Surgery: Major trauma and burns

🩺 Major trauma and burns. Trauma is the leading cause of death in people under 45. Care follows one simple rule -treat the greatest threat to life first -using the <C>ABCDE primary survey, with catastrophic bleeding controlled before anything else. In the UK, severely injured patients go to major trauma centres. Fractures and orthopaedic injuries are on the Trauma and Orthopaedics page; brain injury medicine is in the Neurology chapters.
Your four questions for every patient: What will kill this patient first -and have I treated it? Where is the bleeding (chest, abdomen, pelvis, long bones, the floor)? Does this patient need theatre, interventional radiology or CT -and in what order? What injuries might I have missed (the tertiary survey)?

---

Trauma Systems and the Trauma Team

• Major trauma networks (England since 2012) -severely injured patients bypass local hospitals and go to a major trauma centre (neurosurgery, interventional radiology, cardiothoracics, 24/7 consultant-led trauma teams), with trauma units for less severe injuries.
• Pre-alert -ambulance crews use ATMIST handover: Age, Time of injury, Mechanism, Injuries found, Signs (vital signs), Treatment given.
• Trauma team -team leader (stands back, directs, makes decisions), airway doctor and ODP, procedures doctors, scribe, radiographer, nurses; roles allocated before arrival; "hands-off handover" -everyone listens to the paramedic first.
• Mechanisms suggesting serious injury -high-speed collision, ejection, death in the same vehicle, rollover, pedestrian or cyclist hit at speed, fall from over 2 metres (or less in older people), motorcycle crash, entrapment, blast.
• Damage control resuscitation -stop the bleeding quickly (surgery or interventional radiology), give blood products early, limit crystalloids, accept lower BP until bleeding is controlled, prevent the "lethal triad" -hypothermia, acidosis and coagulopathy.
• Damage control surgery -a short operation to stop bleeding and contamination (packing, shunts, stapling bowel), then ICU to warm and correct clotting, then definitive surgery later.

The Primary Survey

Step	Look for	Do
<C> Catastrophic haemorrhage	Massive external bleeding (limbs, junctional areas)	Direct pressure, wound packing (haemostatic dressings), tourniquet (note the time)
A -Airway with C-spine control	Talking? Noisy breathing, facial trauma, burns, GCS 8 or less	Jaw thrust, suction, adjuncts, rapid sequence intubation; surgical airway if can't intubate or oxygenate; manual in-line stabilisation
B -Breathing	Rate, SpO2, chest movement, trachea, percussion, breath sounds, wounds	Oxygen; treat tension pneumothorax, open pneumothorax, massive haemothorax; chest drain
C -Circulation	HR, BP, capillary refill, skin, mental state; bleeding into chest, abdomen, pelvis, long bones, "on the floor"	Two large-bore IV or intraosseous access; bloods and crossmatch; major haemorrhage protocol; tranexamic acid; pelvic binder; splint femurs; tamponade
D -Disability	GCS, pupils, glucose, limb movements, seizures	Prevent secondary brain injury -oxygen, BP, CO2, glucose; CT head
E -Exposure	Full log roll and inspection (back, perineum, axillae, scalp); temperature	Prevent hypothermia -warm blankets, warmed fluids, warm room

• Adjuncts -ECG monitoring, ABG and lactate, urinary catheter (unless urethral injury suspected), eFAST ultrasound, chest and pelvic X-rays; in stable patients -whole-body CT (trauma CT) is the standard in major trauma centres.
• Reassess after every intervention or change -go back to A if the patient deteriorates.
• AMPLE history -Allergies, Medications (especially anticoagulants), Past history, Last meal, Events and environment.

Airway and Cervical Spine

• A patient who is talking normally has a patent airway for now -reassess often (burns, neck haematoma and facial swelling can worsen).
• Indications for a definitive airway (intubation) -airway obstruction or threat (facial fractures, burns, neck haematoma), GCS 8 or less, failure to oxygenate or ventilate, combative patient needing CT, severe shock.
• Rapid sequence induction with manual in-line stabilisation of the neck (remove the front of the collar); video laryngoscopy helps.
• Can't intubate, can't oxygenate -front of neck access (scalpel cricothyroidotomy) -Difficult Airway Society guidance.
• Cervical spine:
  • Assume a neck injury in significant blunt trauma until cleared.
  • Manual in-line stabilisation, or blocks and tape; rigid collars are used less now (can raise intracranial pressure and cause pressure sores) -follow local policy.
  • Clearance -clinical rules (Canadian C-spine rule) or CT (see Spinal Injury).
• Maxillofacial injury -Le Fort fractures (mid-face -may threaten the airway, mobile maxilla); mandible fractures (bilateral -tongue falls back); epistaxis can be severe; sit up if spine cleared.
• Laryngeal injury -hoarse voice, surgical emphysema in the neck, stridor -secure the airway early (surgical airway may be needed).

