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Silverton-Dougherty2015 ReferenceWorkEntry Ballistics
Silverton-Dougherty2015 ReferenceWorkEntry Ballistics
Ballistic Trauma
Definition
▶ Gunshot Wounds to the Extremity
Ballistics is the science of a projectile traveling
a path and ultimately hitting a target. Once the
projectile hits the intended target, this creates
another area of science termed wounding or
Ballistic Vest terminal ballistics.
While the bullet or projectile is in the barrel of
▶ Body Armor the weapon, this is termed internal ballistics.
After leaving the barrel and prior to hitting the deflection seen off a straight line to the target.
target, this path of the bullet is termed external This rocking back and forth motion has been
ballistics. These three areas are combined to termed tumbling in the past. The bullet moves
define the study of ballistics. very little (1–3 ) off the intended course, and
there is nothing to suggest it will actually tumble
in the air until it hits the target. Once it enters the
Internal Ballistics soft tissue (wounding ballistics), tumbling plays
a major role in wounding.
There are two important variables in studying
internal ballistics: the size of the bullet and the
barrel velocity. Handguns typically shoot Terminal/Wounding Ballistics
a lower-velocity bullet as compared to a rifle.
Handgun chambers are able to handle less pres- Once the bullet strikes the intended target,
sure as compared to rifles. Rifling of the barrel in a cascade of events transpires. The bullet initially
both handguns and rifles assists in stabilizing the penetrates clothing and enters the skin, muscle,
bullet as it moves down the barrel. Barrel length and soft tissue envelope where damage begins to
also is different and contributes to the velocity take place. Many have termed this the release of
and accuracy of a weapon. A typical handgun the kinetic energy to the target; however this
may have a 4- or 6-in. barrel as compared to terminology can be misleading (Fackler 1988;
a rifle with a 22-in. barrel. Once a bullet exits 1996). A faster bullet (62 grain, 3,200 fps M16)
the barrel, no further propulsion is provided by may enter and exit a target with minimal soft
the gunpowder and the bullet will begin the tissue damage. Conversely, a slower moving
gradually lose velocity. bullet (200 grain, 800 fps 45 caliber pistol) may
A typical 9-mm bullet is classified according impart significant damage and not exit the target
to the weight of the bullet (125 grain, 147 grain, (Swan and Swan 1991). A speed of 160 fps is
etc.). The amount and type of powder will deter- required to enter the skin and soft tissue (Belkin
mine the exit muzzle velocity. This can vary from 1978). Thus the wounding potential of various
1,100 to 1,300 ft per second (fps). Compare this calibers is difficult to classify since as much has
to a 30-06 rifle with a 168 grain bullet traveling at to do with where the bullet strikes anatomically.
2,800 fps. The common M16 military rifle Any bone that is hit generally will fracture and or
uses a 62 grain bullet with an exit velocity of become a secondary missile causing additional
3,200 fps. The cartridge in a rifle bullet is able damage. A rifle bullet striking a bone will
to handle more powder than a handgun. Although generally do significantly more damage as com-
different velocities can be achieved with varying pared to a pistol bullet.
powder types and bullet weights, the goal After entering the soft tissues, the bullet may
remains the same, accuracy and reliability while yaw and tumble as well as fragment. This again
maintaining maximum wounding potential. varies on the size, shape, and velocity of the
bullet. A typical handgun bullet (low velocity)
will not exhibit this disorderly conduct as com-
External Ballistics pared to a rifle bullet (high velocity) that may
fragment as much as 50 % and tumble 180
Once the bullet exits the barrel, whether before exciting the target.
a handgun or a rifle, it begins to lose its velocity Tumbling, fragmenting, and rotating all con-
for several reasons. There is no longer the “push” tribute to the soft tissue injury present. Softer tip
from the propellant, the air creates a certain bullets and hollow point bullets are designed to
amount of drag on the projectile, and some degree expand once entering their target to enhance the
of yaw takes effect. Yaw is the amount of wounding potential by creating a larger
Barker Vacuum Pack 199
cross-sectional diameter. Expansion of bullets as this tissue is generally stretched and is still
reliably occurs above 1,200 fps so this limits viable. Overaggressive debridement is not
certain handgun calibers. recommended and causes more morbidity with-
As the bullet traverses the soft tissue envelope, out any benefit. All wounds should be left open.
two cavities are created. The permanent cavity is B
the area of crush and necrosis and a reliable
indicator of wounding capacity. Larger diameter Cross-References
bullets create a larger permanent cavity. The
temporary cavity is the area that surrounds the ▶ Cavitation
permanent cavity as the soft tissues are expanded ▶ Debridement
outward or stretched. This temporary cavity is ▶ Explosion
variable but is usually significantly larger with ▶ Fragment Injury
high-velocity (>2,000 fps) rifles as compared to ▶ High-Velocity
low-velocity (<1,000 fps) handgun calibers. ▶ Mortars
Most handgun calibers only create a minimal if ▶ Spalling
any temporary cavity thus their wounding poten-
tial is limited by the size of the permanent cavity
(Peters and Sebourn 1996). References
The temporary cavity may damage solid struc-
tures such as the kidney or liver that is Belkin M (1978) Wound ballistics. Prog Sur 16:7–2
Fackler ML (1988) Wound ballistics. A review of com-
nonelastic. Muscle however is able to absorb the
mon misconceptions. JAMA 259:2730–2736
temporary cavity since it is highly elastic. Other Fackler ML (1996) Gunshot wound review. Ann Emerg
empty hollow organs, blood vessels, and skin are Med 28:194–203
good energy absorbers and are not confined by Peters CE, Sebourn CL (1996) Wound ballistics of unsta-
ble projectiles. Part II: temporary cavity formation and
hard structures. The brain however is not able to
tissue damage. J Trauma 40:S16–S21
absorb this temporary cavity and is surrounded by Swan KG, Swan RC (1991) Principles of ballistics appli-
the hardened bony structure making most cable to the treatment of gunshot wounds. Surg Clinics
ballistic wounds to the head lethal. North Am 71:221–239
Tumbling and fragmentation is generally seen
with high-velocity bullets and creates significant
soft tissue damage. The bullet will yaw and tum-
ble, creating a larger permanent cavity, and frag- Balloon Occlusion
mentation of the bullet creates additional
permanent cavities in the soft tissue envelope. ▶ Adjuncts to Damage Control Laparotomy:
This fragmentation is one of the major differ- Endovascular Therapies
ences in the wounding potential of high-velocity
versus low-velocity missile wounds.
▶ Bicycle-Related Injuries
Battlefield Trauma Care
▶ Bicycle-Related Injuries
Beak Fracture
▶ Calcaneus Fractures
Bicycle-Related Injuries
Jeanne Mueller
Bed Sore Department of Surgery, Trauma, Loyola
University Medical Center, Maywood, IL, USA
▶ Pressure Ulcers
▶ Pressure Ulcer, Complication of Care in ICU
Synonyms
Definition
Benzodiazepines
Bicycle riding is an increasingly popular form of
▶ Sedation and Analgesia
recreation and transportation for adults and chil-
dren. Resultant injuries cause significant morbid-
ity and mortality. Yearly, crashes involving
Bicolumn Humerus Fracture cyclists cause approximately 900 deaths, 23,000
hospital admissions, 580,000 emergency room
▶ Distal Humerus Fractures visits, and 1.2 million visits to physician offices
Bicycle-Related Injuries 203
and clinics in the USA (Rivara 1996). Statisti- shoulder due to the rider attempting to brace
cally, more injuries occur in males and are asso- themselves from impact on an outstretched arm.
ciated with riding at high speeds. The most Separation or dislocation of the shoulder can also
common injuries are soft tissue and musculoskel- occur from impact (Starling 2003). Strains, frac-
etal trauma. Head injuries are responsible for the tures, and dislocations are readily identified by B
majority of fatalities and long-term disabilities deformity, swelling, pain, bruising, or lack of
(Thompson 2001). function (Thompson 2001). Follow-up imaging
Injury prevention interventions have proven to may be necessary to dictate further management.
be successful in preventing the occurrence or Chest trauma while biking can involve high
decreasing the severity of injury through the speeds, falls from height, and impact with hard
development and enforcement of safety rules and/or sharp objects. Impacts involving these
and protective gear (Cheng 2000). Utilization of significant mechanisms of injury can result in
protective helmets decreases the risk of head serious damage to the chest, which may not be
injury in all ages (Rivara 1996). They also pro- readily identifiable because the damage is inter-
vide substantial protection against lacerations nal (Shotz, International Mountain Biking Asso-
and fractures to the upper and midface. ciation, 2010). Blunt injuries are those that are
caused by impact with an object that is typically
not sharp and does not penetrate the skin. Pene-
Common Injuries trating injuries are usually caused by a sharp or
narrow object that break the skin and enter the
Head injuries occur in 22–47 % of injured bicy- chest cavity. Rapid assessment should include
clists, often as a result of being struck by a motor palpation and observing the chest for deformities.
vehicle, and are responsible for 60 % of all bicy- There may be contusions, abrasions, punctures,
cle-related mortalities (Thompson 2001). It is lacerations, swelling, or crepitus, a grinding sen-
also the leading cause of long-term disability in sation or noise when broken bones rub together
an injured bicyclist (Puranic 1998). A large range (Shotz, International Mountain Biking Associa-
of severity can occur and can be delineated by tion, unk). Assess respiratory effort and for equal
head injury, brain injury, and severe brain injury. chest rise bilaterally as well as for pain. Injuries
Head injury can be defined as any and all injuries that may occur include rib fractures, flail chest,
to the forehead, scalp, ears, skull, and brain, traumatic asphyxia, pulmonary contusion,
including superficial lacerations, abrasions, and pericardial tamponade, commotio cordis, pneu-
bruises on the scalp, forehead, and ears as well as mothorax, open pneumothorax, tension pneumo-
skull fractures, concussion, cerebral contusions, thorax, hemothorax, and hemopneumothorax
and all intracranial hemorrhages (subarachnoid, (Shotz, International Mountain Biking
subdural, epidural, and intracerebral). A brain Association, unk).
injury includes a diagnosis of concussion or Abdominal trauma can be a result of blunt
more serious intracranial injury excluding skull injury or penetration from landing on upturned
fractures without accompanying brain injury. handlebars. This type of injury generally occurs
Finally, a severe brain injury indicates an intra- when a child loses control of the bicycle and
cranial injury or hemorrhage, including all cere- begins to fall, the front wheel rotated into
bral lacerations/contusions, and subarachnoid, a plane perpendicular to the body. The child
subdural, and extradural hemorrhages (Rivara then lands on the end of the handlebar resulting
1996). Facial and ocular injuries can include in serious truncal injury (Winston 1998). Impact
fractures, contusions, dental fractures, or corneal with handlebars has been documented as produc-
foreign bodies (Thompson 2001). ing traumatic abdominal wall hernia; renal, intes-
Musculoskeletal injuries are a common tinal, liver, splenic, and pancreatic injuries;
occurrence in bicycle trauma. Fractures are abdominal wall rupture; transection of the com-
most common in the hand, wrist, forearm, or mon bile duct; traumatic arterial occlusion; groin
204 Bicycle-Related Injuries
injuries; and even death (Winston 1998). To com- themselves. Helmet use can be credited with
plicate matters, underlying organ injuries are reducing the risk of head injury by at least
often occult, as external bruising is infrequent 45 %, brain injury by 33 %, facial injury by
and signs and symptoms may not manifest for 27 %, and fatal injury by 29 % (Thompson
hours after time of injury. 1989). In addition to encouraging helmet use,
Genitourinary trauma exhibits symptoms safety education is an important component of
that are nonspecific and may be masked by or injury reduction strategies. Intersections pose
attributed to other injuries (Rivara 1996). Gross substantial risk for cyclist due to cars turning in
hematuria and inability to void can be indicators multiple configurations, and children are fre-
of bladder or urethral trauma. The degree quently injured due to unsafe crossing patterns.
