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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 PEEPEE PUBLISHERS AND DISTRIBUTORS (P) LTD. Essentials of Trauma Anesthesia and Intensive Care Published by Pawaninder P. Vij and Anupam Vij Peepee Publishers and Distributors (P) Ltd. Head Office: 160, Shakti Vihar, Pitam Pura Delhi-110 034 (India) Correspondence Address: 7/31, First Floor, Ansari Road, Daryaganj New Delhi-110002 (India) Ph: 65195868, 23246245, 9811156083 e-mail: [email protected] e-mail: [email protected] www.peepeepub.com © 2016 by Peepee Publishers and Distributors (P) Ltd. All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopy, recording, translated, or any information storage and retrieval system, without permission in writing from the publisher. This book has been published in good faith that the material provided by authors is original. Every effort is made to ensure accuracy of material, but the authors, publisher and printer will not be held responsible for any inadvertent errors. In case of any dispute, all legal matters to be settled under Delhi jurisdiction only. First Edition: 2016 ISBN: 978-81-8445-193-1 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 Sr Consultant and Coordinator All India Institute of Medical Sciences Department of Critical Care and Emergency Medicine New Delhi, India Sri Balaji Action Medical Institute Anju Gupta MD, DNB, MNAMS, PGCCHM New Delhi, India Assistant Professor Hemangi S Karnik MD Department of Anesthesiology 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 Minal Harde MD, DNB Professor 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 All India Institute of Medical Sciences Resident, Department of Anesthesiology and Critical Care New Delhi, India University College of Medical Sciences and 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 Vimi Rewari MD, MAMS, FIMSA Additional Professor (JPNATC) Professor Department of Microbiology Department of Anesthesiology All India Institute of Medical Sciences 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