Near-death experiences often happen in a situation of high physiological and/or psychological stress. Sustained cardiac arrest, which is the important criterion for clinical death, is a situation in which the oxygenation level of the brain drops drastically. Without resuscitation and depending on physical and physiological conditions, the lack of oxygen causes a cascade of changes in neural activity of the brain continuing over about 10 minutes until neurons become irreversibly damaged and die. Levels of brain damage with prospective chances of recovery to normal are classified in scales of awareness and wakefulness. Neural activity measured as brain waves in EEG recordings after cardiac arrest shows phases of well-organized patterns comparable with EEG patterns during aware stimulus perception and/or action planning. Clinically dead patients, who are observed as unconscious, may subjectively perceive visual/auditory images and may report on their perceptions of near-death experiences after successful resuscitation.

A primary brain injury occurs at the time of initial mechanical trauma. An additional secondary brain injury begins immediately after impact. Inflammatory and neurotoxic processes result in raised intracranial pressure, decreased cerebral perfusion and ischaemia. This secondary injury is worsened by further physiological insults such as hypotension and hypoxia.

Assessment of the patient begins with an ABCD approach and should take place alongside resuscitation. Airway management is the priority, and this must be safely secured when indicated. Cervical spine injury is often associated with a head injury. The neck should be immobilised. Hypoventilation causes hypoxia and hypercapnia. Controlled ventilation to achieve a PaCO2 of 4.5 - 5 kPa and a PaO2 of > 13 kPa is recommended to control intracranial pressure. Hypotension reduces cerebral perfusion; a mean arterial pressure of > 90 mmHg should be targeted. Neurological assessment is undertaken using the Glasgow Coma Scale (GCS). A GCS less than 8 is considered a serious head injury and is often an indication for tracheal intubation. Other indications are described. Transfer to a neurosurgical unit is often required. Safe transfer guidelines must be followed.

Recognition and management of the sick patient outside of the operating theatre is often required by an anaesthetic trainee. There are a number of scoring systems in use, but the majority use the following parameters: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion and temperature. Values within the normal range score 0, and increase to 3 with progressively more abnormal (high or low) scores.

A number of clinical pictures may present with a sick patient but common scenarios encountered include haemorrhage and hypovolaemia, cardiac events (arrhythmias/myocardial infarction/failure), sepsis, pulmonary embolus and various iatrogenic problems ( e.g. pneumothorax, epidural problems, PCA overdose). Rapid diagnosis and management is essential. This will include blood tests, ABG, urinary catheter and often a urinary catheter. Patients may need imaging in the radiology department too, when stable.

Basic resuscitation involves ensuring delivering facemask oxygen, establishing reliable iv access and appropriate monitoring. This may include intravascular monitoring. Often iv fluids are required and should be guided by the monitoring available. Rapid treatment of sepsis is essential with appropriate antibiotics.

It is difficult to manage these patients on the ward and transfer to theatres/ICU is preferable.

Perioperative cardiac arrest occurs in about 1 in 3,000 anaesthetics. The majority occur in older, frailer patients (1 in 1,200), and in high-risk or emergency surgery. The cause may be the result of underlying medical disease – usually cardiac, secondary to surgery – usually due to haemorrhage or secondary to an anaesthetic cause – usually due to hypoxia and hypercapnia, typically resulting from airway problems.

The Resuscitation Council has issued algorithms to guide management of basic and advanced life support in both adults and children. Advanced life support secures the airway and supports the circulation using drugs with the aim of the return of spontaneous circulation. Two main types of arrhythmia occur in a cardiac arrest:

• Non-shockable: pulseless electrical activity (PEA) – a QRS complex without a palpable pulse and asystole

• Shockable: ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT)

Potentially reversible causes of cardiac arrest should be actively sought and treated. There are special circumstances after 28 weeks of pregnancy which require attention and are described. A traumatic cardiac arrest resuscitation algorithm is discussed.

Trauma is the leading cause of mortality and morbidity in children in developed countries. Traumatic brain injury is responsible for the largest proportion of deaths. Preventable death due to major haemorrhage occurs early in the first 24 hours. Mechanisms vary with age. Blunt injury represents over 80% of cases. Falls and road traffic collisions (RTCs) are the most common mechanisms across all ages, except for non-accidental injury (NAI) in < 1 year olds. There has been a substantial rise in penetrating trauma due to gun and knife crime in the adolescent population. The centralisation of trauma services in the United Kingdom with the creation of regional networks has changed how paediatric trauma is managed. Severely injured children are triaged at scene and taken directly to major trauma centres (MTCs). Outcomes have improved, and there is better standardisation between treating institutions. Initial trauma management involves stabilisation, resuscitation, identification and treatment of life-threatening injuries in the primary survey. Some patients will need damage control surgery to control haemorrhage. This is followed by definitive care and rehabilitation. Anaesthetists are an integral part of the trauma team involved throughout the patient journey. Dedicated anaesthetic roles are airway management and ongoing resuscitation during surgery.