of hematuria is not directly correlated to the Safety education programs that have shown the
severity of injury. Bladder injuries are best most promise utilize active learning and feedback
classified as intraperitoneal and extraperitoneal. in a brief intervention. By using role playing and
Extraperitoneal injuries are almost always asso- problem solving to reinforce safety behaviors,
ciated with pelvic fractures, specifically pubic educators can positively impact riders.
ramus fractures. Blunt trauma, such as a straddle
injury from the crossbar of a bicycle, is respon-
sible for 60 % of urethral injuries (Dandan Cross-References
2011). Vulvar, penile, and scrotal contusions
and hematomas can also occur with a straddle ▶ Acetabulum Fractures
injury (Cheng 2000). Other injuries often ▶ Ankle Fractures
take priority over injuries of the GU system ▶ Bladder Rupture (Intra/Extraperitoneal)
and can interfere with a timely urologic assess- ▶ Chest Wall Injury
ment. Coordinated efforts between services ▶ Concussion
caring for the patient are vital to ensure compre- ▶ Debridement
hensive care. ▶ Delayed Diagnosis/Missed Injury
Skin and soft tissue injuries can be signifi- ▶ Distal Humerus Fractures
cant. Simple abrasions, contusions, and lacera- ▶ Distal Radius Fractures
tions will require local care, while a “road rash” ▶ Femoral Shaft Fractures
can involve partial or full-thickness injuries ▶ Head Injury
(Thompson 2001). Deeper injuries may require ▶ Intracranial Hemorrhage
bedside or surgical debridement. Prevention of ▶ Lung Injury
infection becomes a priority as the wounds can ▶ Pelvis Fractures
be dirty or embedded with soil or debris. Spoke ▶ Pneumothorax
injuries can often be seen in the toes and feet in ▶ Pneumothorax, Tension
children. They often cause significant damage to ▶ Proximal Femoral Fractures
the soft tissues, which can lead to amputation ▶ Subarachnoid Hemorrhage
(Starling 2003). These injuries can be prevented ▶ Subdural Hematoma
by utilizing spoke shields and wearing proper ▶ Tibial Fractures
footwear. ▶ Traumatic Brain Injury, Mild (mTBI)
Injury prevention initiatives aim at educat-
ing riders and parents of riders in safe operation
of bicycles. Helmet use is the single most effec- References
tive way to reduce bicycle-related fatalities. Sta-
tistically, younger children are more likely to Cheng RL (2000) Sports injuries: an important cause of
morbidity in urban youth. Pediatrics 105(3):e32
wear a helmet over older riders. A child who
Dandan I (2011) Medscape reference drugs, diseases, and
rides with companions wearing helmets or adults procedures. http://emedicine.medscape.com/article/
in general are more likely to wear a helmet 828251-overview. Retrieved 3 June 2013
Bladder Incontinence 205
Bike Helmets
Definition
▶ Bicycle-Related Injuries
Inability to empty the bladder in a controlled
fashion resulting in involuntary leakage of urine.
Bladder incontinence following trauma may
Bike Safety be the result of injury to the nervous system
(SCI, TBI), peripheral nerve injury, or from the
▶ Bicycle-Related Injuries basic inability to mobilize adequately. Minimiz-
ing incontinence is crucial from the perspective
of protecting the perineal skin and upper genito-
urinary system as well as the psychosocial impact
Bioethics of incontinence.
The neurogenic bladder will be characterized
▶ Brain Death, Ethical Concerns by the type of nerve injury. Upper motor neuron
▶ Ethical Issues in Trauma Anesthesia (UMN) injuries as seen in TBI and SCI will cause
a hyperreflexic or spastic bladder that has a low
maximum storage volume. There may also be
contraction of the urinary sphincter during
Biomedical Ethics detrusor contraction, or dysergia, that results in
incomplete emptying. A peripheral nerve or
▶ Ethical Issues in Trauma Anesthesia lower motor neuron (LMN) injury from pelvic
trauma might result in an areflexic or flaccid
bladder. In this case, the bladder will not void
normally, but once volumes exceed the storage
Biotrauma capacity of the bladder, the intravesicular pres-
sure will rise rapidly and result in uncontrolled
▶ Barotrauma emptying of the bladder. Both UMN and LMN
206 Bladder Rupture (Intra/Extraperitoneal)
lesions can cause uncontrolled emptying and, hydrating during the day, and taking only sips
therefore, urinary incontinence. after dinner, fairly regular intervals for
Management of the bladder requires an catheterizing can be achieved.
understanding of the pattern of filling and emp- Timed toileting is an important concept in
tying. “Bladder scans” or ultrasound quantifica- maximizing continence irrespective of the cause
tion of bladder volume prior to and following for incontinence. Regular, frequent transfers to
a void is very helpful in characterizing function. the toilet or commode (as often as every 2 h)
A void of 200 cc and a post-void residual (PVR) can “catch” the emptying of the bladder. There
of 200 cc suggest dyssynergia between the may be no emptying at some attempts, but in
detrusor and sphincter muscle contraction. repeating this process over a 48-h period,
Patients typically have enough warning time in a pattern will likely emerge when the bladder
this situation to maintain continence. A void of empties based on the activities of the patient. As
200 cc with negligible PVR volumes suggests an understanding of the intervals between voids is
a spastic bladder. This may lead to significant attained, the frequency of regular transfers to the
urinary urgency resulting in incontinence. Anti- toilet can be changed to match the pattern of the
cholinergic medications like oxybutinin and patient.
tolterodine will diminish detrusor muscle con-
traction and allow the bladder to fill to more
normal volumes (400–500 cc) before voiding. Cross-References
A patient who has not voided 8–10 h might
have a bladder volume of 1,100 cc. This suggests ▶ Rehabilitation Nursing
a flaccid bladder. Ultimately the bladder will
exceed the compliance of the bladder wall’s
transitional epithelium and cause an abrupt rise Recommended Reading
in intravesicular pressure. This results in “over-
flow” voiding which rarely occurs in a continent Corocos J, Schick E (2008) Textbook of neurogenic
bladder, 2nd edn. CRC Press
fashion. Of significant importance with the flac-
cid bladder is the risk of urinary reflux,
hydronephrosis, and subsequent structural kid-
ney injury that can occur in a high-pressure blad-
der. Planned evacuation of bladder is required to Bladder Rupture (Intra/
avoid overflow voiding and urinary reflux. This Extraperitoneal)
is typically accomplished with intermittent cath-
eterization. A straight catheter is passed through Rona Altaras
the urethra and into the bladder on a timed basis. Division of Acute Surgery/Trauma/Surgical
The interval of catheterization should be based Critical Care, Lawnwood Regional Medical
on the volume of the bladder and not time Center, Fort Pierce, FL, USA
elapsed. The filtration rate of the kidneys
and therefore the filling demand on the
bladder vary based on fluid intake and body Synonyms
position. If the bladder is catheterized every
6 h, midday volumes may be very low and Intra/extraperitoneal bladder injury
night time volumes very high secondary to
position-related fluid shifts within the body.
The bladder should be catheterized when it con- Definition
tains 400–500 cc. Determining this is based on
trial and error, but by wearing compression The bladder is an extraperitoneal muscular
stockings to minimize dependent edema, urine reservoir located anatomically in the
Bladder Rupture (Intra/Extraperitoneal) 207
pelvic space behind the pubic symphysis. about 14 days, and the healing of the injury is
The proximity to bony structures of the pelvis confirmed with a cystogram study. The excep-
predisposes this organ to injury. Most injuries tion to the nonoperative management of
are seen at the dome of the bladder, which is its extraperitoneal injuries occurs with involve-
weakest part. ment of the neck of the bladder containing the B
Most bladder ruptures are caused by blunt anatomically important sphincter. Also, in cases
trauma; penetrating trauma is less common. In of surgical interventions for orthopedic or
motor vehicle collisions, the injury can occur abdominal explorations, the bladder should be
either by direct blow of the steering wheel or by repaired during the same session.
the classic lap belt mechanism. The treatment of intraperitoneal injuries is
Gross hematuria is the classic sign of bladder surgical on a routine basis. Postoperatively,
rupture and is present in 90 % of the cases. a bladder catheter is left indwelling for about
Rest of the patients will have microhematuria. 2 weeks. And a cystogram should be obtained
An important fact is that 85 % of bladder prior to catheter removal to confirm the healing.
ruptures are the result of pelvic fractures, but Surgical technique: The bladder is approached
that only 10 % of pelvic fractures are associated through a lower midline incision. It is prudent to
with bladder injuries. Clinically, most of palpate the bladder through the laceration in
the patients will present with lower abdominal order to exclude other injuries. The edges are
pain and tenderness associated with inability debrided to healthy tissue and the laceration is
to void and signs of trauma in the lower pelvic then closed in two layers of absorbable suture. In
trauma like perineal or suprapubic ecchymosis. cases of extraperitoneal ruptures with pelvic
hematoma, it is beneficial to avoid severe
Diagnosis bleeding by entering the hematoma. To achieve
The diagnosis can easily be established with a CT this, the bladder is approached via a cephaladly
cystogram utilizing about 400 cm3 of contrast. placed anterior cystotomy. The laceration is then
CT cystogram is equivalent to contrast cystogram closed after adequate inspection of the bladder
to detect bladder injuries and can be performed as intravesically again with absorbable suture
an integral part of the trauma screen (Quagliano (Coburn 2012).
et al. 2006). Of note is that the excretion phase of Complications: Urinoma, neurogenic bladder,
abdominal CT scanning has a high rate of sexual dysfunction, fistulas to rectum or vagina,
false-negative results and is not adequate to and urinary incontinence are the most complica-
diagnose most bladder ruptures. The sunburst tions of the bladder rupture.
pattern of contrast extravasation is typical of
extraperitoneal injury. The intraperitoneal
bladder rupture will demonstrate contrast in the Cross-References
peritoneal cavity.
▶ Bladder Incontinence
Management ▶ Urinoma
Injuries are divided in intra- or extraperitoneal
type, according to their anatomical location.
