Essentials of
Trauma Anesthesia
and
Intensive Care
Dr Babita Gupta
Additional Professor (JPNATC)
Department of Anesthesiology, Pain Medicine and Critical Care
All India Institute of Medical Sciences
New Delhi
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,Essentials of Trauma Anesthesia and Intensive Care
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First Edition: 2016
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, Late Shri B L Gupta
I still hear your guiding voice like an angel
Urging me to walk ahead during odd times,
I can still feel your warm embrace
Telling me to keep faith and walk the right path;
You fill in strength in my failed steps even today,
And take it to the path of successful satisfaction.
This book is dedicated to my beloved father, Late Shri B L Gupta, whose impressive career graph made way
through many odd circumstances. His unquenchable thirst for knowledge battled all obstacles. His life has been
an inspiration for all of us. We still derive strength from his hard work, honesty, dedication and disciplined
lifestyle.
This book is due to the incessant support and guidance of my husband, Anil Gupta, whose unlimited love has
taken me through all impediments of life and inspired me to tirelessly work for this book.
My little princess, Malvika, I can never thank her enough for her unconditional support and love. Without her
understanding, this task would have been impossible to accomplish.
, Foreword
It is a pleasure to write a foreword for the book “Essentials of Trauma Anesthesia and
Intensive Care” compiled and authored by Dr Babita Gupta and team.
Trauma is a disease of modern society and attained epidemic proportion in the current
millennium and consumes significantly to the financial burden (3% of GDP in India) on our
health care system. It also poses with various challenges to all personnel caring for them.
Trauma Anesthesia and Intensive Care has seen epochal changes in the last few years;
thereby significantly improving the overall outcome of severely injured patients, who were
once considered non-salvageable. The availability of state of art equipment and high standard
of care provided at Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical
Sciences, New Delhi has paved the way to many such dedicated trauma centers across
the country.
Anesthesiologists are in a unique position to provide best care to a critically injured patient during his entire
journey from emergency room to operating room to Intensive Care Unit and during follow-up. As a surgeon, I realize the
tremendous importance of the role of anesthesiologist not only in airway management and resuscitation, but also in
their ability to alleviate acute and chronic pain in an agonizing trauma patient, by multimodal approach. Trauma
anesthesia and critical care is a growing specialty in India and other developing countries, and surprisingly, yet there
is sparse published material in the form of book which can lucidly cover perioperative management of trauma patients.
The book “Essentials of Trauma Anesthesia and Intensive Care” is one such effort to fill this void.
Luminary and eminent faculty members in the field of Anesthesiology and Intensive Care have contributed to the
book “Essentials of Trauma Anesthesia and Intensive Care”. The chapters of the book are simple to comprehend,
focused, provide latest guidelines and moreover have been presented in an interesting way. The rich illustrations
enhance the value of this book. I am sure this book will be of immense benefit to all the anesthesiologists and
intensivists caring for trauma patients. I am also confident that it will find a place in the personal library of all
anesthesiologists. I compliment and congratulate the whole team for tremendous endeavor, and wish them success!
Prof MC Misra
Director, All India Institute of Medical Sciences
and Chief, JPN Apex Trauma Center, AIIMS
New Delhi
,ggp
, Preface
The glory of medicine is that it constantly moves forward; there is always more to learn. The ills of today do
not cloud the horizon of tomorrow, but act as a spur to greater effort—William James Mayo. In keeping with
the lines of Mayo, we bring the readers a publication that is the first of its kind, offering a comprehensive
overview of managing trauma patients through data and studies. This book is a humble effort to bring forth
extensive insight and knowhow on managing trauma patients both perioperatively and in the intensive care
unit.
