Trauma, Burns, and Surgical or Perioperative Critical Care
Trauma
The primary survey follows airway with cervical spine protection, breathing, circulation, disability, and exposure. Children compensate well and then decompensate abruptly. Tension pneumothorax requires immediate needle decompression, followed by a chest tube. Spinal cord injury without radiographic abnormality is a pediatric classic after acceleration-deceleration injury. Focused assessment with sonography for trauma helps detect free fluid, but it does not exclude retroperitoneal or hollow viscus injury. Damage-control surgery prioritizes hemorrhage control and temporary closure over definitive repair.
Burns
Estimate total body surface area using modified Lund and Browder charts or age-adjusted rule of nines; the child's head is proportionally larger and legs smaller. Fluid resuscitation commonly uses 4 mL/kg per percent total body surface area over 24 hours, with half in the first 8 hours, plus maintenance fluid containing dextrose. Titrate to urine output of 1-2 mL/kg per hour. Watch for inhalation injury, carbon monoxide and cyanide toxicity, hypothermia, and compartment syndromes requiring escharotomy.
Perioperative traps
Succinylcholine is contraindicated in burns after about 48-72 hours, in denervation injury, and in hyperkalemia because of upregulation of extrajunctional receptors. Abdominal compartment pressure above 10-12 mmHg with organ dysfunction suggests intra-abdominal hypertension. Postoperative apnea and hypothermia are common in neonates.
Worked rule
A 20 kg child with 30% total body surface area burn needs 4 x 20 x 30 = 2400 mL in 24 hours, or 1200 mL in the first 8 hours, plus maintenance, adjusted to urine output.