This differentiation matters due to different References
treatment modalities. The treatment of contu-
sions, which are injuries causing hematuria Coburn M (2012) Genitourinary trauma. In: Mattox KL,
without contrast leak, is nonoperative, with Moore EE, Feliciano DV (eds) Trauma, 7th edn. Mc
a large bore bladder catheter. The treatment of Graw Hill, New York
Quagliano P, Delair S et al (2006) Diagnosis of blunt
extraperitoneal injuries in most of cases is also bladder injury: a prospective ccoperative study of
accomplished with a large bore (18–20 French) computed tomography cystography and conventional
bladder catheter. The catheter is removed after retrograde cystography. J Trauma 61(2):410–422
208 Blast
therefore while a patient with ruptured TMs may ▶ ARDS, Complication of Trauma
indeed have BLI, they do not necessarily coexist ▶ Barotrauma
(Kizer 2000). ▶ Blast
The clinical presentation of blast lung injury ▶ Body Armor
may include shortness of breath, chest tightness ▶ Cardiopulmonary Resuscitation in Adult
or pain, tachypnea, hypoxia, hemoptysis, and Trauma
subsequent respiratory failure. When severe ▶ Cardiopulmonary Resuscitation in Pediatric
lung injury is present, the patient tends to Trauma
clinically decline fairly rapidly, and many blast ▶ Explosion
lung injuries do result in near-immediate death ▶ Hypoxemia, Severe
(CDC 2006). Assessment consists of assessing ▶ IED (Improvised Explosive Device)
vital signs and obtaining a chest X-ray or even ▶ Imaging of Aortic and Thoracic Injuries
CT scan of the chest. The patient have unilateral ▶ Lung Injury
involvement if one side is facing the blast, and the ▶ Massive Transfusion and Complications
blast occurs in an open space, with an increased ▶ Pneumothorax
risk of bilateral lung involvement if closer to ▶ Pneumothorax, Tension
the blast or in an enclosed space at the time of ▶ Pulmonary Trauma, Anesthetic
the blast. Imaging may show the characteristic Management for
“butterfly” or “batwing” appearance. The diag- ▶ Spalling
nosis of BLI is sometimes complicated by other ▶ Ventilatory Management of Trauma Patients
injuries, such as a pneumothorax or hemothorax,
which may also be identified on imaging (CDC
2006; Wightman and Gladish 2001). References
Treatment of BLIs is comprised of providing
supplemental oxygen and positive-pressure CDC (2006) Bombings: injury patterns and care. Blast
curriculum: one-hour module. http://www.bt.cdc.gov/
ventilation and performing intubation and
masscasualties/bombings_injurycare.asp. Accessed
mechanical ventilation if needed. Because the 28 July 2013
cause of lung injury following a blast can come Kizer KW (2000) Dysbarism. In: Tintinalli JE, Kelen GD,
as a result of the blast but could also be linked to Stapyczynski JS (eds) Emergency medicine:
a comprehensive study guide, 5th edn. McGraw-Hill,
fluid resuscitation or blood product transfusion
New York, p 1276
(Mackenzie and Tunnicliffe 2011), these resusci- Mackenzie IM, Tunnicliffe B (2011) Blast injuries to the
tative efforts must be performed judiciously in lung: epidemiology and management. Philos Trans
blast-injured patient. Those patients who are at R Soc Lond B Biol Sci 366(1562):295–299
Wightman JM, Gladish SL (2001) Explosions and blast
risk of having a BLI should have an X-ray and be
injuries. Ann Emerg Med 37:664–678
considered for arterial blood gas (ABG) evalua- Yeh D, Schecter WP (2012) Primary blast injuries – an
tion. Should a patient be vitally stable, asymp- updated concise review. World J Surg 36(5):966–972
tomatic, and both the chest X-ray and ABG be
within normal limits, the patient should be
observed for 4–6 h prior to discharge to monitor
for potentially delayed presentation of BLI (CDC Blast TBI
2006).
▶ Neurotrauma, Military Considerations
Cross-References
and distribute products, and follow adverse Nathoo N, Lautzenheiser K, Barnet G et al (2009) The first
events (Shaz and Hillyer 2010). direct human blood transfusion: the forgotten legacy of
George W. Crile. Op Neurosurg 64:20–27
Trauma surgeons, a group responsible for the Shaz B, Hillyer C (2010) Transfusion medicine as
use of large volumes of blood products in a very a profession: evolution over the past 50 years.
time-sensitive manner, are recommended to Transfusion 50:2536–2541
become familiar with local blood banks and the Sturgis C (1941) The history of blood transfusion. In: 43rd
annual meeting of MLA, 30 May 1941
transfusion medicine specialists who administer
them. In a series of recent studies, improved
communication, ordering flow, and emphasis
on the shared goals of patient safety have Blood Clot
improved outcomes in critically injured patients
(Alter and Klein 2008). Roughly 10–15 % of all ▶ Venous Thromboembolism (VTE)
injured patients seen in level I trauma centers
that require blood transfusion, and we see a large
increase in patient mortality as the number of
units of blood products infused increases (Como Blood Component Administration
et al. 2004).
▶ Blood Therapy in Trauma Anesthesia
Cross-References
Blood Mobile
Definition
▶ Blood Bank
Blood therapy in trauma anesthesia represents
administration of either specific blood compo-
nents or fresh whole blood (FWB) with the goal
Blood Poisoning of supporting oxygen delivery and/or process of
coagulation. Controlling the hemorrhage and
▶ Sepsis, Treatment of increasing the circulating volume directly or
Blood Therapy in Trauma Anesthesia 215
indirectly support maintenance of circulation. questionable what represents the best blood trans-
Initial blood therapy in trauma often involves fusion strategy for an acutely hemorrhaging
administration of group O uncrossmatched red patient that is rapidly losing whole blood.
blood cells (RBCs), fresh frozen plasma (FFP), Over a period of 30 years, the American
and platelets. Group-specific blood components College of Surgeons Committee on Trauma has B
or FWB may be administered if there was provided a foundation of care for injured
enough time to perform type and cross testing patients by publishing the Advanced Trauma
in the blood bank. In case of life-threatening Life Support (ATLS) and teaching the ATLS
injuries, blood therapy is initially guided by the course. The basic premise is that injured patients
patient’s clinical status. However, subsequent should receive two large-bore peripheral intra-
therapy is usually guided by a series of hemato- venous (IV) lines and ongoing crystalloid solu-
logic and coagulation tests. tions as soon as possible (ATLS 2008). In case of
hypotension, rapid administration of 1–2 L of
crystalloids (20 mL/kg for pediatric patients) is
Preexisting Condition recommended. Subsequently, 3-for-1 blood
replacement should follow (3 mL of crystalloids
The decision about urgent/emergent administra- for 1 mL of blood lost). Subsequently, excessive
tion of blood in trauma usually occurs in an acute crystalloid administration may have significant
setting during life-threatening hemorrhage in the dilutional effect and can worsen coagulopathy of
emergency room and/or in the operating room. acute trauma, resulting in even more difficulty
Sometimes this may occur in the intensive care controlling the hemorrhage and potential for iat-
unit if the patient has bypassed the operating rogenic injury. In case of unacceptably poor
room in need of obtaining adequate vascular perfusion, surgical control of the ongoing hem-
access and hemodynamic stabilization. orrhage and RBC administration are necessary.
A multidisciplinary clinical team is usually In the past, administration of FFP and platelets
involved in assessment and resuscitation from was usually guided by laboratory testing and
the time of patient’s arrival to the emergency often delayed: FFP to be given when PT and
room onward. However, blood component PTT were prolonged more than 1.5 times the
administration in trauma may also be elective in normal value and platelets usually administered
patients that have survived acute trauma; they are when the count was less than 50,000. However
recovering and need supportive blood therapy. subsequently, the delay in obtaining the results
Since such elective administration of blood is of laboratory testing and ongoing hemorrhage
not much different from any other elective worsen the coagulopathy even more. Thus, in
blood transfusion, the focus of this entry will be order to achieve a timely hemostatic resuscita-
blood therapy in acute hemorrhage. tion, this practice is being replaced by early
transfusion of RBCs, FFP, and platelets in the
Historical Prospective balanced 1:1:1 ratio.
Historically, separation of whole blood into Justification for institution of such transfusion
RBCs, plasma, and platelets was started because practice is not only clinical. A simple laboratory
of better preservation of each component experiment of diluting plasma and measuring
under special storage conditions and more flexi- prothrombin time (PT) demonstrated that PT
bility with administration of blood components exceeds 1.5 times the normal value when 40 %
than with administration of whole blood. In of plasma was mixed with 60 % of normal saline.
general, administration of a specific blood On the other hand, when a whole blood unit of
component to a patient that is either anemic, 500 mL, with a hematocrit (Hct) of 40–50 %,
coagulopathic, and/or thrombocytopenic repre- platelet count of 250,000, and coagulation factor
sents a goal-oriented therapy and more rational activity of 100 %, is separated into three
blood utilization. However, it still remains blood components (RBCs, FFP, and platelets)
216 Blood Therapy in Trauma Anesthesia
and the patient’s ABO/Rh type is determined, the received FWB; however, the evidence from large
group-specific blood products can begin to be prospective randomized trials is still missing.
released. Antibody screen is performed as well. If Despite that this military experience led to a fresh
the antibody screen results are negative, then the new way of looking into the balanced resuscitation
blood bank proceeds with an abbreviated with a fixed RBC to FFP ratio. B
crossmatch (electronic or immediate spin). An
abbreviated cross-match is used to ensure ABO
Acute Complications of Massive Blood
compatibility. If the antibody screen results are
Transfusion
positive, then the blood bank needs to determine
It is not always possible to easily distinguish
the type of the antibody and start providing
complications of massive blood transfusion
RBC units that do not have matching antigens on
(MBT) from deterioration in clinical condition
their surface. Administration of such PRBC units
of an acutely hemorrhaging anesthetized patient.
can result in hemolytic transfusion reaction.
If suspected these complications should be
Performing all these tests can cause a lot of pres-
considered in the context of patient’s medical
sure on the blood bank staff in order to try to
history, the injuries being treated, the course of
identify the antibody as soon as possible and pro-
surgery and ongoing blood loss, type of anes-
vide appropriate blood products. Some facilities
thetic being administered, as well as possible
stop crossmatching RBCs as soon as the patient
vital organ dysfunction.
has received ten RBC units in less than 24 h.
Such practice is justified by assumption that the 1. Acid-base and electrolyte abnormalities –
circulating blood has been so much diluted with Acidosis is primarily metabolic and a
transfused products that pre-existing antibodies consequence of hypoperfusion and anaerobic
have also been diluted. metabolism. Successful restoration of
If during the resuscitation the rhesus adequate tissue perfusion will be the
(Rh)-negative patient received Rh-positive best contribution to normalization of meta-
blood, it may be difficult to determine the bolic acidosis. Otherwise, with sustained
patient’s true Rh type during the blood bank hypoperfusion and continuous production of
testing. If there is any question about patient’s lactate, administration of sodium bicarbonate
true Rh type and especially if the patent is and calcium gluconate may be necessary.
a female, the blood bank should provide Citrate (anticoagulant in the RBC units) binds
Rh-negative RBCs due to the concerns of possi- calcium and can cause a dramatic decrease in
ble Rh alloimmunization. If the resources are serum calcium level. However, administration
limited or the patient already used a significant of sodium bicarbonate should be sensible
portion of the blood bank inventory, the switch because metabolic alkalosis may ensue post-
from providing Rh-negative to Rh-positive units operatively subsequent to administration of
may be inevitable. Under such circumstances, large amounts of sodium bicarbonate, success-
WinRho (RhIG) infusion to prevent Rh ful resuscitation, and lactate metabolism.
alloimmunization may be considered especially Hyperkalemia and hypokalemia may be sec-
in young women (Roback et al. 1999). ondary consequences of acidosis or alkalosis,
The experience regarding the use of FWB in respectively. These fluctuations are particu-
trauma patients is limited to the military experi- larly important to consider in children and
ence and comes from Combat Support Hospital in renal failure patients. Hypernatremia may be
Baghdad (Perkins et al. 2011). Treatment facilities a consequence of administration of a large load
across Iraq and Afghanistan have administered of sodium citrate during an MBT as well as
more than 8,000 FWB transfusions to more than administration of sodium bicarbonate.
