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Anesthesia for adult trauma patients

Samuel Galvagno, DO, PhD, FCCM
Maureen McCunn, MD, MIPP, FCCM
Section Editors
Michael Avidan, MD
Maria E Moreira, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA


Although the most critically injured patients are ideally transported to a designated trauma center, anesthesiologists in other hospitals may provide care for a patient who requires immediate surgical or other interventions after traumatic injury.

This topic reviews anesthetic management of adult trauma patients. Other topics address immediate management of trauma patients upon arrival to the emergency department and initial decisions regarding diagnostic, surgical, and other interventions:

(See "Initial management of trauma in adults".)

(See "Initial evaluation of shock in the adult trauma patient and management of NON-hemorrhagic shock".)

(See "Overview of damage control surgery and resuscitation in patients sustaining severe injury".)

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Literature review current through: Oct 2017. | This topic last updated: Sep 21, 2017.
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  1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
  2. McCunn M, Dutton RP, Dagal A, et al. Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist? Anesth Analg 2015; 121:1668.
  3. Abcejo AS, Savica R, Lanier WL, Pasternak JJ. Exposure to Surgery and Anesthesia After Concussion Due to Mild Traumatic Brain Injury. Mayo Clin Proc 2017; 92:1042.
  4. Behrens V, Dudaryk R, Nedeff N, et al. The Ryder Cognitive Aid Checklist for Trauma Anesthesia. Anesth Analg 2016; 122:1484.
  5. Tobin JM, Grabinsky A, McCunn M, et al. A checklist for trauma and emergency anesthesia. Anesth Analg 2013; 117:1178.
  6. Hagberg CA, Kaslow O. Difficult airway management algorithm in trauma updated by COTEP. ASA Newsletter 2014; 78:56.
  7. Miraflor E, Chuang K, Miranda MA, et al. Timing is everything: delayed intubation is associated with increased mortality in initially stable trauma patients. J Surg Res 2011; 170:286.
  8. Jain U, McCunn M, Smith CE, Pittet JF. Management of the Traumatized Airway. Anesthesiology 2016; 124:199.
  9. Kummer C, Netto FS, Rizoli S, Yee D. A review of traumatic airway injuries: potential implications for airway assessment and management. Injury 2007; 38:27.
  10. Lewis P, Wright C. Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access. Emerg Med J 2015; 32:463.
  11. Engels PT, Erdogan M, Widder SL, et al. Use of intraosseous devices in trauma: a survey of trauma practitioners in Canada, Australia and New Zealand. Can J Surg 2016; 59:374.
  12. Reitsma S, Slaaf DW, Vink H, et al. The endothelial glycocalyx: composition, functions, and visualization. Pflugers Arch 2007; 454:345.
  13. Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg 2011; 254:598.
  14. Hess JR, Holcomb JB, Hoyt DB. Damage control resuscitation: the need for specific blood products to treat the coagulopathy of trauma. Transfusion 2006; 46:685.
  15. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007; 62:307.
  16. Ansari BM, Zochios V, Falter F, Klein AA. Physiological controversies and methods used to determine fluid responsiveness: a qualitative systematic review. Anaesthesia 2016; 71:94.
  17. Hasanin A. Fluid responsiveness in acute circulatory failure. J Intensive Care 2015; 3:50.
  18. Bentzer P, Griesdale DE, Boyd J, et al. Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids? JAMA 2016; 316:1298.
  19. Meyer DE, Vincent LE, Fox EE, et al. Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality. J Trauma Acute Care Surg 2017; 83:19.
  20. 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: the PROPPR randomized clinical trial. JAMA 2015; 313:471.
  21. Sisak K, Soeyland K, McLeod M, et al. Massive transfusion in trauma: blood product ratios should be measured at 6 hours. ANZ J Surg 2012; 82:161.
  22. Curry N, Davis PW. What's new in resuscitation strategies for the patient with multiple trauma? Injury 2012; 43:1021.
  23. Morrison JJ, Ross JD, Dubose JJ, et al. Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: findings from the MATTERs II Study. JAMA Surg 2013; 148:218.
  24. Stinger HK, Spinella PC, Perkins JG, et al. The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital. J Trauma 2008; 64:S79.
  25. Schöchl H, Nienaber U, Hofer G, et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010; 14:R55.
  26. Holcomb JB, Minei KM, Scerbo ML, et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients. Ann Surg 2012; 256:476.
  27. Kozek-Langenecker SA, Ahmed AB, Afshari A, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016. Eur J Anaesthesiol 2017; 34:332.
