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).

A – Airway with cervical spine protection

• Assess for patency: look for obstruction, facial trauma, or burns.
• Intervene with suction, airway adjuncts (e.g., oropharyngeal/nasopharyngeal airway), or definitive airway (endotracheal intubation) as needed.
• Always assume cervical spine injury in trauma patients; apply cervical collar and maintain manual in-line stabilization during airway maneuvers.

B – Breathing and ventilation

• Evaluate chest movement, symmetry, respiratory rate, and effort.
• Auscultate lung fields; identify pneumothorax, hemothorax, or flail chest.
• Provide oxygen; initiate positive pressure ventilation if inadequate.
• Consider needle decompression or chest tube for tension pneumothorax or massive hemothorax.

C – Circulation with hemorrhage control

• Check pulse rate, blood pressure, capillary refill, and skin perfusion.
• Look for external bleeding; apply direct pressure or tourniquets.
• Establish two large-bore IVs or intraosseous access.
• Initiate fluid resuscitation and activate massive transfusion protocol if needed.
• Perform FAST exam and pelvic X-ray for occult bleeding.

D – Disability (neurologic evaluation)

• Perform rapid neurologic assessment using the Glasgow Coma Scale (GCS).
• Check pupillary size and response.
• Identify signs of traumatic brain injury or spinal cord injury.

E – Exposure and environmental control

• Fully expose the patient to identify hidden injuries.
• Prevent hypothermia using warm blankets, warming devices, and warmed IV fluids.
• Maintain privacy and dignity once life-threatening injuries are excluded.

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.

Component	Response	Score
Eye Opening	Spontaneous	4
	To voice	3
	To pain	2
	No response	1
Verbal Response	Oriented	5
	Confused	4
	Inappropriate words	3
	Incomprehensible sounds	2
	No response	1
Motor Response	Obeys commands	6
	Localizes pain	5
	Withdraws from pain	4
	Abnormal flexion (decorticate)	3
	Abnormal extension (decerebrate)	2
	No response	1

System	Considerations in Trauma and Anesthetic Implications
Airway	Facial fractures, airway edema, blood/vomit, cervical spine instability; may require RSI or surgical airway
Neurologic	Traumatic brain injury (TBI), spinal cord injury; avoid hypoxia/hypotension, maintain cerebral perfusion, use GCS
Cardiovascular	Hemorrhagic shock, tamponade, myocardial contusion; requires volume resuscitation, blood products, vasoactive agents
Pulmonary	Pneumothorax, hemothorax, pulmonary contusion, flail chest; manage with chest tubes, lung-protective ventilation
Gastrointestinal	Bowel injury, hepatic/splenic laceration; risk of peritonitis, sepsis, rapid deterioration; damage control laparotomy may be needed
Hematologic	Coagulopathy (trauma-induced or dilutional), massive transfusion; use balanced ratios, TXA, monitor with TEG/ROTEM
Renal	Hypoperfusion, rhabdomyolysis, contrast-induced nephropathy; maintain perfusion, monitor creatinine, avoid nephrotoxins
Endocrine	Adrenal insufficiency (especially in chronic steroid users), hyperglycemia; consider stress-dose steroids, tight glucose control
Other	Hypothermia, acidosis, electrolyte disturbances (esp. hyperkalemia); actively warm patient, correct derangements, monitor closely

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 an unstable or uncleared cervical spine need in-line stabilization during intubation. Video Laryngoscopy (VL) may further reduce neck movement during intubation.

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

Positioning is dictated by injury and surgical needs, with attention to spinal precautions and pressure point protection.

Positioning should allow for:

• Surgical access
• Hemodynamic optimization
• Prevention of pressure injuries
• Ongoing access to IV lines and monitoring

Trauma patients are often unstable, and movement may precipitate hemodynamic deterioration. Team communication is essential.

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:

	Abdominal Trauma	Extremity Trauma	Thoracic Trauma	Burns	Pelvic Fractures	TBI
Unique considerations	Hollow viscus or solid organ injury; contamination risk; risk of abdominal compartment syndrome	Compartment syndrome, tourniquet use, long bone hemorrhage, external fixator	May require lung isolation, PEEP titration, and avoidance of nitrous oxide	Anticipate airway edema and hypermetabolic response	High risk of hemorrhage; consider early use of REBOA	Maintain normocapnia, avoid hypotension, optimize cerebral perfusion
Position	Supine; may require arms tucked and wide exposure	Supine; limb may be prepped/draped independently, traction devices possible	Supine with single-lung ventilation setup if needed	Supine; avoid pressure on burns, special pads if needed	Supine; pelvic binder or external fixator may be in place	Supine, head midline, 30° elevation to optimize venous return
Surgical time	Short for damage control, long for definitive repair	Often prolonged if multiple fractures or staged fixation	Varies depending on injury; may be urgent/emergent	Often prolonged depending on TBSA and grafting	Staged procedures often required	Often combined with other injury repair, timing dependent
Estimated Blood Loss (EBL)	High risk of major bleeding, especially with liver/spleen injuries	Moderate; varies by fracture severity and soft tissue injury	Can be significant with vascular or pulmonary vessel injury	Variable; large TBSA burns may lose significant volume	Very high, particularly with open or unstable fractures	Usually minimal unless combined with multisystem trauma
Postoperative disposition	ICU for continued resuscitation, possible second-look laparotomy	Step-down or floor if stable; ICU if polytrauma	ICU likely for respiratory support and monitoring	ICU for ventilatory and fluid management, infection monitoring	ICU for hemodynamic monitoring and ongoing resuscitation	Neuro ICU; monitor ICP, avoid secondary brain injury
Pain management	Multimodal; systemic opioids, epidural rarely used due to coagulopathy	Regional (e.g., femoral or fascia iliaca block) plus systemic meds	Paravertebral, epidural, or serratus plane blocks; minimize opioids	IV opioids, ketamine, adjunctive anxiolytics; regional rarely feasible	Systemic opioids, consider lumbar plexus or LFCN blocks	IV acetaminophen, opioids with caution; avoid sedation masking exam
Potential complications	Sepsis, multi-organ failure, re-bleeding, abdominal compartment syndrome	Infection, fat embolism, delayed union, neuropathy	Pneumothorax, hemothorax, respiratory failure	Airway loss, sepsis, hypothermia, metabolic derangements	Hemorrhage, coagulopathy, urologic or bowel injury	Elevated ICP, seizures, neurogenic pulmonary edema