1,000 patients. Many retrospective studies came 2. Hypothermia is usually caused by multiple
out of this military experience and demonstrated environmental factors in the field, skin
satisfactory or superior outcomes in patients who exposure during the patient assessment in
218 Blood Therapy in Trauma Anesthesia
Cross-References
Blunt Chest Trauma
▶ Exsanguination Transfusion
▶ Hemorrhage ▶ Airbag Injuries
B
References
Blunt Chest Wall Trauma
Ertl A, Diedrich A, Satish R (2007) Techniques used for
the determination of blood volume. Am J Med Sci ▶ Chest Wall Injury
334:32–36
Feldschuh J, Katz S (2007) The importance of correct
norms in blood volume measurement. Am J Med Sci
334:41–46
Jacob M, Conzen P, Finsterer U (2007) Technical and Blunt Craniocervical Arterial Injuries
physiological background of plasma volume measure-
ment with indocyanine green: a clarification of ▶ Neurotrauma, Complications: Blunt Cerebro-
misunderstandings. J Appl Physiol 102:1235–1242
Manzone T, Dam HQ, Soltis D et al (2007) Volume anal- vascular Injuries
ysis: a new technique and new clinical interest
reinvigorate a classic study. J Nucl Med Technol
35:55–63
Riley A, Arakawa Y, Worley S et al (2010) Circulating Blunt Ocular Injury
blood volumes: a review of measurement techniques
and a meta-analysis in children. ASAIO J 56:260–264
▶ Eye Trauma, Anesthesia for
The types of injuries found in wearers of body and exposures for these arteries, not commonly
armor and the treatment of them must be known needed in civilian trauma settings. The main
by the providers if they are to recognize them and target area in civilian penetrating trauma is the
to effectively treat them. trunk, which is covered by armor in combat.
Several epidemiologic studies have shown Pre-deployment training and practice should be
a substantial reduction in the number of fatal done if one is not familiar with these key expo-
thoracic and abdominal injuries incurred during sures. In a forward surgical setting, reestablishing
conflict situations in combatants wearing mod- flow to the injured arteries can be obtained by
ern body armor. In Iraq and Afghanistan, only temporary shunting, or vessels may be temporar-
5–7 % of reported injuries were thoracic, the ily or permanently ligated. Surgeons need to
lowest for American military personnel in know which vessels and in what circumstances
modem warfare (Owens et al. 2008). A greater they can be safely ligated.
proportion of head and neck wounds was also Second category of injuries noted in wearers
noted in comparison with earlier non-armored of body armor is BABT. BABT is defined as the
conflicts both areas not sufficiently protected nonpenetrating injury resulting from a ballistic
by armor. In both Iraq and Afghanistan the died impact on body armor and has two mechanisms
of wound rate (DOW) is lower than any earlier causing injury. Deformation of the armor caused
conflicts and body armor contributed to this. It is by the projectile striking, but not penetrating the
unclear just how much body armor contributed armor, can cause injury to the structures directly
to this improvement as there were many other under the area of armor struck. The other
changes in protection, evacuation, and field and mechanism is similar to primary blast injury
hospital treatment of casualties that were initi- with energy transfer causing injury or dysfunc-
ated in this conflict. tion at a distance from the area struck.
Injuries noted in wearers of body armor fall The increase in available energy of bullets and
into basically two categories. First category is the desire of armor designers to minimize the
injuries sustained in areas of the body where the weight and bulk of personal armor systems has
body armor does not cover around the armor increased the risk of BABT in military and secu-
trauma (AAT). Second category is injuries rity forces personnel. With the lighter flexible
sustained in areas covered by the armor or behind armor development, projectiles are stopped
armor blunt trauma (BABT) where the projectile from entering the body by allowing deformation
impacts the body armor and does not penetrate, inward of the body armor dissipating of the
but causes injury none the less. projectile’s energy (Bass and Salzar 2006). This
First category AAT are treated just like any injury potential is appreciated and forms a part of
injury to that particular body area armor or not. how the NIJ determines levels of protection for
Most commonly injured areas are head, neck, body armor: the 44-mm standard. Using the NIJ
axilla, groin, and shoulder areas and of course levels of protection, assuming the armor is not
the extremities. The current body armor has penetrated which constitutes vest failure, the
been improved to have kevlar pads to afford measure of performance is based solely on a
some protections to these areas, but projectiles 44-mm static measurement of the deformation
can still get through these “chinks in the armor.” depth backface signature (BFS) created in a clay
Experienced snipers can take advantage of these model. Derived from ballistic impacts on armor
weaknesses in protection and concentrate fire in animals, a 44-mm limit was determined as the
there causing significant and often fatal injuries. maximum allowable BFS depth in the clay for
Injuries to the subclavian-axillary arteries, a vest to meet ballistic resistance standards and be
femoral-iliac arteries, carotids, and distal extrem- rated as acceptable for field use. Bass et al. state
ity arteries are quite common in AAT injuries. that the introduction of modern high impact
Surgeons tasked with care of combat victims strength, deformable materials into helmets, and
must be facile with proximal vascular control body armor for this ballistic impact protection
Body Armor 227
Cross-References
Bogota Bag
▶ Abdominal Compartment Syndrome
Jamie J. Coleman ▶ Damage Control Resuscitation
Department of Surgery, Indiana University ▶ Methods of Containment of the Open
School of Medicine, Indianapolis, IN, USA Abdomen, Overview
▶ Open Abdomen, Temporary Abdominal
Closure
Synonyms
Bowel Accident
Preexisting Condition
▶ Bowel Incontinence
Fluid content is the primary determinant of stool
volume and consistency and reflects a balance
between luminal input and output (Pasricha
Bowel Active Agents in the ICU 2008). Alterations in secretion, absorption,
and/or motility along the length of the bowel
Melissa A. Reger1, Staci A. Anderson1 and can lead to excess fluid removal and constipation.
Mary M. Wolfe2 There are many potential causes for constipation
1
Department of Pharmacy, Community Regional in the trauma patient including medications,
Medical Center, Fresno, CA, USA dehydration, underlying bowel condition, lack
2
Department of Surgery, Community Regional of fiber in diet, immobility, pain, inability to act
Medical Center, Fresno, CA, USA or respond to the urge to defecate, hormonal
disturbances, neurogenic disorders, and lack of
privacy (Dorman et al. 2004; Pasricha 2008).
Synonyms Medications that are commonly associated with
constipation include opiates, anticholinergics,
Bowel regimens; Cathartics; Constipation; and others (Table 1) (Cassagnol et al. 2010). As
Evacuants; Laxation; Laxatives; Purgatives the population ages, there may be an increase
in the prevalence of constipation, primarily
due to decreased mobility, comorbid medical
Definition conditions, and polypharmacy.
Bowel Active Agents in the ICU, Table 1 Medications have reflex bowel activity and may require digital
associated with constipation rectal stimulation to produce a bowel movement.
Medication class Example agents This is achieved by placing a gloved finger into the
Opiates Morphine, hydrocodone, fentanyl, rectum and slowly rotating, while maintaining
hydromorphone, oxycodone contact with the anterior portion of the rectal wall B
Anticholinergics Tolterodine, scopolamine, (Steins et al. 1997). In addition, manual digital
benztropine, atropine
pressure applied to the abdomen or manual
Antispasmodics Oxybutynin, hyoscyamine,
cyclobenzaprine, baclofen disimpaction may be necessary to assist with
Tricyclic Amitriptyline, doxepin, bowel evacuation. Because stimulation of the
antidepressants desipramine, nortriptyline vagus nerve may occur, this should be used with
Antiparkinsonians Carbidopa, entacapone, caution in patients with cardiac disorders and
trihexyphenidyl, amantadine, recent bowel or genitourinary surgery.
pramipexole
Calcium channel Verapamil, diltiazem
blockers Medications for Constipation
Diuretics Furosemide, torsemide, Numerous drug products are available to help
hydrochlorothiazide, metolazone, relieve constipation in the ICU patient
triamterene (Table 2). Bulk-forming agents, such as psyllium
Anticonvulsants Phenobarbital, phenytoin, and methylcellulose, can assist with constipation
carbamazepine, levetiracetam,
pregabalin
and have very few side effects. Bulk-forming
Vinca alkaloids Vinblastine, vincristine,
agents absorb water in the intestine to form
vinorelbine a viscous liquid which promotes peristalsis and
Antihistamines Diphenhydramine, promethazine, reduces transit time. They also soften the stool
famotidine (Cassagnol et al. 2010). Caution must be taken
Antacids Calcium carbonate, aluminum when administering these to patients with poor
hydroxide
intake of liquids as the constipation could worsen
Iron supplements Ferrous sulfate, ferrous gluconate,
polysaccharide-iron complex
if not given with at least 8 oz of water. Since these
Antidiarrheals Loperamide, bismuth, agents thicken when mixed with water, caution
diphenoxylate/atropine, opium should be taken when administering through a
tincture feeding tube as clogging of the tube may occur.
Osmotic agents, such as lactulose, sorbitol,
and magnesium hydroxide, exert their action by
given orally or added to tube feedings. Prune osmotically drawing water into the bowel and
juice acts as a natural laxative because of its stimulating peristalsis. Saline laxatives, which
high content of sorbitol, a nondigestible sugar can contain magnesium or phosphate, should be
that occurs naturally. used with caution in patients with renal impair-
The ideal pharmacologic intervention consists ment, cardiac disease, and preexisting electrolyte
of the combination of a stool softener and a motil- abnormalities or in patients on diuretic therapy as
ity agent. A stool softener without a motility agent electrolyte abnormalities may occur (Pasricha
causes “all mush and no push.” A retrospective 2008). Effects of these agents may not be seen
analysis of critically ill patients found that the use for 24–48 h after administration, generally with
of a stimulant or osmotic laxative was associated higher doses producing faster results. Polyethyl-
with the occurrence of a bowel movement, while ene glycol is a newer agent that produces similar
prokinetic agents (metoclopramide, erythromy- effects to other osmotically active agents but with
cin) were not (Patanwala et al. 2006). Rarely, fewer side effects and improved compliance.
patients may require additional interventions Stool softeners such as docusate and mineral
based on their disease states. For example, oil are necessary in bowel care to limit the pain
patients with quadriplegia or paraplegia who associated with bowel movements. Docusate is an
have an upper motor neuron cord lesion generally anionic surfactant that lowers the surface tension
232 Bowel Active Agents in the ICU
of the stool, similar to the action of soap, and within 6 h. Due to the stimulating effect of both of
allows for softening of the stool. Docusate alone these agents, common side effects include abdom-
for treatment of constipation has proven to be inal pain and cramping.
