Trauma and emergency surgery

What it is

The injured or acutely ill surgical patient arrives with little warning and many hidden problems: bleeding that is not yet visible, a full stomach, a possible cervical spine injury, a head injury, cold, and an unknown history. Assessment follows the primary survey (airway with cervical spine protection, breathing, circulation with haemorrhage control, disability and exposure), done by a team in parallel rather than one step at a time. The anaesthetist's role is to secure the airway, restore circulation and keep the patient alive long enough for the surgeon to stop the bleeding. Induction is a rapid-sequence technique with manual in-line stabilisation of the neck and drugs chosen and reduced for a patient whose blood pressure depends on sympathetic drive; ketamine or etomidate are common choices, and any induction agent can cause collapse in hypovolaemia. Damage-control resuscitation aims to stop bleeding early, accept a lower blood pressure until control is achieved (except in brain or spinal cord injury, where perfusion pressure must be protected), give blood products in a balanced ratio rather than large volumes of crystalloid, give tranexamic acid early, and fight the lethal triad of hypothermia, acidosis and coagulopathy, together with low ionised calcium. Damage-control surgery does only the minimum needed to stop bleeding and contamination; definitive repair follows once the patient is warm, perfused and no longer coagulopathic in intensive care.

What changes in this patient

• Full stomach: pain, opioids, fear and injury slow gastric emptying, so fasting time does not protect against aspiration.
• Hidden haemorrhage in the chest, abdomen, pelvis, long bones or onto the floor; tachycardia, narrow pulse pressure and agitation come before hypotension.
• Possible cervical spine injury: the collar limits mouth opening and laryngoscopy, so its front is removed and the neck held in line by an assistant.
• Head injury: hypoxia and hypotension, even brief, worsen secondary brain injury; carbon dioxide must be kept normal.
• Little time and history: allergies, medicines (especially anticoagulants) and last meal may be unknown.
• Trauma-induced coagulopathy starts early from tissue injury and shock, before any dilution.

Anaesthetic plan (and why)

1. Join the trauma team briefing and run the primary survey in parallel — airway, breathing and circulation problems kill in that order.
2. Prepare suction, a videolaryngoscope, a bougie and a front-of-neck kit — trauma airways are often bloody, immobile and difficult.
3. Rapid-sequence induction with in-line neck stabilisation and a reduced, titrated induction agent — limits aspiration and collapse.
4. Two large-bore cannulas or a rapid infuser, warmed blood and early activation of the massive transfusion protocol — bleeding outpaces crystalloid.
5. Accept a lower blood pressure until the bleeding is controlled, but protect brain and spinal cord perfusion — less bleeding, protected brain.
6. Give balanced red cells, plasma and platelets and early tranexamic acid, guided by viscoelastic tests if available — corrects coagulopathy.
7. Warm everything (fluids, air, room) and check ionised calcium, potassium and lactate often — cold, citrate and acid worsen bleeding.
8. Support damage-control surgery and plan intensive care before the end — definitive repair waits until the patient is stable.

The primary survey from the anaesthetist's point of view

Risks and complications

• Cardiovascular collapse at induction in an under-resuscitated patient.
• Aspiration of gastric contents during induction or with an unprotected airway.
• Failed intubation in a bloody airway with a stabilised neck; worsening of a spinal injury with excessive neck movement.
• Missed injuries: tension pneumothorax after starting positive-pressure ventilation, cardiac tamponade, ongoing pelvic bleeding.
• Complications of massive transfusion: hypocalcaemia, hyperkalaemia, hypothermia, circulatory overload and transfusion-related lung injury.
• Suxamethonium can cause dangerous hyperkalaemia from a day or two after burns, crush or spinal cord injury.

Next step

• Continue resuscitation in intensive care: lactate, base deficit, haemoglobin, clotting tests, ionised calcium and temperature until stable.
• Plan definitive surgery when the patient is warm, perfused and no longer coagulopathic, usually within the next days.
• Call a senior anaesthetist early for any major trauma, a difficult airway or massive transfusion; one person should lead.
• Complete the secondary and tertiary surveys to find missed injuries, and start venous thromboembolism prophylaxis once bleeding allows.
• Debrief the team and report transfusion reactions and adverse events.

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Elsewhere in DurgiPedia

• Level of consciousness and the Glasgow Coma Scale
• Shock physiology
• Blood transfusion: bedside checks, monitoring and reactions
• Consent in emergencies and the exceptions to consent

Connections

← All of anaesthesia

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: Trauma Assessment (StatPearls (NCBI Bookshelf), 2026); Massive Transfusion (StatPearls (NCBI Bookshelf), 2025).

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Representative model, for educational purposes only.