Residency · Residency · Anesthesiology

Anesthesia for the Trauma Patient: Primary Survey and Damage Control Resuscitation

Introduction

Trauma is the leading cause of death in individuals under 45 years of age. The anesthesiologist is a critical member of the trauma team, responsible for airway management, resuscitation, hemodynamic optimization, and anesthetic care during emergent surgical procedures. A systematic approach guided by Advanced Trauma Life Support (ATLS) principles and contemporary damage control resuscitation strategies is essential.

The Primary Survey: ABCDE

A - Airway with Cervical Spine Protection

Airway patency is assessed by evaluating vocalization, stridor, gurgling, and obstruction. Inline cervical spine stabilization must be maintained during all airway maneuvers until injury is excluded. The anterior portion of the cervical collar is removed, with manual inline stabilization applied by an assistant during laryngoscopy.

The anesthesiologist should anticipate a difficult airway due to facial trauma, expanding neck hematoma, blood or vomit in the oropharynx, and cervical spine immobilization that limits mouth opening and neck extension. Rapid sequence induction is the default technique because all trauma patients are treated as having a full stomach. Video laryngoscopy improves first-pass success and is recommended. A surgical airway (cricothyrotomy) must be immediately available.

B - Breathing and Ventilation

The chest is inspected, palpated, percussed, and auscultated. Immediately life-threatening conditions must be identified and treated. Tension pneumothorax presents with a deviated trachea, absent breath sounds, and hypotension, and is treated with needle decompression at the second intercostal space in the midclavicular line followed by chest tube placement. Open pneumothorax is sealed with a three-sided occlusive dressing followed by a chest tube. Massive hemothorax, defined as more than 1500 mL of initial output or more than 200 mL per hour ongoing, may require thoracotomy. Flail chest, with paradoxical chest wall movement, may require intubation and positive pressure ventilation.

C - Circulation and Hemorrhage Control

Sources of hemorrhage are identified: external, thoracic, abdominal, pelvic, long-bone fractures, and retroperitoneal. Direct pressure is applied to external hemorrhage, and tourniquets are used for extremity exsanguination. Large-bore IV access is established with two 14 to 16 gauge IVs or intraosseous access. Resuscitation should begin with blood products rather than crystalloid in hemorrhagic shock. Hemorrhagic shock is classified by ATLS class (I through IV) based on estimated blood loss, heart rate, blood pressure, and mental status.

D - Disability (Neurologic Assessment)

The Glasgow Coma Scale evaluates eye opening, verbal response, and motor response. Pupil size and reactivity are assessed. A GCS of 8 or below mandates endotracheal intubation for airway protection. A brief extremity assessment for lateralizing signs is performed.

E - Exposure and Environmental Control

The patient is completely undressed for thorough examination. Hypothermia must be prevented through the use of warm IV fluids, forced-air warming, and increased room temperature. The patient is log-rolled to examine the back, spine, and perineum.

Airway Management in Trauma

Rapid Sequence Induction

Preoxygenation with 100% oxygen is performed, though it may be limited to seconds in the crashing patient. Ketamine at 1 to 2 mg/kg IV is the induction agent of choice in hemodynamically unstable patients because it preserves SVR and cardiac output. Etomidate at 0.2 to 0.3 mg/kg IV is an alternative that provides hemodynamic stability, though there are concerns about adrenal suppression. Propofol and thiopental should be avoided in hemorrhagic shock due to profound vasodilation and myocardial depression. Succinylcholine at 1.5 mg/kg IV or rocuronium at 1.2 mg/kg IV is used for neuromuscular blockade. Cricoid pressure (Sellick maneuver) is applied but released if it impedes laryngoscopy. A bougie, video laryngoscope, and surgical airway kit must be immediately available.

Special Airway Situations

Facial fractures may preclude bag-mask ventilation, and early surgical airway may be needed. For neck trauma with an expanding hematoma, awake intubation may be preferred if time permits. In laryngotracheal injury, positive pressure ventilation through a partial airway disruption should be avoided; management may require advancement of the ETT distal to the injury or tracheostomy.

Damage Control Resuscitation (DCR)

Principles

Permissive hypotension targets a systolic blood pressure of 80 to 90 mmHg (MAP 50 to 60 mmHg) until surgical hemorrhage control is achieved. This approach minimizes clot disruption and dilutional coagulopathy. The important exception is that permissive hypotension must be avoided in traumatic brain injury, where the target is a systolic blood pressure above 100 mmHg or MAP above 80 mmHg.

