Trauma and Burn Emergencies
Control the bleeding, then follow the alphabet
Modern trauma care puts catastrophic haemorrhage control ahead of the airway: ABCDE. Apply direct pressure, then a tourniquet placed high and tight on the limb, and record the time. Permissive hypotension (systolic around 80–90 mmHg) is accepted in penetrating trauma without traumatic brain injury. Massive transfusion proceeds in balanced ratios, and tranexamic acid is given within three hours of injury. Tension pneumothorax is a clinical diagnosis - needle decompression comes before any chest radiograph. The lethal triad is hypothermia, acidosis and coagulopathy, so warm the patient, keep them dry, and limit crystalloid.
Burns are assessed with the rule of nines in adults: head 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%. In children the head is proportionally larger (about 18%) and the legs smaller (about 14% each). The Parkland formula is 4 mL of lactated Ringer's per kilogram per percent total body surface area over 24 hours, with half given in the first eight hours counted from the time of injury - not from arrival. Inhalation injury, hoarseness, soot or singed nasal hair mandates early intubation before oedema closes the airway. Circumferential full-thickness burns need escharotomy. Never use ice or ice-cold water, and never neutralise a chemical burn.
Worked example: a 70 kg adult with 40% TBSA. 4 × 70 × 40 = 11,200 mL in 24 hours. Half, 5,600 mL, is due in the first eight hours from the burn. If the patient arrives two hours after injury, that 5,600 mL is delivered over the remaining six hours.
Traps: running the clock from arrival, giving the whole first half rapidly, and forgetting that fluid resuscitation is titrated to urine output rather than to the formula.