Objectives

1. Describe in a structured approach the advantages and disadvantages of various types of intravascular access and infusion devices in the trauma patient.

2. Present practical guidelines for the establishment of central venous access in the critically injured patient.

3. Describe in detail the technique for insertion of various central access sites, with current standard of care recommendations in the trauma patient.

4. Describe the relevancy of peripheral arterial cannulation in the trauma setting.

5. Present current recommendations regarding intraosseous access in the trauma patient.

INTRODUCTION

Advanced Trauma Life Support (ATLS) guidelines recommend that, in the initial management of hemorrhagic shock, prompt access must be obtained [1]. This is best accomplished by the insertion of two large-caliber (16 G angiocaths or larger) peripheral intravenous (IV) catheters before consideration is given to central venous catheters, or venous cutdowns [1]. Obviously, the condition of the arriving trauma patient, that is, massive extremity injury and extent of the injury, may not allow for any reasonable peripheral venous access for IV insertion. This chapter reviews the management of intravascular access in the trauma patient in the hospital setting where definitive care is to be provided. The main areas to be covered include venous access as well as arterial access in critically injured patients. Clinical experience and evidence-based medicine is balanced to provide a framework for guiding the management of patients from a vascular access standpoint.

PERIPHERAL INTRAVENOUS (PIV) CATHETERS

Prior to arrival in the emergency department, PIV cannulation has usually been performed in the field by prehospital personnel [1, 2].

Objectives

1. List the basic guidelines for monitoring of patients receiving anesthesia.

2. Evaluate options, functions, use, and problems associated with monitoring devices, particularly in the trauma setting.

3. Interpret the information provided by monitoring devices.

INTRODUCTION

In 1986, the American Society of Anesthesiologists (ASA) prepared and approved “Standards for Basic Anesthetic Monitoring” [1]. This document outlines the responsibilities of the anesthesiologists in assessing patients' vital signs throughout the anesthetic period. Similar guidelines have been published by the Australian and New Zealand College of Anaesthetists (ANZCA) and The Royal College of Anesthetists [2, 3]. Both the Royal College and the ASA note that, in extreme circumstances, provision of life-saving measures takes precedence over application of monitors. Nonetheless, monitoring is intended to improve the quality of care and outcome for patients, and every attempt should be made to appropriately monitor the trauma patient.

All anesthesia providers have an obligation to carefully assess their patients receiving any form of anesthetic. Basic principles include monitoring the physiologic variables of oxygenation, ventilation, circulation, and temperature. Oxygenation can be assessed with pulse oximetry, inhaled and exhaled gas analysis, and blood gas analysis. Ventilation is assured by end-tidal carbon dioxide measurement, listening to the patient's breath sounds, and monitoring the ventilator. Circulation is assessed by electrocardiogram and blood pressure measurements, whether noninvasively by a cuff or invasively by an intraarterial catheter. Circulation can also be monitored invasively through echocardiography and pulmonary artery catheter measurements. Urine output provides a rough estimate of tissue perfusion and thus is another monitor for circulation.