Hemostatic resuscitation involves transfusing pRBCs, FFP, and platelets in a balanced ratio of approximately 1:1:1. Crystalloid should be limited because large-volume crystalloid exacerbates the lethal triad of hypothermia, acidosis, and coagulopathy.

The Lethal Triad

The lethal triad consists of hypothermia (which impairs coagulation enzyme function, causes platelet dysfunction, and increases cardiac irritability), acidosis (which worsens coagulopathy and causes myocardial depression), and coagulopathy (both dilutional and consumptive, worsened by hypothermia and acidosis). Damage control resuscitation aims to interrupt this vicious cycle.

Massive Transfusion Protocol (MTP)

The MTP should be activated early when massive hemorrhage is anticipated. The first cooler typically contains 6 units of pRBCs, 6 units of FFP (or equivalent), and 1 apheresis platelet unit. Tranexamic acid at 1 g IV should be administered within 3 hours of injury, as established by the CRASH-2 trial, with a second gram infused over 8 hours. Calcium chloride at 1 g IV should be considered for every 4 to 6 units of blood products to counteract citrate-induced hypocalcemia. Viscoelastic testing with TEG or ROTEM should be used to guide targeted component therapy when available. Ionized calcium, potassium, pH, lactate, and fibrinogen levels require ongoing monitoring.

Intraoperative Anesthetic Management

Hemodynamic monitoring includes an arterial line, central venous access, urinary catheter, and temperature probe. A rapid infusion device with blood warmer is used for high-volume resuscitation. The anesthetic is titrated to hemodynamic status; severely shocked patients may require only oxygen, a muscle relaxant, and a low-dose amnestic such as midazolam or scopolamine.

The risk of anesthesia awareness is high in trauma patients receiving reduced anesthetic doses due to hemodynamic instability, and the rationale should be documented. Normothermia must be maintained aggressively. For persistent hypotension despite volume resuscitation, norepinephrine is the first-line vasopressor, and vasopressin at 1 to 2 units IV bolus may be used for refractory vasodilatory shock.

Damage control surgery should be considered: an abbreviated surgical procedure to control hemorrhage and contamination, temporary abdominal closure, and ICU resuscitation before definitive repair.

Point-of-Care Testing

Arterial blood gas analysis provides pH, lactate (a marker of tissue hypoperfusion), base deficit, and hemoglobin. Viscoelastic assays (TEG/ROTEM) guide transfusion of specific components including fibrinogen, platelets, and FFP. Ionized calcium should be maintained above 1.0 mmol/L. Serial hemoglobin or hematocrit measurements should be obtained, keeping in mind that initial values may not reflect true blood loss due to hemoconcentration.

Emergency Department Thoracotomy and REBOA

Resuscitative thoracotomy is indicated for penetrating thoracic trauma with witnessed cardiac arrest or agonal rhythms. It allows open cardiac massage, cross-clamping of the descending aorta, and repair of cardiac injuries.

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is a percutaneous alternative to aortic cross-clamping for non-compressible torso hemorrhage. The balloon is positioned in Zone 1 (supraceliac) or Zone 3 (infrarenal) of the aorta.

Clinical Pearls

Ketamine is the induction agent of choice for the hemodynamically unstable trauma patient; propofol and thiopental may cause cardiovascular collapse. The massive transfusion protocol should be activated early rather than late because retrospective identification of massive hemorrhage is associated with worse outcomes. TXA should be given within 3 hours of injury, as administration beyond this window may increase mortality. Permissive hypotension saves lives in hemorrhagic shock but is contraindicated in traumatic brain injury. The lethal triad of hypothermia, acidosis, and coagulopathy is the enemy, and aggressive prevention through warming, balanced transfusion, and limiting crystalloid is fundamental to damage control resuscitation.

References

1. CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2). Lancet. 2010;376(9734):23-32.
2. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma (PROPPR Trial). JAMA. 2015;313(5):471-482.
3. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Manual. 10th ed. Chicago, IL: ACS; 2018.
4. Cannon JW. Hemorrhagic shock. N Engl J Med. 2018;378(4):370-379.

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