Trauma — RSI, Permissive Hypotension

ABCDE sequence executed in parallel by the trauma team — anesthesia owns the airway + breathing + IV access + drug administration: AIRWAY with c-spine immobilization (patent, positioning, intubation if GCS ≤8 or compromise).

BREATHING (bilateral breath sounds, JVD, tracheal position; decompress tension pneumothorax with needle thoracostomy + chest tube).

CIRCULATION with hemorrhage control (large-bore IVs or IO, blood available, FAST exam, pelvic binder if unstable pelvis, tourniquet for extremity hemorrhage).

DISABILITY (GCS, pupils, lateralizing deficit, glucose check).

EXPOSURE with temperature management (remove all clothing, log roll, examine back, then cover + warm).

Re-survey after each intervention or with any change in physiology.

Verbalize the plan to the team before pushing drugs.

Cervical spine immobilization via manual in-line stabilization (MILS) — assistant holds head neutral.

Remove the anterior portion of the C-collar to allow mouth opening (the posterior portion stays).

Video laryngoscopy is preferred — produces less cervical motion than direct laryngoscopy.

Awake fiberoptic intubation only if patient cooperative + time permits + airway not actively threatened.

Hemodynamically unstable / hemorrhagic shock: AVOID propofol (vasodilator + cardiodepressant) and consider ETOMIDATE 0.1-0.3 mg/kg (hemodynamically neutral, no histamine release; concern about adrenal suppression after single dose largely refuted) OR KETAMINE 1-2 mg/kg (sympathomimetic + bronchodilator + dissociative; depletes catecholamines may unmask shock physiology in critically depleted patients).

Reduce induction dose 30-50% in severe shock.

Some operators use 'awake intubation' with no induction in extremis.

Maintain sedation with low-dose ketamine, scopolamine, midazolam during resuscitation phase to avoid awareness in paralyzed unstable patient.

Rationale: aggressive resuscitation to normal pressures disrupts soft clot + worsens hemorrhage + dilutes clotting factors with crystalloid.

Time-limited concept — restore normal BP after hemostasis achieved.

Combined with balanced 1:1:1 transfusion + TXA + normothermia = damage control resuscitation.

Evidence: Bickell 1994 + Morrison 2011 + multiple subsequent randomized trials in penetrating + blunt trauma without TBI.

Hypotension is THE most modifiable predictor of poor outcome in TBI — even a single brief episode of SBP <90 worsens mortality + morbidity.

Permissive hypotension is CONTRAINDICATED in TBI.

Aggressive volume resuscitation, vasopressors (norepinephrine first-line), early correction of any hypotension.

Avoid hyperventilation routinely — reserve PaCO₂ 30-35 for acute herniation as a bridge to definitive treatment.

Maintain normothermia (avoid both hyperthermia, which raises ICP, and aggressive hypothermia, which has not improved outcomes in trials).

Hyperosmolar therapy (mannitol 0.5-1 g/kg or 3% saline) for elevated ICP.

Multimodal monitoring with ICP + brain tissue oxygen at trauma centers.

1:1:1 ratio PRBC:FFP:platelets.

TXA 1 g IV bolus + 1 g infusion over 8 hr — MUST be given within 3 hours of injury (earlier is better; no benefit and possible harm after 3 hr).

Calcium chloride 1 g per 4-6 units of PRBC for citrate-induced ionized hypocalcemia.

Goal core temperature ≥36°C.

TEG/ROTEM-guided refinement once initial 1:1:1 phase completes — avoids over- or under-transfusion of components.

Damage control surgery philosophy: abbreviated initial operation for HEMORRHAGE CONTROL + CONTAMINATION CONTROL + temporary closure (often abdominal vac/Bogota bag, not formal abdominal closure).

Patient transferred to ICU for warming, correction of coagulopathy + acidosis, ongoing resuscitation.

Planned re-laparotomy in 24-48 hr once physiology has normalized for definitive repair.

Anesthesia role during initial damage control: oxygenation + perfusion + warmth + ongoing resuscitation + product administration + glucose checks.

Don't push for perfect physiologic 'completeness' at the initial operation — get out, optimize, come back.

Structured handoff (SBAR): mechanism of injury, injuries identified, surgical procedures done + planned, ongoing transfusion plan + drips, ventilator settings, neuro exam baseline, lines + drains, antibiotics, tetanus status, family notified status, planned next operation timing.

Trauma resuscitation continues in ICU — ongoing blood products, TEG-guided correction, normothermia, ventilator weaning, sedation strategy.

Multidisciplinary handoff including trauma surgery, ICU, nursing, blood bank liaison.

Document the handoff time + recipient.