Avowing that love awakens one’s attention to the material world and to one another, Corinne provides a theory for establishing human–nonhuman connection, the energizing and curative praxis of belonging with. The heroine’s thing therapy positively associates women with materiality and, while exercising her right to connect with things, she sustains her élan vital. This chapter argues that she harnesses her feminist thing theory to teach her lover to respect the female body’s integrity and rights and to challenge his repressive politics: If Oswald could belong with materiality by sensuously responding to things, he could remedy his commitment to abstraction and his nationalistic gender proscriptions. Diagnosing Oswald’s melancholy as also emerging from his identification with “modern” (post Renaissance) art, associated with Napoleon’s tyranny and a self-absorptive grief that paralyzes creative potential, Corinne offers a remedy: companionship with classical art. Her thing theory has political ramifications, for it provides a workshop for practicing an embodied cosmopolitanism that itself ameliorates nationalism’s intolerances.

Fluid management is a complex yet fundamental aspect in the care of patients undergoing cardiac surgery, and different to that for patients in general intensive care and other surgical specialties. The underlying cardiac disease and impaired cardiovascular reserve of patients in this high-risk population means that significant hemodynamic alterations can impact adversely on their short- and long-term outcomes. Volume replacement during and after cardiac surgery is not influenced by filling pressures in isolation, but requires a critical balance with vasomotor tone, fluid responsiveness and cardiac contractility. The timing, type, volume and monitoring of fluid administration are important considerations. So far, the evidence does not favor a specific choice of fluid therapy and none of the available fluid therapies has been assessed for comparative endothelial homeostatic potential. This leaves a significant knowledge gap and an incentive for researchers, clinicians and industry to design and test safer and more efficacious choices for clinical use.

In the USA, injury is the leading cause of death among individuals between the ages of 1 and 44 years, and the third leading cause of death overall. Approximately 20 to 40% of trauma deaths occurring after hospital admission are related to massive hemorrhage and are potentially preventable with rapid hemorrhage control and improved resuscitation techniques. Over the past decade, the treatment of this population has transitioned into a damage control strategy with the development of resuscitation strategies that emphasize permissive hypotension, limited crystalloid administration, early balanced blood product transfusion, and rapid hemorrhage control. This resuscitation approach initially attempts to replicate whole blood transfusion, utilizing an empiric 1:1:1 ratio of plasma:platelets:red blood cells, and then transitions, when bleeding slows, to a goal-directed approach to reverse coagulopathy based on viscoelastic assays. Traditional resuscitation strategies with crystalloid fluids are appropriate for the minimally injured patient who presents without shock or ongoing bleeding. This chapter focuses on the assessment and resuscitation of seriously injured trauma patients who present with ongoing blood loss and hemorrhagic shock.

Injuries caused by knives and bullets frequently produce life-threatening and life-changing injuries, often in urban environments and associated with the abuse of alcohol and drugs. The development of pre-hospital care includes introducing critical care paramedics and critical care response teams, and enhanced assessment techniques. Its success is driven by the concept of scoop and play that is intended to deliver the right patient, with the right treatment, utilising the right transport modality, to the right hospital. Bespoke trauma networks and systems help to meet these objectives. The war in Afghanistan has driven rapid innovation and clinical advances embracing resuscitation, life-saving surgery, and new techniques in trauma reconstruction. These advances have now been introduced into civilian practice and are the backbone of the management of critically injured patients with knife and bullet injuries. Where and when possible, these advances are underpinned by research and delivered by inclusive trauma training.

• Optimal initial management of the trauma patient during the first several hours after injury offers the best chance of a good outcome. Patient management consists of rapid primary survey, resuscitation of vital functions, a more detailed secondary assessment, diagnostic tests to ascertain the extent of traumatic injury and finally, the initiation of definitive care.

In this chapter, we explore how data-driven modeling can improve the understanding of OHCA risk, help identify the limitations of current AED placement strategies, and guide the development of optimal AED networks to increase the chance of AED use and OHCA survival. More specifically, we frame AED network design and related response efforts as a facility location problem, focusing on the maximum coverage location and p-median problems. We also highlight how novel tools that combine techniques from areas including information theory and machine learning with optimization models can shape the future of OHCA response efforts and AED placement strategies.

Key Learning Points

1. 1. Depth and extent of the burn determine management and the need for referral.

2. 2. Lund and Browder charts should be used to estimate the extent of burn (% total body surface area (TBSA)).

3. 3. Increasing age, % TBSA involved and associated inhalation injury correlate with severity.

4. 4. Severe burns require burn shock resuscitation and should be managed in a burns centre.

5. 5. The Parkland formula provides a guide to initial resuscitative fluid requirements.