[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anaesthesia and ICU](https://durgical.com/en/anaesthesia/) › [By patient and by surgery](https://durgical.com/en/anaesthesia/areas/by-patient/) › Trauma and emergency surgery

# Trauma and emergency surgery

- Patient and surgery

Anaesthesia for an injured or acutely ill patient who may be bleeding, has a full stomach and cannot wait for the usual preparation.

Updated Nov 13, 2026

## Key points

- Assess with the primary survey: airway with cervical spine protection, breathing, circulation with bleeding control, disability, exposure; a team works on all at once.
- Treat every trauma patient as having a full stomach and an unstable neck: rapid-sequence induction with manual in-line stabilisation.
- Hypovolaemic patients collapse on induction: reduce and titrate the induction agent and have blood and a vasopressor ready.
- Damage-control resuscitation: permissive hypotension until bleeding is controlled (not in brain injury), balanced blood products, early tranexamic acid.
- The lethal triad is hypothermia, acidosis and coagulopathy; low ionised calcium from citrate in transfused blood worsens it.

On this page

- The basics Key points
- What it is
- What changes in this patient
- Anaesthetic plan (and why)
- The primary survey from the anaesthetist's point of view
- Next step
- Memory aid
- Elsewhere in DurgiPedia

- Clinical Risks and complications

- Study Test yourself

- Connections Connections

## 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)

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

| Step | Look for | Anaesthetic action |
| --- | --- | --- |
| Airway and cervical spine | Obstruction, blood, facial or neck injury, collar in place | Suction, oxygen, rapid-sequence intubation with in-line stabilisation; surgical airway if needed |
| Breathing | Tension pneumothorax, haemothorax, flail chest | Decompression and chest drain before or right after positive-pressure ventilation |
| Circulation | Tachycardia, cold skin, falling pressure, sources of bleeding | Large-bore access, blood products, tranexamic acid, haemorrhage control |
| Disability | Glasgow Coma Scale, pupils, lateralising signs | Avoid hypoxia and hypotension; record neurology before induction |
| Exposure | Hidden wounds, temperature | Full exposure, then warming |

## 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.

## Memory aid

The lethal triad, cold, acid and clotting failure, feeds itself: each one worsens the other two, so treat all three together.

## Test yourself

Think of the answer, then tap the question to see it.

## Why is rapid-sequence induction used for almost every trauma patient?

Injury, pain and opioids slow gastric emptying, so the stomach is assumed full regardless of fasting time; a rapid-sequence technique limits the time the airway is unprotected.

## What is permissive hypotension and when should it not be used?

Accepting a lower blood pressure until surgical bleeding control, to reduce bleeding. It is avoided in traumatic brain or spinal cord injury, where perfusion pressure must be maintained.

## What makes up the lethal triad of trauma?

Hypothermia, acidosis and coagulopathy. Each worsens the others; low ionised calcium from citrate in transfused blood adds to the problem.

## Why can starting positive-pressure ventilation make a trauma patient worse?

It can turn a simple pneumothorax into a tension pneumothorax and reduces venous return in a hypovolaemic patient, so pressure may fall sharply.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anaesthesia/trauma-and-emergency-surgery/)

## Elsewhere in DurgiPedia

- [Level of consciousness and the Glasgow Coma Scale](https://durgical.com/en/clinical-exam/level-of-consciousness-and-the-glasgow-coma-scale/)
- [Shock physiology](https://durgical.com/en/physiology/shock-physiology/)
- [Blood transfusion: bedside checks, monitoring and reactions](https://durgical.com/en/nursing/blood-transfusion-bedside-checks-monitoring-and-reactions/)
- [Consent in emergencies and the exceptions to consent](https://durgical.com/en/medical-ethics/consent-in-emergencies-and-the-exceptions-to-consent/)

## Connections

## Related 8

- [Massive haemorrhage in theatre](https://durgical.com/en/anaesthesia/massive-haemorrhage-in-theatre/)
- [Rapid-sequence induction and intubation](https://durgical.com/en/anaesthesia/rapid-sequence-induction-and-intubation/)
- [The unanticipated difficult airway: plans A to D](https://durgical.com/en/anaesthesia/the-unanticipated-difficult-airway-plans-a-to-d/)
- [Neurosurgery and raised intracranial pressure](https://durgical.com/en/anaesthesia/neurosurgery-and-raised-intracranial-pressure/)
- [Shock: a bedside approach by type](https://durgical.com/en/anaesthesia/shock-a-bedside-approach-by-type/)
- [Perioperative hypothermia and shivering](https://durgical.com/en/anaesthesia/perioperative-hypothermia-and-shivering/)
- [Orthopaedic surgery: tourniquets, cement and blood loss](https://durgical.com/en/anaesthesia/orthopaedic-surgery-tourniquets-cement-and-blood-loss/)
- [Transfusion thresholds in the ICU](https://durgical.com/en/anaesthesia/transfusion-thresholds-in-the-icu/)

## Related conditions 9

- [Major trauma (polytrauma): ATLS primary survey](https://durgical.com/en/conditions/major-trauma-atls-primary-survey/)
- [Hypovolaemic shock](https://durgical.com/en/conditions/hypovolaemic-shock/)
- [Traumatic brain injury](https://durgical.com/en/conditions/traumatic-brain-injury/)
- [Cervical spine fracture](https://durgical.com/en/conditions/cervical-spine-fracture/)
- [Spinal cord injury](https://durgical.com/en/conditions/spinal-cord-injury/)
- [Pneumothorax](https://durgical.com/en/conditions/pneumothorax/)
- [Cardiac tamponade](https://durgical.com/en/conditions/cardiac-tamponade/)
- [Pelvic fracture](https://durgical.com/en/conditions/pelvic-fracture/)
- [Burns (thermal, chemical, electrical; inhalation injury)](https://durgical.com/en/conditions/burns/)

## In Pharmacology 8

- [Ketamine](https://durgical.com/en/pharmacology/ketamine/)
- [Etomidate](https://durgical.com/en/pharmacology/etomidate/)
- [Rocuronium](https://durgical.com/en/pharmacology/rocuronium/)
- [Suxamethonium](https://durgical.com/en/pharmacology/suxamethonium/)
- [Tranexamic acid](https://durgical.com/en/pharmacology/tranexamic-acid/)
- [Calcium chloride](https://durgical.com/en/pharmacology/calcium-chloride/)
- [Calcium gluconate](https://durgical.com/en/pharmacology/calcium-gluconate/)
- [Norepinephrine](https://durgical.com/en/pharmacology/norepinephrine/)

[← All of anaesthesia](https://durgical.com/en/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](https://www.ncbi.nlm.nih.gov/books/NBK555913/) (StatPearls (NCBI Bookshelf), 2026); [Massive Transfusion](https://www.ncbi.nlm.nih.gov/books/NBK499929/) (StatPearls (NCBI Bookshelf), 2025).

## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake

Representative model, for educational purposes only.

---
Source: https://durgical.com/en/anaesthesia/trauma-and-emergency-surgery/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anaesthesia/trauma-and-emergency-surgery/