Key strategies in trauma anesthesia for severe hemorrhage: a narrative review

Abstract

Trauma anesthesia demands a high level of expertise. In this context, anesthesiologists are required to manage complex physiology and rapidly evolving scenarios in critically injured patients, who often present profound hemodynamic instability. In addition to providing intraoperative anesthesia, trauma anesthesiologists serve as active resuscitationists and are key players in the trauma team from the moment of the patient’s arrival. General trauma resuscitation follows the ABCDE approach. The key areas of trauma anesthesia include airway management (A, airway), with rapid sequence induction and strategies for handling difficult airways; ventilation techniques (B, breathing) aimed at protecting the traumatized lungs under pressure; and hemodynamic resuscitation (C, circulation), which incorporates permissive hypotension, implementing massive transfusion protocols, and managing trauma-induced coagulopathy. Neuromonitoring and brain protection (D, disability) are crucial in cases of traumatic brain and spinal cord injuries, requiring precise blood pressure control and intracranial pressure monitoring. Advanced monitoring techniques (E, exposure), which include point-of-care ultrasound and invasive hemodynamic assessment, further enhance intraoperative decision-making. Above all, effective trauma anesthesia hinges on seamless interdisciplinary collaboration (F, force), with decision-making shared between anesthesiologists and trauma surgeons in high-risk surgeries. In this review, we highlight the pivotal role of trauma anesthesiologists in severe hemorrhage management, one of the most critical challenges in trauma resuscitation, and emphasize that an integrated, proactive approach is essential not only for improving immediate survival, but also for optimizing long-term recovery of the patient.

Introduction

Trauma remains one of the leading causes of morbidity and mortality in all age groups [1,2]. Trauma anesthesia is a critical and demanding medical subspecialty that requires rapid and precise decision-making in high-risk scenarios. Trauma patients often present with complex, multifactorial challenges, including massive transfusion for massive hemorrhage, hemodynamic instability, airway compromise, and potential neurological injuries. Each phase of patient care, from initial resuscitation to intraoperative management and stabilization, requires a tailored multidisciplinary approach to optimize outcomes.

Anesthesiologists play a key role in trauma care. They have to navigate dynamic physiology and unpredictable events from the patient’s arrival at the hospital to the postoperative critical care phase. In patients with severe abdominal injuries, each 3-min delay in bleeding control is associated with a 1% increase in mortality risk [3]. The “golden hour” principle emphasizes the importance of timely intervention, as early and decisive action can significantly impact survival [4]. Damage-control resuscitation (DCR) is a strategic approach for addressing life-threatening problems. Unlike standard treatment planning, which is based on a complete diagnosis, patients with traumatic injuries require immediate intervention as time is of the essence. In such uncertain and rapidly changing situations, clinicians must prioritize and treat the most pressing issues without delay. Hemorrhage that is life-threatening often necessitates surgical intervention. In such cases, patients may be taken directly to the operating room (OR) without a definitive diagnostic confirmation. Consequently, while the surgeon focuses on controlling the hemorrhage, the anesthesiologist must manage the patient's overall physiological status and should ensure the continuity of the resuscitative efforts initiated in the resuscitation bay. This represents a shift from the anesthesiologist’s conventional role of confirming potential risks and focusing primarily on anesthesia management toward a novel role that involves actively identifying underlying problems and dynamically making diagnoses in response to evolving clinical situations.

In the early phase of trauma care, patients most commonly die from hemorrhage; therefore, DCR primarily focuses on hemorrhage control. DCR typically includes damage-control surgery to stop the bleeding, permissive hypotension to prevent exacerbation of hemorrhage due to elevated blood pressure, and early blood transfusion to treat trauma-induced coagulopathy [5]. Anesthesiologists must be well versed in the principles of DCR, as the practice of trauma anesthesia demands a careful balance between rapid intervention and deliberated clinical judgment to ensure patient safety and maintain hemodynamic stability. This delicate balance has been supported by technological advances, which have allowed expansion of the scope and precision of trauma anesthesiology.

In this review, we explore the key aspects of traumatic anesthesia, particularly in cases of severe hemorrhage and hemodynamic instability. Trauma resuscitation must continue seamlessly into the OR. Trauma resuscitation follows the ABCDE approach, although recent paradigms have introduced the xABCDE sequence, in which “x” stands for exsanguination, emphasizing the need for immediate control of compressible hemorrhage [6]. However, since the primary focus of “x” is rapid bleeding control, rather than a reorganization of overall resuscitative priorities, we retain the conventional ABCDE structure in this review, to emphasize the anesthesiologist's critical role in managing the airway (A), breathing (B), circulation (C), disability and brain and spinal cord protection (D), and advanced monitoring, point-of-care ultrasound, and coagulation assessment (E, exposure). By synthesizing current evidence and clinical insights, we seek to provide a structured, evidence-based framework to enhance clinical decision-making and improve outcomes for critically injured patients.

