Emergency Surgery
Overview
Emergency surgery (응급수술) refers to surgery that must be performed immediately within a defined time in situations where the patient's life or major organ function is acutely threatened. If it is not performed within several hours of onset or injury, it can lead to death or permanent disability; unlike elective surgery, the processes of preoperative evaluation, consent, fasting, and testing are compressed or partially omitted. It is a representative multidisciplinary area of care in which emergency medicine, trauma surgery, anesthesiology and pain medicine, and critical care medicine operate in concert, and the allocation of time and personnel resources directly determines the patient's prognosis.
Main Content
Definition and Time-Based Classification
Emergency surgery is divided according to the severity of the condition and the permissible delay. Typically, immediate is within 1 hour, emergent within 6 hours, urgent within 24 hours, and semi-urgent within 48 hours. For example, decompression of tension pneumothorax, drainage of cardiac tamponade, and repair of a ruptured aortic aneurysm belong to the immediate group, while acute appendicitis or strangulated hernia belong to the emergent group. The American Association for the Surgery of Trauma (AAST) and guidelines in various countries specify target times to operating room entry and use them as hospital evaluation metrics.
Emergency Surgery by Major Condition
- Abdomen: acute appendicitis, perforated gastroduodenal ulcer, acute cholecystitis, bowel obstruction, strangulated hernia, mesenteric ischemia, ruptured abdominal aortic aneurysm, traumatic abdominal injury
- Trauma: Damage Control Surgery. It consists of three stages: stage 1 hemostasis and decontamination, stage 2 physiological resuscitation in the intensive care unit, and stage 3 planned reoperation, and the goal is to correct the lethal triad of hypothermia, acidosis, and coagulopathy.
- Neurosurgery: acute epidural hematoma, acute subdural hematoma, intracranial hemorrhage accompanied by signs of brain herniation
- Cardiac and vascular: type A aortic dissection, cardiac tamponade, acute myocardial infarction complications requiring coronary artery bypass grafting
- Obstetrics and gynecology: ruptured ectopic pregnancy, ovarian torsion, placental abruption, and emergency cesarean section
- Orthopedics: open fractures, pelvic ring fractures, limb injuries accompanied by major vascular injury, replantation of amputated parts
- Thoracic: chest tube insertion for tension pneumothorax, hemothorax, repair of cardiac injury
- Urology: testicular torsion (6-hour golden time), drainage of obstructive urinary tract infection
Preoperative Evaluation and Resuscitation
In emergency situations, the ABCDE approach prioritizing airway, breathing, and circulation is fundamental. Damage control resuscitation involves transfusing red blood cells, plasma, and platelets in a ratio close to 1:1:1 and adopting a permissive hypotension strategy that avoids excessive fluid administration until bleeding is controlled. Recently, the use of fresh whole blood and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become established tools of damage control resuscitation. Consent should in principle be obtained from the patient himself or herself, but when the patient is unconscious or a surrogate cannot arrive in time, presumed consent and the immunity provisions under the Emergency Medical Service Act apply. Fasting is still important for safety, but recent guidelines are being relaxed on an evidence-based basis, such as allowing clear liquids up to 2 hours before.
Anesthesia and Operating Room Management
Emergency surgery is usually performed under general anesthesia, and because of the high risk of aspiration, rapid sequence intubation (RSI) and cricoid pressure are used. Patients in hemorrhagic shock require reduced induction drug doses and maintenance of blood pressure. Hybrid operating rooms, which handle computed tomography, angiography, and surgery for critically ill patients in a single space, have a large time-saving effect and have spread mainly around regional trauma centers.
Postoperative Management and Complications
After surgery, body temperature, acid-base status, and coagulation status are reassessed in the intensive care unit, and abdominal compartment syndrome, sepsis, acute kidney injury, venous thromboembolism, and surgical site infection are monitored. ERAS protocols, including early enteral nutrition and early mobilization, are expanding in scope of application even after emergency surgery.
Korea's Emergency Surgery System
Based on the Emergency Medical Service Act, regional emergency medical centers, local emergency medical centers, and regional trauma centers are designated, and doctor helicopters and a dedicated severe trauma system are in operation. However, the shortage of surgical personnel at night and on holidays, gaps in care due to the departure of residents, and emergency room overcrowding remain ongoing challenges.
Latest Trends
The trends of 2024–2025 fall largely into four streams. First, artificial intelligence-based triage and image reading are being introduced into emergency rooms, assisting with bleeding prediction, automatic detection of cerebral hemorrhage, and determination of surgical priority. Second, standardization of damage control resuscitation is progressing, and the results of whole blood transfusion, hypothermia prevention, and REBOA clinical studies (e.g., REBOA-related randomized trials) are being reflected in guidelines. Third, hybrid operating rooms, mobile CT, and remote consultation systems are expanding, and the emergency medical network is being reorganized in the direction of reducing transfer delays. Fourth, after the large-scale medical workforce gap in 2024, the manpower shortage in the emergency and trauma fields has deepened, and discussions continue on the dispatch of military medical officers, institutionalization of physician assistant (PA) nurses, and improvement of emergency surgery fees and compensation. In addition, evidence-based operations such as relaxation of preoperative fasting guidelines, emergency application of ERAS, and disclosure of patient safety indicators are being strengthened.
Related Topics
- [[Trauma Surgery]]
- [[Critical Care Medicine]]
- [[Damage Control Surgery]]
- [[Regional Trauma Center]]
- [[Emergency Medical System]]