an ineffective method (Cassagnol et al. 2010). Enemas and suppositories generally provide
Mineral oil is a nonabsorbable oil that softens fast and localized effects. Bowel distention
the stool. However, this can lead to malabsorption alone, by any means, can produce a bowel move-
of fat-soluble vitamins, leakage of oil past the ment in most patients. This can be facilitated by
anal sphincter, and pneumonitis if aspirated, and anything from normal saline to commercially
thus its regular use is limited (Pasricha 2008). available preparations. Caution should be used
Stimulant laxatives have a direct effect on the with all of these agents and attention paid to
enterocytes and GI smooth muscle to stimulate their contents. For example, repeated use of tap
intestinal motility. Bisacodyl is available as an water enemas can lead to hyponatremia due to an
oral or rectal preparation for use by adults and increase in free water or too many sodium phos-
children over the age of 6. Suppositories generally phate enemas may put a patient at risk for
produce a more rapid effect (within 30–60 min) hypernatremia and hyperphosphatemia. Another
when compared to the oral route (6 h) (Pasricha type of enema is the return-flow enema, also
2008). The oral preparation is an enteric-coated called a Harris flush. In this procedure, a bag
tablet, so manipulation (crushing) of the tablet is filled with a small amount of fluid (usually
not advised. Senna is another commonly used warm tap water) is elevated above the patient’s
stimulant agent. It is derived from the plant Cassia hips, and the fluid is instilled into the colon
acutifolia and is considered an herbal preparation, through a tube. The bag is then lowered, allowing
which makes standardized dosing difficult. It is the solution to run back into the bag. This process
usually administered orally and produces an effect is repeated several times, stimulating peristalsis
Bowel Active Agents in the ICU 233
and allowing the patient to expel flatus and stool. Agents that are not beneficial include erythro-
Glycerin suppositories act as a colonic lubricant mycin due to its action on the stomach and small
and usually produce a bowel movement in less intestine that are mediated through motilin recep-
than an hour (Pasricha 2008). This preparation tors that do not extend into the colon. The effects
has very few side effects, except for some local of metoclopramide are confined largely to the B
irritation, and is arguably the drug of choice for upper gastrointestinal tract. It has no clinically
pediatric trauma patients. As previously men- significant effects on the motility of the colon,
tioned, bisacodyl suppositories are very effective and its ability to improve transit in motility dis-
at rapidly producing a bowel movement, by both orders is limited (Pasricha 2008).
local irritation and digital stimulation during
administration. However, when considering use Conclusions and Recommendations
of enemas and suppositories, care must be taken Prevention is the best medicine, and it is no
in those patients with distal bowel injury and/or different when it comes to constipation. Treat-
recent anastomosis. ment recommendations consist of an initial
Prevention of constipation is an exciting new assessment of the patients’ medication regimen
area of research. It would be ideal to limit the and removal of unnecessary medications that
adverse effects of medications such as opioids on can predispose patients to constipation. Pharma-
the bowel. Enteral naloxone, a pure opiate antag- cologic therapy is most beneficial when it is
onist, has been studied to treat opiate-induced started early and includes a combination of
constipation. Enteral administration has the the- a stool softener (docusate) twice daily with
oretical benefit of little to no systemic exposure the addition of a stimulant agent (senna or
due to extensive first-pass metabolism in the bisacodyl) at bedtime. Bisacodyl has the advan-
liver. However, opiate withdrawal symptoms tage of a suppository formulation that is espe-
have still been reported with its use (Foss 2001). cially useful after surgery, whereas senna is
Methylnaltrexone is an antagonist of the mu- better tolerated via feeding tube administration.
opioid receptor with limited ability to cross the If constipation remains a problem, other agents
blood–brain barrier. Therefore, it functions in the can be added (polyethylene glycol, saline laxa-
periphery and does not affect opiate analgesia tives) until the goal of a bowel movement is
efficacy or induce withdrawal symptoms. attained. Once the sweet smell of success has
Methylnaltrexone has been shown to decrease been achieved, the regimen should be tapered
oral-cecal transit times in both acute and chronic down to limit the occurrence of diarrhea due to
opioid administration (Foss 2001). Subcutaneous these agents, as this can lead to other needless
administration and medication cost limit its tests and procedures.
usefulness. Alvimopan, another peripherally
acting mu-opioid receptor antagonist, has been
shown to accelerate gastrointestinal recovery Cross-References
in patients undergoing laparotomy for bowel
resection. However, in studies of alvimopan for ▶ Acute Pain Management in Trauma
opiate-induced bowel dysfunction in patients ▶ Bowel Incontinence
with chronic non-cancer pain, there was a ▶ Fluid, Electrolytes, and Nutrition in Trauma
higher incidence of myocardial infarction in Patients
alvimopan-treated patients. This led to the imple- ▶ Geriatric Trauma
mentation of a risk evaluation and mitigation ▶ ICU Management
strategy by the FDA and restriction of the medi- ▶ Nutritional Support
cation to patients undergoing bowel resection ▶ Pain
(Kraft et al. 2010). For this reason, alvimopan ▶ Sedation and Analgesia
cannot be recommended for the prevention of ▶ Sedation, Analgesia, Neuromuscular Blockade
opiate-induced constipation in the trauma patient. in the ICU
234 Bowel Incontinence
▶ Orthotics History
to understand and simple for brain death. shrunken and piknotic. Autolysis of the
Brain death criteria were first defined in 1968 by cerebellar granular layer and the pituitary gland
the “Harvard criteria” (Beecher and Harvard Ad was evident in all cases. There was not any
Hoc Committee 1968). According to Harvard reactive astrocytosis or infiltration of the cells
Ad Hoc Committee “An organ, brain or other in or around necrotic tissue.
that no longer function and has no possibility of
functioning again is for all practical purposes
dead” (Beecher 2007). Then in 1971, two Application
neurosurgeons described brain death as “point
of no return” (Mohandas and Chou 1971); these Diagnosis of Brain Death
criteria were based on a clinical basis and no For the diagnosis of brain death, the patient
confirmatory tests were mandatory. should have a history or findings of direct or
indirect insult to the brain which result in
a structural brain damage and a deep coma. The
patient should also be apneic under controlled
Definition
mechanical ventilation. An unresponsive coma
caused by alcohol, sedative or depressant drug
We don’t know life: how can we know death? overdose, metabolic or endocrine disorders,
Confucius.
electrolyte disturbances, hypothermia, and
Brain death defines a clinical situation after neuromuscular blocker drugs can be potentially
a severe direct or an indirect injury to the brain. reversible and cannot be classified as brain death.
This is an irreversible loss of the whole brain In the absence of these reversible causes,
function above the medulla spinalis which a neurologic examination of a brain death case
includes unconsciousness with a Glasgow Coma should lack all evidence of responsiveness to
Score of 3, fixed dilated pupils, absence of all painful stimulus. Eye opening or eye movement
cranial nerve functions, and the absence of to noxious stimuli should be absent. Painful
a spontaneous respiratory drive. stimuli can be made by nail bed pressure and
supraorbital pressure or jaw thrust maneuver.
No grimacing or facial muscle movement
Preexisting Condition must be seen.
In the presence of coma as defined above with
Pathophysiology Glasgow Coma Scale point 3, and absence of
Following a direct or an indirect injury of the brainstem reflexes which includes light, corneal,
brain, intracranial pressure increases to a level occulocephalic, occulovestibular, pharyngeal,
which interrupts blood flow to the brain. Follow- tracheal reflexes, and a positive apnea test
ing the cessation of blood flow to the brain, (detailed information about the absence of brain
within 3–5 days, the brain is liquefied which reflexes and the apnea test is given below) shows
was described as a “respirator brain” by Walker brain death. In most of the cases, deep tendon
et al. (1975). Microscopic examination shows reflexes are absent however in some cases spinal
autolysis and aseptic necrosis. According to reflexes and myoclonus may persist and can be
Ujihira et al. (1993), neuropathological findings misunderstood both by family members and
are brain edema, congestion, herniation, and medical personal.
various subarachnoid hemorrhages. Histologi- Several centers usually perform two
cally, the neurons’ cytoplasm was pale and neurologic examinations within a 12–24-h
ghost-like. In the white matter, myelin staining period, but one should be sufficient to pronounce
was pale, and nuclei of the glial cells were brain death. One absolute requirement is that
Brain Death 237
similar to asking a family member’s permission • The principle of ain dochin nefesh mipnei
to declare someone dead after a cardiac arrest. nefesh – that one life may not set aside to
Death is not a choice. ensure another life – applies with full force
Indeed, even the terminology we use to even where the life to be terminated is of short
describe brain death confuses the issue and can duration and seems to lack the meaning or
stir some controversies. It is often confusing to purpose and even when the potential recipient
practitioners as well as to family members, when has excellent chances for full recovery and
they are told that their loved ones are meeting long life.
criteria for “brain death,” when vital signs often • If on the other hand if the donor is dead, the
seem to be normal with or without use of vaso- harvesting of organs to save another life
pressors or inotropes. Since “brain-dead” patients becomes a mitzvah of the highest order.
show traditional signs of life as warm, moist skin, • New York is the only state that requires med-
a pulse, and breathing, it is not surprising that ical personnel to make a reasonable effort to
many people think that “brain death” is a separate notify family members before a determination
type of death that occurs before “real death.” This of brain death and to make “reasonable
is often confounded when medical providers accommodations” for the patient’s religious
repeat that “life support” as being removed in beliefs.
such patients (Capron 2001).
Buddhist:
Being sensitive to family and explaining the
differences between the above terminologies may • In 2006, the family of a Buddhist man in
alleviate some concerns regarding sensitivity in Boston who had been declared legally brain-
such a difficult situation. dead argues that, because his heart was
still beating, his spirit and consciousness still
lingered and that removing him from life sup-
Autonomy Myth: “Physicians Define Death”
port would be akin to killing him.
Physicians do not define death. Through consen-
• In Tibetan Buddhism, a person has multiple
sus, the law, and religious beliefs, societies select
levels of consciousness, which may not corre-
the vital functions that must irreversibly cease
spond with brain activity
to consider someone dead. Physicians define
and execute the medical procedures necessary Christians:
to determine if someone meets these societal
• Christians who ardently support the traditional
definitions. Societies define death.
circulatory-respiratory definition of death tend
Whether someone is dead is dependent
to be fundamentalists or evangelicals.
on the societal context. Although there is
• Most main stream Protestant groups in the
widespread acceptance of the concept of
United States accept brain death as a valid
irreversible cessation of whole brain function as
criterion for death, as does the Roman Catho-
a definition of death, the acceptance is not
lic Church, albeit some controversy.
universal.
Because they do not define death, physicians Islamic law:
must be aware of the societal and religious con-
• In 1986, the Academy of Islamic Jurispru-
text in which they are practicing. Variations in the
dence, a group of legal experts convened by
acceptance of brain death as a concept are
the Organization of the Islamic Conference,
outlined below.
issued an opinion stating that a person should
Jewish Law:
be considered legally dead when either “com-
• There still exists opposition in the Jewish Law plete cessation of the heart or respiration
regarding the halachic acceptability of brain occurs” or “complete cessation of all functions
death criteria. of the brain occurs.”
Brain Death, Ethical Concerns 241
Brain death is a clinical decision to be made by case reports for information about the validity of
the attending physician. The concept of brain these tests.
death and the process of declaration is based on Demonstration of Cessation of Cerebral
systematic neurological examination focusing on Blood Flow as a Precise Indicator of Brain
irreversibility of brain dysfunction, in the Death: (Wijdicks 2010)
absence of confounding factors. The determina-
• There may be two distinct patterns of bran
tion of irreversibility is a clinical decision, based
death. The most common pattern is character-
on available history, evidence of injury on neu-
ized by increased intracranial pressure (ICP)
roimaging, and absence of brainstem reflexes,
above the mean arterial pressure (MAP),
including the documentation of apnea despite
resulting in no net cerebral blood flow.
subjecting the brainstem to hypercarbia.
