Trauma, Burns, Shock, and Resuscitation
Hemorrhagic shock and massive transfusion
Primary survey first (airway, breathing, circulation, disability, exposure) with simultaneous hemorrhage control. In hemorrhagic shock, activate the massive transfusion protocol early with a balanced ratio near 1:1:1 of plasma, platelets, and red cells, give tranexamic acid within 3 hours of injury, keep the patient warm, and correct calcium and acidosis. Permissive hypotension is acceptable in penetrating trauma before control; it is not appropriate in traumatic brain injury, where perfusion pressure matters.
Burns
Estimate total body surface area with the Rule of Nines (head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%). Resuscitate with lactated Ringer's using a Parkland-type estimate of 2–4 mL/kg/%TBSA, giving half in the first 8 hours counted from the time of burn - not from arrival. Titrate to urine output around 0.5–1 mL/kg/h in adults. Intubate early for inhalation injury; suspect carbon monoxide when SpO2 is normal but the patient is altered; hydroxocobalamin treats cyanide exposure. Do not give prophylactic antibiotics.
Traps
The most common burn errors are over-resuscitation and starting the clock at hospital arrival. In trauma, vasopressors before volume in uncontrolled hemorrhage are wrong. Watch for hypothermia, missed tension pneumothorax, and abdominal compartment syndrome.
Worked example
70 kg patient with 40% TBSA burn: 4 × 70 × 40 = 11,200 mL over 24 hours, 5,600 mL in the first 8 hours from the burn time. If the patient arrives 2 hours after injury, the remaining 6 hours absorb that first half.
Rule of thumb
Burns: clock starts at the burn, not the door. Trauma: stop the bleeding before you fine-tune the numbers.