This article appeared in the November 2013 issue of Anesth Analg:
These recommendations are essentially what we do at our institution.
I would just add a couple of things:
- After induction and intubation, do not reflexly turn the sevo up to 2 percent before seeing the next BP. More often than not, the initial blood pressure will be very low owing to hypovolemia. Avoid the reflex to prevent recall and wait until there is adequate blood pressure for the patient to tolerate inhalation anesthesia. Recall is very unlikely for some time after the induction drugs (propofol, etomidate, ketamine) have been given. I have yet to have a trauma victim complain of recall.
- We have agreed with our trauma surgeons that all trauma patients will be given 1 gram Ceftriaxone and 500 mg of metronidazole. So, no need to ask.
- Please do not take yourself away from more important tasks by attempting to start the a-line. It is more difficulty to start an a-line in a hypovolemic/hypothermic patient than in one who has been fluid resuscitated and warmed. Wait until things settle down and the resuscitation has progressed. If labs or a clot are needed and there is no a-line, stick a vein (including EJ or IJ) with a 25 gauge needle. As far as I know, an a-line has never saved anyone’s life. But, avoiding the lethal triad (hypothermia/coagulopathy/acidosis) has.