• The second pattern is where the ICP does not
Ancillary tests are appropriately used in situ-
exceed MAP, but there is an inherent pathol-
ations where the clinical examination is
ogy that affects brain tissue on a cellular level
compromised: for example, in situations where
to the extent that brain death occurs (Bader
elicitation and interpretation of brainstem
et al. 2003; Palmer and Bader 2005).
reflexes is difficult as in the presence of severe
facial injuries obviating documentation of pupil- Role of EEG as Ancillary Test in Declara-
lary or corneal reflexes, upper cervical spine tion of Brain Death:
injury preventing motor responses, and in clinical
conditions that retain carbon dioxide, thus mak- • EEG was one of the first confirmatory tests
ing interpretation of apnea test difficult. These that was proposed for brain death declaration.
tests are best reserved for the above conditions. However, isoelectric EEG can be associated
Even if confounding variables may be present, with retained cerebral blood flow, and thus,
i.e., pentobarbitone coma, physicians may be these patients would seem brain dead on one
tempted to use ancillary tests in lieu of clinical laboratory test but not on another.
criteria; however, many physicians may rather
Role of Transcranial Doppler in Declara-
choose to observe patients, until those
tion of Brain Death:
confounding variables are corrected.
Interestingly, the most common ancillary test- • Transcranial Doppler (TCD) ultrasound has
ing that was performed included: emerged as a noninvasive method in the dec-
laration of brain death. Ten percent of patients
• EEG (84 %)
do not possess adequate insonation windows
• Conventional angiography (74 %)
to perform TCDs; thus, presence of a baseline
• Radionuclide scintigraphy (66 %)
is paramount.
• Trans cranial Doppler (42 %)
• There have been studies demonstrating no
• Somatosensory-evoked potentials (SSEP)
flow pattern in middle cerebral artery seg-
(24 %)
ments, but indicating flow in basilar arteries.
• Magnetic resonance angiography (9 %)
• Retrospective data showed that TCD con-
• CT angiography (6 %)
firmed brain death in 57 % of patients, while
• CT perfusion (3 %)
it was inconclusive in 43 % patients with no
• Atropine challenge (3 %)
flow signals seen on first examination in 8 %
• Mean arterial pressure = intracranial pressure
and waveform patterns in remaining patients
for 30 min (3 %)
(35 %) being inconsistent with standard brain
Contrary to popular belief, none of the ancil- death criteria for cerebral circulatory arrest
lary tests, i.e., cerebral angiography, EEG, and (Sharma et al. 2011).
nuclear medicine testing, to demonstrate cessa- • Recent meta-analysis of TCD data demon-
tion of cerebral blood flow have been validated as strated a sensitivity of 89 % and a specificity
accurate as ancillary tests. We primarily rely on of 99 %. The study found two false-positive
Brain Death, Ethical Concerns 243
results, in which brain stem function showed clinical decision that the family may have taken,
brain death shortly thereafter (Monteiro et al. unless it is a request by the family per se to ask
2006). about eligibility regarding organ donation, espe-
cially if their loved ones were in fact organ recip-
Role of Computed Angiography (CTA) in
Declaration of Brain Death:
ients. In this case, it is best to refer them to the B
organ donation team, once the clinical decision
• Greer et al. describe a case in which computed has been made to declare brain death or the fam-
angiography (CTA) was performed to evalu- ily decides to discontinue technological support,
ate for cerebral circulatory arrest, later proved in which case donation after cardiac death may
wrong by Transcranial Doppler. happen. The authors have been involved in situ-
ations where formal brain death declaration has
Beneficence Myth: “It is Okay to Rely on the not been performed, only to the requested by the
Organ Donor Team to Confirm Brain Death” organ donation team to perform an apnea test, and
Clinicians sometimes inappropriately defer deci- declare, due to family wishes.
sions regarding brain death to the organ procure-
ment team (OPT). The OPT is a tempting Justice Myth: “The Concept of Death by Brain
resource because of their familiarity with the Criteria was Developed Because of Organ
concepts and procedures for determining death. Donation Demands”
This temptation must be resisted. The OPT has an Organs suitable for transplant are clearly scarce.
inherent conflict of interest. The duty of the Given this and the tragic circumstances that
attending physician is to their patient whereas invariably accompany a brain death determina-
the duty of the OPT is to the patients needing tion, it seems just to try to salvage some good
organ transplants. The attending physician must from the situation.
make the determination of brain death It is often expressed that concept of death by
completely independent of the OPT. brain death criteria was developed because of
Brain death and organ donation although intu- organ donation demands. Physicians often may
itively seem related are in fact two separate topics seem burdened to declare patient’s brain death
that deserve equal attention. As per federal guide- due to institutional, regional, and national pres-
lines, any patient admitted to a hospital with sure to provide organs to patients on the trans-
a Glasgow Coma Score of less than equal to 5 plant list. Indeed Troug RD (2007) raises
must be notified to the local transplant network significant issues relating to the flourishing
for possible eligibility for organ donation. This organ transplant industry and its demands on
process as it should proceed in parallel with the declaration of brain death. He cites that in 1968,
ICU care of these patients, until either the pri- the Ad Hoc Committee at Harvard claimed that
mary team declares patient’s brain death or the brain death criteria were needed to clarify defini-
family decides to stop continuation of technolog- tion of death as the now obsolete criteria would
ical support (“withdrawal of care”). lead to controversy in obtaining organs for
Often, treating physicians confuse the two transplantation.
entities: withdrawal of technological support or In fact, upon careful review of the history of
brain death declaration and at times relies on the organ transplantation and the history of brain
organ donor team to declare brain death. This death declaration processes, it is obvious that
practice should not be encouraged, as brain brain death concept and organ transplantation
death declaration is a process that any physician arose separately and advanced in parallel, and
who is intimately familiar with end-of-life issues only began to process together in the late 1960s.
should be also familiar with, and may be able to It may be impossible to deny that the final suc-
guide families in that regard. The organ donation cesses of transplants were indeed improved by
teams’ involvement and interaction with the pri- the development and refinement of the concept of
mary treatment team must never cloud any brain death (Machado et al. 2007).
244 Brain Edema
Family understanding about brain death is Monteiro LM, Bollen CW, van Huffelen AC,
an important factor that contributes to the decision Ackerstaff RG, Jansen NJ, van Vught AJ
(2006) Transcranial Doppler ultrasonography to con-
to donate organs after declaration. In a survey firm brain death: a meta-analysis. Intensive Care Med
conducted by Siminoff et.al (2007), following fac- 32(12):1937–1944
tors were involved against organ donation: Palmer S, Bader MK (2005) Brain tissue oxygenation in
brain death. Neurocrit Care 2(1):17–22
• Family perception that the patient would not Sharma D, Souter MJ, Moore AE, Lam AM (2011)
want to donate (51 %). Clinical experience with transcranial Doppler ultraso-
nography as a confirmatory test for brain death:
• Family stamina or emotional turmoil (44 %),
a retrospective analysis. Neurocrit Care 14(3):
that accompany donation especially in youn- 370–376
ger patients. Siminoff L, Mercer MB, Graham G, Burant C (2007) The
• Disfigurement concerns (43 %). reasons families donate organs for transplantation:
implications for policy and practice. J Trauma
• Mistrust of the health care system (25 %). This
62(4):969–978
was thought to be due to lack of adequate Truog RD (2007) Brain death – too flawed to endure, too
emotional support that the treating physicians ingrained to abandon. J Law Med Ethics J Am Soc
provided the families in making decisions Law Med Ethics 35(2):273–281
Wijdicks EF (2010) The case against confirmatory tests
regarding organ donation.
for determining brain death in adults. Neurology
• Family determination (incorrectly) that the 75(1):77–83
patient was ineligible (19 %).
• Family disagreed over donated decision (14 %).
• Termination of mechanical support (12 %).
Summary
Brain Edema
Brain death is a clinical diagnosis. Physician inti-
▶ Traumatic Brain Injury, Anesthesia for
mately knowledgeable with the process must be
cognizant of social, cultural, and religious prac-
tices, and rely on best available clinical evidence
during declaration.
Brain Injury
References
Definition
Brainstem Death
Brown Séquard Syndrome (BSS), sometimes
▶ Brain Death, Ethical Concerns referred to as Brown-Séquard hemiplegia
or paralysis, was first observed in 1849 by B
Mauritian physiologist and neurologist Brown-
Séquard (Brown-Sequard 1850). The syndrome
is characterized by a functional lateral
Breathing Passage hemisection of the spinal cord. The most com-
mon cause of BSS is trauma involving a pene-
▶ Airway Anatomy trating mechanism, for example, a stab or
gunshot wound (Musker and Musker 2011). In
addition, blunt trauma, pressure contusion,
motor vehicle accidents, or severe falls that
cause unilateral facet fracture and dislocation
Broken Ankle may also lead to the development of BSS.
Neurologically, these patients present with
▶ Ankle Fractures loss of motor function (hemiparaplegia) and sen-
sation on the ipsilateral side of the hemisection.
Interruption of the lateral corticospinal tracts
may lead patients to present with ispilateral
spastic paralysis below the level of lesion as
Brown-Séquard Hemiplegia well as Babinski’s sign. Damage to the posterior
column results in ipsilateral loss of tactile
▶ Brown-Séquard Syndrome discrimination, vibration sense, and propriocep-
tion. Nerve fibers of the spinothalamic tract
(pain and temperature sensation) crossover
within the spinal cord from the periphery; thus,
contralateral loss of such sensation usually
Brown-Séquard Paralysis occurs two to three segments below location of
injury.
▶ Brown-Séquard Syndrome Overall prognosis for BSS is better than any
other spinal cord injury. For example, patients
with cervical BSS achieve higher functional
improvement by time of discharge compared
with patients with CCS (McKinley et al. 2007).
Brown-Séquard Syndrome In general, treatment focuses on addressing the
underlying cause of the syndrome, which may
MariaLisa Itzoe and Daniel M. Sciubba involve first administering to other injuries if
Department of Neurosurgery, The Johns any are present. Recovery of function tends to
Hopkins University School of Medicine, be progressive: motion is regained in the
Baltimore, MD, USA ipsilateral proximal extensor muscles before the
ipsilateral distal flexor muscles, and pain/temper-
ature sensation is regained in the ipsilateral
Synonyms extremities before the contralateral extremities
(Little and Halar 1985). Voluntary motor strength
Brown-Séquard hemiplegia; Brown-Séquard and functional gate are usually regained within
paralysis 6 months post injury. Up to 90 % of patients
246 bTBI
regain some degree of ambulation by the end of removed to improve RBC storage. In the 1970s,
their recovery (Little and Halar 1985). European countries began removing the buffy coat
layer to reduce WBC contamination that was lead-
ing to febrile transfusion reactions. While North
References American blood banks use a platelet-rich plasma
method to separate component blood products,
Brown-Sequard C-E (1850) De La Transmission Croisee Canada and much of Europe use the buffy coat
Des Impressions Sensitives Par La Moelle Epiniere.
method as their primary method of platelet product
Comptes rendus de la Societe de biologie 2:33–44
Little JW, Halar E (1985) Temporal course of motor preparation. All of these methods produce high-
recovery after Brown-Sequard spinal cord injuries. quality platelets with roughly equivalent yields
Paraplegia 23(1):39–46 (Hogman et al. 2010).