The burden of trauma is exponentially increasing around the world—even more so in India. Appropriate
and timely management is critical to a positive outcome, warranting a sound approach and a solid
understanding of the pathophysiology of trauma patients. The ATLS ® principles help protocolize the
management of the emergency department; however, there is inadequate literature on trauma patient
management in the operating room and thereafter in the intensive care unit. Anesthesiologists are often
involved in the overall care of trauma patients in the emergency department, OR, and the ICU; therefore,
they need continuing education to enhance their knowledge and skills. The contents of this book were
chosen to address the lacunae in the knowledge and management of trauma patients and to keep physicians
and anesthesiologists updated on the state of the art. Special emphasis have been given to topics such as
airway management, head trauma, and thoracic and spine injury. One neglected, yet important, topic—brain
death and subsequent organ donation—is discussed in detail.
The inspiration for this book was the lack of a textbook that succinctly addresses this critical subject,
especially in the Indian sub-continent. A bleeding polytrauma patient, in extremis, may initially appear to be
a gruesome, non-salvageable case, prompting anesthesiologists to prematurely terminate resuscitative efforts.
However, if appropriately managed during the initial phases, not only with correct scientific knowledge but
also with empathy and compassion, a young, healthy, productive life can be saved, thus giving a feeling of
gratification.
No words can adequately express my gratitude toward Prof MC Misra, Director, All India Institute of
Medical Sciences and Chief, JPN Apex Trauma Center. He has been a constant inspiration not only to me but
to the entire medical fraternity as we work toward a common cause—providing high quality care to trauma
patients. My sincere thanks go to Prof MK Arora for his invaluable support and guidance. It would have been
difficult to write and finish this book without the moral support and positive attitude of my beloved teacher, Dr
Bharati Tendolkar, who is a mother figure and constant inspiration for me. This book would not have been
possible without the efforts, feedback, and suggestions of all co-authors, whose inputs provided a huge
impetus for the project. The work of my dear colleagues and the staff at JPN Apex Trauma Center was always
of the highest standards, whether it was providing photos, X-rays, or CT images. I owe gratitude to the
technical staff of OT assistants and hospital attendants for their unconditional support. I am also obliged to
Shri Narayanji, Anil Bhat and Lakhan for volunteering to complete photography and other jobs in the OR. My
special thanks to Ms Pallavi Tiwari, who helped me throughout the editing process.
I am sure this book will provide knowledge and translate into a better understanding of the effective
management of trauma patients in the OR and the intensive care unit.
Enjoy reading!
Babita Gupta
, About The Book
Dear Readers,
It is my pleasure to introduce the book ‘Essentials of Trauma Anesthesia and Intensive
Care’ and the chief author and editor, Dr Babita Gupta to the readers. This book extensively
discusses the anesthetic and critical care management of various injuries and covers the
recent guidelines in the management of a severely injured patient in the operating room
and intensive care unit. All the chapters also concisely cover the initial management of
various injuries.
This book has been prepared by renowned faculty members in the field of Anesthesia and
critical care. It is a comprehensive book written in a lucid style, and directed not only to all
anesthesiologists and intensivists, but also emergency physicians, surgeons and orthopedic
surgeons managing trauma patients. This book should prove to be useful to postgraduates,
senior residents and consultants.
The highlights of the book are:
• Burden of trauma
• Role of anesthesiologist in acute trauma care
• Initial approach to trauma patients
• Anesthetic and critical care management in specific trauma, spine trauma situations such as, traumatic brain
injury, thoracic trauma, cardiac trauma, spine trauma, musculoskeletal trauma and abdominal trauma
• Principles of damage control surgery and damage control resuscitation
• Massive transfusion protocols
• Regional anesthesia with special emphasis on ultrasound-guided nerve blocks
• Brain death and organ donation
No other textbook covers trauma management in such a comprehensive manner, the way ‘Essentials of Trauma
Anesthesia and Intensive Care’ does. I am sure this book will definitely find its place in the top reference books in the
armamentarium of all anesthesiologists and intensivists caring for trauma patients.
