What are the key considerations in preoperative trauma planning?

Key Considerations in Preoperative Trauma Planning

The most critical consideration in preoperative trauma planning is minimizing the time elapsed between injury and operation for patients requiring urgent surgical bleeding control, as this directly impacts mortality outcomes. 1

Initial Assessment Framework

Hemodynamic Evaluation

• Assess circulatory status using the following parameters 1:
  • Vasopressor requirements (none, moderate: 2-4 mg/h norepinephrine, severe: >4 mg/h)
  • Blood transfusion needs (none, moderate: 1-4 units PRBC, severe: ≥5 units)
  • Lactate levels (<2.5 mmol/L, 2.5-4 mmol/L, >4 mmol/L)

Hemorrhage Assessment

• Evaluate traumatic hemorrhage using the American College of Surgeons classification 1:
  • Class I: Blood loss <15% (up to 750 mL), pulse <100, normal BP
  • Class II: Blood loss 15-30% (750-1500 mL), pulse 100-120, normal BP
  • Class III: Blood loss 30-40% (1500-2000 mL), pulse 120-140, decreased BP
  • Class IV: Blood loss >40% (>2000 mL), pulse >140, decreased BP

Coagulation Status

• Assess for coagulopathy 1:
  • Mild: PTr <1.2, fibrinogen >1.5 g/L, platelets >100,000/mm³
  • Moderate: PTr 1.2-1.5, fibrinogen 1-1.5 g/L, platelets 50-100,000/mm³
  • Severe: PTr >1.5, fibrinogen <1 g/L, platelets <50,000/mm³

Immediate Management Decisions

Bleeding Control

• Apply direct pressure for external bleeding
• Use tourniquets for uncontrolled arterial bleeding from mangled extremity injuries 1
  • Leave tourniquets in place until surgical control is achieved
  • Minimize application time to prevent complications (nerve paralysis, limb ischemia)

Ventilation Strategy

• Maintain normoventilation in trauma patients without signs of cerebral herniation 1
• Avoid hyperventilation and excessive positive end-expiratory pressure (PEEP) in hypovolemic patients 1
  • Hyperventilation can increase mortality through vasoconstriction and decreased tissue perfusion
  • Excessive PEEP may compromise venous return and worsen hypotension

Transfusion Planning

Blood Component Preparation

• Ensure immediate availability of Group O RBCs for life-threatening hemorrhage 1
  • Group O RhD negative and K-negative RBCs for women <50 years and children
  • Group O RhD positive RBCs for adults without childbearing potential

Haemostatic Resuscitation

• Implement balanced transfusion strategy with goals to 1:
  • Restore and maintain normal tissue perfusion
  • Maintain and monitor hemostasis
  • Avoid the lethal triad of hypothermia, acidosis, and coagulopathy
• Treat electrolyte abnormalities promptly (aim for ionized calcium >1.0 mmol/L)

Risk Stratification for Surgical Decision-Making

Patient Risk Categories 1

1. Low-risk patient

   • Stable circulatory status
   • Mild coagulopathy
   • Mild hypothermia (>35°C)
   • Stable respiratory function
   • No rhabdomyolysis
   • Mild associated injuries (ISS <25)
   • Approach: Early safe definitive orthopaedic surgery

2. Intermediate-risk patient

   • Moderate circulatory shock
   • Moderate coagulopathy
   • Moderate hypothermia (32-35°C)
   • Moderate ARDS or hypoxemia
   • Severe rhabdomyolysis
   • Intermediate risk associated injuries (ISS >25)
   • Approach: Initial resuscitation, temporary stabilization and prompt individualized management

3. High-risk patient

   • Severe circulatory shock
   • Severe coagulopathy
   • Severe hypothermia (<32°C)
   • Severe ARDS or hypoxemia
   • Massive rhabdomyolysis
   • High-risk associated injuries (ISS >40)
   • Approach: Damage-control orthopaedics followed by delayed definitive surgery

Special Considerations

Vascular Injuries

• For patients with suspected vascular injuries (weak pulses distal to injury) 2:
  • Perform CT angiography immediately
  • Measure Ankle-Brachial Index (ABI) while awaiting CTA (ABI <0.9 has 87% sensitivity for vascular injury)
  • For hemodynamically unstable patients with suspected vascular injury, proceed directly to surgical exploration

Associated Emergent Surgeries

• Prioritize based on risk level 1:
  • Low-risk: Laparotomy, spine surgery, multi-site orthopedic surgery
  • Intermediate-risk: Decompressive craniectomy, resuscitative thoracotomy
  • High-risk: Resuscitative laparotomy, pelvic packing, angioembolization

Common Pitfalls to Avoid

1. Delayed surgical intervention - Minimize time between injury and operation for patients requiring urgent bleeding control 1

2. Hyperventilation - Avoid routine hyperventilation which can worsen outcomes through vasoconstriction and decreased cerebral blood flow 1

3. Prolonged tourniquet application - While effective for hemorrhage control, prolonged application (>2 hours) increases risk of nerve paralysis and limb ischemia 1

4. Inadequate temperature management - Hypothermia worsens coagulopathy and increases mortality; active warming measures should be implemented

5. Failure to recognize trauma-induced coagulopathy - Approximately 25% of severe trauma patients present with coagulopathy, which is fatal in 30-50% of cases if untreated 1

By systematically addressing these key considerations in preoperative trauma planning, clinicians can optimize patient outcomes and reduce morbidity and mortality associated with traumatic injuries.