Trauma Case Management
Preoperative
When the patient comes from emergency room in an unstable condition, it is sometimes difficult to assimilate all the information that is being reported off to you (if you get a report at all). There are some key details that should never be overlooked and are definitely important to know in order to manage a trauma.
  • How much fluid has the patient received?
This can get out of hand very quickly in even well managed trauma cases. The transition from administering crystalloids to blood can easily get delayed further compromising patient outcome. A poorly resuscitated patient will also be poorly responsive to vasopressors. If blood transfusions have been started it is important to note if they were type and cross matched to avoid compatibility related reaction.
  • Does the patient have adequate venous access?
A trauma patient going to the OR should have at least 2 IV lines (if not a central line) regardless of how severe the trauma is. Things can change quickly so preparation is key.
  • Is there an arterial line?
This is especially helpful if the patient is expected to have massive transfusions. ABGs and continuous hemodynamic monitoring will be needed.
  • What were the recent lab values?
Electrolytes and blood count should be evaluated. 
  • Radiology reports
Cervical spine stability must be maintained with a  C collar especially if radiology reports were not cleared. Placement of ETT should also be confirmed.
  • Degree of trauma
Talk to the surgical team to get their view on how severe the trauma is. It might seem common sense but sometimes even the most important information tends to get lost in translation.

Preoperative Setup
Hotline with blood tubing, arterial line setup, vasopressors such as phenylepherine drip, ephedrine and vasopressin (1u/ml), level 1 rapid infusor, bair hugger, central line kit with CVP monitoring set up.

Intraoperative
It can be a daunting task to prioritize things for a trauma case. Everything seems important and it may be difficult to organize appropriately in such a high stress time. Fluid and blood administration takes high priority for me (generally, depends on the case). If the patient is very unstable it may not be appropriate to hold off on making incision. However, if the patient is hemodynamically stable it may be wise to get properly set up with vasopressor drips, bair hugger, arterial line etc. Patient may lose significant amount of blood on incision depending on the degree of trauma. Resuscitation may be difficult especially if the patient is already fluid depleted.
Another important factor to consider is temperature. Hypothermia can severely increase trauma related mortality and is unfortunately, ends up being last thing on the to-do list. Use of hotline, air humidivent, and bair hugger should all be incorporated soon after patient arrive to the OR.
Massive transfusion is bound to cause severe electrolyte imbalances that could lead to possibly fatal outcomes such as arrhythmias, and vasodilation. Therefore, correcting abnormal laboratory values such as potassium, calcium, magnesium, and arterial blood gases should not be delayed. Hyperkalemia is often noted with massive transfusion so EKG changes should be noted carefully.