Surgical emergency
A surgical emergency is a medical condition that demands immediate surgical intervention to avert an acute threat to life, organ function, limb viability, or tissue integrity, often arising from external trauma, acute disease onset, exacerbation of chronic conditions, or complications of prior interventions.[1] These situations differ from elective procedures by requiring urgent action, typically within hours, to prevent irreversible harm or death, and may involve abdominal, thoracic, vascular, or soft tissue domains.[2][1] Common examples of surgical emergencies encompass a range of acute abdominal conditions such as appendicitis, bowel obstruction, gastrointestinal perforation, cholecystitis, and incarcerated or strangulated hernias, alongside trauma-induced injuries and severe infections like perirectal abscesses or soft tissue infections.[3][4] In the United States, emergency general surgery affects approximately 4 million patients annually as of 2023, with seven procedures—partial colectomy, small bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy—accounting for about 80% of all such operations, postoperative deaths, complications, and associated costs around $28 billion.[5][6][7] The management of surgical emergencies prioritizes rapid patient assessment, resuscitation, hemodynamic stabilization, and diagnostic evaluation using tools like imaging and laboratory tests, followed by nonelective surgery under local, regional, or general anesthesia as needed.[8][3] Timely intervention yields high survival rates, such as 95-99% for appendicitis and over 80% for perforated peptic ulcers or incarcerated hernias when addressed promptly, underscoring the critical role of accessible surgical services in reducing morbidity and mortality.[3] Globally, these emergencies constitute 1-3% of deaths and approximately 1.5% of disability-adjusted life years, comprising up to 60% of surgical caseloads in low- and middle-income countries, where basic procedures can be performed cost-effectively at district-level facilities.[3]Overview
Definition
A surgical emergency is defined as an acute medical condition that necessitates immediate surgical intervention to avert death, permanent disability, or severe morbidity, typically within hours of presentation.[3] These conditions are characterized by their life-threatening nature, often involving processes such as uncontrolled hemorrhage, organ perforation, or critical obstruction that demand rapid operative management to stabilize the patient.[3] Representative examples include acute appendicitis, where untreated inflammation can lead to peritonitis, or major trauma resulting in internal bleeding, though specific etiologies are addressed elsewhere.[3] Such emergencies are commonly managed at first-level healthcare facilities using standardized procedures, particularly in low- and middle-income countries (LMICs) and resource-limited settings, emphasizing the urgency to prevent fatal outcomes if delayed beyond 24 hours in many cases.[3] Surgical emergencies are distinct from other categories of surgery based on the timeline and risk of deterioration. Elective surgery refers to planned procedures scheduled in advance to address non-urgent issues, such as elective tumor resections or joint replacements, allowing for comprehensive preoperative preparation.[2] In contrast, urgent surgery involves conditions that require intervention within days to avoid significant harm but do not pose an immediate threat to life, such as certain infections or stable fractures.[9] Emergency surgery, however, mandates prompt action, often through immediate hospital admission via emergency departments, to address acutely life-threatening states like perforated viscera or severe vascular injuries.[9] The concept of surgical emergencies evolved historically alongside key medical advancements, particularly in the 19th and 20th centuries. The introduction of general anesthesia in 1846 and antiseptic techniques by Joseph Lister in the 1860s revolutionized surgical practice by enabling safer, more prolonged operations and reducing postoperative infections, thus allowing for effective management of acute conditions that were previously untreatable or fatal.[10] By the mid-20th century, further refinements in these areas, combined with improved access to care and technology, formalized the structured approach to surgical emergencies; for instance, in the United States, mortality from such conditions dropped from 38 per 100,000 in 1935 to 4 per 100,000 by 1990, reflecting the impact of these developments.[3]Epidemiology
