevention of a bad outcome of trauma is therefore very important. In both the USA and Germany it has been demonstrated that providing expert trauma care, starting at the site of trauma, does decrease the overall cost (macro-economically). Anaesthesiologists play an important role in the treatment of severely traumatized patients. With their expertise in physiology, pharmacology, and technical skills they are the ideal experts in life support, both before and during surgery, as well as after surgery. No other specialist combines in one person more capability in cardiopulmonary and cerebral resuscitation, airway control, acquisition of vascular access, treatment of shock, providing anaesthesia and pain treatment, and providing intensive care than the anaesthesiologist. These are the skills needed in the life support of trauma victims. Thus, anaesthesiologists are an indispensable part of the modem trauma team.
1. to stabilize and support the vital organ functions in emergency room, operating room, and intensive care unit (basic and advanced life-support), after first treatment at the trauma site; 2. to suppress and/or prevent the stress resulting from transportation, and diagnostic and surgical procedures in emergency room and operating room (anaesthesia); 3. to start and/or proceed with the correction of the physico-chemical imbalances resulting from trauma and surgery (i.e, acid-base balance, electrolytes, temperature, etc.); 4. to initiate measures that guarantee pain treatment and stress prevention in the postoperative period (pain management). Because of these many objectives and the requirement that all the necessary skills are present, trauma anaesthesia is a field for the experienced anaesthesiologist. Anaes-
Dr L.It.D.J. Boolj, Institute forAnaesthesiology,Catholic UniversityNijmegen, P.O. Box 9101, 6400 HB Nijmegen,The Netherlands Prof.
113
114
CURRENTANAESTHESIAAND CRITICALCARE
thesia for trauma patients is frequently complicated because of technical difficulties (intubation problems, aspiration, difficult vascular access, etc), and the fact that patients can belong to either sex, all age groups, may have all possible types of concurrent diseases, and may possibly use a variety of drugs. They can also be pregnant, be intoxicated by drugs and alcohol, or have a full stomach. For many of these items the information is missing when the anaesthesiologist is confronted with the trauma patient and also preoperative examinations or function and laboratory testing frequently are not available. Furtherm/ore, the necessary surgery may involve the musculo-skeletal system, the gastrointestinal system, the cardiovascular system, the lungs, or the central nevous system. Thus, the only place for newcomers and residents is when they are intensively supervised and coached. However, in most hospitals trauma care depends on surgical and anaesthesia trainees and junior staff, because of the acute and unpredictable timing of the events. In many trauma patients multiple organ sys-
terns, and their pathophysiologic response to injury, are involved. This leads to more extensive changes than the anatomical injuries alone. The pathophysiology of trauma is, in addition, rapidly changing, and these changes can interfere with anaesthetic care. Trauma care, at least in emergency room and operating theatre, should, therefore, preferably be administered by one team, wbJch implies long hours of close cooperation. In this focus on trauma anaesthesia some experts in the field give their opinion on some of the many facets of this interesting part of our speciality. Their common interest is the improvement of quality of care for trauma patients. Drs McKee and Baskett discuss anaesthetic trauma care at the trauma site, Professor P. Carli and his team (Paris, France) focus on early treatment in the hospital, Professor L. Booij (Nijmegen, The Netherlands) on the operative period, Dr G. Nolan (Bath, UK) on the care in the Intensive Care Unit and Dr A. Suttcliff (Birmingham, UK) discusses trauma anaesthesia for paediatric patients.
