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Gupta B, Singh Y, Bagaria D, Nagarajappa A. Comprehensive Management of the Patient With Traumatic Cardiac Injury. Anesth Analg 2023; 136:877-893. [PMID: 37058724 DOI: 10.1213/ane.0000000000006380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.
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Affiliation(s)
- Babita Gupta
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Yudhyavir Singh
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Nagarajappa
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Gómez-Ramos JJ, Marín-Medina A, Prieto-Miranda SE, Dávalos-Rodríguez IP, Alatorre-Jiménez MA, Esteban-Zubero E. Determination of plasma lactate in the emergency department for the early detection of tissue hypoperfusion in septic patients. Am J Emerg Med 2018; 36:1418-1422. [DOI: 10.1016/j.ajem.2017.12.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/27/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022] Open
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McCullough AL, Haycock JC, Forward DP, Moran CG. Early management of the severely injured major trauma patient. Br J Anaesth 2014; 113:234-41. [PMID: 25038155 DOI: 10.1093/bja/aeu235] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The major trauma team relies on an efficient, communicative team to ensure patients receive the best quality care. This requires a comprehensive handover, rapid systematic review, and early management of life- and limb-threatening injuries. These multiple injured patients often present with complex conditions in a dynamic situation. The importance of team work, communication, senior decision-making, and documentation cannot be underestimated.
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Affiliation(s)
| | - J C Haycock
- Nottingham University Hospital, Nottingham, UK
| | - D P Forward
- Nottingham University Hospital, Nottingham, UK
| | - C G Moran
- Nottingham University Hospital, Nottingham, UK
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Wiggans MG, Starkie T, Shahtahmassebi G, Woolley T, Birt D, Erasmus P, Anderson I, Bowles MJ, Aroori S, Stell DA. Serum arterial lactate concentration predicts mortality and organ dysfunction following liver resection. Perioper Med (Lond) 2013; 2:21. [PMID: 24472571 PMCID: PMC3964326 DOI: 10.1186/2047-0525-2-21] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 09/19/2013] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The aim of this study was to determine if the post-operative serum arterial lactate concentration is associated with mortality, length of hospital stay or complications following hepatic resection. METHODS Serum lactate concentration was recorded at the end of liver resection in a consecutive series of 488 patients over a seven-year period. Liver function, coagulation and electrolyte tests were performed post-operatively. Renal dysfunction was defined as a creatinine rise of >1.5x the pre-operative value. RESULTS The median lactate was 2.8 mmol/L (0.6 to 16 mmol/L) and was elevated (≥2 mmol/L) in 72% of patients. The lactate concentration was associated with peak post-operative bilirubin, prothrombin time, renal dysfunction, length of hospital stay and 90-day mortality (P < 0.001). The 90-day mortality in patients with a post-operative lactate ≥6 mmol/L was 28% compared to 0.7% in those with lactate ≤2 mmol/L. Pre-operative diabetes, number of segments resected, the surgeon's assessment of liver parenchyma, blood loss and transfusion were independently associated with lactate concentration. CONCLUSIONS Initial post-operative lactate concentration is a useful predictor of outcome following hepatic resection. Patients with normal post-operative lactate are unlikely to suffer significant hepatic or renal dysfunction and may not require intensive monitoring or critical care.
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Affiliation(s)
- Matthew G Wiggans
- Hepatobiliary Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK.,Peninsula College of Medicine and Dentistry, University of Exeter and Plymouth University, Research Way, Plymouth, Devon PL6 8BU, UK
| | - Tim Starkie
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Golnaz Shahtahmassebi
- Centre for Health Statistics, Tamar Science Park, Davy Road, Plymouth, Devon PL6 8BX, UK
| | - Tom Woolley
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - David Birt
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Paul Erasmus
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Ian Anderson
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Matthew J Bowles
- Hepatobiliary Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Somaiah Aroori
- Hepatobiliary Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - David A Stell
- Hepatobiliary Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK.,Peninsula College of Medicine and Dentistry, University of Exeter and Plymouth University, Research Way, Plymouth, Devon PL6 8BU, UK
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Gray LD, Morris CG. Organisation and planning of anaesthesia for emergency surgery. Anaesthesia 2013; 68 Suppl 1:3-13. [PMID: 23210552 DOI: 10.1111/anae.12054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Patients presenting for emergency surgery represent a category at high risk of complications, with substantial morbidity and mortality, whose management may be extremely challenging. In this first of two articles we consider the identification and evaluation of high risk emergency patients, the provision of critical care support, the management of sepsis, common postoperative complications and in-theatre death.
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Affiliation(s)
- L D Gray
- Department of Anaesthesia and Intensive Care Medicine, Queen's Medical Centre, Nottingham, UK
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Abstract
Lactate levels are frequently elevated in critically ill patients and correlate well with disease severity. Elevated lactate levels are prognostic in prehospital, emergency department, and intensive care unit settings. This review discusses the role of lactate as a biomarker in diagnosing and assessing the severity of systemic hypoperfusion, as well as the role of serum lactate measurements in guiding clinical care and enabling prognosis in critically ill patients.
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