Surgical emergencies represent a substantial public health challenge, contributing to approximately 28% of the global disease burden in emergency care settings. In high-income countries, such as those in the National Health Service in England, emergency general surgery accounts for more than one-third of all hospital admissions. In low- and middle-income countries (LMICs), the burden is disproportionately higher, with at least 60% of all surgical operations performed for emergencies, driven by factors like trauma and infections; for instance, studies in LMICs report that surgical conditions overall comprise up to 57.5% of hospital admissions in district-level facilities. Globally, non-traumatic emergency general surgery conditions led to 896,000 deaths and 25 million disability-adjusted life years (DALYs) in 2010, with 70% of these deaths occurring in LMICs despite lower per capita mortality rates there compared to high-income countries. More recent analyses from 2019 indicate a substantially higher burden for broader emergency conditions, with approximately 27 million deaths and 1 billion DALYs globally.[11][12][3][13][14][15] Prevalence varies markedly by region and etiology. In LMICs, non-traumatic abdominal emergencies, such as perforations and obstructions, often constitute 30-40% of surgical emergency cases, reflecting higher rates of infectious and obstructive conditions. In contrast, high-income countries see trauma dominating emergency surgical presentations, accounting for up to 50% of cases in some systems, alongside vascular emergencies. These regional disparities underscore the influence of socioeconomic factors, with LMICs facing greater unmet needs—estimated at 143 million additional procedures annually to avert deaths and disabilities.[16] Demographically, surgical emergencies affect all age groups but exhibit distinct patterns. Trauma-related cases peak among young adults aged 20-40 years, while vascular and abdominal issues are more prevalent in the elderly over 65 years, with the proportion of octogenarians undergoing emergency procedures rising due to population aging. Gender differences are pronounced, particularly in trauma, where males outnumber females at a ratio of approximately 2:1, though overall emergency surgical admissions show a male-to-female ratio closer to 1.7:1.[14][17][18] Trends indicate a rising incidence of surgical emergencies, fueled by aging populations, increasing road traffic accidents, and non-communicable diseases. Post-2020 data reveal further escalation due to delayed care during the COVID-19 pandemic, with postponement of elective procedures leading to higher rates of emergent presentations and complications; for example, one study documented a 14.4% increase in trauma cases in the post-pandemic period, alongside extended surgical delays in LMICs.[16][19][20]Causes and Pathophysiology
Traumatic Causes
Traumatic causes of surgical emergencies arise from physical injuries inflicted by external forces, primarily categorized as blunt or penetrating trauma. Blunt trauma occurs when an object impacts the body without breaching the skin, often resulting from high-energy events such as motor vehicle collisions (MVCs) or falls, leading to internal organ damage through compression, shearing, or deceleration forces.[21] Penetrating trauma, conversely, involves an object piercing the skin and underlying tissues, such as stab wounds or gunshots, directly disrupting vascular and organ structures.[22] These mechanisms account for a significant portion of surgical interventions, with MVCs being a leading cause globally, contributing to approximately 1.19 million deaths annually from road traffic injuries as of 2023.[23] The pathophysiology of traumatic surgical emergencies centers on immediate tissue disruption and systemic responses that can rapidly progress to life-threatening conditions. In blunt trauma, forces like those in high-speed impacts cause organ lacerations or ruptures; for instance, rapid deceleration in MVCs can shear the spleen or liver, resulting in massive intraperitoneal hemorrhage.[24] Penetrating injuries often lead to vascular breaches, such as hemothorax from thoracic stab wounds, where blood accumulates in the pleural space, compressing the lung and impairing ventilation.[25] A common sequela across both types is hypovolemic shock due to significant blood loss, characterized by decreased cardiac output, tissue hypoperfusion, and metabolic acidosis if untreated.[24] Additionally, compartment syndrome may develop in extremities or the abdomen from swelling and bleeding, increasing intracompartmental pressure and risking ischemia.