© 1996 Pearson Professional Ltd
Editorial
Trauma anaesthesia
L. H. D. J. Booij
In the ideal situation, anaesthetic care for trauma patients begins at the site of trauma and continues during transportation of the patient to the hospital. With proper treatment during that period there is a better guarantee of the prevention of future harm to the patient, and a better final outcome. This contributes considerably to the decrease in morbidity and mortality in trauma victims. In many countries anaesthesiologists staff trauma teams which provide life-support at the trauma site. In the hospital more diagnostic and treatment possibilities are available, the application of which should start in the emergency room and be continued in the operating theatre and in the intensive care unit. Here also anaesthesiologists play an important role in life-support and in facilitating diagnostic and treatment procedures by other specialists. Over the years trauma anaesthesia has developed. Its objectives are:
Trauma is one of the major causes of death in people below the age of 40 years. In the countries of the European Union approximately 75 000 persons die from road accidents alone. About 2 million persons are seriously injured. The overall cost of trauma (for example initial and later medical care, disability and the resulting disability benefits) is enormous, and in Europe is estimated to be more than 70 billion ECUs. However, road accidents only represent about 40% of all fatal accidents, another 40% occur at home, about 5% at work and about 15% during sports. Figures on non-fatal accidents are less reliable, but indicate that they are most frequent at home, followed by sports, work, and finally in traffic. All over the world there is a rapid increase in assault as the origin of trauma. Prevention of a bad outcome of trauma is therefore very important. In both the USA and Germany it has been demonstrated that providing expert trauma care, starting at the site of trauma, does decrease the overall cost (macro-economically). Anaesthesiologists play an important role in the treatment of severely traumatized patients. With their expertise in physiology, pharmacology, and technical skills they are the ideal experts in life support, both before and during surgery, as well as after surgery. No other specialist combines in one person more capability in cardiopulmonary and cerebral resuscitation, airway control, acquisition of vascular access, treatment of shock, providing anaesthesia and pain treatment, and providing intensive care than the anaesthesiologist. These are the skills needed in the life support of trauma victims. Thus, anaesthesiologists are an indispensable part of the modem trauma team.
1. to stabilize and support the vital organ functions in emergency room, operating room, and intensive care unit (basic and advanced life-support), after first treatment at the trauma site; 2. to suppress and/or prevent the stress resulting from transportation, and diagnostic and surgical procedures in emergency room and operating room (anaesthesia); 3. to start and/or proceed with the correction of the physico-chemical imbalances resulting from trauma and surgery (i.e, acid-base balance, electrolytes, temperature, etc.); 4. to initiate measures that guarantee pain treatment and stress prevention in the postoperative period (pain management). Because of these many objectives and the requirement that all the necessary skills are present, trauma anaesthesia is a field for the experienced anaesthesiologist. Anaes-
Dr L.It.D.J. Boolj, Institute forAnaesthesiology,Catholic UniversityNijmegen, P.O. Box 9101, 6400 HB Nijmegen,The Netherlands Prof.
113
114
CURRENTANAESTHESIAAND CRITICALCARE
thesia for trauma patients is frequently complicated because of technical difficulties (intubation problems, aspiration, difficult vascular access, etc), and the fact that patients can belong to either sex, all age groups, may have all possible types of concurrent diseases, and may possibly use a variety of drugs. They can also be pregnant, be intoxicated by drugs and alcohol, or have a full stomach. For many of these items the information is missing when the anaesthesiologist is confronted with the trauma patient and also preoperative examinations or function and laboratory testing frequently are not available. Furtherm/ore, the necessary surgery may involve the musculo-skeletal system, the gastrointestinal system, the cardiovascular system, the lungs, or the central nevous system. Thus, the only place for newcomers and residents is when they are intensively supervised and coached. However, in most hospitals trauma care depends on surgical and anaesthesia trainees and junior staff, because of the acute and unpredictable timing of the events. In many trauma patients multiple organ sys-
terns, and their pathophysiologic response to injury, are involved. This leads to more extensive changes than the anatomical injuries alone. The pathophysiology of trauma is, in addition, rapidly changing, and these changes can interfere with anaesthetic care. Trauma care, at least in emergency room and operating theatre, should, therefore, preferably be administered by one team, wbJch implies long hours of close cooperation. In this focus on trauma anaesthesia some experts in the field give their opinion on some of the many facets of this interesting part of our speciality. Their common interest is the improvement of quality of care for trauma patients. Drs McKee and Baskett discuss anaesthetic trauma care at the trauma site, Professor P. Carli and his team (Paris, France) focus on early treatment in the hospital, Professor L. Booij (Nijmegen, The Netherlands) on the operative period, Dr G. Nolan (Bath, UK) on the care in the Intensive Care Unit and Dr A. Suttcliff (Birmingham, UK) discusses trauma anaesthesia for paediatric patients.