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Background: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies., Methods: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted., Results: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak)., Conclusions: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients., (© 2024. The Author(s).)

Trauma is the leading nonobstetric cause of maternal death and affects 1 in 12 pregnancies in the United States. Adhering to the fundamentals of the advanced trauma life support (ATLS) framework is the most important component of care in this patient population. Understanding the significant physiologic changes of pregnancy, especially with regard to the respiratory, cardiovascular, and hematologic systems, will aid in airway, breathing, and circulation components of resuscitation. In addition to trauma resuscitation, pregnant patients should undergo left uterine displacement, insertion of 2 large bore intravenous lines placed above the level of the diaphragm, careful airway management factoring in physiologic changes of pregnancy, and resuscitation with a balanced ratio of blood products. Early notification of obstetric providers, initiation of secondary assessment for obstetric complications, and fetal assessment should be undertaken as soon as possible but without interference to maternal trauma assessment and management. In general, viable fetuses are monitored by continuous fetal heart rate for at least 4 hours or more if abnormalities are detected. Moreover, fetal distress may be an early sign of maternal deterioration. When indicated, imaging studies should not be limited out of fear for fetal radiation exposure. Resuscitative hysterotomy should be considered in patients approaching 22 to 24 weeks of gestation, who arrive in cardiac arrest or present with profound hemodynamic instability due to hypovolemic shock., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2023 International Anesthesia Research Society.)

Competing Interests: The authors declare no conflicts of interest.

We present a brief history of the scientific and educational development of trauma anesthesiology. Key milestones from the past 50 years are noted, as well as the current standing of the subspecialty and prospects for the future., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)

Introduction: Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented., Methods: Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay., Results: Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel., Conclusion: We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.

Despite mixed results regarding the clinical utility of checklists, the anesthesia community is increasingly interested in advancing research around this important topic. Although several checklists have been developed to address routine perioperative care, few checklists in the anesthesia literature specifically target the management of trauma patients. We adapted a recently published "trauma and emergency checklist" for the initial phase of resuscitation and anesthesia of critically ill trauma patients into an applicable perioperative cognitive aid in the form of a pictogram that can be downloaded by the medical community. The Ryder Cognitive Aid Checklist for Trauma Anesthesia is a letter-sized, full-color document consisting of 2 pages and 5 sections. This cognitive aid describes the essential steps to be performed: before patient arrival to the hospital, on patient arrival to the hospital, during the initial assessment and management, during the resuscitation phase, and for postoperative care. A brief online survey is also presented to obtain feedback for improvement of this tool. The variability in utility of cognitive aids may be because of the specific clinical task being performed, the skill level of the individuals using the cognitive aid, overall quality of the cognitive aid, or organizational challenges. Once optimized, future research should be focused at ensuring successful implementation and customization of this tool.

Purpose of Review: The aim of the present review was to describe recent changes in blood banking thinking, practice, and products that affect trauma care., Recent Findings: Prompt balanced hemostatic resuscitation of major hemorrhage from trauma improves outcome and reduces blood use. New blood processes and products can help deliver appropriate doses of procoagulant plasma and platelets quicker and more safely. New processes include holding larger inventories of thawed plasma with risk of wastage and rapid plasma thawers. New products in the blood bank include group A or group A low-titer B thawed plasma and AB or A liquid (never-frozen) plasma for resuscitation, prepooled cultured whole blood-derived platelets in plasma, and prepooled cryoprecipitate in varying pool sizes. Single-donor apheresis or pooled whole blood-derived platelets in additive solution, designed to reduce plasma-related transfusion reactions, are also increasingly available but are not an appropriate blood component for hemorrhage control resuscitation because they reduce the total amount of administered plasma coagulation factors by 10%., Summary: Early initiation of balanced massive transfusion protocols leading to hemostatic resuscitation is lifesaving. Changing blood product availability and composition will lead to higher complexity of massive transfusion. It is critical that anesthesiologists understand the composition of the available new blood products to use them correctly.