[26] Common examples illustrate the urgency of these injuries. Abdominal trauma frequently involves solid organ injury, such as splenic rupture from blunt force in MVCs, leading to hemodynamic instability requiring emergent splenectomy.[27] Thoracic trauma, including pneumothorax from rib fractures or penetrating wounds, causes lung collapse and potential tension physiology, necessitating immediate chest tube insertion to restore negative intrapleural pressure.[28] Head trauma can result in intracranial bleeding, such as epidural hematoma from arterial rupture due to skull fracture, elevating intracranial pressure and risking herniation.[29] Risk factors unique to trauma include high-speed impacts in MVCs, which amplify kinetic energy transfer, and interpersonal violence, often manifesting as penetrating injuries in urban settings.[30][31]Non-Traumatic Causes
Non-traumatic surgical emergencies arise from endogenous disease processes that compromise organ function and necessitate urgent operative intervention, distinct from external injuries. These conditions often involve acute inflammation, obstruction, ischemia, or perforation within the abdominal cavity, vascular system, or urological structures, leading to systemic instability if untreated. Common presentations include severe pain, hemodynamic compromise, and signs of peritonitis or shock, with pathophysiology centered on local tissue damage progressing to widespread inflammation or vascular collapse.[32] Abdominal causes predominate, encompassing inflammatory and obstructive pathologies of the gastrointestinal tract. Acute appendicitis, for instance, begins with luminal obstruction by fecalith or lymphoid hyperplasia, resulting in bacterial overgrowth, mucosal ischemia, and potential perforation that spills contents into the peritoneal cavity, causing secondary peritonitis characterized by polymorphonuclear infiltration and fibrinous exudates. Perforated peptic ulcers, often due to Helicobacter pylori infection or nonsteroidal anti-inflammatory drug use, similarly lead to peritonitis through gastric or duodenal wall breach, allowing acidic contents and bacteria to irritate the peritoneum and provoke a robust inflammatory response with cytokine release and fluid shifts. Bowel obstruction from non-traumatic etiologies, such as adhesions (post-surgical scarring), volvulus, or tumors, impedes intestinal transit, leading to proximal dilation, bacterial proliferation, and strangulation ischemia if untreated; in low- and middle-income countries (LMICs), typhoid fever-induced ileal perforation emerges as a notable variant, driven by Salmonella typhi invasion of the Peyer's patches, exacerbating perforation risk due to delayed presentation. Acute cholecystitis involves gallbladder inflammation from cystic duct obstruction by gallstones, progressing to gangrenous changes and perforation in severe cases, with bile stasis fostering bacterial infection. Risk factors for these abdominal emergencies include chronic conditions like inflammatory bowel disease, dietary habits such as low-fiber intake promoting adhesions and constipation, and infectious agents like H. pylori eroding mucosal barriers.[32][33][34][35] Vascular emergencies, such as ruptured abdominal aortic aneurysm (AAA), stem from degenerative weakening of the aortic wall, where atherosclerosis and proteolytic enzyme activity degrade elastin and collagen, leading to aneurysmal dilation and eventual rupture into the retroperitoneum or peritoneum, causing hypovolemic shock from massive hemorrhage. Pathophysiologically, intraluminal pressure exceeds wall tensile strength, as described by Laplace's law, resulting in rapid exsanguination and peritoneal irritation if free rupture occurs. Key risk factors include advanced age, male sex, smoking (which promotes oxidative stress and matrix metalloproteinase upregulation), hypertension (accelerating wall stress), and familial predisposition, with atherosclerosis as a foundational chronic condition.[36][37][38] Urological non-traumatic emergencies often involve obstructive processes, exemplified by acute urinary retention, where sudden inability to void leads to bladder distension, potential overflow incontinence, and post-renal azotemia if prolonged. Causes include benign prostatic hyperplasia (BPH) compressing the urethra, urethral strictures from prior instrumentation, or neurogenic bladder dysfunction from diabetic neuropathy; in surgical contexts, it may arise post-operatively due to anesthesia-induced detrusor atony. Pathophysiology entails mechanical blockage or detrusor underactivity, causing hydronephrosis and electrolyte imbalances, necessitating emergent decompression to avert renal failure. Risk factors encompass older age, male gender (due to prostate enlargement), and chronic conditions like diabetes impairing autonomic innervation.