Trauma and Environmental Emergencies
Control the killable things first
Trauma transport is built around a primary survey that is repeated: catastrophic hemorrhage control, airway, breathing (with a low threshold for needle decompression or finger thoracostomy), circulation, disability, and exposure with active prevention of hypothermia. Massive external bleeding is controlled with direct pressure or a tourniquet; junctional bleeding with a junctional device, and suspected pelvic fracture with a binder. Tranexamic acid, when used, is given early - within three hours of injury.
Key concepts: the lethal triad of hypothermia, acidosis, and coagulopathy, and its prevention in a cold aircraft; permissive hypotension for penetrating trauma without brain injury versus a higher systolic target (roughly at least 110 mmHg) when traumatic brain injury is suspected; spinal motion restriction based on mechanism and exam; burn resuscitation with 2-4 mL/kg per percent TBSA of crystalloid, half in the first eight hours counted from the time of injury.
Environmental: exertional heat stroke (cool first, transport second), hypothermia, frostbite (rapid warm-water immersion, never rubbing), altitude illness, dysbarism, and envenomation.
Trap: pulse oximetry is normal in carbon monoxide poisoning. Another: burn fluids cannot be titrated against a urine output nobody is measuring - document and report hourly output.
Worked example: 70 kg patient with 40% TBSA, injured 2 hours ago. 4 × 70 × 40 = 11,200 mL over 24 hours; half (5,600 mL) in the first eight hours from injury, so 5,600 ÷ 6 remaining hours ≈ 933 mL/h. Rule of thumb: time zero is the burn, not your arrival.