Dr Bharati Tendolkar
Professor and Head
Department of Anesthesiology and Critical Care
LTTMC and Sion Hospital, Mumbai
, Contributors
Amala Kudalkar MD Chandni Sinha MD
Professor Assistant Professor
Department of Anesthesiology Department of Anesthesiology and Critical Care
LTM Medical College and Sion Hospital All India Institute of Medical Sciences
Mumbai, India Patna, India
Anjan Trikha MD Chhavi Manchanda MD, FRCA
Professor St Elizabeth Medical Center of Boston
Department of Anesthesiology Tufts University, Boston, USA
Pain Medicine and Critical Care Deven Juneja MD, FNB
All India Institute of Medical Sciences Sr Consultant and Coordinator
New Delhi, India Department of Critical Care and Emergency Medicine
Sri Balaji Action Medical Institute
Anju Gupta MD, DNB, MNAMS, PGCCHM New Delhi, India
Assistant Professor
Department of Anesthesiology
Hemangi S Karnik MD
Professor
DSIC, New Delhi, India
Department of Anesthesiology
LTM Medical College and Sion Hospital
Antara Gokhale MD, DNB, EDIC
Mumbai, India
Consultant, Intensivist
Royal Hospital, Muscat
Kiran Kiro MD
Assistant Professor
Arunima Prasad MD Department of Anesthesiology and Critical Care
Attending Consultant GB Pant Hospital and Associated Maulana Azad
Department of Anesthesiology Medical College
Fortis Hospital, Noida New Delhi, India
Ex-Resident (JPNATC)
Department of Anesthesiology Manish Kotwani MD
Pain Medicine and Critical Care Assistant Professor
All India Institute of Medical Sciences Department of Anesthesiology
New Delhi, India LTM Medical College and Sion Hospital
Mumbai, India
Ashish Bindra MD, DM
Assistant Professor (JPNATC) Manpreet Kaur MD
Department of Neuroanesthesiology and Critical Care Assistant Professor
All India Institute of Medical Sciences Department of Anesthesia and Critical Care
New Delhi, India Lady Hardinge Medical College and Hospital
New Delhi, India
Ashok Kumar Saxena MD, DA, FAMS, FICA
Professor
Minal Harde MD, DNB
Associate Professor
Department of Anesthesiology and Critical Care
Department of Anesthesiology
University College of Medical Sciences and GTB Hospital
TN Medical College and BYL Nair Hospital
New Delhi, India
Mumbai, India
Babita Gupta MD Monica S Tandon MD
Additional Professor (JPNATC) Professor
Department of Anesthesiology, Department of Anesthesiology and Critical Care
Pain Medicine and Critical Care GB Pant Hospital and Associated Maulana Azad
All India Institute of Medical Sciences Medical College
New Delhi New Delhi, India
,viii Essentials of Trauma Anesthesia and Intensive Care
Namita Baldwa MD, DNB Rakesh Garg MD, DNB, MNAMS, PDCCHM
Assistant Professor Assistant Professor (Dr BRAIRCH)
TN Medical College and BYL Nair Hospital Department of Anesthesiology and Critical Care
Mumbai, India All India Institute of Medical Sciences
New Delhi, India
Naveen Malhotra MD, FICA
Professor Rashmi Ramachandran MD
Department of Anesthesiology Additional Professor
Pt BDS PGIMS, Rohtak Department of Anesthesiology
Haryana, India Pain Medicine and Critical Care
All India Institute of Medical Sciences
Navin Pajai MD New Delhi, India
Assistant Professor
Department of Anesthesiology
Senthil Packia Sabapathy K MD
Seth GS Medical College and KEM Hospital
Resident
Mumbai, India
Department of Anesthesiology
Pain Medicine and Critical Care
Neha Gupta MD
Resident, Department of Anesthesiology and Critical Care All India Institute of Medical Sciences
University College of Medical Sciences and New Delhi, India
GTB Hospital
New Delhi, India Smita Prakash MD
Senior Specialist
Nita D’Souza DNB VMMC and Safdarjang Hospital
Consultant, Ruby Hall Clinic New Delhi, India
Pune, India
Sona Dave MD, DNB
Pradeep Bhatia MD Professor
Head, Department of Anesthesiology and Critical Care Department of Anesthesiology
All India Institute of Medical Sciences TN Medical College and BYL Nair Hospital
Jodhpur, Rajasthan Mumbai, India
Prashant Nasa MD, IDCCM, FNB, FCCP, FICCM, EDIC Swati Chhabra MD
Specialist and Head, Critical Care Medicine Assistant Professor