  28. Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100.
  29. Hiippala ST, Myllylä GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 1995; 81:360.
  30. Li J, Sun SL, Tian JH, et al. Cell salvage in emergency trauma surgery. Cochrane Database Syst Rev 2015; 1:CD007379.
  31. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma 2011; 70:652.
  32. David JS, Godier A, Dargaud Y, Inaba K. Case scenario: management of trauma-induced coagulopathy in a severe blunt trauma patient. Anesthesiology 2013; 119:191.
  33. Chang R, Cardenas JC, Wade CE, Holcomb JB. Advances in the understanding of trauma-induced coagulopathy. Blood 2016; 128:1043.
  34. CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376:23.
  35. CRASH-2 collaborators, Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 2011; 377:1096.
  36. Fahrendorff M, Oliveri RS, Johansson PI. The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products - A systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2017; 25:39.
  37. Hunt H, Stanworth S, Curry N, et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev 2015; :CD010438.
  38. Schöchl H, Schlimp CJ. Trauma bleeding management: the concept of goal-directed primary care. Anesth Analg 2014; 119:1064.
  39. Maegele M, Nardi G, Schöchl H. Hemotherapy algorithm for the management of trauma-induced coagulopathy: the German and European perspective. Curr Opin Anaesthesiol 2017; 30:257.
  40. Winearls J, Mitra B, Reade MC. Haemotherapy algorithm for the management of trauma-induced coagulopathy: an Australian perspective. Curr Opin Anaesthesiol 2017; 30:265.
  41. Forsythe SM, Schmidt GA. Sodium bicarbonate for the treatment of lactic acidosis. Chest 2000; 117:260.
  42. Serpa Neto A, Hemmes SN, Barbas CS, et al. Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis. Anesthesiology 2015; 123:66.
  43. PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology, Hemmes SN, Gama de Abreu M, et al. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet 2014; 384:495.
  44. Gu WJ, Wang F, Liu JC. Effect of lung-protective ventilation with lower tidal volumes on clinical outcomes among patients undergoing surgery: a meta-analysis of randomized controlled trials. CMAJ 2015; 187:E101.
  45. Guay J, Ochroch EA. Intraoperative use of low volume ventilation to decrease postoperative mortality, mechanical ventilation, lengths of stay and lung injury in patients without acute lung injury. Cochrane Database Syst Rev 2015; :CD011151.
  46. Yang D, Grant MC, Stone A, et al. A Meta-analysis of Intraoperative Ventilation Strategies to Prevent Pulmonary Complications: Is Low Tidal Volume Alone Sufficient to Protect Healthy Lungs? Ann Surg 2016; 263:881.
  47. Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013; 369:428.
  48. Herff H, Paal P, von Goedecke A, et al. Influence of ventilation strategies on survival in severe controlled hemorrhagic shock. Crit Care Med 2008; 36:2613.
  49. Sikorski RA, Koerner KA, Fouche-Weber LY, Galvagno SM. Choice of general anesthetics for trauma patients. Curr Anesthesiol Rep 2014; 4:225.
  50. Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother 2014; 48:62.
  51. Herbstritt A, Amarakone K. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation? Emerg Med J 2012; 29:256.
  52. Head BP, Patel P. Anesthetics and brain protection. Curr Opin Anaesthesiol 2007; 20:395.
  53. Beck-Schimmer B, Breitenstein S, Urech S, et al. A randomized controlled trial on pharmacological preconditioning in liver surgery using a volatile anesthetic. Ann Surg 2008; 248:909.
  54. Julier K, da Silva R, Garcia C, et al. Preconditioning by sevoflurane decreases biochemical markers for myocardial and renal dysfunction in coronary artery bypass graft surgery: a double-blinded, placebo-controlled, multicenter study. Anesthesiology 2003; 98:1315.
  55. Hofstetter C, Boost KA, Flondor M, et al. Anti-inflammatory effects of sevoflurane and mild hypothermia in endotoxemic rats. Acta Anaesthesiol Scand 2007; 51:893.
  56. Lee HT, Emala CW, Joo JD, Kim M. Isoflurane improves survival and protects against renal and hepatic injury in murine septic peritonitis. Shock 2007; 27:373.
  57. Lee JJ, Li L, Jung HH, Zuo Z. Postconditioning with isoflurane reduced ischemia-induced brain injury in rats. Anesthesiology 2008; 108:1055.
  58. Reutershan J, Chang D, Hayes JK, Ley K. Protective effects of isoflurane pretreatment in endotoxin-induced lung injury. Anesthesiology 2006; 104:511.
  59. De Hert SG, Turani F, Mathur S, Stowe DF. Cardioprotection with volatile anesthetics: mechanisms and clinical implications. Anesth Analg 2005; 100:1584.
  60. de Vasconcellos K, Sneyd JR. Nitrous oxide: are we still in equipoise? A qualitative review of current controversies. Br J Anaesth 2013; 111:877.
