Difference between revisions of "Trauma surgery"
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Trauma is a leading cause of death and disability worldwide, particularly in individuals under 45. Anesthetic management of trauma patients requires rapid decision-making, physiologic insight, and close coordination with surgical, emergency, and critical care teams. Hemorrhagic shock remains a primary driver of early mortality, with damage control resuscitation (DCR) principles serving as the cornerstone of early care (Fort & Zack-Guasp 2020).<ref>{{Cite journal|last=Fort|first=Alexander C.|last2=Zack-Guasp|first2=Richard A.|date=2020-03|title=Anesthesia for Patients with Extensive Trauma|url=https://pubmed.ncbi.nlm.nih.gov/32008648|journal=Anesthesiology Clinics|volume=38|issue=1|pages=135–148|doi=10.1016/j.anclin.2019.10.012|issn=1932-2275|pmid=32008648}}</ref> Anesthetic care begins in the trauma bay and extends through the operating room (OR) to the intensive care unit (ICU), requiring continuity and adaptability (Tobin et al. 2018). | |||
== Overview == | == Overview == | ||
=== Indications === | === Indications === | ||
Trauma surgery under anesthesia is indicated when patients present with injuries requiring emergent or urgent operative intervention, such as: | |||
* Uncontrolled hemorrhage | |||
* Hollow viscus or solid organ injury | |||
* Penetrating trauma | |||
* Open fractures | |||
* Vascular compromise | |||
* Compartment syndrome | |||
Indications for anesthetic involvement extend beyond the OR, often beginning with airway support, hemodynamic resuscitation, and pain management in the emergency department (Pollock et al. 2023). | |||
=== Surgical procedure === | === Surgical procedure === | ||
Trauma surgery encompasses a wide range of procedures, from exploratory laparotomy and thoracotomy to damage control orthopedics and vascular repair. Procedures are often staged, with initial operations focused on hemorrhage and contamination control, followed by definitive repair after physiologic stabilization (Tobin et al. 2018). | |||
== Preoperative management == | == Preoperative management == | ||
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | === Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | ||
Initial evaluation follows Advanced Trauma Life Support (ATLS) principles, with a primary survey (ABCDE) to identify and address life-threatening conditions (Fort & Zack-Guasp 2020).<ref>{{Cite journal|last=Fort|first=Alexander C.|last2=Zack-Guasp|first2=Richard A.|date=2020-03|title=Anesthesia for Patients with Extensive Trauma|url=https://pubmed.ncbi.nlm.nih.gov/32008648|journal=Anesthesiology Clinics|volume=38|issue=1|pages=135–148|doi=10.1016/j.anclin.2019.10.012|issn=1932-2275|pmid=32008648}}</ref> Neurologic status should be assessed with the Glasgow Coma Scale (GCS). Patients with traumatic brain injury, thoracic trauma, or unstable hemodynamics require special anesthetic consideration. | |||
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=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
Essential investigations include: | |||
* Point-of-care labs (ABG, lactate, Hgb) | |||
* Type and crossmatch | |||
* Coagulation panel | |||
* Focused Assessment with Sonography for Trauma (FAST) | |||
* Chest/pelvis radiographs | |||
* Extended FAST (E-FAST) including lung and cardiac views (Pollock et al. 2023) | |||
Viscoelastic testing (e.g., TEG/ROTEM/QUANTRA) aids in goal-directed blood product administration during active resuscitation (Pollock et al. 2023). | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
Premedication is often avoided in unstable trauma patients due to risk of hypotension and hypoventilation. Preoxygenation should be optimized; apneic oxygenation may be used if necessary (Tobin et al. 2018). Anticipate difficult airway and cervical spine precautions. | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
Regional anesthesia is increasingly used for trauma, particularly for extremity and rib fractures. Early blockade may improve pain control, decrease opioid exposure, and reduce the risk of chronic pain (Torrie 2022). However, coagulopathy, hypotension, and polytrauma may limit feasibility. Single-shot blocks are preferred in unstable patients (Torrie 2022). | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
Standard ASA monitors are used, but trauma patients often require: | |||
* Arterial line (preferably pre-induction) | |||
* Large-bore IV or intraosseous access | |||
* Central venous access if volume resuscitation is ongoing | |||
* Temperature monitoring | |||
* POCUS or TEE for hemodynamic assessment (Pollock et al. 2023) | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
Rapid sequence induction (RSI) is standard in trauma to mitigate aspiration risk. | |||
Ketamine and etomidate are commonly used induction agents due to hemodynamic stability; propofol is often avoided in hypovolemic patients (Pillay & Hardcastle 2016). RSI with succinylcholine or rocuronium are used for neuromuscular blockade. | |||
In patients with maxillofacial trauma, airway burns, or penetrating neck injuries, surgical airway may be required. Airway ultrasound may aid in identifying the cricothyroid membrane in challenging scenarios (Pollock et al. 2023). | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