Beyond anesthesia: the trauma anesthesiologist as a frontline resuscitationist

Resuscitation leadership and takeover

When a trauma patient is transferred from the resuscitation bay (trauma bay) to the OR, the anesthesiologist plays a pivotal role in the ongoing resuscitation [7]. This responsibility requires a rapid albeit thorough assessment of the patient’s condition, while ensuring a seamless handover from the trauma team. Key tasks include determining the current phase of the massive transfusion protocol (MTP), evaluating hemodynamic stability, confirming airway security, and verifying the placement of arterial or central venous lines. Additionally, whenever feasible, issues such as fasting status, prior cardiopulmonary resuscitation events, and preexisting medical conditions should be clarified.

Beyond resuscitation, anesthesiologists must optimize the OR environment by ensuring integration of the immediate life-saving priorities of the trauma bay with the technical precision of the surgical suite. Patients with trauma are highly susceptible to hypothermia, which is a component of the lethal triad; thus, thermal management requires special attention. This includes pre-warming of the OR, using active warming devices, such as forced-air warming blankets or fluid warmers, and minimizing the patient’s exposure to maintain the core temperature and prevent coagulopathy [8]. A seamless transition will enable the trauma surgeon to shift focus from the initial resuscitation to definitive surgery, while the anesthesiologist ensures optimal patient management through clear communication, rapid clinical decision-making, and a readiness for dynamic clinical changes. Mastering this process as a coordinated effort between anesthesiologists and the trauma surgical team enhances patient survival, regardless of when emergencies arise [9].

In cases of severe trauma, patients commonly present to the OR without basic diagnostic evaluations, relevant medical histories, or preoperative computed tomography imaging. While the surgeon focuses on surgical intervention, the anesthesiologist should perform continuous physiological assessments, including point-of-care ultrasound (POCUS) for pulmonary or cardiac evaluation, and electroencephalography (EEG) for cerebral monitoring. By actively integrating the trauma team and optimizing the resuscitation-to-surgery transition, anesthesiologists contribute directly to improving the survival outcomes of critically injured patients.

Direct-to-OR: the ultimate test of anesthesiologist-led resuscitation

Direct-to-OR (DOR) is among the most demanding forms of anesthesiologist-led resuscitation. This trauma care strategy involves transport of critically injured patients directly from the prehospital setting, such as the scene of injury, ambulance, or helicopter, to the OR for immediate resuscitation and surgical intervention, bypassing traditional resuscitation areas, such as the emergency department or trauma bay [10,11].

The primary objective of DOR is to minimize delays in life-saving procedures, particularly delays in hemorrhage control, which is a time-critical task. Delays in early resuscitative intervention have been associated with decreased survival [12]. Within the OR, anesthesiologists typically assume the role of team leader; therefore, in cases of DOR resuscitation, they are naturally positioned to lead resuscitative efforts.

The decision to implement DOR is typically made by the trauma teams based on prehospital findings, including injury patterns and physiology. The DOR program is not only effective in identifying severely injured patients requiring life-saving interventions or emergency surgery, but also contributes to improved survival in selected time-sensitive subgroups [13,14].

DOR represents a paradigm shift for anesthesiologists who are accustomed to structured preoperative assessments and preparations. In some cases, the anesthesiologist must initiate anesthesia induction and resuscitation simultaneously, often without preexisting intravenous or arterial lines. While surgeons focus on controlling the primary source of hemorrhage, anesthesiologists play a critical role in coordinating ongoing resuscitation and identifying hidden injuries under extreme time constraints. Despite the potential benefits of DOR, the patients that are most likely to benefit remain unclear, underscoring the need for further research and the development of institution-specific protocols tailored to local conditions and patient populations [15–17].

