الفهرس 
Incidence and Risk Factors of TraumaOnly 14 pages are availabe for public view
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Abstract
Trauma is the sixth leading cause of death worldwide, accounting for 10% of all mortality. Traumatic injures are estimated to become the number one as the cause of death for men and women under the age 45 by the year 2020. In the United States, more than 50 million patients receive medical care for trauma annually, and trauma accounts for approximately 30 percent of all intensive care unit admissions.
Patients with traumatic injuries have a significantly lower likelihood of mortality or morbidity when treated at a designated trauma center. Older age, obesity, and major comorbidities are associated with worse outcomes following trauma. In trauma patients with significant hemorrhage, a lower Glasgow coma score and older age are both independently associated with increased mortality, according to multivariable logistic regression analysis of two large databases. In addition, according to a large retrospective study from the United States National Trauma Databank, warfarin use is associated with an approximately 70 percent increased risk of mortality following trauma, after adjusting for other important risk factors.
Trauma patients present unique challenges to anesthesiologist. As 50 % of trauma deaths occur immediately and 20 % of them occur late while the remaining 30 % of trauma deaths occur within a few hours of injury which are called the ”golden hours” as these deaths are preventable during those hours through effective resuscitation and good management followed by definitive surgical care. So, because many trauma victims require immediate surgery under anesthesia, anesthesiologists can directly affect their survival and contribute to better patient outcomes.
Trauma scores, scales & triage should be applied to evaluate and assess all traumatic patients at the scene of trauma & during transport to a hospital & whenever the number of patients exceeds the capabilities of the available resources during mass casualty incidents to quickly determine which victims need immediate transport to the closest & most appropriate medical center for emergency surgery and which can wait. Also, Emergency Medical Services in relation to trauma as a prehospital care of the acutely injured patient by an effective trauma team with a proficient team leader are referred to better outcomes.
The primary survey is designed to evaluate airway, breathing, circulation, disability and exposure & to recognize and treat immediately life-threatening conditions within the first few minutes of the patient’s arrival to the hospital. The secondary survey is described as a head-to-toe examination and is intended to diagnose all injuries before formulating a definitive management strategy.
Evaluation of the circulation during the primary survey includes assessment of the circulatory perfusion, control of haemorrhage & restoration of intravascular volume (if depleted) with frequent re-evaluation. However that, Permissive hypotension is becoming standard practice in hemorrhaging patients without traumatic brain injury. Trauma patients have improved outcomes when a lower than normal blood pressure (mean arterial pressure of 60 to 70 mmHg) is taken as the target for fluid administration during active hemorrhage. As hypotensive resuscitation had demonstrated improved survival, shorter hospital stay & fewer postoperative complications whereas the avoidance of the bolus doses of resuscitative fluids preserves normothermia and prevents excessive dilution of erythrocytes & clotting factors, decreased blood viscosity & blow-out of hemostatic plugs with increasing blood pressure. It is now appreciated that aggressive volume loading may precipitate further blood loss via hemodilution & an increase in blood pressure which may lead to “ pop the clot & disrupt the partially formed thrombus ” at the injured blood vessels which cause rebleeding & a subsequent further deterioration in vital signs.
Haemorrhage is considered as the primary source of hemodynamic instability in trauma patients until proven otherwise. Acute blood loss is a very common problem following traumatic injury. So, rapid recognition & restoration of homeostasis is the corner stone of the initial care of any badly injured patient.
All trauma patients are assumed to have a “full stomach” & so aspiration prophylaxis must be undertaken with premedication by anti-emetic drugs prior to anesthetic induction & applying cricoid pressure together with presence of ready suction device & available different airways. The standard of care for initiation of anesthesia & securing the airway following trauma is rapid sequence intubation RSI (after optimal preoxygenation) unless the patient has a known cervical spine injury or difficult airway, in which case an awake intubation should be considered which can only be safely conducted when patients are stable, cooperative & breathing spontaneously. Although many Neuromuscular Blockade (NMB) drugs exist, only succinylcholine & rocuronium are recommended for RSI in the trauma patients. In many traumatic cases, the combination of etomidate with a rapid onset neuro-muscular blockade (NMB) drug (succinylcholine or rocuronium) will provide the best (safest & most efficacious) induction conditions for the trauma patients. Comatosed patients, those in severe shock or in full arrest, require nothing for induction more than oxygen & possibly a neuromuscular blocking drug until the patient’s blood pressure & heart rate rebound enough that anesthetics can be added. Volatile anesthetics & intravenous anesthetic drugs (for induction or maintenance) are selected based on a patient’s neurological & hemodynamic condition and often required titration with careful attention to patient response wjth frequently reduced doses for trauma patients (who are often hypovolemic) but N2O should be avoided for the trauma victim due to its rapid distension effect on air-containing injuries such as pneumothorax or any hollow viscous injury. Generally, awake extubation in the lateral position after removal of gastric tube is applied.
Regional anesthesia (RA) & its role in the trauma patients are complex due to its risk/benefit ratio and so can be applied according to hemodynamic state of the patient & the spectrum of injuries & alone or with general anesthesia to provide profound pain relief which has been shown to reduce morbidity & improve short- and long-term outcomes.
Recent advances in the field of trauma anesthesiology have been reached. So, the good resuscitation & effective damage control operations to address multiple critical injuries have improved survival. Also, the recent rules regarding the transfusion of blood & its components, glutamine supplementation and the use of recombinant human clotting factor VIIa (rFVIIa) concentrate with specific procoagulant therapy for topical use on external hemorrhage as fibrin sealant bandages, chitosan & zeolite agents, have led to a “sea change” in trauma management that has resulted in the survival of soldiers and the others injured under war conditions.
Preoperative, intraoperative & postoperative complications for the trauma victim such as hypothermia, coagulopathy, hazards of massive blood transfusion & acidosis should be suspected & well prophylacted as trauma-associated hypothermia (for example) increases morbidity & mortality. So, all warming techniques & prophylactic measures against any complication should be applied for traumatic patients to improve their survival.