Maintenance anesthesia is guided by surgical stage and patient physiology. A typical combination of volatile anesthetics, opioids, and adjuncts (e.g., ketamine infusion) is used as tolerated. Continuous reassessment is essential. | |||
Permissive hypotension (SBP 80–90 mmHg) is accepted in select patients without TBI (Fort & Zack-Guasp 2020). <ref>{{Cite journal|last=Fort|first=Alexander C.|last2=Zack-Guasp|first2=Richard A.|date=2020-03|title=Anesthesia for Patients with Extensive Trauma|url=https://pubmed.ncbi.nlm.nih.gov/32008648|journal=Anesthesiology Clinics|volume=38|issue=1|pages=135–148|doi=10.1016/j.anclin.2019.10.012|issn=1932-2275|pmid=32008648}}</ref> | |||
Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used for non-compressible torso hemorrhage (Pollock et al. 2023). | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
Emergence is often delayed in intubated or unstable patients requiring vasopressor support. | |||
If extubation is considered, ensure: | |||
* Adequate reversal of paralysis | |||
* Hemodynamic stability | |||
* Lack of vasopressive agents | |||
* Full return of airway reflexes | |||
* Pain well controlled | |||
* Patient not receiving large volume resuscitation (blood products/crystaloid/colloids) | |||
Otherwise, patients should remain intubated and sedated for ICU transfer. | |||
== Postoperative management == | == Postoperative management == | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
Most poly-trauma patients require ICU-level care postoperatively, especially those with ongoing ventilation, multisystem injuries, or high transfusion requirements. Effective handoff communication is essential for continuity of care (Tobin et al. 2018). | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
Multimodal analgesia should be used, including: | |||
* Opioids | |||
* Acetaminophen, NSAIDs (if renal and bleeding risk acceptable) | |||
* Ketamine | |||
* Lidocaine infusion | |||
* Regional anesthesia if feasible (Torrie 2022) | |||
Chronic pain and opioid dependence are common post-trauma sequelae, so early and adequate pain control is critical. | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
Trauma "Triad of Death:" | |||
* Hypothermia | |||
* Acidosis | |||
* Coagulopathy | |||
* | |||
* Rebleeding | |||
* ARDS | |||
* Acute kidney injury | |||
* Sepsis | |||
* Chronic pain and opioid dependence | |||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
While core principles remain the same, anesthetic considerations differ across trauma subtypes: | |||
* '''Thoracic trauma''': May require lung isolation, PEEP titration, and avoidance of nitrous oxide (Pollock et al. 2023). | |||
* '''Burns''': Anticipate airway edema and hypermetabolic response. | |||
* '''Pelvic fractures''': High risk of hemorrhage; consider early use of REBOA. | |||
* '''TBI''': Maintain normocapnia, avoid hypotension, optimize cerebral perfusion. | |||
{| class="wikitable wikitable-horizontal-scroll" | {| class="wikitable wikitable-horizontal-scroll" | ||
Revision as of 10:35, 16 July 2025
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
Large bore PIV (14, 16g), Sheath introducers (Cordis), triple lumen central line, arterial line |
| Monitors | |
| Primary anesthetic considerations | |
| Preoperative |
Full stomach, airway trauma, hypovolemia |
| Intraoperative |
bleeding |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Trauma is a leading cause of death and disability worldwide, particularly in individuals under 45. Anesthetic management of trauma patients requires rapid decision-making, physiologic insight, and close coordination with surgical, emergency, and critical care teams. Hemorrhagic shock remains a primary driver of early mortality, with damage control resuscitation (DCR) principles serving as the cornerstone of early care (Fort & Zack-Guasp 2020).[1] Anesthetic care begins in the trauma bay and extends through the operating room (OR) to the intensive care unit (ICU), requiring continuity and adaptability (Tobin et al. 2018).
Overview
Indications
Trauma surgery under anesthesia is indicated when patients present with injuries requiring emergent or urgent operative intervention, such as:
- Uncontrolled hemorrhage
- Hollow viscus or solid organ injury
- Penetrating trauma
- Open fractures
- Vascular compromise
- Compartment syndrome
Indications for anesthetic involvement extend beyond the OR, often beginning with airway support, hemodynamic resuscitation, and pain management in the emergency department (Pollock et al. 2023).
Surgical procedure
Trauma surgery encompasses a wide range of procedures, from exploratory laparotomy and thoracotomy to damage control orthopedics and vascular repair. Procedures are often staged, with initial operations focused on hemorrhage and contamination control, followed by definitive repair after physiologic stabilization (Tobin et al. 2018).
Preoperative management
Patient evaluation
Initial evaluation follows Advanced Trauma Life Support (ATLS) principles, with a primary survey (ABCDE) to identify and address life-threatening conditions (Fort & Zack-Guasp 2020).[2] Neurologic status should be assessed with the Glasgow Coma Scale (GCS). Patients with traumatic brain injury, thoracic trauma, or unstable hemodynamics require special anesthetic consideration.