Airway: mastering airway challenges

Difficult airways

Airway management in patients with trauma, particularly cases involving cervical spine immobilization, uncertain fasting status, an inability to position the patient, blunt facial and/or thoracic injuries, the presence of vomitus or blood in the airway, and penetrating neck injuries, presents unique challenges [18]. The abovementioned scenarios are frequently classified as difficult airways because associated factors, such as damaged dentition, soft tissue trauma, hematomas, or active bleeding, can hinder laryngoscope insertion, obstruct the intubator’s view, and impede endotracheal tube placement. Additionally, displaced soft tissues may obstruct the vocal cords during bag-mask ventilation after neuromuscular blockade (NMBA) administration. Furthermore, even a single drop of blood on a videolaryngoscope lens can obscure the operator’s view entirely, necessitating the use of alternative devices or techniques. Given these complexities, airway management in trauma should always be approached as potentially difficult, and thorough preparation should be made for emergency scenarios [19].

Rapid sequence intubation protocol: toward first-pass intubation success

In trauma cases, rapid sequence induction is the standard approach. Thorough preparation is paramount. Yankauer suction and suction lines must be immediately available, and the operating table should be positioned to allow a rapid head-down tilt to reduce the aspiration risk in cases of regurgitation. Equipment readiness includes availability of a preloaded stylet with an appropriately sized endotracheal tube, a balloon syringe, and a timer for monitoring the fast-onset NMBA effect (60–90 s). First-pass intubation success is vital, as additional trauma can further distort an already injured airway and may render further noninvasive attempts impossible.

For patients in whom neck extension is restricted or in whom difficult airways are suspected, a hyperangulated videolaryngoscope blade can significantly improve glottic visualization [20]. Fiberoptic bronchoscopy can provide guidance for the proper airway within the confines of limited mouth opening. Although the efficacy of applying cricoid pressure remains controversial and current guidelines do not uniformly endorse its use, they acknowledge that such pressure may be applied selectively and released if it impedes laryngoscopy or intubation. However, even when performed by skilled personnel using proper techniques, this could still be considered in high-risk situations [21–23]. Meticulous preparation and a clear backup plan, including the readiness for providing a surgical airway, are essential for managing airway challenges in trauma settings.

Unanticipated difficult airway: from videolaryngoscopy to surgical airway

In critically ill patients, videolaryngoscopy is generally superior to direct laryngoscopy for better glottic visualization and higher first-pass success rates [24].

In contrast to patients without trauma, airway management in patients with trauma often necessitates earlier escalation to surgical airway intervention, due to anatomical distortion, direct airway injury, or rapidly worsening physiological or anatomical conditions. If the first intubation attempt fails, noninvasive airway management should be initiated, and if effective, a subsequent intubation attempt may be considered. However, the cause of the initial failure should be considered, and changes such as switching to a different device or operators should be deliberated. In cases where adequate oxygenation cannot be maintained, even a single failed attempt may necessitate immediate transition to a surgical airway [19]. Although tracheostomy is a representative surgical airway, it is generally inappropriate in emergent, time-critical situations and is thus excluded as a first-line option. Cricothyroidotomy is the procedure of choice in these settings. Therefore, in patients with anticipated airway difficulty, the trauma surgeon may be asked to prepare for cricothyroidotomy to allow its immediate implementation, if necessary. In cases of severe trauma, the trachea may also be exposed externally, allowing direct tracheal intubation when necessary (Fig. 1).

Fig. 1.

Direct tracheal intubation through the wound in a case of severe trauma in which the trachea was exposed.

Choosing induction agents in hemodynamically unstable trauma patients

The choice of anesthetic induction agent in trauma patients is critical, as it directly affects cardiovascular stability, airway security, and overall outcomes. Patients with major trauma frequently have significant physiological derangements and require cautious titration of induction agents to avoid exacerbation of hypotension. Even patients who initially appear hemodynamically stable may experience dramatic decreases in blood pressure. This phenomenon, known as postintubation hypotension, may be associated with the use of specific drugs and the severity of injury [25]. Vasopressor use during intubation has been considered to prevent postintubation hypotension, but the effectiveness of this approach remains unclear [26].

Ketamine and etomidate are preferred in hemodynamically unstable patients because they have a minimal impact on blood pressure. Although many studies have compared ketamine with etomidate, neither agent has demonstrated clear superiority [27,28]. Ketamine has historically been contraindicated in patients with traumatic brain injury because of concerns about increasing intracranial pressure (ICP). However, recent evidence has suggested that its effect on ICP is minimal, and its use is considered acceptable when it is clinically indicated [29,30]. Other agents, including propofol and midazolam, may also be used; however, careful selection is needed, as each has specific advantages and limitations (Table 1).

Table 1.

