Evolving Frontiers: Shaping the Future of Trauma Anaesthesia and Critical Care

BURDEN OF TRAUMA

Trauma is one of the leading causes of mortality, morbidity, and hospitalization in the young productive population across the globe. Approximately 4.4 million deaths occur annually every year, 1.2 million being due to road traffic accidents as per the World Health Organization (WHO) data published in the year 2020.¹ Although death is an easily measurable and important indicator of the severity of the problem, it is important to know that among those who survive trauma, a greater proportion of trauma victims suffer from physical disability or mental illness throughout their lives. This loss can be quantified as “disability-adjusted life years” or “DALY,” which is defined as one lost year of healthy life, either due to premature death or disability. In India, in the year 2021, the estimated DALYs from injuries per 100,000 people were 3426.² Apart from the death and loss of productive years of life, trauma is a huge financial burden, not only for the individual and the family affected but also for the healthcare system and the government.

The traditional trimodal death distribution pattern implies that trauma-related death occurs in one of three peaks.³ The first peak is within seconds to minutes after injury and can be mitigated by preventive measures. The second peak occurs within minutes to hours after injury and can be decreased with early and appropriate emergency care during pre-hospital and in-hospital phases of management. The third peak is days to weeks later, which can be reduced by optimal care during the initial preceding period and in the intensive care unit (ICU). Although the traditional three peaks of mortality have now been reduced to two peaks due to better trauma care,⁴ the fact remains that developing countries may still observe three peaks due to a lack of a pre-hospital care system and suboptimal adherence to standard protocols described in “Advanced trauma life support.”

TRAUMA ANESTHESIOLOGIST IN TRAUMA CARE SYSTEM

A multidisciplinary team is required to care for patients who have sustained traumatic injuries, with an anesthesiologist playing a key role in the team. An anesthesiologist is in a pivotal position to be a key resource during the entire journey of the patient right from the emergency room (ER) to the operation room (OR) and to the ICU due to the unique combination of his knowledge and skills. The continuum of care of a trauma patient starts from the pre-hospital period, continues in the ER and OR and many times extends in the ICU. Rapid recognition and appropriate response to an immediate life-threatening injury during the pre-hospital phase, in the ER and OR can have far-reaching beneficial consequences. Advanced critical care management, including continuation of resuscitation, pain management, renal replacement therapy, lung protective ventilation strategies, etc., can eventually improve the outcome of the trauma patient.

NEED FOR TRAUMA ANESTHESIA AND CRITICAL AS A SUBSPECIALTY

Although the basic knowledge and skills of a general anesthesiologist are an asset for the management of any critical patient, a trauma victim may present with unique challenging situations, requiring a high level of expertise and experience. This includes a wide range of skills, like performing Extended Focused Assessment with Sonography for Trauma in the ER and making appropriate decisions or securing an airway in a case of airway trauma. Few invasive procedures such as needle thoracentesis, thoracostomy and pericardiocentesis are unique to the trauma population and will be performed by a trauma anesthesiologist while working in the ER. The anesthetic management of a critically injured patient is equally challenging and requires a special skill set to competently manage them. The concept of shifting the patient directly to OR, massive transfusion of blood and blood products as per the institute protocol, prevention of lethal triad, expeditiously obtaining vascular access, mechanical ventilation in a patient with lung laceration, or providing one-lung ventilation in a patient requiring emergency thoracotomy, all require special considerations and may have to be dealt with differently from a non-trauma patient. The concepts of damage control surgery and damage control resuscitation and a higher proportion of patients requiring post-operative mechanical ventilation are the special features in the trauma OR. Anesthesia and surgery must collaborate seamlessly, starting from initial trauma response activation to ICU and beyond to optimize patient outcomes. This synergy is crucial for managing pain, stabilizing the patient’s condition and supporting surgical interventions effectively. Trauma anesthesiologists and intensivists require comprehensive and extensive knowledge, not only of anesthesia and drugs but also trauma surgery, to understand the nitty-gritty of traumatic injury management. A geriatric patient with a hip fracture requires a multidisciplinary system of care, often involving orthogeriatric programs, to address the complex medical, surgical and rehabilitative needs of this patient population. This system focuses on early surgical intervention, followed by a comprehensive approach to managing comorbidities, optimizing pain control, preventing complications and promoting functional recovery. Hybrid OR suite is a futuristic approach in acute trauma management, which integrates surgical procedures with advanced imaging technology, allowing simultaneous intraoperative diagnostic evaluation and surgical intervention with real-time guidance. Working in a hybrid OR can pose challenges for delivering anesthesia, requiring careful planning and suitable equipment with special configuration and suitable ergonomics.

