--- module: 044-02 language: en chapter: 44 title: "Trauma, Resuscitation, Altered Consciousness, and Perioperative Assessment" module_title: "Resuscitation physiology, occult injury, and perioperative risk control" source_sha256: d11d342b2db2b860645b3f524cb7dd9404105169657ec03f043b7e373691d351 --- # Resuscitation, occult injury, perioperative risk ## Resuscitation as hypothesis testing ### Identify threat, intervene, check response ### Normal first pressure or scan does not end it #### Compensation hides injury, bleeding evolves ### Mechanism predicts concealed injury ### Definitive control alongside diagnosis ### Record hypothesis, response, remaining uncertainty #### Short repeated cycles give speed and accuracy ## Haemorrhage control and transfusion ### External haemorrhage before airway ### Pelvic binder at the greater trochanters #### Reduces pelvic volume and motion ### Blood components beat large crystalloid volumes ### Citrate binds calcium #### Lowers contractility and coagulation ### Tranexamic acid early, within validated window ### Massive transfusion needs repeated tests #### Ratio first, then targeted replacement #### Rising pressure does not prove haemostasis ## Airway prediction, induction, confirmation ### Shock, obesity, pregnancy shorten safe apnoea ### Induction removes sympathetic tone #### Positive pressure reduces venous return #### Arrest in hypovolaemia, tamponade, right failure ### Waveform carbon dioxide most reliable #### Falling trace: disconnection, displacement, arrest ### Preparation: roles, two suction systems, devices #### Check hypotension, endobronchial tube after ## Obstructive and haemorrhagic shock ### Tension pneumothorax restricts venous return #### Treat without imaging #### Needle fails: length, kinking, clot, position #### Finger thoracostomy or tube more definitive ### Tamponade may lack distended veins ### Haemorrhagic shock lowers oxygen delivery #### Tachycardia and vasoconstriction hold pressure ### Permissive hypotension in selected torso trauma #### Unsuitable in severe brain injury, differs in pregnancy ## Occult injury and imaging ### Secondary survey finds concealed injury ### Abdominal bleeding may be painless #### Seat-belt mark, lower ribs, falling haemoglobin ### Negative focused scan misses injuries #### Retroperitoneal, hollow viscus, diaphragm ### Tomography is a destination, not treatment room ### Pregnancy: maternal perfusion resuscitates fetus ### Tertiary survey after consciousness returns ### Pulse does not reassure about compartments ## Brain injury and altered consciousness ### Hypoxaemia and hypotension worsen outcome ### Document findings before sedation and paralysis ### Herniation: pupil, motor fall, bradycardic hypertension #### Osmotherapy and hyperventilation buy time #### Do not remove the mass ### Support and test reversible causes together ### Naloxone titrated to ventilation ### Persistent unresponsiveness after convulsion ## Cardiac arrest and post-arrest care ### Compressions maximise coronary, cerebral flow ### Sudden carbon dioxide rise suggests return ### Prevent a second wave of organ injury #### Avoid hypoxaemia and prolonged hyperoxia ### Confounders obscure neurological assessment #### Early poor motor response is insufficient ### Handover: timings, rhythm, presumed cause ## Preoperative risk and functional capacity ### Risk modification, not ritual clearance ### Match surgical stress to organ reserve ### Routine tests create incidental findings ### Functional capacity has many limits #### Stair failure may be knee pain ### Frailty predicts delirium and slow recovery ### Discuss function and rehabilitation burden ## Perioperative medicines ### Stopping anticoagulation trades clot for bleeding #### Bridging itself causes bleeding ### Antiplatelets depend on stents and urgency ### Withhold cotransporter inhibitors early #### Fasting and stress cause ketoacidosis ### Do not omit antiseizure or Parkinson medicines ## Postoperative deterioration and handover ### Never dismissed as just surgery ### Timing and phenotype narrow the cause #### Hypotension: bleeding, vasodilation, heart #### Hypoxaemia: atelectasis, aspiration, embolism #### Delirium may be first sign of sepsis ### Handover: findings, airway, drains, plans ### Recovery measured by eating, walking, self-care