Induction Agents for Rapid Sequence Intubation in Trauma Patients

Pharmacological profiles	Etomidate	Ketamine	Propofol	Midazolam
Dose	0.2–0.3 mg/kg	1–2 mg/kg	1–2 mg/kg	0.2 mg/kg
Onset	10–20 s	30–40 s	9–20 s	1–3 min
Advantage	Rapid onset	Analgesic effect	Rapid onset	Decreased ICP
	Little effect on hemodynamic status	Maintain blood pressure in hypovolemic patients	Short duration of action	No pain at injection site
		Preserve respiratory drive		Availability of reversal agent
Disadvantage	Possible adrenal suppression	Increased airway secretions	Reduce vascular resistance	Possible hypotension
	Pain at injection site	May increase ICP (?)	Cardiac depressant	Long duration of action
	Myoclonic movement	Hallucination
Consideration	No analgesic effect	Cardiovascular effect	Hypotension	Amnesia effect
	Amnesia effect

ICP: intracranial pressure. (?) Indicates controversial evidence. Historical concerns about ICP elevation have not been consistently demonstrated in contemporary studies with controlled ventilation.

Remimazolam may also be considered in trauma patients with hemodynamic instability, given its relatively favorable profile in terms of respiratory depression, systemic vascular tone, and myocardial function as compared to other induction agents [31,32]. In clinical practice, remimazolam has been used successfully in cardiac surgery and trauma cases with limited cardiopulmonary reserve; however, its relatively slow onset limits its applicability in emergency settings [33,34]. Hence, further investigation into its use and dosing in trauma populations is warranted.

Breath: mechanical ventilation strategies for traumatized lungs

Although mechanical ventilation is typically considered as being within the domain of intensive care, trauma anesthesiologists must be cognizant of ventilatory principles as they directly and immediately influence patient survival. Lung-protective strategies should be applied consistently, regardless of whether the injury involves blunt, penetrating, or even chest trauma, as the basic goals remain the same: minimize ventilator-induced lung injury and maintain adequate gas exchange [35,36]. Even in cases of suspected or confirmed lung injury, such as pulmonary contusion or pneumothorax, protective ventilation remains the preferred approach because of the potential for worsening air leaks or barotrauma under excessive pressure.

Low tidal volume ventilation, typically 6–8 ml/kg of predicted body weight, is recommended for preventing volutrauma or barotrauma. Positive end-expiratory pressure (PEEP) can be applied with careful consideration, with typical levels ranging from 5 to 10 cmH₂O, balancing the need for preventing atelectasis with avoidance of exacerbating the underlying air leak syndromes. In cases of chest trauma, PEEP use can be beneficial: recent animal studies have demonstrated that high PEEP may help prevent progression to acute respiratory distress syndrome (ARDS) [37,38]. However, patients with chest trauma may be more susceptible to complications, such as barotrauma; therefore, careful monitoring and a cautious approach are essential. Although high levels of PEEP were previously thought to increase ICP, recent evidence has suggested that PEEP can be safely applied in patients with traumatic brain injury without significantly increasing ICP [39]. The fraction of inspired oxygen (FiO₂) should be titrated to avoid unnecessary hyperoxia [40]. In most cases, maintaining the SpO₂ around 95% is sufficient. Even in polytrauma patients with brain injury, arterial partial pressure of oxygen should be maintained between 60 and 100 mmHg during the intervention [41]. Overventilation causing hypocapnia must be avoided, particularly in patients with suspected or confirmed traumatic brain injury, because this can lead to cerebral vasoconstriction, reduced cerebral perfusion, or worsened secondary brain injury. Although hyperventilation may temporarily lower ICP, current guidelines advise against prolonged prophylactic use with PaCO₂ < 25 mmHg [42]; normocapnia should be the target whenever feasible. These principles provide a practical and physiologically sound foundation for ventilatory management in trauma patients, and emphasize the need to minimize iatrogenic harm while ensuring adequate oxygenation and ventilation.

Circulation: hemodynamics, coagulation, and blood strategy

Blood pressure management in shock: permissive hypotension and hemodynamic context

Blood pressure is a critical parameter in trauma-induced shock cases, particularly in those with massive hemorrhage. A normal initial blood pressure reading may provide reassurance, while an elevated blood pressure suggests relative, although often temporary, stability. In contrast, hypotension is associated with significant hemorrhage and requires immediate intervention.