Purpose of Review: To provide a review of the current literature on the management of obstetric hemorrhage., Recent Findings: Obstetric hemorrhage remains a prominent cause of maternal morbidity and mortality. When postpartum hemorrhage is refractory to manual and pharmacologic treatments, escalating interventions may be needed. Second-line interventions include the use of intrauterine balloon (or gauze) tamponade and uterine compression sutures. If these therapies fail to stop the bleeding, patients may need to undergo radiological embolization, pelvic devascularization, or hysterectomy. In recent years, pelvic arterial embolization has become a common treatment for intractable postpartum hemorrhage in an effort to avoid hysterectomy. The use of prophylactic arterial catheterization in the management of cases with expected major postpartum hemorrhage (e.g., placenta increta or percreta) has also been reported. However, the efficacy and safety of this technique requires further study., Summary: Postpartum hemorrhage is best managed by using a stepwise progressive approach. Manual and pharmacologic interventions are first-line treatments. Second-line treatments are used when bleeding continues; and hysterectomy is reserved for only the most extreme cases. Outcomes may be improved by thorough preparation, anticipating the risk of obstetric hemorrhage, and coordinating consultants for interventional procedures.

Study Objective: To test the hypothesis that emotional intelligence, as measured by a BarOn Emotional Quotient Inventory (EQ-i), the 125-item version personal inventory (EQ-i:125), correlates with resident performance., Design: Survey (personal inventory) instrument., Setting: Five U.S. academic anesthesiology residency programs., Participants: Postgraduate year (PGY) 2, 3, and 4 residents enrolled in university-based anesthesiology residency programs., Measurements: Residents confidentially completed the BarOn EQ-i:125 personal inventory. The deidentified resident evaluations were sent to the principal investigator of a separate data collection study for data analysis. Data collected from the inventory were correlated with daily evaluations of the residents by residency program faculty. Results of the individual BarOn EQ-i:125 and daily faculty evaluations of the residents were compiled and analyzed., Main Results: Univariate correlation analysis and multivariate canonical analysis showed that some aspects of the BarOn EQ-i:125 were significantly correlated with, and likely to be predictors of, resident performance., Conclusions: Emotional intelligence, as measured by the BarOn EQ-i personal inventory, has considerable promise as an independent indicator of performance as an anesthesiology resident., (Copyright © 2013 Elsevier Inc. All rights reserved.)

This article provides an update for the anesthesiology community on the mechanisms and limitations of common modalities used to assess the early hemodynamic status in patients with trauma. Figures are provided to illustrate important concepts through the use of computer simulation and real-world examples. This article is of value to anesthesiologists whose practice includes management of hemorrhagic shock., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The management of trauma patients has matured significantly since a systematic approach to trauma care was introduced nearly a half century ago. The resuscitation continuum emphasizes the effect that initial therapy has on the outcome of the trauma patient. The initiation of this continuum begins with prompt field medical care and efficient transportation to designated trauma centers, where lifesaving procedures are immediately undertaken. Resuscitation with packed red blood cells and plasma, in parallel with surgical or interventional radiologic source control of bleeding, are the cornerstones of trauma management. Adjunctive pharmacologic therapy can assist with resuscitation. Tranexamic acid is used in Europe with good results, but the drug is slowly being added to the pharmacy formulary of trauma centers in United States. Recombinant factor VIIa can correct abnormal coagulation values, but its outcome benefit is less clear. Vasopressin shows promise in animal studies and case reports, but has not been subjected to a large clinical trial. The concept of "early goal-directed therapy" used in sepsis may be applicable in trauma as well. An early, appropriately aggressive resuscitation with blood products, as well as adjunctive pharmacologic therapy, may attenuate the systemic inflammatory response of trauma. Future investigations will need to determine whether this approach offers a similar survival benefit.

