Trauma care centre in India –Anaesthesiologist’s perspective Authors:
1. Dr. Babita Gupta, M.D.
Assistant Professor, Department of Anaesthesia
All India Institute of Medical Sciences
Ansari Nagar, New Delhi - 110029
2. Dr. Rakesh Kapoor, M.D.
Senior Resident, Department of Anaesthesia
All India Institute of Medical Sciences
Ansari Nagar, New Delhi – 110029



Trauma is the most serious public health problem facing society today. Trauma primarily affects the younger population. It is responsible for 76% of all deaths in the 15 to 24 year age group. High YPLL (Year of potential life lost) is significant as death in young people have great social and economic consequences. Trauma care systems in India are at nascent stage of development. Anaesthesiologists have a major role in the management of trauma patients.
Trauma epidemiology
Countries with reliable death registration systems produce mortality statistics that are published annually by the world health organization. In the vast majority of these countries, mortality from trauma ranks usually from third to fifth place. Accelerated urbanization and industrialization have led to an alarming increase in the rate of accidental injuries in India. India has 1% of the motor vehicles in the world, but bears the burden of 6% of the global vehicular accidents. Road traffic accidents are increasing at an alarming annual rate of 3%. A vehicular accident is reported every 3 minutes and a death every 10 minutes on Indian roads.
Status of trauma care in India
In India there is gross disparity between trauma services available in various parts of country. Rural India has insufficient services for trauma care. In metropolis also there is no government agency to integrate policymaking, planning and drafting legislation. There are no dedicated trauma surgeons in India. Clinical decisions are delayed, in the absence of clear responsibility amongst specialists.
There are multiple reasons of failure of trauma centers in India. The Ministry of Health does not have a designative unit to deal with issue related to trauma. The Centralized Ambulance Transport Service (CATS) by government of Delhi is noteworthy step but is mainly restricted to prehospital care. Recently legislative provisions for the minimum qualification of ambulance personnel, the type and quality of ambulance equipment are placed. The concept of a dedicated trauma team is not accepted at all levels. The lack of precise and predetermined rate allocation during peak periods of activity stresses the fragile current systems.
Concept of golden hour
The timing of death after trauma has been having trimodal distribution. The first peak of death is within minutes of injury. These deaths are because of catastrophic injury to vital organs. This accounts for 50% of total deaths. The second peak occurs in the first few hours after injury. Most injuries in this group are treatable. A well organized trauma care system that reduces the time interval between injury and expert definitive treatment is important. The remaining trauma fatalities from sepsis and multiple organ dysfunctions, forms third peak. On these basis Trunkey et al, provide concept of Golden hour. In emergency medicine, the golden hour is the first sixty minutes after the occurrence of major multi system trauma. It is widely believed that the victim’s chances of survival are greatest if he receives definitive care within the first hour. It involves 3R rule –getting the right patient, to the right place and at the right time.
Role of anaesthesiologist
The presence of an experienced anaesthesiologist and the immediate availability of an open OR are most important resource of trauma center. Anaesthesiologists are among the few specialists who can provide continuity of care for severely injured patients in the chain of trauma care, which includes: emergency medical technicians, emergency department staff, staff aiding in the transferring of patients to other departments or hospitals, aiding surgeons in the operating room, critical care unit staff. Anaesthesiologists have particular skills in airway, ventilation, circulatory, and pain management therefore plays a vital role in trauma care team. His role begins in care of trauma patient from prehospital setup, ER to operating room, to ICU. This had lead to new specialization of trauma anaesthesia and critical care specialist.
ANAESTHESIOLOGY+CRITICAL CARE MEDICINE+EXPOSURE TO FIELD/EMERGENCY MEDICINE=LIFE SUPPORT PHYSICIAN=TRAUMA ANAESTHESIA/CRITICAL CARE SPECIALIST.
Prehospital trauma care
Anaesthesiologists can play an active role in the management of trauma patients outside the hospital. If prehospital resuscitation efforts fail in the event of a cardio respiratory arrest occurring outside hospital, further resuscitation attempts in the emergency room are usually futile. ABCDE is mainstay that is:
Airway with cervical spine control
Breathing with ventilatory support
Circulation and hemorrhage control
Disability-rapid assessment of neurological function.
Exposure –while considering the environment and preventing hypothermia.
Prehospital intubations and controlled ventilation may reduce morbidity and mortality in patients having traumatic brain injury, agonal respiration and obvious respiratory distress and circulatory failure. Properly applied manual in-line stabilization, RSI oral intubations is considered safe in patients with potential cervical spine injury.
“ Safety first” should be the primary concern when approaching an accident scene. Information about potential hazard to rescue personnel and patients should be obtained. Personnel should also lead the medical rescue work in mass casualty situations and should be familiar with risks and understand protocols for dealing with casualties of accidental toxic release.
Emergency department care
The priorities for initial assessment and management of trauma patients are outlined in the advanced trauma life support (ATLS) guidelines. Anaesthesiologists are experts not only in difficult airways, the practice of resuscitation, and monitoring and performing invasive procedures but are present in hospital on 24-hour basis. Anaesthesiologists are the trauma team leaders in some countries, having multiple responsibilities like perform primary and secondary assessments, establish the priorities for investigations and intervention, coordinate the team members, ordering procedures, receiving information and resolving disputes, order fluids, blood, blood products and analgesia, supervise patient transfer and spinal precautions, provide clinical education for team member during resuscitation. With the advanced communications, like voice, video and data, preparation is initiated before arrival of trauma patients. Anaesthesiologist should have final check on drugs, fluids equipments and monitors in EMS. Characteristics of the trauma anaesthesia or critical care specialist include:
• Experienced with an extensive range of anaesthesia techniques for emergency and elective trauma cases.