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | |
| Cardiovascular | |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Essential investigations include:
- Point-of-care labs (ABG, lactate, Hgb)
- Type and crossmatch
- Coagulation panel
- Focused Assessment with Sonography for Trauma (FAST)
- Chest/pelvis radiographs
- Extended FAST (E-FAST) including lung and cardiac views (Pollock et al. 2023)
Viscoelastic testing (e.g., TEG/ROTEM/QUANTRA) aids in goal-directed blood product administration during active resuscitation (Pollock et al. 2023).
Operating room setup
Patient preparation and premedication
Premedication is often avoided in unstable trauma patients due to risk of hypotension and hypoventilation. Preoxygenation should be optimized; apneic oxygenation may be used if necessary (Tobin et al. 2018). Anticipate difficult airway and cervical spine precautions.
Regional and neuraxial techniques
Regional anesthesia is increasingly used for trauma, particularly for extremity and rib fractures. Early blockade may improve pain control, decrease opioid exposure, and reduce the risk of chronic pain (Torrie 2022). However, coagulopathy, hypotension, and polytrauma may limit feasibility. Single-shot blocks are preferred in unstable patients (Torrie 2022).
Intraoperative management
Monitoring and access
Standard ASA monitors are used, but trauma patients often require:
- Arterial line (preferably pre-induction)
- Large-bore IV or intraosseous access
- Central venous access if volume resuscitation is ongoing
- Temperature monitoring
- POCUS or TEE for hemodynamic assessment (Pollock et al. 2023)
Induction and airway management
Rapid sequence induction (RSI) is standard in trauma to mitigate aspiration risk.
Ketamine and etomidate are commonly used induction agents due to hemodynamic stability; propofol is often avoided in hypovolemic patients (Pillay & Hardcastle 2016). RSI with succinylcholine or rocuronium are used for neuromuscular blockade.
In patients with maxillofacial trauma, airway burns, or penetrating neck injuries, surgical airway may be required. Airway ultrasound may aid in identifying the cricothyroid membrane in challenging scenarios (Pollock et al. 2023).
Positioning
Maintenance and surgical considerations
Maintenance anesthesia is guided by surgical stage and patient physiology. A typical combination of volatile anesthetics, opioids, and adjuncts (e.g., ketamine infusion) is used as tolerated. Continuous reassessment is essential.
Permissive hypotension (SBP 80–90 mmHg) is accepted in select patients without TBI (Fort & Zack-Guasp 2020). [3]
Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used for non-compressible torso hemorrhage (Pollock et al. 2023).
Emergence
Emergence is often delayed in intubated or unstable patients requiring vasopressor support.
If extubation is considered, ensure:
- Adequate reversal of paralysis
- Hemodynamic stability
- Lack of vasopressive agents
- Full return of airway reflexes
- Pain well controlled
- Patient not receiving large volume resuscitation (blood products/crystaloid/colloids)
Otherwise, patients should remain intubated and sedated for ICU transfer.
Postoperative management
Disposition
Most poly-trauma patients require ICU-level care postoperatively, especially those with ongoing ventilation, multisystem injuries, or high transfusion requirements. Effective handoff communication is essential for continuity of care (Tobin et al. 2018).
Pain management
Multimodal analgesia should be used, including:
- Opioids
- Acetaminophen, NSAIDs (if renal and bleeding risk acceptable)
- Ketamine
- Lidocaine infusion
- Regional anesthesia if feasible (Torrie 2022)
Chronic pain and opioid dependence are common post-trauma sequelae, so early and adequate pain control is critical.
Potential complications
Trauma "Triad of Death:"
- Hypothermia
- Acidosis
- Coagulopathy
- Rebleeding
- ARDS
- Acute kidney injury
- Sepsis
- Chronic pain and opioid dependence
Procedure variants
While core principles remain the same, anesthetic considerations differ across trauma subtypes:
- Thoracic trauma: May require lung isolation, PEEP titration, and avoidance of nitrous oxide (Pollock et al. 2023).
- Burns: Anticipate airway edema and hypermetabolic response.
- Pelvic fractures: High risk of hemorrhage; consider early use of REBOA.
- TBI: Maintain normocapnia, avoid hypotension, optimize cerebral perfusion.
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Fort, Alexander C.; Zack-Guasp, Richard A. (2020-03). "Anesthesia for Patients with Extensive Trauma". Anesthesiology Clinics. 38 (1): 135–148. doi:10.1016/j.anclin.2019.10.012. ISSN 1932-2275. PMID 32008648. Check date values in:
|date=(help) - ↑ Fort, Alexander C.; Zack-Guasp, Richard A. (2020-03). "Anesthesia for Patients with Extensive Trauma". Anesthesiology Clinics. 38 (1): 135–148. doi:10.1016/j.anclin.2019.10.012. ISSN 1932-2275. PMID 32008648. Check date values in:
|date=(help) - ↑ Fort, Alexander C.; Zack-Guasp, Richard A. (2020-03). "Anesthesia for Patients with Extensive Trauma". Anesthesiology Clinics. 38 (1): 135–148. doi:10.1016/j.anclin.2019.10.012. ISSN 1932-2275. PMID 32008648. Check date values in:
|date=(help)
Top contributors: Alexander Doyal and Mitchel DeVita