A Checklist for Trauma and Emergency Anesthesia

Abstract

Death from traumatic injury is the leading cause of death in children and adults younger than 45 years of age. For adults older than 45 years of age, trauma is the third leading cause of death, the primary causes being cardiovascular events and malignancies. Despite this huge burden, the Anesthesiology Residency Review Committee of the Accreditation Council for Graduate Medical Education has as a requirement that residents in anesthesiology programs only manage 20 trauma cases during their residency. The requirement does not define what constitutes “trauma” and does not specify the educational objective for their experience providing care to patients who have sustained trauma. Once they finish training, anesthesiologists will be involved in the management of patients who have sustained traumatic injuries. If they work in a rural area, they may not be challenged with the kind of penetrating injuries common in an urban level I trauma center. However, trauma is ubiquitous, and rural medical centers see severe trauma from motor vehicle crashes, from farming or manufacturing mishaps, and from natural accidents. Because residency may impart limited training in management of trauma, we propose that anesthesiologists use a standardized “trauma and emergency checklist” to facilitate the care they provide these patients and (hopefully) improve outcomes. Checklists have been shown to decrease patient morbidity and mortality by assuring that the health care provider does not overlook some important aspect of care. Checklists are used when preparing an anesthetic workstation at the beginning of the day. The algorithms promulgated by the Advanced Trauma Life Support and Advanced Cardiac Life Support courses are checklists. Even trauma surgeons in the military, who have a great deal of experience in managing patients who sustain blast injury, use checklists. Military surgeons use checklists to manage trauma for the same reason that anesthesiologists use checklists when checking an anesthesia workstation, or that an airline pilot uses a checklist before every takeoff and landing. The checklist assures that critical steps are not missed. Checklists are easy. Missing critical steps can be deadly. Checklists have been shown to decrease inpatient complications and death. 1 Standardized checklists can be especially useful during emergencies. 2,3 A trauma and emergency anesthesia checklist can serve as a template of care for the initial phase of operative anesthesia, as well as resuscitation. The goal of this manuscript is not to provide a definitive checklist. The definitive checklist, if it ever exists, should be created, and vetted, by a learned society within the trauma anesthesiology community. Our goal for this manuscript is to initiate a discussion about what should be on a trauma anesthesia checklist, providing a nidus for a definitive document (Fig. 1).