Trauma and Critical Care
Primary survey
The ABCDE sequence treats what kills first. Airway with cervical spine protection; breathing, where tension pneumothorax, open pneumothorax, massive haemothorax and flail chest are identified and treated immediately (needle or finger thoracostomy then chest drain, three-sided dressing, tube and blood respectively); circulation with control of external haemorrhage, recognition of shock, FAST scan and pelvic binder; disability with Glasgow Coma Scale and pupils; exposure with prevention of hypothermia. Adjuncts include ECG, arterial blood gases, urinary catheter, nasogastric tube and plain radiographs.
Shock
The classic classes use estimated blood loss: class I under 15%, class II 15–30% (tachycardia, narrowed pulse pressure), class III 30–40% (hypotension, tachypnoea, oliguria, confusion) and class IV over 40%. Young patients and those on beta-blockers compensate deceptively; a normal blood pressure does not exclude major haemorrhage. Remember the non-haemorrhagic causes: tension pneumothorax, cardiac tamponade, neurogenic and septic shock. Damage control resuscitation uses permissive hypotension, early balanced blood products in a 1:1:1 ratio and tranexamic acid within three hours.
Critical care
ARDS is acute onset hypoxia with a PaO2/FiO2 ratio ≤300 on PEEP ≥5, bilateral infiltrates not explained by cardiac failure; ventilation is lung-protective at 6 mL/kg predicted body weight with plateau pressure below 30 cmH2O and prone positioning in severe cases.
Worked example: a patient opening eyes to pain (2), making incomprehensible sounds (2) and withdrawing from pain (4) scores GCS 8 - a score of 8 or less mandates a definitive airway.