Although permissive hypotension is emphasized in the trauma field, it is not necessarily acceptable. Rather, this focus reflects concerns that aggressive fluid resuscitation or vasopressor use to elevate blood pressure before hemorrhage control may be harmful. This underscores the importance of achieving rapid hemostasis while maintaining a minimal level of tissue perfusion. Tissue perfusion can be assessed using indicators such as urine output, lactate clearance, or central venous oxygen saturation [43]. When available, device-derived indices, such as the perfusion index, can provide additional noninvasive information on peripheral circulation. In urgent situations where additional equipment is lacking, simple peripheral perfusion monitoring techniques, such as capillary refill assessment, may be useful, although their interpretation should always consider the clinical context and available resources [44]. Maintaining blood pressure is critically important when adequate perfusion cannot be ensured [5,45].

Many patients with trauma arrive at the hospital with an invasive arterial line, which allows continuous real-time blood pressure monitoring. However, a single snapshot of blood pressure does not convey the whole story; reviewing the patient’s hemodynamic history, including prior hypotension episodes, vasopressor and inotropic use, can provide insight into the resuscitation trajectory and physiological reserve. In some cases, patients may appear hemodynamically stable because of ongoing massive transfusions or resuscitative endovascular balloon occlusion of the aorta support. Given that aortic manipulation is common in abdominal or thoracic surgery, placement of an arterial line in the upper extremity is generally preferred. Advanced real-time hemodynamic monitoring, including pulse pressure variation (PPV) and stroke volume variation (SVV), can guide fluid responsiveness and resuscitation strategies [46]. In patients with lung injury, conditions such as hemothorax, hemoperitoneum, or reduced lung compliance may reduce the reliability of PPV and SVV. Nevertheless, meta-analyses have suggested that these indices can provide meaningful information even under conditions of low tidal volume ventilation or reduced compliance [47].

Judicious use of vasopressors and inotropes: balancing perfusion and bleeding risk

Aggressively increasing blood pressure with large volumes of fluid or vasopressors can worsen bleeding and impair coagulation; therefore, allowing permissive hypotension until definitive hemorrhage control is achieved is generally recommended. The optimal target systolic blood pressure remains controversial, but the general consensus is preserving adequate organ perfusion without provoking excessive hemorrhage and tailoring the target to the individual physiology. For example, in cases of traumatic brain injury, permissive hypotension is not advised because maintaining cerebral perfusion pressure (CPP) is crucial for preventing secondary brain injury [48].

Vasopressors and inotropes might play critical roles in trauma-induced shock, but must be used judiciously based on institutional protocols and patient-specific needs [49]. Vasopressors, such as norepinephrine, are used to maintain systemic vascular resistance in cases of distributive or refractory shock. Inotropes, such as dobutamine or epinephrine, may support myocardial contractility in cardiogenic or mixed shock states. Recent findings linking circulatory shock to arginine vasopressin deficiency have renewed interest in the potential role of vasopressin in shock management [50].

Vasopressors have generally been used with caution in cases of hemorrhagic shock because of concerns about worsening ischemia and increasing mortality. However, recent evidence suggests that low-dose vasopressors may reduce transfusion requirements without negatively impacting survival [51]. High-quality evidence on the early use of vasopressors remains limited and , blood pressure management should continue to prioritize hemorrhage control and volume replacement because excessive vasopressor use has been linked to increased mortality [52,53].

Rather than pursuing a fixed numeric target, blood pressure management in trauma cases should be individualized and must be guided by indicators of tissue perfusion, with the optimal goal determined by the pathophysiology and clinical context. Focused and adaptive strategies are essential for improving the outcomes of patients with severe shock.

Trauma-induced coagulopathy: why it matters?

Trauma-induced coagulopathy (TIC) is a complex and multifactorial hemostatic disorder observed in severely injured patients. Although no universally accepted definition has been established, TIC is increasingly recognized as a distinct, early coagulopathic state that develops rapidly after trauma, independent of iatrogenic dilution or hypothermia [54]. Traditionally, TIC has been attributed to consumptive or dilutional coagulopathy secondary to massive hemorrhage. However, recent studies have highlighted the pivotal role of endogenous mechanisms triggered by tissue injury, hypoperfusion, endothelial dysfunction, and inflammation. Key pathophysiological pathways include protein C pathway activation, platelet dysfunction, hyperfibrinolysis, and disruption of endothelial glycocalyx integrity, all of which contribute to impaired clot formation and increased bleeding risk [55]. Therefore, even within the TIC spectrum, the mechanisms underlying bleeding may vary, and in some cases, a hypercoagulable state may be present. Consequently, individualized treatment strategies have gained increased attention.

