Perioperative management of the hand trauma patient

Realizing that miracle drugs that can reverse severe brain damage have not yet been identified, studies in recent years have focused on identifying risk factors for head trauma and resuscitative events that might impede or improve outcome. Risk factors for poor outcome include advanced age, alcoholism, delay in transfer and operation, management errors and technical mistakes. Quality assurance programmes, now established in all United States hospitals, may be flawed in that assessments of preventable trauma deaths are often based on unsubstantiated subjective case review methods. Studies of the cerebral effects of anaesthetic agents have reconfirmed the detrimental effects of nitrous oxide in the trauma victim. Ketamine, a N-methyl D-aspartate receptor antagonist, has shown surprising cerebral protective effects in animal models. Appropriate fluid therapy after head injury requires avoidance of sugar-containing solutions, maintenance of normovolaemia and consideration of use of hypertonic solutions to maintain vascular volume. Although hypothermia continues to be an appealing means of affording brain protection after head injury, the degree and duration have still not been established. Establishment of the airway in the neck injured patient should be by careful endotracheal tube placement which causes less cervical movement than mask ventilation and less risk of infection or trauma than the nasotracheal route.