Trauma and Emergency Surgery
The exam tests structured resuscitation, damage-control thinking, burns and critical care physiology. Stems often present an unstable patient where the correct answer is a manoeuvre, not a scan.
Primary survey and immediate threats
- ATLS sequence A-B-C-D-E, with catastrophic haemorrhage control first in massive external bleeding.
- Tension pneumothorax is clinical: hypotension, absent breath sounds, distended neck veins, tracheal shift. Needle decompression in the 2nd intercostal space midclavicular line or 5th intercostal space anterior axillary line, followed by a chest drain.
- Cardiac tamponade: Beck's triad; pericardiocentesis is temporising, thoracotomy or sternotomy is definitive.
- FAST detects free fluid in pericardium, perihepatic, perisplenic and pelvic spaces; it is repeated, not a one-off test.
- Pelvic binder for suspected pelvic fracture with haemodynamic instability; do not spring the pelvis repeatedly.
Haemorrhage, resuscitation and damage control
- Permissive hypotension (systolic 80–90 mmHg) in penetrating trauma without traumatic brain injury; avoid in brain injury and pregnancy.
- Massive transfusion in balanced ratios close to 1:1:1 red cells, plasma and platelets, with calcium replacement and warming.
- Tranexamic acid 1 g over 10 minutes then 1 g over 8 hours, within 3 hours of injury (CRASH-2).
- Lethal triad: hypothermia, acidosis, coagulopathy. Damage-control laparotomy means stop bleeding, control contamination, temporary closure and ICU - planned relook, not definitive repair.
Burns
- Wallace rule of nines: each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, head 9%, perineum 1%. Palm of patient's hand is about 1%.
- Parkland formula: 4 mL/kg/% total body surface area in 24 hours, half in the first 8 hours from the time of the burn, the rest over 16 hours. Titrate to urine output 0.5 mL/kg/h (1 mL/kg/h in children).
- Inhalation injury: soot, hoarseness, stridor, singed nares - intubate early before oedema closes the airway.
- Circumferential full-thickness burns need escharotomy; avoid prophylactic systemic antibiotics; update tetanus.
Worked example
A 70 kg man with 40% TBSA burns arrives 2 hours after injury. Parkland volume = 4 × 70 × 40 = 11,200 mL. Half (5,600 mL) is due in the first 8 hours from the burn, so 700 mL/h for the remaining 6 hours, then 350 mL/h for 16 hours, titrated to urine output and haemodynamics.
Traps that lose marks
Using the time of arrival rather than the time of burn to calculate fluids; giving colloid as first-line resuscitation; forgetting analgesia and temperature control; missing associated trauma in the intoxicated patient.