Two major approaches have emerged in the management of TIC:

1) MTPs: MTPs involve empirical use of fixed-ratio component therapy (e.g., 1:1:1 ratio of plasma:platelets:red blood cells [RBCs]) aimed at early correction of coagulopathy while awaiting laboratory confirmation.

2) Patient blood management (PBM): PBM is a goal-directed strategy utilizing point-of-care tools to overcome the limitations of MTPs and optimize individualized hemostatic resuscitation.

Massive transfusion protocols: when, how, and why to start

Purpose and principles of MTPs

Massive transfusion is commonly defined as the administration of 10 or more units of RBCs within 24 hours, whereas MTPs are protocols designed for the rapid delivery of balanced transfusion rapidly to exsanguinating patients. Accordingly, the MTP initiation criteria, transfusion ratios, and composition and volume of each cycle may vary between institutions. Nevertheless, the core principle of an MTP is rapid administration of a predefined balanced transfusion, which reduces mortality in patients with trauma [56]. This effect is thought to result not only from volume restoration but also from the early administration of plasma and other components that contribute to the correction of TIC.

Ratio-based resuscitation and operational considerations

Following the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, an initial transfusion ratio of plasma, platelets, and red blood cells equal to or below 1:1:2 has been recommended [57]. However, in the PROPPR trial, although the overall mortality was similar between groups, the group that received a 1:1:1 ratio showed reduced hemorrhage-related mortality. Therefore, in centers with a high volume of trauma patients, a 1:1:1 transfusion strategy may be considered [58]. However, protocols must be tailored to each institution’s capabilities and logistical constraints. Operational barriers, such as blood bank turnaround time, interdepartmental communication, and product availability, should be addressed through interdisciplinary planning and simulation-based training.

Whole blood and future directions

Historically, transfusion involved the transfer of whole blood. This was followed by the development of treatments involving blood components. However, transfusing blood products in a 1:1:1 ratio essentially recreates the composition of whole blood, suggesting that direct whole-blood transfusion may be preferable. Whole-blood transfusion has been used with demonstrated efficacy in military settings and is again increasingly being adopted in civilian trauma resuscitation, with promising results. Further research in whole-blood transfusion is warranted to clarify its role in modern trauma care [59].

Patient blood management and goal-directed therapy

From product-centered to patient-centered: a paradigm shift

While fixed-ratio transfusion remains the recommended strategy, support for goal-directed strategies, guided by viscoelastic testing to tailor treatment to the patient's needs, is growing. Under the concept of PBM, transfusion medicine has shifted focus from a product-centered model to one that prioritizes patient outcomes [60,61]. Rather than relying solely on fixed ratios, PBM emphasizes individualized care, judicious blood product use, and integration of diagnostic tools to guide hemostatic therapy. This approach aims not only to deliver blood to the patient, but also to provide the right therapy at the right time to the right patient.

Beyond fixed ratios: goal-directed therapy

While traditional MTP involves continuous administration of blood products until hemostasis is achieved, followed by laboratory-guided component therapy, goal-directed therapy emphasizes the use of targeted transfusions that are based on laboratory findings from the outset. Advanced viscoelastic assays, such as thromboelastography and rotational thromboelastometry, enable near-instantaneous assessment of TIC and provide timely guidance for individualized transfusion strategies [62]. These viscoelastic assays support the precise administration of specific blood products, such as fibrinogen concentrate, cryoprecipitate, or prothrombin complex concentrate, based on the patient's real-time coagulation profile. This reflects the core principles of PBM: proactive, data-driven, and patient-specific hemostatic management. Precision hemostatic management improves clinical outcomes, minimizes transfusion-related complications, and promotes efficient use of limited and valuable blood resources [63,64]. The Trauma A5-based algorithm, a well-established algorithm published in the Korean Journal of Anesthesiology, provides a valuable example applicable to massive bleeding and transfusion scenarios (Fig. 2) [65]. Several studies have demonstrated that resuscitation guided by viscoelastic testing can reduce blood product use and improve survival [66].

Fig. 2.

