Blood, fluids, and electrolytes in the pediatric trauma patient.

Successful resuscitation of pediatric trauma patients begins with identification of the physiological abnormalities that require intervention. Health care practitioners in the prehospital, emergency room, and operating room settings must be familiar with normal physiological parameters to be able to recognize abnormalities and begin resuscitative efforts. Recognition of shock may be more subtle in the pediatric patient, because blood pressure can be maintained in the face of a marked decrease in circulating blood volume. Once recognized, shock requires aggressive treatment that must be aimed at supporting and stabilizing vital organ function. Obtaining adequate access to the vascular system to carry out resuscitation is challenging. The IO method of obtaining access is being used with greater frequency when time is critical for resuscitation, as is often the case in pediatric trauma. The area of fluid management and blood transfusion has undergone extensive change in the last decade but needs continued investigation in the pediatric trauma population. Studies targeting this population are limited, and current practices are based largely on extrapolation from adult experience and studies. The area continues to evolve, but further research is needed to improve resuscitation in the pediatric trauma patient.

Trauma anesthesia for disasters. Anything, anytime, anywhere.

Field anesthesia can be practiced safely and effectively but requires special training to acquire familiarity with the techniques. Because field anesthesia may be required even in sophisticated countries for entrapment situations, skill should be maintained by practicing the appropriate techniques on a regular basis. Field anesthetic techniques are not second rate methods; they are just different. Although improvisation in the disaster situation has merit, it is not the place for experimenting with new and untried techniques.

Trauma anesthesia and critical care: the concept and rationale for a new subspecialty.

Proper care of the severely injured patient will require the development of a new anesthesia specialist. The trauma anesthesiologist, like the cardiovascular anesthesiologist, must become thoroughly familiar with one disease. The anesthesiologist who manages patients with traumatic disease must become an expert in critical care, high-risk anesthesia practice, and emergency resuscitation of the trauma patient. An outline for a fellowship in trauma anesthesia and critical care is included.

Critical care transport: a trauma perspective.

The realm of CCT is a challenging one, an arena open to advances in skills and technology that will improve the patient's ultimate outcome as well as provide that patient with the best possible conditions for transfer. Considering the background of skills and knowledge an anesthesiologist possesses, he or she is a "natural" for this subspecialty.

Military medicine: trauma anesthesia and critical care on the battlefield.

This article presents a few of the basic guidelines that must be considered once a decision is made to provide anesthesia and advanced surgical care in the battlefield--or in civilian catastrophes (for example, terrorist incidents, and man-made or natural disasters) that resemble the battlefield. However, it must be stressed that the most central consideration in battlefield anesthesia is the selection, training, and experience of the battlefield anesthesiologist. There are strict guidelines for providing safe anesthesia under the dire circumstances of war or similar civilian circumstances; the properly trained and experienced TA/CCS, however, will be best able to deliver battlefield anesthesia and to improvise equipment and agents for its safest delivery in those circumstances.

Hyperbaric medicine: an integral part of trauma care.

In conclusion, HBO constitutes an important therapeutic tool in managing a variety of syndromes associated with trauma and is thought to possess potential benefits for the management of others. Because its therapeutic efficacy and limitations are as yet incompletely understood and appreciated, continuing research is warranted. This article provides a discussion of these conditions and applications as well as descriptions of the basic physics of gas behavior, the principle of the physiologic basis of HM, the general manner of clinical application of pressure and oxygen, and the special set of problems encountered when providing sophisticated medical care in the hyperbaric environment. Ultimately, this article encourages the highly motivated trauma anesthesiologist to enhance his or her contribution to and active participation in the field of HM.

Mechanisms and patterns of injury: the key to anticipation in trauma management.

Traumatic injuries are classified into blunt and penetrating injuries. Penetrating injuries are caused when an object such as a knife or bullet crushes and tears the tissues that it traverses. The energy transfer from the penetrating object to the tissues determines the degree of injury, and the wounding tract determines the pattern of injury. Blunt trauma produces injury by transferring energy through acceleration forces (+ and -) to the victim (usually from motor vehicles or falls). The pattern and severity of injury are determined by the magnitude and orientation of the acceleration change to the victim's anatomy.

Airway management: considerations in the trauma patient.

The five components integral to modern, sophisticated airway management in trauma patients include equipment, pharmacologic adjuncts, manual techniques, physical circumstances, and patient profile. Although there is a finite number of pieces and types of equipment, pharmacologic adjuncts, and manual techniques, the last two components are variable. For purposes of brevity and clarity, this article has presented definitive airway management in terms of a well-organized, fully-equipped admitting (resuscitation) area of a trauma center, but a trauma patient may require airway management in a variety of physical circumstances, including the field, the transport vehicle, and numerous locations within the trauma center. We believe that the commonly used airway management algorithms are a poor substitute for a conceptual understanding of the basic principles of the five components of airway management, although these decision trees may be useful as learning tools. The construction of a truly complete decision tree is virtually impossible because of the high number of individual patient profiles.

Fluid therapy and the resuscitation of traumatic shock.

Fluid management of the traumatized patient begins with assessment of volume status via palpation of pulses; evaluation of mental status; and measurement of urine output, arterial blood pressure, and central pressures. Intravascular line placement and choice of initial resuscitation fluids should be individualized to the clinical situation, although in most situations a crystalloid solution continues to be the initial fluid of choice. Following initial stabilization, the intravenous fluid administered can be tailored to a given situation, chosen only after the deranged fluid balance is sequentially classified according to alterations of volume, concentration, and composition. Parenteral fluids may be divided into two groups: crystalloids and colloids. The indications, complications, and controversies surrounding various resuscitation modalities have been reviewed.

General anesthesia: management considerations in the trauma patient.

Endotracheal intubation and mechanical ventilation are vital components of the resuscitation of the most seriously injured patients and those suffering from multisystem trauma. Therefore, general anesthesia administered both intravenously and endotracheally becomes the anesthetic of choice for most of this patient population. Endotracheal intubation and anesthetic induction techniques are designed to protect the patient's cervical spinal cord from injury and his or her airway from aspiration of gastric contents. Anesthetic drugs are chosen to minimize cardiovascular depression, to maximize oxygen delivery to the tissues, and to decrease intracranial pressure. Monitoring techniques include the basic noninvasive monitoring set forth in the American Society of Anesthesiologist's standards, as well as invasive cardiac monitoring via arterial catheters and pulmonary artery catheters. Attention to detail in the recovery room will continue the success of a well-conducted general anesthetic for the trauma patient.

Burns and associated nonthermal trauma: an analysis of management, outcome, and relation to the Injury Severity Score.

Nonthermal trauma in patients with burns necessitates additional considerations in management. The charts of all patients with nonthermal trauma admitted to a regional burn center from 1977 to 1987 were reviewed. The causative events and types of injury were determined. The most common injuries were fractures caused by jumping from burning buildings. Fracture management varied, and the only complications that occurred among the 15 of 61 patients with fractures were associated with overlying burns. The mortality rate was 20%, which is comparable to that predicted from the patients' ages and the percent of total body surface area burned. The mortality rate predicted from the Injury Severity Score is much lower, which brings into question its use for analysis of this patient population.