NMC Speciality Hospital Department of Anesthesiology
Al Nahda, Dubai (UAE)
Pt BDS PGIMS, Rohtak
Haryana, India
Praveen Talawar MD
Assistant Professor
Sweta Salgaonkar MD
Department of Anesthesiology
Professor and Pain Consultant
Pain Medicine and Critical Care
Department of Anesthesiology
All India Institute of Medical Sciences
Seth GS Medical College and KEM Hospital
New Delhi, India
Mumbai, India
Purva Mathur MD
Additional Professor (JPNATC) Vimi Rewari MD, MAMS, FIMSA
Department of Microbiology Professor
All India Institute of Medical Sciences Department of Anesthesiology
New Delhi, India Pain Medicine and Critical Care
All India Institute of Medical Sciences
Rachna Wadhwa MD New Delhi, India
Professor
Department of Anesthesiology and Critical Care Yash Javeri DA, IDCCM
University College of Medical Sciences and Director and Senior Consultant
GTB Hospital Apex Healthcare Consortium
New Delhi, India New Delhi, India
, Contents
SECTION I: INTRODUCTION TO TRAUMA AND TRAUMA CARE
1. Burden of Trauma
Babita Gupta ................................................................................................................................. 1
2. Trauma Care Systems
Babita Gupta ................................................................................................................................. 9
3. Triage and Trauma Scoring
Chandni Sinha, Babita Gupta ..................................................................................................... 20
4. Approach to a Trauma Patient and Anesthetic Considerations
Babita Gupta ............................................................................................................................... 32
SECTION II: AIRWAY CONSIDERATIONS
5. Airway Management in Trauma
Babita Gupta ............................................................................................................................... 53
6. Perioperative Management of Laryngotracheobronchial Injuries
Babita Gupta ............................................................................................................................... 82
7. Maxillofacial Trauma
Babita Gupta ............................................................................................................................... 91
SECTION III: CIRCULATORY ISSUES
8. Pathophysiology and Management of Shock
Amala Kudalkar, Babita Gupta ................................................................................................. 113
9. Hemodynamic Monitoring in a Trauma Patient
Hemangi S Karnik, Manish Kotwani ......................................................................................... 132
10. Massive Blood Transfusion: MBT Protocols, Blood Components, Complications
Smita Prakash ........................................................................................................................... 150
11. Coagulopathy in Trauma: Pathophysiology and Management
Pradeep Bhatia ......................................................................................................................... 170
SECTION IV: ANESTHETIC DRUGS AND REGIONAL ANESTHETIC TECHNIQUES IN TRAUMA
12. Intravenous Anesthetic Agents
Nita D’Souza, Babita Gupta ...................................................................................................... 187
13. Acute Pain Management in Trauma
Sweta Salgaonkar, Navin Pajai ................................................................................................. 208
14. Regional Anesthesia Techniques in Trauma Patients
Ashok Kumar Saxena, Neha Gupta, Babita Gupta, Rachna Wadhwa ................................... 228
SECTION V: SPECIFIC TRAUMA SITUATIONS AND ANESTHETIC MANAGEMENT
15. Traumatic Brain Injury
Monica S Tandon, Kiran Kiro .................................................................................................... 254
16. Thoracic Trauma and Anesthetist
Sona Dave, Minal Harde, Babita Gupta ................................................................................... 286