Chest Trauma

Injury	Signs	Immediate treatment
Tension pneumothorax	Respiratory distress, low SpO2, hypotension, distended neck veins, absent breath sounds and hyper-resonance on one side, tracheal deviation away (late)	Immediate decompression -needle (2nd intercostal space mid-clavicular, or 4th/5th space mid-axillary) or finger thoracostomy; then chest drain. A clinical diagnosis -don't wait for X-ray
Open pneumothorax ("sucking chest wound")	A chest wound bubbling with breathing	Vented chest seal (or three-sided dressing); chest drain away from the wound
Massive haemothorax	Shock, dull to percussion, absent breath sounds on one side	Blood, chest drain; thoracotomy if over about 1,500 mL drained at once or over 200 mL/hour continuing
Flail chest	Two or more ribs broken in two or more places -a segment moves inwards on breathing in (paradoxical); underlying lung contusion	Oxygen, good analgesia (epidural or nerve blocks), ventilation if failing; rib fixation in some
Cardiac tamponade	Beck's triad -low BP, raised JVP, muffled heart sounds; penetrating wound; pericardial fluid on FAST	Resuscitative thoracotomy (traumatic arrest) or sternotomy; pericardiocentesis only as a temporary measure

• Other important chest injuries (found on the secondary survey or CT):
  • Simple pneumothorax -chest drain if ventilated, large, or transferring by air.
  • Pulmonary contusion -hypoxia worsening over 24–48 hours; careful fluids.
  • Blunt aortic injury -deceleration injury (high-speed crash, fall); widened mediastinum on chest X-ray; CT angiography; TEVAR; keep BP controlled.
  • Blunt cardiac injury -arrhythmias, raised troponin; ECG monitoring.
  • Diaphragmatic rupture -usually left side; bowel in the chest on X-ray; surgical repair.
  • Oesophageal and tracheobronchial injury -surgical emphysema, persistent air leak despite a chest drain.
• Rib fractures in older people -high risk of pneumonia and death; analgesia (consider nerve blocks), physio, incentive spirometry, early senior review.
• Resuscitative thoracotomy -for traumatic cardiac arrest from penetrating chest injury (tamponade) with recent signs of life -releases tamponade, controls bleeding, allows cross-clamping of the aorta.
• Traumatic cardiac arrest -treat reversible causes (HOTT -Hypovolaemia, Oxygenation, Tension pneumothorax, Tamponade) -bilateral thoracostomies, blood, airway -chest compressions are less important than fixing the cause.

Haemorrhagic Shock and Major Haemorrhage

• Shock -not enough oxygen delivery to the tissues; in trauma it is bleeding until proven otherwise.
• Signs -tachycardia, cool pale skin, slow capillary refill, anxiety or confusion, low urine output, then low BP (late -young fit people compensate until they have lost a lot of blood).
• Beware -beta-blockers, pacemakers, athletes, older people and pregnancy can hide shock; a normal Hb early on doesn't exclude major bleeding; lactate and base deficit help.
• Other causes of shock in trauma -tension pneumothorax, tamponade (obstructive), spinal cord injury (neurogenic -low BP with slow heart rate and warm peripheries), cardiac contusion.
• Major haemorrhage protocol:
  • Activate early; give blood products in a balanced ratio (red cells to plasma about 1:1, with platelets) -prehospital teams often carry blood; limit crystalloid.
  • Tranexamic acid -1 g IV within 3 hours of injury (ideally as soon as possible), then 1 g over 8 hours (CRASH-2) -giving it after 3 hours may be harmful.
  • Monitor with point-of-care viscoelastic testing (ROTEM, TEG) and labs; fibrinogen (cryoprecipitate or fibrinogen concentrate) if under about 1.5 g/L; calcium (citrate in blood products lowers it).
  • Reverse anticoagulants -prothrombin complex concentrate and vitamin K for warfarin; specific reversal for DOACs (idarucizumab for dabigatran; andexanet or PCC per local policy for factor Xa inhibitors).
• Permissive hypotension -target systolic about 80–90 mmHg (or a palpable radial pulse) until bleeding is controlled -but not in head injury (keep systolic at 110 mmHg or more to protect brain perfusion).
• Stop the bleeding -surgery, interventional radiology (embolisation), pelvic binder, splints; REBOA (balloon in the aorta) in a few specialist centres.
• Prevent hypothermia -warmed blood and fluids, warm blankets and environment.

