Trauma and Emergency Surgery
Trauma and Emergency Surgery is assessed through ATLS sequencing, time-critical interventions, burns and critical care. Marks go to candidates who treat the patient in the order the physiology demands.
Primary survey
Airway with cervical spine protection, breathing, circulation with haemorrhage control, disability (GCS, pupils, glucose), exposure with temperature control. Adjuncts include monitoring, urinary and gastric catheters, FAST and chest and pelvic radiographs.
- Tension pneumothorax is a clinical diagnosis: needle decompression at the 5th intercostal space in the anterior axillary line, then a chest drain.
- Massive haemothorax (over 1500 mL drained or over 200 mL/h for 4 hours) needs thoracotomy.
- Unstable pelvic fracture: pelvic binder at the level of the greater trochanters, then angio-embolisation or pre-peritoneal packing.
Shock
Class III is the first with hypotension. Damage-control resuscitation means permissive hypotension (systolic around 90 mmHg) until haemorrhage control, balanced blood products, tranexamic acid within 3 hours, and definitive control by laparotomy, REBOA or angiography.
Abdominal trauma
The spleen is the commonest injured organ; non-operative management is standard in stable patients with angio-embolisation for a high-grade blush. Laparotomy for peritonitis, evisceration, instability with a positive FAST, or pneumoperitoneum.
Burns
Parkland: 4 mL/kg/%TBSA crystalloid over 24 hours, half in the first 8 hours from the time of the burn. Rule of nines: each arm 9%, each leg 18%, trunk 36%, head 9%, perineum 1%. Intubate early for stridor, hoarseness or soot with facial burns; escharotomy for circumferential full-thickness limb or chest burns.
Worked example
A 70 kg man with 30% TBSA burns presents 2 hours after injury. Parkland = 4 × 70 × 30 = 8400 mL/24 h; half (4200 mL) is due in the first 8 hours from injury, leaving 6 hours, so 700 mL/h.
Traps
Using arrival time instead of burn time; adding inhalation injury to the TBSA percentage; giving crystalloid boluses instead of blood in class III shock.