Trauma and Emergency Surgery
Initial assessment
Use ABCDE with cervical spine protection. Treat catastrophic haemorrhage first in the c-ABC variant. Tension pneumothorax and cardiac tamponade are clinical diagnoses treated before imaging. Shock in trauma is haemorrhagic until proven otherwise; classify by blood loss and response to fluids. Permissive hypotension and damage control resuscitation (blood products, tranexamic acid within 3 hours, warming) reduce the lethal triad of hypothermia, acidosis and coagulopathy.
Torso and extremities
FAST detects free fluid; CT is for the stable patient. Pelvic fracture with haemodynamic instability needs a binder and angioembolisation or packing. Hard signs of extremity vascular injury (pulsatile bleeding, expanding haematoma, absent pulse, bruit, ischaemia) need exploration; soft signs need imaging. Compartment syndrome: pain on passive stretch, tense compartment, pressure above 30 mmHg.
Burns and the acute abdomen
Estimate burn area with the Rule of Nines; Parkland formula 4 mL/kg/% total body surface area in 24 hours, half in the first 8 hours from the time of injury. Inhalation injury causes stridor, soot and hoarseness - intubate early. Escharotomy for circumferential full-thickness burns. In the acute abdomen, pneumoperitoneum means perforation until proven otherwise; mesenteric ischaemia presents with pain out of proportion and metabolic acidosis.
Rule of thumb
In trauma, treat the greatest threat first: a patient with distended neck veins, hypotension and muffled heart sounds needs pericardial decompression, not a CT scan.