Abdominal Trauma

• Blunt trauma -the spleen and liver are most often injured; also bowel and mesentery (seatbelt injuries), pancreas, kidneys, duodenum.
• Penetrating trauma -stab wounds (liver, small bowel, colon, diaphragm) and gunshot wounds (unpredictable track -usually need laparotomy).
• Signs -abdominal pain, tenderness, guarding, distension, bruising (a seatbelt sign -linked with bowel and lumbar spine injuries), shoulder tip pain (Kehr's sign -splenic injury, blood under the diaphragm); examination is unreliable with head injury, intoxication or distracting injuries.
• Investigations:
  • eFAST (ultrasound at the bedside) -free fluid in the abdomen, pericardium, pleura, pneumothorax; quick and repeatable, but a negative scan doesn't exclude injury.
  • CT with contrast -the investigation of choice in stable patients.
• Management:
  • Unstable with free fluid (or peritonitis) → laparotomy (damage control).
  • Stable solid organ injury (spleen, liver, kidney) → often non-operative management with close monitoring ± angioembolisation; repeat assessment.
  • Hollow organ injury (bowel perforation -free air, peritonitis) → surgery.
  • Penetrating wounds with shock, peritonitis or evisceration → laparotomy; stable stab wounds may be observed or explored.
• After splenectomy -vaccines (pneumococcal, Hib, meningococcal ACWY and B, annual flu), consider long-term antibiotics, an alert card -risk of overwhelming post-splenectomy infection (see the Infectious Diseases chapter).
• Delayed splenic rupture -a subcapsular haematoma can bleed days later -warn patients managed without surgery.
• Abdominal compartment syndrome -tense abdomen, rising airway pressures, falling urine output after massive resuscitation -measure bladder pressure; decompressive laparotomy.

Pelvic Fractures

• High-energy pelvic fractures can bleed heavily (venous plexus, bone, and arteries) -a cause of shock that is easy to miss.
• Patterns:
  • Anteroposterior compression ("open book") -the pelvis opens at the symphysis; increases pelvic volume and bleeding.
  • Lateral compression -commonest; side impacts.
  • Vertical shear -falls from height; unstable.
• Suspect it in high-energy mechanisms, shock without an obvious cause, leg length difference, perineal bruising, blood at the urethral meatus.
• Don't "spring" the pelvis -it can dislodge clots; apply a pelvic binder at the level of the greater trochanters (not the iliac crests) early, before imaging, in suspected pelvic fracture with shock.
• Management of bleeding -binder, blood products, interventional radiology embolisation (arterial bleeding), pre-peritoneal pelvic packing, external fixation; definitive fixation later.
• Associated injuries -bladder and urethral injury (don't catheter if blood at the meatus -see Urology), rectal and vaginal injuries (open fracture -antibiotics), lumbosacral nerve injury.
• Low-energy pubic rami fractures in older people -from a fall; pain on weight bearing (see the Trauma and Orthopaedics page) -usually managed with analgesia and mobilisation.

