Trauma, Burns and Surgical Critical Care
This domain tests protocol fidelity under time pressure: the primary survey, haemorrhage control, burn resuscitation and the recognition of surgical catastrophes in the ICU. The Board likes calculations and sequences.
Primary survey
ABCDE with simultaneous resuscitation. Catastrophic haemorrhage control first, then airway with cervical protection, breathing (exclude tension pneumothorax - needle decompression at the second intercostal space mid-clavicular or fifth space anterior axillary line, then a chest drain), circulation, disability, exposure. Treat as you find: do not move to B while A is unresolved.
Haemorrhagic shock
Permissive hypotension (systolic about 80-90 mmHg) until surgical control in penetrating trauma without head injury. Balanced transfusion in a 1:1:1 ratio of red cells, plasma and platelets; tranexamic acid 1 g within 3 hours of injury then 1 g over 8 hours; calcium replacement; active warming. The lethal triad is acidosis, hypothermia and coagulopathy, and damage control laparotomy addresses all three by packing and temporary closure. Activate massive transfusion by score early, not by haemoglobin late.
Burns
Rule of Nines: each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, head 9%, perineum 1%; the patient's palm is about 1%. Superficial epidermal burns are excluded from the count. Parkland formula: 4 mL/kg per percent TBSA of lactated Ringer's over 24 hours, half in the first 8 hours from the time of injury. Inhalation injury - stridor, hoarseness, soot, enclosed-space fire - means early intubation. Escharotomy for circumferential full-thickness burns compromising perfusion. Suspect carbon monoxide and cyanide in closed-space fires; carboxyhaemoglobin gives falsely normal saturation.
Worked example
A 70 kg man with 40% TBSA burns, injured 2 hours ago. Parkland gives 4 x 70 x 40 = 11,200 mL over 24 hours; half (5,600 mL) in the first 8 hours from injury, so 800 mL/h for the remaining 6 hours. Titrate to urine output 0.5-1 mL/kg/h rather than to the formula alone.
Traps
Giving a fluid bolus to a trauma patient with an unsecured airway. Counting superficial erythema in TBSA. Using haemoglobin as a transfusion trigger in active haemorrhage. Forgetting analgesia, tetanus prophylaxis and temperature control. Attributing abdominal distension and rising airway pressures after laparotomy to lung pathology rather than abdominal compartment syndrome.