Trauma surgery

Trauma surgery

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	Unrated
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). 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). 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).

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).

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).

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