Head Injury

• Primary brain injury -happens at the time of impact. Secondary brain injury -from hypoxia, low BP, high or low CO₂, low or high glucose, seizures, raised intracranial pressure -preventable.
• GCS -eyes (4), verbal (5), motor (6); severity: mild 13–15, moderate 9–12, severe 3–8. Record each part, plus pupils.
• CT head within 1 hour (adults, NICE NG232) if any of:
  • GCS under 13 on first assessment in ED, or under 15 at 2 hours after injury.
  • Suspected open or depressed skull fracture.
  • Signs of basal skull fracture -panda eyes, Battle's sign (bruising behind the ear), CSF from the nose or ear, blood behind the eardrum.
  • Post-traumatic seizure.
  • Focal neurological deficit.
  • More than one episode of vomiting.
• CT head within 8 hours if loss of consciousness or amnesia plus any of -age 65 or over, bleeding or clotting disorder, dangerous mechanism, more than 30 minutes of amnesia for events before the injury; and for people on anticoagulants even without these features (per NICE).
• Intracranial haematomas:
  • Extradural -usually the middle meningeal artery after a temporal skull fracture; a lucid interval then rapid deterioration; lens-shaped (biconvex) on CT -urgent craniotomy.
  • Acute subdural -torn bridging veins; older people, alcohol, anticoagulants; crescent-shaped; surgery if large or with midline shift.
  • Chronic subdural -weeks after minor trauma; confusion, headache, fluctuating drowsiness in older people -burr holes.
  • Traumatic subarachnoid haemorrhage, contusions, diffuse axonal injury (coma with a near-normal CT).
• Raised intracranial pressure -falling GCS, a dilating pupil on one side (third nerve compression -coning), Cushing's response (rising BP, falling heart rate, irregular breathing -late) -head up 30°, intubate and ventilate (normal CO₂), hypertonic saline or mannitol, urgent neurosurgery.
• Neuroprotective care -SpO₂ over 94%, PaCO₂ about 4.5–5.0 kPa, systolic BP 110 or more (or MAP over 80), normal glucose and sodium, avoid fever, treat seizures.
• Discharge advice for minor head injury -a responsible adult, written advice, return if drowsy, vomiting, severe headache, confusion, seizures, weakness or CSF leak.

Spinal Injury

• Suspect spinal injury in significant blunt trauma, especially with a head injury, falls from height, diving, or high-speed crashes; older people can fracture their neck with simple falls.
• Canadian C-spine rule (alert, stable adults):
  • High risk → image -age 65 or over, dangerous mechanism (fall from over 1 metre or 5 stairs, axial load to the head, high-speed crash, rollover, ejection, bicycle collision), or paraesthesia in the limbs.
  • Low-risk features (simple rear-end crash, sitting in ED, walking since the injury, delayed neck pain, no midline tenderness) → test active neck rotation -if they can rotate 45° left and right, imaging is not needed.
• Imaging -CT is first-line for the adult cervical spine (NICE NG41); MRI for neurological signs, ligament injury or cord compression; CT of thoracic and lumbar spine as part of trauma CT.
• Spinal cord syndromes:
  • Complete cord injury -no movement or feeling below the level.
  • Central cord syndrome -older people with neck hyperextension (spondylosis) -arms weaker than legs.
  • Anterior cord syndrome -loss of power and pain/temperature below the level; preserved proprioception and vibration.
  • Brown-Séquard (hemisection, often penetrating) -weakness and loss of proprioception on the same side, loss of pain and temperature on the opposite side.
• Neurogenic shock -injuries above about T6 -loss of sympathetic tone: low BP with bradycardia, warm peripheries; fluids, vasopressors, atropine. (Spinal shock is different -temporary loss of reflexes below the injury.)
• Care -log rolling and spinal precautions, avoid hypotension and hypoxia, catheter (urinary retention), pressure care, VTE prophylaxis, early transfer to a spinal injuries centre; autonomic dysreflexia later (injury above T6 -sudden severe hypertension from a full bladder or bowel -sit up, remove the trigger).
• Thoracolumbar fractures -burst or chance (seatbelt) fractures; check for associated bowel injuries.

Secondary and Tertiary Surveys

• Secondary survey -a head-to-toe examination and full history once the primary survey is complete and the patient is stable:
  • Head and face (scalp wounds, eyes -pupils and visual acuity, ears -haemotympanum, nose, teeth, jaw).
  • Neck, chest, abdomen, pelvis, perineum (and rectal or vaginal examination when indicated).
  • Limbs -deformity, wounds, pulses, nerve function, compartments.
  • Back (log roll) -spinal tenderness, steps, wounds.
  • Full neurological examination.
• Tertiary survey -a repeat full examination within 24 hours (and again when the patient is awake) to catch missed injuries -commonly hand and foot fractures, ligament injuries, small bowel injuries.
• Imaging review -review all imaging with a senior radiologist report.
• Other early tasks -tetanus status (immunoglobulin and vaccine for tetanus-prone wounds), antibiotics for open fractures (within 1 hour), analgesia, VTE prophylaxis, family communication, safeguarding (non-accidental injury, domestic abuse).
• Rhabdomyolysis -crush injuries, long lies; very high CK, dark urine, AKI, high potassium -IV fluids (see the Renal chapters).
• Fat embolism syndrome -24–72 hours after long bone (femur) fractures -breathlessness and hypoxia, confusion, petechial rash (chest, axillae, conjunctivae) -supportive care; early fracture fixation reduces risk.