[39][40][41] Infectious progressions, such as amebic liver abscess, represent another pathway, where Entamoeba histolytica trophozoites invade the portal venous system, forming necrotic hepatic lesions that can rupture into the peritoneum, inducing suppurative peritonitis with trophozoite dissemination and secondary bacterial superinfection. This is more prevalent in endemic regions with poor sanitation, highlighting infectious risk factors alongside immunosuppression from malnutrition or alcoholism. Non-traumatic soft tissue infections, including perirectal abscesses and necrotizing fasciitis, also constitute surgical emergencies. Perirectal abscesses arise from obstructed anal glands leading to suppuration in perianal spaces, potentially progressing to necrotizing infection if untreated, requiring incision and drainage. Necrotizing fasciitis involves polymicrobial or monomicrobial (e.g., group A Streptococcus) invasion along fascial planes, causing rapid tissue necrosis due to toxin production and vascular thrombosis, necessitating urgent surgical debridement to halt progression and reduce mortality. Risk factors include diabetes, obesity, and immunosuppression, with delayed intervention increasing systemic toxicity.[32][42][43][44] Ischemic mechanisms, like mesenteric occlusion from emboli or thrombosis, underlie conditions such as acute mesenteric ischemia, where arterial compromise leads to bowel wall infarction and translocation of endotoxins, amplifying systemic inflammatory response syndrome. Overall, these non-traumatic causes underscore the interplay of chronic vulnerabilities and acute decompensation, with geographical disparities—such as higher infectious perforations in LMICs—emphasizing the role of access to care.[32][42]Diagnosis
History and Physical Examination
The history and physical examination form the cornerstone of initial evaluation in suspected surgical emergencies, guiding clinicians toward prompt recognition of conditions requiring operative intervention. History taking begins with a focused assessment of the onset, location, and nature of symptoms, as these elements help differentiate urgent pathologies. For instance, sudden severe abdominal pain may indicate visceral perforation, while a history of trauma, such as high-speed motor vehicle collisions, raises concern for internal injuries.[45] Associated factors, including comorbidities like anticoagulation use or recent surgical history, are elicited to contextualize the presentation and identify risk amplifiers.[46] Physical examination commences with vital signs to detect instability, where tachycardia often signals hypovolemic shock from hemorrhage, and hypotension indicates advanced decompensation.[46] Abdominal palpation is performed gently, starting away from the tender area to assess for rebound tenderness suggestive of peritonitis or guarding indicating localized inflammation.[45] Auscultation evaluates bowel sounds, with absent noises pointing to ileus or peritonitis and high-pitched tinkles suggesting obstruction.[45] In trauma settings, a systematic head-to-toe inspection identifies deformities, tenderness, or crepitus that may necessitate surgical exploration.[46] Red flags signaling systemic involvement demand immediate attention, including fever indicative of infection or peritonitis, persistent hypotension from ongoing hemorrhage, and altered mental status reflecting hypoperfusion or shock.[47] These findings, such as syncope accompanying severe pain in ruptured abdominal aortic aneurysm, underscore the need for rapid escalation.[47] Despite their utility, history and physical examination have limitations, particularly in early disease stages where symptoms remain non-specific, potentially delaying diagnosis. In the elderly, atypical presentations—such as muted pain or absent fever in acute cholecystitis—affect up to 25% of cases, compounded by communication barriers from dementia or sensory deficits.[48] In children, vague symptoms like irritability or lethargy in intussusception (occurring in 17% of cases) further obscure localization, emphasizing the need for heightened vigilance across age groups.[49]Laboratory and Imaging Studies