• Expert in all forms of airway management and all resuscitation procedures.
• Expert in diagnosis of crucial traumatic conditions (cervical cord injury or pneumothorax).
• Able to perform simple surgical procedures, such as cricothyroidotomy and intercostals tube thoracostomy.
Shock and trauma anaesthesia
Traumatic shock is not only hemorrhagic but also is neurologic and cardiogenic. Bleeding can be surgically controlled and oxygen delivery restored through adequate transfusion, but patient can still die as a result of the accumulated metabolic load of prolong hypoperfusion. Anaesthesiologist must have clear understanding of the end points of resuscitation from traumatic shock and means to achieve them. Anaesthesiologist can facilitate resuscitation efforts by installing invasive monitoring (arterial line, pulmonary artery catheter) in the operating room and by monitoring and treating perfusion related variables. Trauma anaesthetist should be well versed with invasive catheterization techniques and should be aware of the possible complications of catheterization. Although blood transfusion therapy is an extremely important component of resuscitation for trauma patients, adherence to the indications for blood component therapy is necessary because of possible adverse effects and cost of transfusion therapy. Blood component therapy is supportive rather than primarily therapeutic. Blood salvage by cell saver is technique, not without complication.
Perioperative anaesthetic management
Trauma anesthesiologists deal with patients having multiple injuries and involving various body systems. These pose a great challenge and are of utmost concern.
• Maxillofacial trauma-Because of its intimate association with the airway, anaesthesiologists must have working knowledge of the anatomy, types of injuries and their impact on care. Barriot and riou describe retrograde intubation for 13 patients of severe maxillofacial injury who could not be intubated with direct laryngoscopy. TTJV can be life saving alternative in inexperienced hand. Percutaneous cricothyroidotomy are recommended in airway cart and practitioners become familiar with their use.
• Head and spinal cord trauma -This is significant cause of morbidity and mortality. The goal of anesthetic-critical care management are to continue the initial resuscitation and maintenance of vital organ function, optimize CPP, avoid cerebral ischemia and avoid drugs and techniques that may raise ICP.
• Orthopedic injuries-In 1980 LaDuca et al give concept of early fracture fixation. They found less incidence of sepsis; wound complication and fat embolism with early mobilization of patients. Intramedullary reaming of femoral fractures in the presence of severe lung damage can result in significantly impaired pulmonary functions. The use of unreamed nails prevents this complication. Blood loss and fluid management in patients with pelvic fracture is of concern. Postoperative pain management is administered via multiple routes –intramuscular, IV patient control analgesia or through the epidural space. Bone cementing is associated with pulmonary embolism.
• Abdominal trauma-The most common cause of morbidity and mortality is exanguinating hemorrhage in early period and sepsis in later stages. The initial focus is on control of hemorrhage, limitation of contamination, rapid staging and treatment of injuries38.
• Burn injury-This constitutes one of the most costly and challenging forms of trauma care. Anaesthetic management of burn patients requires the application of a wide range of knowledge with understanding of pathophysiology of burn. Assess airway early via direct layngoscopy, fiberoptic nasopharyngoscopy, bronchoscopy or flow-volume loops. Ventilation and oxygenation is challenging and may require high –flow and PEEP. Burn shock occurs as result of massive vasodilatation and need vasopressors. Anaesthetic considerations include maintenance of cardiovascular status, avoidance of hypothermia, and selection of sites for monitor placement.
• Pain management- this is important because the effect of pain and the related stress response is almost always detrimental to patients. Various modes of delivering analgesia are intramuscular, intravascular infusions, patient controlled analgesia (ivpca), intercostals nerve blocks, epidural analgesia and various regional block techniques.
• Recent advances: HBOT: the use of hyperbaric oxygen therapy (HBOT) for acute trauma and post trauma patients has not been clearly codified but is of great benefit. The following are the posttraumatic syndromes treatable with HBOT: air or gas embolism, carbon monoxide poisoning and smoke inhalation, Crush injury, compartment syndrome, exceptional blood loss, thermal burns, narcotizing soft tissue infections, refractory osteomyelitis. Factor Viia: Factor Viia is a revolutionary new pharmaceutical that promises to change the anaesthesia and critical care approach to major trauma. It is potent procoaglant agent, which enables haemostasis at site of tissue injury. 85% of patients treated with factor Viia have an immediate correlation of coagulopathy and sustained haemostasis, although it also has the possibility of producing life-threatening complications.
Summary
In summary, mortality by trauma in India is very high. Trauma care centers and trauma anaesthesiologists is the need of the hour. Anaesthesiologists can be the ideal trauma life support physicians. The future of trauma anaesthesiologists is very challenging, since they are involved in the care of trauma patients in prehospital, in emergency department, in operation theaters to the intensive care unit (ICU). A concerted effort from all other departments to recognize anaesthesiologist as their team leader is the essence to make trauma center a success.
Suggested Reading:
1. Joshipura MK, Shah HS, Patel PR, Divatia PA. Trauma care systems in India -An overview-Indian J Crit Care Med 2004; 8:93-97.
2. Roberts PC, Beale RJ. The Golden Hour. In: Adams AP, Cashman JN,eds. Recent advances in Anaesthesia and Analgesia. (No 20 ) London: Churchill Livingstone, 1998;143-162
3. Trauma. Anesthesiology Clinics of North America 1999; 17 (1):17-323


Name and address of Corresponding Author:
Dr. Babita Gupta, Assistant Professor, Department of Anaesthesia
All India Institute of Medical Sciences
Email: drbabitagupta@hotmail.com