Trauma in Older People, Pregnancy and Children

• Older people -"silver trauma":
  • Serious injuries from low-energy falls (standing height) -head injury, cervical spine (odontoid fractures), rib and pelvic fractures.
  • Vital signs mislead -beta-blockers hide tachycardia; "normal" BP may be low for a hypertensive patient; lactate helps.
  • Anticoagulants -high risk of intracranial bleeding; reverse quickly.
  • Look for the cause of the fall (syncope, stroke, infection); early geriatric input; delirium prevention.
• Pregnancy:
  • Resuscitating the mother is the best way to save the fetus.
  • After about 20 weeks -manual uterine displacement to the left or left lateral tilt (the uterus compresses the IVC, lowering BP).
  • Physiological changes -higher heart rate, lower BP, larger blood volume (signs of shock appear late), raised diaphragm (chest drains higher), aspiration risk.
  • Risks -placental abruption (pain, bleeding, uterine tenderness, fetal distress), uterine rupture, preterm labour; fetal monitoring by obstetrics.
  • Anti-D immunoglobulin for rhesus-negative women (Kleihauer test).
  • Resuscitative hysterotomy (perimortem caesarean section) within 4–5 minutes of maternal cardiac arrest after about 20 weeks.
  • Domestic abuse -ask privately.
• Children:
  • Use weight-based doses and equipment (length-based tapes); higher heart rates and lower BPs are normal by age.
  • Children compensate well -low BP is a very late sign of shock.
  • Flexible ribs -serious lung injury without rib fractures.
  • Fluid boluses of 10 mL/kg of blood in haemorrhage.
  • Safeguarding -injuries inconsistent with the story or the child's development, delayed presentation, bruising in non-mobile babies (see the Paediatrics chapters).

Penetrating and Blast Injury

• Stab wounds -injury follows the blade; don't remove impaled objects in ED (remove in theatre).
• "The box" -stab wounds between the nipples, clavicles and costal margin may injure the heart (tamponade) -FAST for pericardial fluid; low threshold for surgery.
• Thoracoabdominal wounds (below the nipple line) may injure both the chest and abdomen, including the diaphragm.
• Neck wounds -if the platysma is breached, risk of vascular, airway and oesophageal injury; hard signs (expanding haematoma, pulsatile bleeding, stridor, air bubbling) → theatre; CT angiography if stable.
• Gunshot wounds -energy and track are unpredictable; often need surgery; document and preserve forensic evidence (police involvement -follow GMC guidance on disclosure).
• Blast injury:
  • Primary -pressure wave -blast lung, ruptured eardrums, bowel perforation.
  • Secondary -fragments (penetrating injuries).
  • Tertiary -being thrown (blunt injuries, amputations).
  • Quaternary -burns, crush, inhalation, psychological.
• Major incidents -triage by priority (P1 immediate, P2 urgent, P3 delayed, dead), METHANE report (Major incident, Exact location, Type, Hazards, Access, Number of casualties, Emergency services) -follow the hospital major incident plan.
• Bites (human, dog, cat) -clean, explore, leave open often; co-amoxiclav prophylaxis for high-risk bites (hands, face, cats, human bites, immunosuppressed); tetanus and rabies risk assessment (see the Infectious Diseases chapter).

Burns Assessment

• First aid -stop the burning (remove from source and remove clothing and jewellery), cool the burn with cool running water for 20 minutes (useful up to 3 hours after the burn), keep the patient warm, cover with cling film (lay in strips, don't wrap circumferentially), analgesia.
• Primary survey as for trauma -burns patients may also have other injuries (explosions, jumping from buildings).
• Burn size -percentage of total body surface area (TBSA); don't include simple erythema (like sunburn):
  • Wallace rule of nines (adults) -head and neck 9%, each arm 9%, front of trunk 18%, back of trunk 18%, each leg 18%, perineum 1%.
  • Patient's palm and fingers = about 1% TBSA (small or patchy burns).
  • Lund and Browder chart -the most accurate, especially in children (larger heads, smaller legs).
• Burn depth:

  Depth	Appearance	Healing
  Epidermal (superficial)	Red, painful, no blisters (sunburn)	Days; not counted in TBSA
  Superficial partial thickness	Pink, blisters, moist, very painful, blanches with brisk refill	About 2 weeks, little scarring
  Deep partial thickness	Dry, blotchy red, sluggish or no blanching, reduced sensation	Over 3 weeks; scarring; often needs grafting
  Full thickness	White, brown or black, leathery, painless (nerves destroyed), no blanching	Won't heal without surgery (excision and skin graft)

• Referral to a specialist burns service (National Burn Care Referral Guidance) -includes: 2% TBSA or more in children, 3% or more in adults (partial thickness); any full-thickness burn; burns to the face, hands, feet, perineum, genitalia or across major joints; circumferential burns; chemical, electrical or friction burns; inhalation injury; burns with other trauma or significant comorbidity; suspected non-accidental injury; burns not healing within 2 weeks.
• Safeguarding -in children and vulnerable adults, look for patterns suggesting deliberate injury: glove or stocking scalds (forced immersion) with clear edges and no splash marks, cigarette burns, delayed presentation, story not matching the injury.

Burns Resuscitation and Early Care

• Large burns cause massive fluid shifts (capillary leak) -"burns shock".
• IV fluid resuscitation is needed for burns of about 15% TBSA or more in adults and 10% or more in children.
• Parkland formula -4 mL × weight (kg) × %TBSA of Hartmann's solution over 24 hours, timed from the time of the burn (not arrival):
  • Half in the first 8 hours, half in the next 16 hours.
  • Many services now start lower (2–4 mL/kg/%TBSA) because over-resuscitation ("fluid creep") causes oedema, compartment syndromes and lung problems -follow local burns guidance.
  • Children also need maintenance fluids with glucose.
• Titrate to urine output -catheterise; aim for about 0.5 mL/kg/hour in adults and 1 mL/kg/hour in children.
• Escharotomy -for circumferential full-thickness burns:
  • Chest -stiff eschar restricts breathing (rising airway pressures, poor ventilation).
  • Limbs -compartment-like ischaemia (pain, falling pulses).
  • Cuts through the burnt skin to release it (usually in the burns centre or by trained staff).
• Other early care -analgesia (IV opioids), keep warm (large burns lose heat fast), elevate burnt limbs, tetanus, nutrition early (very high metabolic demands -NG feeding), stress ulcer prophylaxis, avoid prophylactic antibiotics (treat infection if it develops), psychological support.
• Later problems -infection and sepsis, contractures, hypertrophic scarring (pressure garments, silicone, physiotherapy), Marjolin's ulcers (SCC in old burn scars).
• Minor burns (managed locally) -clean, deroof or leave small blisters (local policy), non-adherent dressings, review at 48 hours, analgesia, tetanus.

Inhalation Injury

• Suspect it with burns in an enclosed space, burns to the face and neck, singed nasal hairs or eyebrows, soot in the mouth or nose, carbonaceous sputum, hoarse voice, stridor, cough, breathlessness.
• Upper airway burns -airway swelling worsens over hours -early intubation by an experienced anaesthetist before swelling makes it impossible (use an uncut tube -the face swells).
• Lower airway injury -chemical damage from smoke -bronchospasm, ARDS, pneumonia; ventilation, bronchoscopy, nebulised heparin in some centres.
• Carbon monoxide poisoning:
  • Headache, nausea, confusion, seizures, coma; "cherry red" skin is rare and late.
  • Pulse oximetry is falsely normal -check carboxyhaemoglobin on a co-oximetry blood gas.
  • High-flow 100% oxygen via a non-rebreathe mask (halves CO half-life); hyperbaric oxygen in selected cases (specialist advice).
• Cyanide poisoning (burning plastics and furniture) -high lactate, coma, shock, persistent acidosis despite resuscitation -hydroxocobalamin IV.
• Everyone from a house fire with symptoms -oxygen, ABG with COHb and lactate, chest X-ray, observe.