Laboratory studies play a crucial role in confirming suspected surgical emergencies by providing objective data on infection, inflammation, metabolic derangements, and coagulation status. A complete blood count (CBC) is routinely obtained to assess for leukocytosis, which often indicates an infectious or inflammatory process; for instance, a white blood cell count exceeding 15,000/mm³ with a left shift (increased immature neutrophils) is suggestive of acute appendicitis or peritonitis. Electrolyte panels help identify imbalances such as hypokalemia or hyponatremia in cases of bowel obstruction or prolonged vomiting, while elevated serum lactate levels (>2 mmol/L) signal tissue ischemia or sepsis in conditions like mesenteric ischemia or perforated viscus. Blood typing and cross-matching are essential in trauma or major hemorrhage scenarios to prepare for potential transfusion. Coagulation studies, including prothrombin time (PT) and international normalized ratio (INR), are indicated in patients with liver disease or anticoagulation use to evaluate bleeding risks before intervention. In suspected sepsis, blood cultures and inflammatory markers like C-reactive protein (CRP) or procalcitonin may be drawn to guide antibiotic therapy, though these are adjunctive rather than diagnostic. Imaging modalities are selected based on the suspected etiology, availability, and patient stability to visualize anatomical disruptions or fluid collections. Plain abdominal X-rays are a rapid initial tool for detecting bowel gas patterns indicative of obstruction (e.g., dilated loops >3 cm) or free intraperitoneal air suggesting perforation, with upright views showing subdiaphragmatic air in up to 70% of cases. Chest X-rays can identify pneumothorax or hemothorax in thoracic emergencies. Ultrasound (US) serves as a first-line, non-ionizing option, particularly in hemodynamically stable patients, to detect free fluid in the abdomen (e.g., in ruptured ectopic pregnancy or trauma) or gallstones in cholecystitis, with sensitivity for hemoperitoneum around 85-90%. Computed tomography (CT) scans with intravenous contrast are the gold standard for most abdominal surgical emergencies due to their high sensitivity and specificity; for example, CT detects appendiceal inflammation or perforation with accuracy >95% and identifies vascular injuries or solid organ lacerations in trauma. In polytrauma, the Focused Assessment with Sonography for Trauma (FAST) exam integrates US to rapidly screen for intra-abdominal bleeding. Advanced imaging like CT angiography is reserved for vascular emergencies such as aortic dissection or mesenteric artery occlusion, offering detailed vessel patency assessment. Magnetic resonance imaging (MRI) is rarely used in acute settings due to time constraints and limited availability, though it may be considered for non-emergent clarification of soft tissue pathology. Interpretation requires correlation with clinical findings, as imaging alone may not distinguish surgical from non-surgical causes.Treatment
Preoperative Management
Preoperative management in surgical emergencies prioritizes immediate stabilization of vital functions and logistical preparation to minimize perioperative risks and facilitate timely intervention. This phase employs a structured, multidisciplinary approach to address physiological derangements while adhering to evidence-based protocols, ensuring the patient is optimized for the operating room without delay. The ABCDE framework, derived from Advanced Trauma Life Support (ATLS) principles, guides the initial resuscitation in both traumatic and non-traumatic surgical emergencies by systematically evaluating and treating threats in order of priority.- Airway: Assess patency through inspection for obstructions, stridor, or foreign bodies; secure with basic maneuvers (e.g., head-tilt chin-lift or jaw thrust) or advanced airway interventions (e.g., endotracheal intubation) if compromised, aiming to maintain oxygenation and prevent aspiration.[50]
- Breathing: Evaluate respiratory rate (normal 12–20 breaths/min), effort, chest symmetry, and oxygen saturation (>94%); provide high-flow oxygen (10–15 L/min via non-rebreather mask), bag-mask ventilation, or chest decompression for tension pneumothorax to ensure adequate ventilation and gas exchange.[50]
- Circulation: Check pulse rate (60–100 beats/min), capillary refill (<2 seconds), and blood pressure; establish two large-bore intravenous lines for fluid administration and hemorrhage control, elevating legs if hypotensive to improve venous return.[50]
- Disability: Gauge level of consciousness using the AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive) and perform a rapid neurological exam (pupils, limbs); address hypoglycemia with dextrose or protect the airway if altered mental status is present.[50]
- Exposure/Environment: Fully undress the patient to identify injuries or sources of bleeding while preventing hypothermia through warming blankets or fluids, followed by re-covering to maintain normothermia.[50]