  61. Enlund M, Edmark L, Revenäs B. Is nitrous oxide a real gentleman? Acta Anaesthesiol Scand 2001; 45:922.
  62. Myles PS, Leslie K, Chan MT, et al. Avoidance of nitrous oxide for patients undergoing major surgery: a randomized controlled trial. Anesthesiology 2007; 107:221.
  63. Dutton RP. Resuscitative strategies to maintain homeostasis during damage control surgery. Br J Surg 2012; 99 Suppl 1:21.
  64. Lin JY, Hung LM, Lai LY, Wei FC. Kappa-opioid receptor agonist protects the microcirculation of skeletal muscle from ischemia reperfusion injury. Ann Plast Surg 2008; 61:330.
  65. Puana R, McAllister RK, Hunter FA, et al. Morphine attenuates microvascular hyperpermeability via a protein kinase A-dependent pathway. Anesth Analg 2008; 106:480.
  66. Messina AG, Wang M, Ward MJ, et al. Anaesthetic interventions for prevention of awareness during surgery. Cochrane Database Syst Rev 2016; 10:CD007272.
  67. Schneider G. [Intraoperative awareness]. Anasthesiol Intensivmed Notfallmed Schmerzther 2003; 38:75.
  68. Borzova V, Smith CE. Monitoring and prevention of awareness in trauma anesthesia. Internet J Anesth 2009; 23:1.
  69. Warren J, Fromm RE Jr, Orr RA, et al. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004; 32:256.
  70. Shere-Wolfe RF, Galvagno SM Jr, Grissom TE. Critical care considerations in the management of the trauma patient following initial resuscitation. Scand J Trauma Resusc Emerg Med 2012; 20:68.
  71. Morrison JJ, Ross JD, Markov NP, et al. The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. J Surg Res 2014; 191:423.
  72. Gelman S. The pathophysiology of aortic cross-clamping and unclamping. Anesthesiology 1995; 82:1026.
  73. Jain V, Chari R, Maslovitz S, et al. Guidelines for the Management of a Pregnant Trauma Patient. J Obstet Gynaecol Can 2015; 37:553.
  74. Suresh MS, Wali A. Failed intubation in obstetrics: airway management strategies. Anesthesiol Clin North Am 1998; 16:477.
  75. Johnson MD, Ostheimer GW. Airway management in obstetric patients. Sem Anesth 1992; 1:1.
  76. Cheng V, Inaba K, Johnson M, et al. The impact of pre-injury controlled substance use on clinical outcomes after trauma. J Trauma Acute Care Surg 2016; 81:913.
  77. Demetriades D, Gkiokas G, Velmahos GC, et al. Alcohol and illicit drugs in traumatic deaths: prevalence and association with type and severity of injuries. J Am Coll Surg 2004; 199:687.
  78. Chapman R, Plaat F. Alcohol and anaesthesia. Contin Educ Anaesth Crit Care Pain 2009; 9:10.
  79. Adams C. Anaesthetic implications of acute and chronic alcohol abuse. S Afr J Anaesthesiol Analg 2010; 16:42.
  80. Aguayo LG, Peoples RW, Yeh HH, Yevenes GE. GABA(A) receptors as molecular sites of ethanol action. Direct or indirect actions? Curr Top Med Chem 2002; 2:869.
  81. Spies CD, Rommelspacher H. Alcohol withdrawal in the surgical patient: prevention and treatment. Anesth Analg 1999; 88:946.
  82. Schiødt FV, Rochling FA, Casey DL, Lee WM. Acetaminophen toxicity in an urban county hospital. N Engl J Med 1997; 337:1112.
  83. Hernandez M, Birnbach DJ, Van Zundert AA. Anesthetic management of the illicit-substance-using patient. Curr Opin Anaesthesiol 2005; 18:315.
  84. Bala N, Kaur G, Attri JP, et al. Psychiatric and anesthetic implications of substance abuse: Present scenario. Anesth Essays Res 2015; 9:304.
  85. Kram B, Kram SJ, Sharpe ML, et al. Analgesia and Sedation Requirements in Mechanically Ventilated Trauma Patients With Acute, Preinjury Use of Cocaine and/or Amphetamines. Anesth Analg 2017; 124:782.
  86. Lange RA, Hillis LD. Cardiovascular complications of cocaine use. N Engl J Med 2001; 345:351.
  87. Murphy JL Jr. Hypertension and pulmonary oedema associated with ketamine administration in a patient with a history of substance abuse. Can J Anaesth 1993; 40:160.
  88. Jatlow P, Barash PG, Van Dyke C, et al. Cocaine and succinylcholine sensitivity: a new caution. Anesth Analg 1979; 58:235.
  89. Goldfrank, LR, Flomenbaum, et al. Goldfrank's Toxicologic Emergencies, 8th Ed, McGraw-Hill Medical Publishing Division, 2006.
  90. Vadivelu N, Mitra S, Kaye AD, Urman RD. Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient. Best Pract Res Clin Anaesthesiol 2014; 28:91.
  91. Pulley DD. Preoperative Evaluation of the Patient with Substance Use Disorder and Perioperative Considerations. Anesthesiol Clin 2016; 34:201.
  92. Symons IE. Cannabis smoking and anaesthesia. Anaesthesia 2002; 57:1142.
  93. Mills PM, Penfold N. Cannabis abuse and anaesthesia. Anaesthesia 2003; 58:1125.
  94. Tait RJ, Caldicott D, Mountain D, et al. A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol (Phila) 2016; 54:1.
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