Purpose of Review: This review will analyze and comment on selected recent literature pertaining to airway management and initial fluid resuscitation in the trauma patient. It will also review airway devices currently being used in the trauma setting., Recent Findings: Although a recent study has questioned the efficacy of manual inline immobilization, this technique continues to be endorsed by trauma guidelines and is safely used in most trauma centers. Clinicians have also incorporated the use of videolaryngoscopy and other adjuncts for difficult airway management in trauma patients. However, no single airway management tool has proven to be superior in this setting. Crystalloid solutions remain frontline therapy for the initial resuscitation of the hemorrhagic trauma patient, as studies with hypertonic saline and vasopressors have not shown superior results. Conversely, increased amounts of fresh frozen plasma and fibrinogen have been reported to increase survival in trauma patients., Summary: As trauma continues to be a major cause of morbidity and mortality worldwide, the use of newer airway adjuncts needs to be specifically investigated in trauma patients, as this population frequently has airway management difficulties. Further research is also required to elucidate the type and amount of fluid that will provide an adequate organ perfusion without increasing nonsurgical bleeding.

Background: Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI., Methods: A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted., Results: One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations., Conclusion: This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

Objective: The current international standard (IEC 60601-1-8) stipulates that medical device audible alarms should be priority-encoded and validated for efficacy. Evidence suggests that the melodic alarms described in the standard are not functioning as originally intended. We present a multi-disciplinary, human factors paradigm for audible alarm development whereby urgency information is encoded via modulation of the physical characteristics of sounds. We also test the feasibility of this approach using information measures., Methods: We designed series of experimental sounds that varied along controlled physical and acoustical dimensions. Subjects rated these sound series for perceived urgency. Based on these ratings, selected sounds from each series were assigned a priority category from 'low' to 'high' - we call these resulting sets of sounds 'urgency-codecs'. The method of categorical judgments (based on information theory) was used to compare each urgency-codec for ability to convey urgency information., Results: Subjects were consistent in their ratings of the three series of experimental sounds for perceived urgency. The urgency data pertaining to one of the series (harmonic interval) was successfully fit to a psychophysical empirical law. The urgency-codec derived from another sound series (melodic interval) was found to have the highest signal (correct interpretation of urgency level by subjects) transmission rate., Conclusions: The proposed paradigm is feasible, and it offers an evidence-based strategy for alarm sound design and testing. This approach would be performed before implementation of new alarm sounds in clinical settings, and should result in development of alarm sounds that satisfy the requirements of priority-encoding and validation.

Unlabelled: Hextend (HEX) is a colloid solution that is FDA-approved for volume expansion during surgery. ATL-146e is a novel adenosine A2A receptor agonist that has anti-inflammatory, neuroprotective, and coronary vasodilator properties. Three series of experiments were designed to evaluate the therapeutic potential of HEX+/-ATL-146e for emergency resuscitation from traumatic brain injury (TBI) + hemorrhagic hypotension., Methods: In the first two studies in vivo, anesthetized, ventilated pigs (30-45 kg) received a fluid percussion TBI, 45% arterial hemorrhage, and 30 minutes shock period. In Series 1, resuscitation consisted of unlimited crystalloid (n = 8) or HEX (n = 8) to correct systolic arterial pressure >100 mm Hg and heart rate <100 bpm for the first 60 minutes ("emergency phase"), and then maintain cerebral perfusion pressure (CPP) > 70 mm Hg for 60-240 minutes. In Series 2 (n = 31), resuscitation consisted of a 1 L bolus of HEX + ATL-146e (10 ng/kg/min, n = 10) or HEX +placebo (n = 10) followed by crystalloid to the same endpoints. In Series 3 in vivo, the hemodynamic response evoked by 0, 10, 50, or 100 ng/kg/min ATL-146e was measured before or 60 minutes after HEX resuscitation from 45% hemorrhage., Results: Following TBI+hemorrhage, there were 4/22 deaths in series 1 and 11/31 deaths in series 2. In those alive at 30 minutes, mean arterial pressure, cardiac index, mixed venous O2 saturation, and cerebral venous O2 saturation were all reduced by 40-60%, while heart rate and lactate were increased 2-5 fold. With no resuscitation (n = 2), there was minimal hemodynamic compensation and progressive acidosis. Upon resuscitation, these values corrected but intracranial pressure progressively rose from <5 mm Hg to 15-20 mm Hg. Series 1: With HEX (n = 8) versus crystalloid (n = 8), CPP was less labile, acid/base was maintained, and the fluid requirement was reduced by 60% (all p < 0.05) Series 2: With ATL-146e (n = 10) versus placebo (n = 10), stroke volume and cardiac output were improved by 40-60%, and the fluid requirement was reduced by 30% (all p < 0.05). Series 3: ATL-146e caused a dose-related increase (p < 0.05) in stroke volume after, but not before, hemorrhage. The effects on pre-load, afterload, and heart rate were similar before and after hemorrhage., Conclusions: HEX alone is a safe and efficacious low volume alternative to initial crystalloid resuscitation after TBI. An adenosine A2A agonist combined with 1 L of HEX safely and effectively counteracted a decrease in cardiac performance noted after TBI+hemorrhage without causing hypotension or bradycardia.