Trauma A5 algorithm (ROTEM) for bleeding management in trauma/orthopedic surgery, providing real-time guidance for the targeted administration of fibrinogen concentrate, fresh frozen plasma (FFP), cryoprecipitate, platelet concentrate or prothrombin complex concentrate (PCC). ISS: Injury Severity Score, TASH: trauma associated severe hemorrhage, A5_EX: amplitude of clot firmness 5 min after coagulation time (CT) in EXTEM, CTFIB: CT in FIBTEM (CTFIB > 600 s reflects a flatline in FIBTEM), ML: maximum lysis (within 1-h run time), A5_FIB: amplitude of clot firmness 5 min after CT in FIBTEM, bw: body weight, CTEX: CT in EXTEM, 4F-PCC: four-factor prothrombin complex concentrate, IU: international units, FFP: fresh frozen plasma, CT_IN: CT in INTEM, CT_HEP: CT in HEPTEM, TXA: tranexamic acid. Reproduced from Görlinger K, Görlinger et al. The role of evidence-based algorithms rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019;72:297-322, with permission from the Korean Society of Anesthesiologists.

Disability: neuromonitoring and brain protection during trauma care

Even in hemorrhage-dominant cases, the actual or suspected presence of neurotrauma necessitates vigilant management to prevent secondary brain injury within the ABCDE framework. Therefore, perioperative anesthetic strategies should incorporate the principles of ICP control, CPP optimization, and neuromonitoring [67].

Permissive hypotension is contraindicated in patients with TBI or suspected spinal cord injury. Instead, systolic blood pressure should be maintained above 100–110 mmHg, or mean arterial pressure ≥ 80 mmHg, to preserve adequate cerebral and spinal perfusion. Hypotension, even briefly, is associated with worse outcomes, including increased mortality and long-term neurological impairment [68,69].

Elevated ICP, whether clinically overt or occult, can be exacerbated by hypoxia, hypercapnia, hypertension, or hypervolemia. Basic neuroprotective strategies, including head elevation and maintaining normocapnia (PaCO₂ 35–40 mmHg), normoxia, and fluid balance should be implemented [42].

POCUS may assist in detecting increased ICP, particularly in resource-limited or time-critical settings. Optic nerve sheath diameter measurements based on ocular ultrasound may provide indirect evidence of elevated ICP [70]. When immediate computed tomography imaging is unavailable, POCUS, processed EEG, and cerebral oximetry may aid in screening for midline shifts or cerebral edema. Although their results are not definitive, these bedside tools can support early decision-making in patients with unstable trauma when neurosurgical consultation is delayed [71]. Anesthesiologists may be the first to detect neurological deterioration during surgery, particularly in patients undergoing thoracoabdominal surgery, highlighting the value of vigilant neuromonitoring even when addressing neurotrauma is not the primary focus.

Exposure: POCUS and advanced monitoring

Intraoperative POCUS: the anesthesiologist as a frontline diagnostician

In trauma cases treated without preoperative imaging or radiological support, the anesthesiologist often assumes the dual role of providing diagnostic and therapeutic guidance, frequently using POCUS in this role. In urgent scenarios, POCUS enables rapid bedside detection of life-threatening thoracic and cardiac conditions, such as tension pneumothorax, hemopericardium, hemoperitoneum, and hemothorax, facilitating immediate targeted intervention [72–74]. When transthoracic echocardiography is hampered by surgical exposure, POCUS—including transesophageal echocardiography and inferior vena cava diameter measurement—can provide continuous intraoperative evaluation of cardiac function and volume status [75,76]. Focused Assessment with Sonography for Trauma (FAST) is a bedside ultrasound technique that evaluates free fluid in the pericardial, right upper, left upper, and suprapubic areas. When extended to the thoracic region for detecting hemothorax or pneumothorax, it is referred to as extended FAST (eFAST) [77]. Further targeted assessments may be performed after eFAST and thoracic or cardiovascular evaluations. Although most available evidence has been derived from non-randomized and non-standardized studies, the increasing reliance on perioperative POCUS highlights the expanding role of anesthesiologists in trauma care. Routine training in POCUS and integration of this modality into trauma protocols are essential.

With real-time and accurate assessments, these findings can be shared with the surgical team to guide decision-making and improve patient outcomes [78,79]. Its clinical applications can be broadened to include gastric POCUS for evaluating fasting status, airway POCUS for confirming endotracheal tube placement or detecting upper airway injury, POCUS-based inferior vena cava diameter measurement for evaluating volume status changes, and transocular POCUS for estimating ICP [80].

Advanced physiological monitoring and technological innovations

Advanced physiological monitoring technologies are essential for real-time assessment and resuscitation guidance in patients with major trauma, particularly in those without complete imaging [81]. These patients often require immediate surgical intervention, which requires rapid data-driven decision-making.