McKinley W, Santos K, Meade M, Brooke K (2007) Inci-
During the buffy coat production of platelet
dence and outcomes of spinal cord injury clinical
syndromes. J Spinal Cord Med 30(3):215–224 concentrates, whole blood first undergoes a “hard
Musker P, Musker G (2011) Pneumocephalus and Brown- spin,” after which the heavy layer of RBC
Sequard syndrome caused by a stab wound to the back. concentrate is removed to be processed into
Emerg Med Australas 23(2):217–219
packed red blood cells. The middle buffy coat
layer is then siphoned off the lighter platelet-
poor plasma and subjected to a slower “soft
spin.” This second spin leaves two layers, a top
bTBI discard layer and a heavier layer of platelet con-
centrate. Due to the relatively low platelet counts
▶ Neurotrauma, Military Considerations when run in a single process, pools of 4–5 buffy
coats are made and mixed with male donor
plasma prior to the final “soft spin.” There are
many variations on the buffy coat method includ-
Buffy Coat ing the addition of additives at various stages to
improve product purity and storage and separa-
Harvey G. Hawes1, Bryan A. Cotton1 and tion of layers at reduced temperatures to improve
Laura A. McElroy2 platelet yield (Lozano et al. 2000). The buffy coat
1
Department of Surgery, Division of Acute Care method has been heavily automated, and when
Surgery, Trauma and Critical Care, University of followed by leukocyte reduction, it can decrease
Texas Health Science Center at Houston, The WBC levels below 1 106 per unit (Ito and
University of Texas Medical School at Houston, Shinomiva 2001).
Houston, TX, USA
2
Department of Anesthesiology, Critical Care
Medicine, University of Rochester Medical Cross-References
Center, Rochester, NY, USA
▶ Apheresis platelets
▶ Blood Bank
Definition ▶ Blood Group Antibodies
▶ Blood Therapy in Trauma Anesthesia
The buffy coat refers to a layer of platelets and
white blood cells (WBCs) that is found between
the heavier red blood cell (RBC) layer and the References
lighter plasma layer after centrifuging whole
Hogman CF, Berseus O, Eriksson L et al (2010) Interna-
blood at high speed. The term “buff,” the
tional forum: Europe. Buffy-coat-derived platelet
yellow-brown color of undyed leather, refers to concentrates: Swedish experience. Clin Lab 56:
the color of the buffy coat. This layer was initially 263–279
Burn Anesthesia 247
Synonyms
▶ Crush Syndrome
Definition
Burn Anesthesia,
Fig. 1 Rule of nines for
4.5 4.5
adult and child
18 4.5
4.5 18 4.5
4.5
9 9
9 9
Adult
9 9
18 18
4.5 4.5 4.5 4.5
Child
(4) electrical burn, (5) children, and (6) age > 60 Burn Anesthesia, Table 1 Parkland formula example
years. Baux’s formula estimates that % mortality 4.0 mL crystalloid/kg/% burn/24 h
for elderly patients is equal to the sum of patient’s 70 kg female with 50 % TBSA burn
age plus % TBSA burn. Inhalation injury adds 4 ml 70 kg 50 % TBSA burn = 4 70 50 =
20–60 % increased mortality to burn of any size 14,000 ml crystalloid in 1st 24 h B
in any age group. Patients >80 years old with 7,000 ml crystalloid in 1st 8 h
inhalation injury have high mortality. Young 3,500 ml crystalloid during 2nd +8 h
patients have an overall mortality 30–40 % 3,500 ml crystalloid during 3rd 8 h
with burns complicated by inhalation injury.
Other mortality factors are (1) coexisting
disease, (2) concomitant injuries, (3) location of is related to the amount of TBSA burned. With
burn, and (4) physical environment (closed space). large superficial, deep partial-thickness, and full-
Three phases of recovery are (1) resuscitation, thickness burns, increased fluid requirements
1st 24–48 h; (2) hypermetabolic, 2 days to require large fluid administration to replace
2 months; and (3) reconstruction, 2 months blood volume lost. Various formulas such as the
to 2 years or until wound heals (Capan Parkland formula (Table 1) have been used to
et al. 1991; Lovich-Sapola 2008). calculate the fluids needed during the 1st 24 h
following injury. The type of fluid used appears
Skin Effects to be less important than accurately calculating
Burn injury patients lose heat. Increased blood volume replacement. It is important to
metabolism is needed to generate heat. Burn monitor mental status, heart rate (HR), blood
injury increases metabolic rate 1 week after pressure (BP), O2 saturation (SpO2), urine output
injury. Edema from fluid resuscitation, (UO), weight, and skin turgor. One should eval-
hypoproteinemia, and an inelastic eschar uate arterial blood gas, CBC, electrolytes, BUN,
(circumferential burns) may compromise creatinine, CVP, pulmonary artery catheter
neurovascular function (extremities, digits) and depending on patient coexisting diseases, and
restrict chest wall respiration. An escharotomy physical status.
may be needed to release compression and An early goal of surgery is to debride to
constriction and restore neurovascular function. a bleeding viable dermal layer with skin grafting
Patients with electrical injuries often require the ultimate goal. Early debridement is often pro-
a fasciotomy and deep compartment decompres- fuse resulting in a large and difficult to estimate
sion release. Infection is a constant possibility intraoperative blood loss. Phenylephrine-soaked
(Capan et al. 1991; Lovich-Sapola 2008). gauze pads on burn wounds can reduce blood
loss, but a falsely elevated BP may result. Vaso-
Cardiovascular Effects pressor support of BP may be necessary. Unstable
Burn shock occurs immediately following vital signs may require postponement of surgery.
extensive burn injury. Cardiac output initially Preoperatively, the patients’ hematocrit should be
decreases due to fluid redistribution caused by 25 %, and blood components should be avail-
translocation of intravascular fluids and tissue able. Intraoperatively, if the patient is unstable in
edema. Within hours, protein and electrolyte loss regard to HR, BP, urine output, and/or SpO2,
occurs into the extravascular space. Prostaglandins, a “stop and talk” time should occur between
oxygen (O2) radicals, myocardial depressant factor, anesthesia and surgery to discuss whether to
and leukotrienes are released, causing increased proceed or stop surgery (Capan et al. 1991;
capillary permeability. Plasma volume falls, Lovich-Sapola 2008).
causing hypovolemia and hemoconcentration.
Systemic vascular resistance increases. Airway and Inhalation Injury
Fluid shifts and tissue edema occur in the 1st Oxygen consumption and carbon dioxide (CO2)
8–12 h and may continue for 24 h. Tissue edema production are increased in burn patients with
250 Burn Anesthesia
Patients with COHb >15 % have elevated may occur and correlates with % TBSA burn.
blood CN levels. Metabolic acidosis Gastritis and duodenitis can occur within 12 h,
indicates possible CN toxicity. O2 and thiosulfate and ulceration within 72 h. To keep gastric pH
or hydroxocobalamin (vitamin B12) are treat- >7.0 and decrease GI bleeding, antacids, H2
ments of choice. Avoid amyl nitrate and sodium blockers, and frequent enteral feedings are B
nitrate, as they form MetHb, shifting the O2 methods of therapy (Capan et al. 1991; Lovich-
dissociation curve more to the left than COHb Sapola 2008; Langley and Sim 2002).
(Capan et al. 1991; Lovich-Sapola 2008;
Herndon et al. 1987). Hematologic Effects
During the 1st days postburn, plasma volume
Kidney Effects decreases cause increased Hct and blood
Renal failure has a high mortality. Oliguria viscosity. Red blood cell half-life decrease;
<0.5 ml/kg/h in 1st 24 h is often due to inadequate hematopoiesis is suppressed. Factors V and VIII
fluid resuscitation. Hypoxemia, hypovolemia, and fibrin split products increase. Increased plate-
decreased cardiac output, myoglobinuria, and/or let adhesiveness and aggregation occur. By 2nd
hemoglobinuria can cause renal failure. A urine week, platelet increases. Disseminated intravas-
output (UO) of 0.5–1.0 ml/kg/h suggests adequate cular coagulopathy (DIC) can occur (Capan et al.
fluid replacement and kidney perfusion, unless the 1991; Lovich-Sapola 2008; Langley and Sim
patient has received hypertonic saline solution 2002).
and/or is hyperglycemic. If the UO is inadequate
(<0.5 ml/kg/h) despite adequate cardiac filling Central Nervous System (CNS) Effects
pressures, osmotic or loop diuretics or low-dose Hypoxia, electrolyte imbalances, sepsis, and
dopamine (1–3 mg/kg/min) may be helpful. If neurotoxic effects of smoke and products of
cardiac output is low, hemodynamic support may combustion can cause early CNS dysfunction.
improve renal perfusion. If Hb or myoglobin is in Burn encephalopathy syndrome presents as
the urine, urine alkalinization is needed to prevent lethargy, disorientation, delirium, seizures, or
their deposition in the kidney. After resuscitation coma. Electrical injury can cause direct nerve
phase, a decrease in UO may indicate sepsis injury (Capan et al. 1991; Lovich-Sapola 2008;
(Capan et al. 1991; Lovich-Sapola 2008; Langley Langley and Sim 2002).
and Sim 2002).
Endocrine, Metabolic, and Nutritional Effects
Liver Effects Burn injury increases metabolism. Increased
Elevated bilirubin and liver enzymes can occur. caloric requirements (2,500 kcal/m2 TBSA) are
Liver injury increases patient mortality. In the needed for wound healing. A 50 % TBSA burn
resuscitation phase, hypoperfusion, hypoxemia, increases basal metabolic rate to 70 % due to
and hypovolemia adversely affect liver metabo- increases in (1) epinephrine, (2) norepinephrine,
lism. Early liver injury can occur without clinical (3) glucagon, (4) cortisol, (5) renin,
signs of shock. Elevated liver enzymes occurs (6) antidiuretic hormone, (7) O2 consumption,
within 24 h. In the hypermetabolic phase, liver (8) CO2 production, (9) minute ventilation,
blood flow, gluconeogenesis, and protein catabo- (10) free fatty acids, (11) glycogen, and (12) glu-
lism increase. Later, sepsis can decrease glucose coneogenesis. Catabolism and protein loss occur
synthesis. Acute hypoglycemia may indicate sepsis (negative nitrogen balance). Relative insulin
and/or acute liver failure (Capan et al. 1991; resistance occurs, associated with glucose intol-
Lovich-Sapola 2008; Langley and Sim 2002). erance, hypocalcemia, hypermagnesemia,
hypophosphatemia, hyperpyrexia, and alterations
Gastrointestinal (GI) Effects in fluid and electrolyte balance. In severe burn
Adynamic ileus often develops within 24 h and patients, major heat loss is due to large evapora-
resolves in 2–3 days. Stress (“Curling”) ulcers tive water loss. Heat conservation methods
252 Burn Anesthesia
include (1) warming patient’s room to >27 C decreases in albumin can alter pharmacodynamics
(77 F); (2) warming skin prep and irrigation and pharmacokinetics of drugs. Changes in free/
solutions, IV fluids, and blood products; protein-bound fraction can occur, with a resulting
(3) use of a radiant heater and warming blanket; altered drug response. During resuscitation phase,
(4) covering body parts not part of surgical generalized hypoperfusion results in delayed drug
field; (5) limiting operative exposure time; and absorption with decreased concentration and bio-
(6) ventilation with heated, humidified gases availability. High or repeated IV doses can cause
at low fresh gas flows (Capan et al. 1991; toxic effects. During the initial phase, small,
Lovich-Sapola 2008; Langley and Sim 2002). repeated IV dosing is safer and more effective.
During the hypermetabolic phase, increased renal
Immunologic Effects and liver blood flow results in rapid drug metabo-
Burn patients have immunosuppression with lism and excretion. Volume of distribution is
cellular (T cells) depressed more than humoral affected by changes in protein binding and extra-
(B cells). Wound infection and sepsis are cellular fluid volume. Increased protein binding
possible. Meticulous attention to sterile causes a decrease in volume of distribution and
technique is required (Capan et al. 1991; elimination of glomerular-filtered drugs.
Lovich-Sapola 2008; Langley and Sim 2002). Decreased protein binding increases elimination.