Critical care management poses similar unique situations, wherein the ICU team encounters patients with open abdomens, postoperative coagulopathy, pulmonary contusion or a postoperative cardiac trauma patient, and abdominal compartment syndrome in an abdominal trauma case, requiring specialized trauma ICU care. In managing musculoskeletal trauma with rhabdomyolysis and associated wounds in a trauma ICU, negative pressure wound therapy can be used to enhance wound healing and reduce infection risk, while hyperbaric oxygen therapy may be beneficial for severe soft-tissue injuries and certain complications. Solid organ injuries and blunt cardiac injuries will also be shifted to the ICU for observation. Geriatric patients admitted to the ICU will require specialized expertise to provide individualized care that considers their unique physiological changes, comorbidities, increased vulnerability to complications and potential for long-term functional decline. Prevention of secondary brain injury in a head-injured patient, protection of the spine in a spine-injured patient, and managing splints and fixators are a few conditions that may be better dealt with, in a dedicated trauma ICU wherein all the staff members are trained to manage them. The management of a brain-dead patient, particularly if they are a potential organ donor is pivotal for maintaining organ viability for transplantation. All the members involved in organ retrieval should also be conversant with the ethical and legal considerations of the state/country surrounding brain death and organ donation.

Research shows that the risk of death of a seriously injured patient decreases when they receive care at a Level I trauma center as compared to a non-trauma hospital.⁵ Moreover, there is a significant decrease in both in-hospital and 1-year mortality in polytrauma patients who receive care in trauma centers vis-à-vis non-trauma centers. Thus, we may conclude that dedicated trauma centers and trauma anesthesia and critical care as a distinct subspecialty may significantly impact morbidity and mortality in the trauma population.

DISASTER MANAGEMENT AND TRAUMA TRAINING PROGRAMS

The skills of an anesthesiologist are not confined to inhospital management but extend much beyond the ED, OR, and ICU. Their expertise extends to pre-hospital settings, for example, air ambulance, training paramedics, and various inhospital locations outside OR and ICU. His presence in all the critical areas gelled with his knowledge and skills makes him a vital member in teaching and training pre-hospital personnel. The initiative taken by the Government of India in the capacity building of paramedics through the pre-hospital trauma technician course is primarily being undertaken by the Anesthesia team in various institutions.

Every hospital must have a clearly laid-out comprehensive disaster management plan, which must be multidisciplinary to effectively address the diverse aspects of disaster preparedness, response, and recovery. The team includes the ER physician, anesthesiologist, surgeon, orthopaedician, other clinical disciplines, administrators, and nurses ensuring a holistic approach to managing disasters. A disaster management plan should be understood and followed by everyone involved. Members, including anesthesiologists, must be able to perform as clinical lead, resource lead, or incident commander during mock drills and the actual event.

TRAUMA RESEARCH

There is limited research in the field of trauma, particularly regarding specific populations, contexts, and interventions. The topics that require further research and validation are low-titer whole blood transfusion in civilian settings, blood alternatives, and the role of estrogen in trauma and shock. While deep hypothermic circulatory arrest is primarily used in elective cardiovascular surgery, there are discussions about its potential application in certain traumatic scenarios where immediate brain protection is crucial, such as severe head injuries with compromised blood flow. However, its use in trauma is still a subject of research and debate. REBOA, or Resuscitative Endovascular Balloon Occlusion of the Aorta, is a relatively recent, minimally invasive technique used to temporarily control bleeding from non-compressible life-threatening injuries to the torso, abdomen or pelvis, where traditional methods such as direct pressure or tourniquets are ineffective. While REBOA has gained popularity as a bridge to definitive treatment and can be life-saving, it is important to understand its limitations and potential complications with further multicentric trials.

NEED FOR ACADEMIC JOURNAL IN TRAUMA ANESTHESIA AND CRITICAL CARE

The research work and publications in trauma anesthesia, resuscitation, and critical care are extremely sparse. Although there are few academic journals and publications focusing on trauma, encompassing various aspects like physical injuries, there are few journals dedicated to trauma surgery and acute care, resuscitation, and related fields. Some prominent journals include the Journal of Trauma and Acute Care Surgery, European Journal of Trauma and Emergency Surgery, and the Journal of Emergencies, Trauma, and Shock. These journals cover a wide range of topics, from research on treatment and prevention to policies and guidelines related to trauma. However, there is no dedicated journal in the field of Trauma Anesthesia and critical care. With this as a premise, it is our effort to promote this discipline through this journal. The aim of this journal is to ensure high-quality research work covering the entire spectrum of the continuum of care and innovations, including artificial intelligence and machine learning in this field. JTARCC will provide a valuable platform to publish their research work, share experiences and challenges with their plausible solutions, and subserve in the growth of the specialty of “Trauma Anesthesia and Critical Care,” thus bolstering interest of trainees in this field.