Objectives: To determine if a structured preoperative ICU consultation would correctly assign patients to preoperative invasive monitoring, postoperative ICU care, or recovery room care, and to compare morbidity, mortality, and resource utilization among all groups., Design: Prospective, observational study., Setting: A university hospital., Patients: A total of 475 patients who were referred preoperatively by surgeons for ICU consultation and were evaluated by ICU physicians., Interventions: Patients assessed to have clinical evidence of cardiovascular compromise were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization. Patients without such evidence, but who were to undergo major operations or had anticipated major fluid replacement were independently selected for invasive monitoring by anesthesiologists. Patients who developed physiologic instability or became unstable due to hemorrhage also underwent invasive monitoring. Nonmonitored patients who remained stable were given postoperative ICU care or went to the recovery room based on an assessment by the surgeon and anesthesiologist at the end of the operation., Measurements and Main Results: Of 8,916 elective surgical cases, ICU physicians were consulted in 475 (5.3%) patients preoperatively. Sixty-seven patients were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization; 60 patients had surgery (0.7% of elective cases, 12.6% of ICU consultations). Patients selected for ICU preoperative monitoring were older than non-monitored patients and had higher numbers of cardiovascular and total risk factors than any other group. They had higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores, higher Therapeutic Intervention Scoring System (TISS) points, a higher number of complications, and longer ICU stays than non-monitored postoperative ICU patients. In addition, they had a higher number of complications than nonmonitored recovery room patients. APACHE II scores, TISS points, number of complications, and ICU days in the preoperative ICU admission group were not increased when compared with all other monitored patients. Neither hospital days nor total hospital charges were increased when compared with the other elective ICU patients. Patients selected for ICU preoperative monitoring who underwent surgery had an 11.7% mortality rate and accounted for four of five cardiovascular-related deaths., Conclusions: A small number of high-risk patients can be selected for preoperative monitoring on the basis of clinical assessment without increasing ICU stay or hospital bills. A structured preoperative consultation correctly identifies those patients who need monitoring and ICU care, but does not overutilize scarce and expensive ICU beds.

The purposes of this study were to evaluate the clinical utility of a colorimetric end-tidal CO2 (ETCO2) detector in confirming proper endotracheal intubation in patients requiring emergency intubation, to determine if this new device can be used as an adjunct to judge the effectiveness of cardiopulmonary resuscitation (CPR), and to determine whether the device can predict successful resuscitation from cardiopulmonary arrest. We studied prospectively 110 patients requiring emergency intubation for either respiratory distress (53 patients) or cardiopulmonary arrest (57 patients) by recording the color range of the indicator after the initial intubation. In patients who suffered a cardiopulmonary arrest, the color range was also recorded during CPR after the endotracheal tube was confirmed to be in the tracheal position and perfusion optimized, and at the moment CPR was stopped. The ETCO2 detector was 100% specific for correct endotracheal intubation in all patients. It was also highly sensitive (0.98) for correct endotracheal intubation in patients with respiratory distress. However, it was not sensitive (0.62) in patients with cardiopulmonary arrest and low perfusion. The sensitivity improved (0.88) when we used the ETCO2 range obtained after attempts to increase perfusion. A low ETCO2 color range in 19 patients undergoing CPR was interpreted as low cardiac output and prompted the physicians to attempt to increase perfusion. Of the patients who underwent CPR, no patient whose ETCO2 level remained less than 2% was successfully resuscitated. Those patients who had an ETCO2 level greater than or equal to 2% had a significantly higher incidence of successful resuscitation.(ABSTRACT TRUNCATED AT 250 WORDS)