Adjust antibiotic dosing if renal failure is present.
Drug loss through burn wounds increases drug
Application requirements. During hypermetabolic phase, ant-
acids and H2-receptor blockers should be
Pediatric Considerations increased in dosing frequency. It is best to titrate
The smaller airway opening of pediatric patients all drugs to their desired effect.
predisposes to airway obstruction. Neck hyperex- Anesthesia induction depends on the patient’s
tension can obstruct the airway. A right main cardiac status. Ketamine is useful if patients are
stem intubation may more easily occur in chil- hypovolemic, as it increases HR and myocardial
dren compared to adults. Compared to adults, in O2 supply and demand. Optimize volume status.
children younger than 8 years old, the subglottic If the blood volume is decreased or catechol-
area is more narrow. A ½ decrease in the tracheal amines are depleted, hypotension can occur.
radius (r) can increase airway resistance (R) by 16 Ketamine (1) allows spontaneous ventilation,
times (r4). Poiseuille’s equation: Resistance, R is (2) maintains BP, (3) provides analgesia and
proportional to 1/r4(R = 8 mLQ/r4). amnesia, and (4) preserves gag reflex, but
For fluid resuscitation, the “rule of nines” in does not fully protect patients from regurgitation
children underestimates the TBSA of the head and aspiration. Standard NPO criteria should
and overestimates the TBSA of the extremities. be followed. Use glycopyrrolate to dry secre-
In children, fluid losses are proportionally greater tions. Premedicate with a benzodiazepine
than adults with similar burn injuries. Hypergly- (midazolam) to reduce hallucinations. Pentothal
cemia should be monitored the first 24 h or propofol also can be safely used, titrating to
postburn. Similar to adults, reliable indicators of effect.
resuscitation are mental status, vital signs, pulse Succinylcholine (Sch) can produce life-
pressure, urine output, body temperature, color of threatening hyperkalemia with potassium release
the distal extremities, and capillary refill (Capan from muscle membranes. It is related to dose,
et al. 1991; Langley and Sim 2002; Lovich- time since injury, and TBSA burn. Increased
Sapola 2008). Sch response most likely occurs after 1 day.
Hyperkalemia can develop within minutes and
Pharmacologic Effects results from muscle denervation. Extrajunctional
Changes in fluid compartments, cardiac output, acetylcholine (Ach) receptors increase through-
renal and liver perfusion, and metabolism and out muscle membranes, causing hypersensitivity
Burn Anesthesia 253
to depolarizing and resistance to nondepolarizing each patient, with electrodes and SpO2 often
muscle relaxants. Sch is best avoided because the placed at nonstandard sites. Sterile needle ECG
period of hyperkalemic response is unclear. electrodes instead of pads increase electrical
Some believe Sch can safely be used up to shock risk. IV lines placed through burned skin
8–24 h after burn injury and then again after areas increase infection risk. Invasive central IV B
8–24 months or until all burned areas have lines should be placed through nonburned skin
healed. For treatment of hyperkalemia, calcium, and securely sutured.
sodium bicarbonate, hyperventilation, CPR,
glucose, and insulin may be necessary. Summary
Precurarization with a nondepolarizing muscle More than other types of trauma, burn injury
relaxant does not appear to prevent hyperkalemic changes normal homeostasis. Multiple changes
response. must be recognized and adapted. Wound debride-
Burn patients’ resistance to nondepolarizing ment 1 day postburn has different physiologic
drugs is possibly due to an increase in Ach changes than reconstructive surgery at 1 month
receptors or altered receptor affinity. This resis- or 1 year. Increased opioids are required for pain
tance (1) develops with burns >25–30 % control. Burn patients deserve our empathy. Any-
TBSA, (2) is rarely seen in <10 % TBSA, thing anesthesia providers can do to decrease
(3) is observed <1st week, (4) peaks at 5–6 burn patients’ suffering will be remembered and
weeks, and (5) is attenuated at 3 months post- appreciated by these patients.
injury. Volume of distribution, wound drug
transfer, and increased plasma protein binding
have minimal effect on nondepolarizing Cross-References
relaxant requirements. Burn patients require
2–5 times the normal nondepolarizing dose for ▶ Acute Pain Management in Trauma
relaxation. A twitch monitor is useful to deter- ▶ Airway Assessment
mine dosing and redosing. Normal doses of ▶ Airway Trauma, Management of
reversal agents (neostigmine) are required ▶ Blast Lung Injury
(Langley and Sim 2002; Gronert and Theye ▶ Chemical Burns
1975; Martyn 1986). ▶ Electrical Burns
▶ Escharotomy
Anesthesia for Burn Dressing Changes ▶ Firework Injuries
Etomidate is not recommended due to adrenal ▶ Flame Burns
suppression. Fentanyl, ketamine, and remifentanil ▶ Fluid, Electrolytes, and Nutrition in Trauma
plus propofol or dexmedetomidine infusions Patients
have been used (Langley and Sim 2002; Martyn ▶ Hypothermia, Trauma, and Anesthetic
1986). Management
▶ Scald Burns
Inhalation Anesthetics
All inhaled agents can be safely used with no
single “best” technique. Isoflurane, sevoflurane, References
and desflurane cause minimal cardiac depression
Capan LM, Miller SM, Turndorf H (eds) (1991) Trauma:
and do not sensitize the myocardium to arrhyth- anesthesia and intensive care. JB Lippincott Co,
mias caused by exogenous catecholamines Philadelphia, PA, pp 629–648
(Langley and Sim 2002; Martyn 1986). Gronert GA, Theye RA (1975) Pathophysiology of
hyperkalemia induced by succinylcholine. Anesthesi-
ology 43:89–94
Monitoring Herndon DN, Langner F, Thompson P et al (1987)
Electrocardiograph (ECG), BP (cuff, arterial Pulmonary injury in burned patients. Surg Clin North
line), and HR monitoring must be adapted to Am 67:31
254 Burn Resuscitation Formula
resolve internal disputes, and keep the organiza- the category of membership such as nonvoting
tion on track to accomplish its goals. They help member, adjunct or honorary, or emeritus status.
the organization in deciding what to do in diffi- It describes the roles of the members and their
cult situations. They may also indemnify mem- authority as well as their ability to vote in elec-
bers from legal jeopardy and protect the tions or other official business. B
constitutional rights of the individual.
Terms of office
While much of what is contained in bylaws
seems to be onerous and at times irrelevant, it This should describe the length of the term as
behooves all organizations in our litigious-prone well as how many times one can be elected and if
society to have bylaws. Unfortunately, too often there is to be a hiatus before being reelected.
we look at bylaws after the litigation process has
Frequency of meetings
commenced.
Once established the organization is held This should address the requirement for
to the standards described in the bylaws by the a certain number of meetings and the amount of
legal system. This can come to haunt the orga- meetings that need to be attended to maintain
nization if bylaws are written and not adhered to. membership. It provides for emergency meetings
The bylaws not only set the standards by decree to deal with sudden potentially catastrophic
of the governing body, but the governing body is events.
responsible to make sure the standards are
Elections
adhered to and provides for methods of resolving
conflicts when adherence is violated. This will address the election process and the
quorum needed for election results to be official.
Process for voting
Application
Issues brought before the board should be in
Structure of the Bylaws a timely manner so as to give its members time for
The bylaws describe who will be members of the serious consideration. The percentage or number
organization and their term of office and provide of votes is described and whether this should be
for succession. It describes and gives power to by open or secret ballot or whether absentee/elec-
committees to pursue and accomplish the mission tronic ballots are to be considered admissible.
of the organization.
Review, revision, and amendment of the bylaws
The bylaws define the following:
Describes how often the bylaws are to be
Purpose of the organization
reviewed. The Joint Commission mandates that
This occurs as a stated mission, vision, and bylaws be reviewed periodically to assure that
specific goals. they are compatible with current legislation and
practice. The process for submission of items to
Titles and function of the officers
be reviewed and who can introduce new amend-
All positions of the governing body are ments should be so stated.
defined such as chair, president, or CEO. It
Conflict resolution
defines how they are elected and describes
a table of succession so that a sudden or Describes modalities for conflict resolution
prolonged vacancy would not adversely impact including “rules of order” and the legal process
the organization. as it affects the functioning of the organization.
Requirements for membership Corrective action
The requirements should speak to academic Describes the process of summary suspen-
and professional credentials. It should describe sions and methods of appropriate notification.
256 Bylaws (Institution)
Appeal of corrective actions electronic documents and may stipulate the time
the report should be issued in relation to meetings.
Describes who in the membership has rights of
appeal and appropriate timelines for notification
The Medical Model
and granting such appeals. It describes who will
The hospital’s governing board is legally and
be at the review hearings and whether legal coun-
morally responsible for the quality of medical
sel will be permitted.
care a patient receives while hospitalized (The
Rules of conduct in meetings Joint Commission Standard MS01.01.01).
The Joint Commission standards require that
Describes whether “Robert’s Rules of Order,” the governing body and the organized medical
the prerogative of the chair, or other guidelines staff work collaboratively, clearly defining their
for conducting the meeting in a professional, effi- roles, responsibilities, and accountabilities.
cient, and courteous manner are utilized. The bylaws delineate these rights and respon-
sibilities and the relationships between the
Quorum for conducting official business leaders of the organized medical staff, its mem-
Describes the number of members necessary bers, and the governing body (The Joint Commis-
to be physically present or by electronic commu- sion (JCAHO) MS10 2005).
nication to conduct official business. The quorum The governing board may control the quality
may be variable for different types of business of the medical staff and does so by choosing the
and must be so stated. leadership for the Medical Board and granting
them authority to form committees including the
Indemnification of members “Medical Staff Credentialing Committee.” It is
the Credentials Committee that recommends to
States that the members will not be held
the Medical Board who should be granted privi-
accountable individually for conduct of the
leges to practice in the hospital.
group as a whole.
Ultimate approval is made by the governing
Compensation to the members body upon recommendation of the Medical
Board.
States what if any monetary compensation or
otherwise may be due to the members.
It may stipulate the direction any compensa- Development of the Bylaws
tion should take. Most organizations follow a generally accepted
format for the bylaws that are considered to have
Conflict of interest
been tested in the courts. This is not unlike the
The members will report any conflict of inter- components of corporate bylaws. The compo-
est circumstances they may be involved in. nents of the bylaws are governed by requirements
Most organizations will require members to from the Joint Commission on the Accreditation
sign a declaration regarding potential or actual of Hospitals (JCAHO), the Center for Medicaid
conflict of interest annually. and Medicare (CMS), and the National Commis-
sion on Quality Assurance (NCQA) (Gassiot
Annual reports
et al. 2007, p. 97). Legal counsel is sought to
The governing body may require monthly, help develop and review the bylaws for compat-
quarterly, or annual reports of the activities of ibility with state and federal laws.
any committees. This may describe who will do The medical staff bylaws describe how often
the reporting, frequency, and by what means. The the committees shall meet, the place, and who
governing body may require “hard copies” or shall attend.
Bylaws (Institution) 257
References
Gassiot CA, Searcy V, Giles CW (2007) The medical staff Bywaters’ Syndrome
handbook: fundamentals and beyond. Jones and
Bartlett Publishers, Sudbury
Lang DA, Kadielski M, Liset JR (1995) Managing medi- ▶ Crush Syndrome
cal staff change through by-laws and other strategies. ▶ Crush Syndrome, Anesthetic Management for
American Hospital Publishing Inc., Chicago