Trauma & Burn

ATLS-driven resuscitation of the blunt/penetrating trauma patient (airway → shock → cavity-specific injury → head/spine) and the management of thermal injury.

High-Yield Points

• Primary survey = ABCDE (Airway, Breathing, Circulation, Disability, Exposure). Always in order; reassess after each intervention. GCS ≤ 8 → definitive airway (intubate) with in-line C-spine stabilization; can't get an oral/ET airway → cricothyroidotomy.
• Hemorrhage is the leading cause of preventable trauma death. Four sites of occult exsanguination: chest, abdomen, pelvis/thighs, "the floor" (scene/external).
• Hemorrhagic shock classes: I <15% (normal), II 15–30% (tachycardia, narrowed pulse pressure), III 30–40% (hypotension first appears, confusion, oliguria), IV >40% (lethargy, negligible urine). Resuscitate with 2 large-bore IVs + warmed LR, then balanced blood products (MTP ~1:1:1) — don't flood with crystalloid in Class IV.
• Distinguish shock by CVP/neck veins: hemorrhage = LOW CVP/flat veins; tamponade & tension pneumothorax = HIGH CVP/distended veins.
• FAST = 4 windows (pericardial, perihepatic/Morrison's pouch, perisplenic, pelvis). Unstable + positive FAST → OR (laparotomy); misses retroperitoneal & hollow-viscus injury.
• Blunt abdomen: stable → CT; unstable despite resuscitation → laparotomy; altered sensorium → consider DPL. Penetrating: GSW (transperitoneal) → laparotomy; anterior stab, stable, no peritonitis → selective (local wound exploration ± CT/DPL).
• Spleen = most common organ injured in blunt trauma; liver = most common in penetrating. Stable low-grade solid-organ injury → nonoperative; instability/ongoing transfusion → OR. Post-splenectomy → vaccinate vs encapsulated organisms (pneumococcus, Hib, meningococcus) to prevent OPSI.
• Pelvic fracture can hide ~1500 mL blood loss → pelvic binder + resuscitation, then angioembolization/packing. Blood at the meatus/high-riding prostate → retrograde urethrogram BEFORE any Foley.
• 6 lethal chest injuries: airway obstruction, tension PTX (needle 2nd ICS MCL before x-ray, before intubation), open PTX (3-sided dressing → chest tube), massive hemothorax (thoracotomy if >1500 mL initial, >200 mL/hr ×3 h, or instability), flail chest (hypoxia from underlying pulmonary contusion → analgesia/epidural), cardiac tamponade (Beck triad → pericardiocentesis if unstable, echo if stable).
• Head bleeds: epidural = middle meningeal artery, lucid interval, biconvex/lens, respects sutures → craniotomy; subdural = bridging veins, crescent, crosses sutures, elderly/alcoholic; SAH = "worst headache"; DAI = gray–white junction petechiae, poor prognosis.
• GCS = Eye(/4)+Verbal(/5)+Motor(/6), range 3–15. CPP = MAP − ICP (target ~60); treat ICP >20 with HOB elevation, sedation, hyperosmolar therapy (mannitol/hypertonic saline), CSF drainage, then craniotomy.
• Basilar skull fracture (raccoon eyes, Battle sign, CSF rhinorrhea) → observe, NO prophylactic antibiotics, NO nasal tubes (use orogastric).
• C-spine clearance (NEXUS): clear clinically only if no midline tenderness, no deficit, normal alertness, no intoxication, no distracting injury — otherwise CT cervical spine.
• Penetrating neck (through platysma) + hard signs (expanding hematoma, active bleed, instability) → OR; stable/no hard signs → CTA.
• Extremity compartment syndrome: pain out of proportion + pain on passive stretch + tense compartment → emergent fasciotomy (pulselessness is late). Crush/rhabdo (myoglobinuria, ↑CK, ↑K⁺) → aggressive IV fluids ± urine alkalinization.
• Burn depth: 1st = epidermis (red, painful); 2nd = partial-thickness (blisters, moist, painful); 3rd = full-thickness (white/leathery, dry, non-blanching, INSENSATE).
• TBSA = rule of nines (head 9, each arm 9, each leg 18, ant trunk 18, post trunk 18, perineum 1). Parkland: 4 mL × kg × %TBSA LR / 24 h — half in first 8 h (from time of burn). Titrate to urine output (~0.5 mL/kg/hr adult; 1–1.5 mL/kg/hr burn/trauma).
• Inhalation injury: facial burns/singed nasal hairs/carbonaceous sputum/hoarseness → early intubation before edema. CO poisoning: pulse-ox falsely normal → diagnose by co-oximetry, treat 100% O2 (hyperbaric for severe/neuro after stabilization).
• Circumferential full-thickness burn with failing distal pulses or restricted chest excursion → escharotomy (through eschar; distinct from fasciotomy).

Key Tables / Differentials

Board Pearls

• Hypotension + absent breath sounds + tracheal deviation + distended neck veins → tension PTX → needle decompression first (no x-ray).
• Beck triad (hypotension, muffled heart sounds, JVD) after precordial wound → tamponade.
• Reduce-en-masse warning: never forcibly reduce a strangulated hernia/incarcerated bowel (returns dead bowel).
• Cherry-red, normal SpO2, confusion after enclosed fire → carbon monoxide → 100% O2.
• Howship–Romberg medial thigh pain → obturator hernia (cross-reference Hernia chapter).
• Stable patient with active contrast extravasation on CT solid-organ injury → angioembolization; unstable → OR (angio needs a stable patient).

Classic Vignette Triggers

• "Lucid interval then blown pupil, lens-shaped bleed" → epidural hematoma → craniotomy.
• "Crescent bleed crossing sutures in an alcoholic" → subdural (bridging veins).
• "Pain on passive stretch, tense compartment after tibia fracture" → compartment syndrome → fasciotomy.
• "Tea-colored urine, dipstick + for blood but few RBCs, after a crush" → rhabdomyolysis → IV fluids + alkalinize.
• "Pelvic fracture + blood at the meatus" → urethral injury → retrograde urethrogram, no Foley.
• "70 kg, 40% burn — fluids in first 8 h?" → 4×70×40 = 11,200 mL/24 h → 5,600 mL in first 8 h.
• "Singed nasal hairs + carbonaceous sputum + hoarseness" → impending airway obstruction → early intubation.
• "Circumferential arm burn, fading pulses, leathery eschar" → escharotomy.