Core tools include invasive arterial pressure monitoring (A-line), for beat-to-beat blood pressure measurement, combined with dynamic parameters, such as PPV and SVV, for evaluating fluid responsiveness. Cerebral oximetry using near-infrared spectroscopy provides insights into cerebral perfusion, while monitoring the depth of anesthesia ensures that sedation is adequate but not excessive. The Oxygen Reserve Index, hemoglobin levels, and indices such as the Pleth Variability Index and Perfusion Index aid in assessing volume status, perfusion, and oxygenation. The Hypotension Prediction Index helps to anticipate and prevent hemodynamic collapse. Five-lead electrocardiography, neuromuscular blockade monitoring, and core or skin temperature are routinely applied, whereas additional modalities, including nociception monitoring and continuous noninvasive blood pressure measurement, can provide indirect yet valuable information on patient status.

Integration of these modalities supports clinicians in dynamically assessing the patient’s physiological status, optimizing resuscitation, and anticipating complications. In trauma cases, monitoring should be prioritized according to the immediate threat to survival, risk of secondary brain injury, need for transfusion, and optimization of oxygen delivery [82,83]. Patients with trauma often arrive in the OR without sufficient preoperative evaluation, and general anesthesia and the ongoing procedure further hamper comprehensive clinical assessment. Therefore, advanced monitoring can provide essential information, such as the detection of extracavitary bleeding or the assessment of brain injury in unconscious patients, which would otherwise be inaccessible intraoperatively. Thus, advanced monitoring compensates for the lack of preoperative laboratory or imaging data, guides PBM and hemodynamic optimization, and ultimately contributes to improved outcomes in patients with severe injuries.

Trauma anesthesia: surgical partnership in high-risk surgery

Partnership between anesthesiologists, surgeons, and critical care teams

In trauma surgery cases, unlike in elective surgery cases, anesthesiologists must engage in continuous diagnostics and immediate interventions to adapt to rapidly evolving patient conditions. This demands not mere coordination, but a genuine partnership, where anesthesiologists, surgeons, and critical care teams share responsibilities and collaborate in high-stake, time-sensitive environments. In Korea in particular, where prehospital trauma care remains predominantly within the domain of emergency or trauma physicians, this shift represents both a challenge and an opportunity for anesthesiologists to redefine their contributions to trauma care.

With critically injured patients, for whom outcomes are uncertain even under the care of experienced trauma surgeons face, shared decision-making and mutual trust among team members are essential to navigate complexity and improve patient care.

Emerging roles and adaptive decision-making

Early identification of deterioration and timely intervention are critical for preventing catastrophic outcomes in trauma cases. With the growing adoption of hybrid ORs and trauma bays, anesthesiologists increasingly participate in resuscitation decision-making early after patient arrival [84]. Although not yet standard practice, this evolving model reflects a forward-looking shift, redefining anesthesiologists as proactive members of the frontline trauma team in time-critical settings. This evolving role not only enhances patient outcomes, but also emphasizes the anesthesiologist's expertise in guiding physiological stabilization alongside surgical intervention.

Training, protocols implementing, and preparing future practitioners next generation

Guidelines for trauma surgery and anesthesia are continuously evolving, necessitating engagement of teams in structured education and shared learning [85]. Integrating case-based discussions, regular updates on clinical protocols, and checklist-based practices into routine training ensures that knowledge is efficiently disseminated across teams. Even with well-established guidelines, translation into routine clinical practice is often slow; however, the high level of expertise required and the practical, immediately applicable nature of trauma care suggest that implementation of new evidence may proceed more rapidly in this field [86].

Adherence to international standards for safe anesthesia is non-negotiable [87]. Continuous education, interdisciplinary seminars, and research collaboration will drive sustained progress. Embedding trauma principles into daily practice is key to shaping the future of anesthesiology in high-risk surgery.

Conclusions

The primary goal in trauma patient management is to save lives, a mission shared equally by anesthesiologists and trauma surgeons. Trauma resuscitation typically follows the ABCDE sequence, and this approach must be continuously maintained throughout the course of trauma patient care. For trauma anesthesiologists, understanding and adhering to the ABCDE principles is crucial, not only to align with the common goal of patient survival but also to remain responsive given the dynamic nature of trauma. In view of the unpredictable course of trauma, unexpected clinical deterioration or new diagnoses often arise, requiring prompt recognition and intervention. Unlike the conventional anesthesia-only focus, trauma care demands a broader perspective from anesthesiologists that may initially pose challenges in terms of adapting to an expanded role. However, this is critical for optimal trauma patient care. A close collaboration between anesthesiologists and trauma surgeons, as a cohesive team, can significantly enhance the outcomes of patients with trauma.