Chemical, Electrical and Other Burns

• Chemical burns:
  • Remove contaminated clothing (protect staff); brush off dry powder; irrigate with large volumes of water for a long time (often over 30–60 minutes) -check skin pH.
  • Alkalis (cement, oven cleaner, drain cleaner) penetrate more deeply than acids -worse injuries.
  • Hydrofluoric acid -severe pain, deep damage, low calcium and arrhythmias -calcium gluconate gel on the skin (± injections), monitor calcium and ECG.
  • Eyes -immediate prolonged irrigation (until pH is normal), then urgent ophthalmology.
• Electrical burns:
  • Low voltage (domestic) -entry and exit wounds, arrhythmias (ECG for all).
  • High voltage (over 1,000 V) -deep tissue damage much worse than the skin suggests ("tip of the iceberg") -rhabdomyolysis, compartment syndrome, AKI, cardiac arrest, spinal injuries (thrown); cardiac monitoring, CK, fluids for a higher urine output, fasciotomy.
  • Lightning -cardiac arrest (often asystole -prolonged CPR may succeed), fern-like skin marks (Lichtenberg figures), eardrum rupture, cataracts later.
• Friction burns and contact burns (hot surfaces -often deep in older people and epileptics).
• Bitumen (tar) burns -cool with water; don't peel off; remove later with paraffin or oil-based products.
• Scalds -commonest burns in children (hot drinks, bath water) -most are superficial but check for safeguarding concerns.
• Toxic shock syndrome -fever, rash and shock in a child with a small burn (a few days later) -staphylococcal or streptococcal toxins -urgent IV antibiotics and fluids.

Cold Injury and Drowning

• Hypothermia -core temperature under 35°C:
  • Mild (32–35°C) -shivering, confusion; moderate (28–32°C) -shivering stops, drowsy, bradycardia, AF; severe (under 28°C) -coma, ventricular fibrillation, asystole.
  • ECG -bradycardia, J waves (Osborn waves), long QT, AF.
  • Handle gently (VF risk); remove wet clothes; passive and active rewarming (blankets, warm air, warmed fluids); ECMO or bypass for severe cases or cardiac arrest.
  • Cardiac arrest -"not dead until warm and dead" -give up to 3 shocks then defer further shocks and withhold adrenaline until temperature is above 30°C, then double the interval between drugs until 35°C (Resuscitation Council UK).
• Frostbite -freezing of tissue (fingers, toes, nose, ears) -rapid rewarming in warm water (37–39°C) once there is no risk of refreezing, analgesia (very painful), elevation, tetanus; iloprost or thrombolysis in specialist centres for severe cases; delay amputation for weeks until the demarcation is clear.
• Non-freezing cold injury (trench foot) -prolonged cold and wet; painful, swollen feet.
• Drowning:
  • Hypoxia is the main problem -start with 5 rescue breaths in cardiac arrest, then CPR.
  • Assume spinal injury only if diving or a clear mechanism.
  • Oxygen, monitor for ARDS and aspiration pneumonia (delayed -observe for at least 6 hours even if well), hypothermia, electrolytes.
• Heat illness -heat exhaustion versus heat stroke (temperature over 40°C with confusion or reduced consciousness) -rapid cooling (cold water immersion, evaporative cooling), fluids, watch for rhabdomyolysis, DIC and liver injury.

Trauma and Burns at a Glance

Problem	Key clues	Immediate action
Catastrophic limb bleeding	Pulsatile or pouring blood	Direct pressure, packing, tourniquet
Tension pneumothorax	Shock, absent breath sounds, hyper-resonance	Needle or finger decompression, chest drain
Massive haemothorax	Shock, dull chest on one side	Blood, chest drain, thoracotomy if heavy bleeding
Cardiac tamponade	Beck's triad, penetrating wound in "the box"	Thoracotomy or sternotomy
Haemorrhagic shock	Tachycardia, cool skin, high lactate	Major haemorrhage protocol, TXA within 3 hours, stop bleeding
Pelvic fracture with shock	High-energy injury, leg shortening	Binder at greater trochanters, IR or packing
Unstable with free abdominal fluid	Positive FAST, shock	Laparotomy
Extradural haematoma	Lucid interval, lens-shaped on CT	Urgent craniotomy
Raised ICP	Falling GCS, fixed dilated pupil, Cushing's response	Head up, ventilate, hypertonic saline or mannitol, neurosurgery
Neurogenic shock	Low BP with slow pulse, warm skin, cord injury	Fluids, vasopressors, atropine
Fat embolism	Hypoxia, confusion, petechiae after femur fracture	Supportive, early fixation
Major burn	15% TBSA or more (adult)	Parkland-guided fluids, urine output 0.5 mL/kg/h
Inhalation injury	Soot, hoarseness, singed hairs, enclosed fire	Early intubation
Carbon monoxide	Headache, confusion, normal SpO2	100% oxygen, COHb level
Hydrofluoric acid burn	Severe pain, low calcium	Irrigate, calcium gluconate gel

Spot the Diagnosis

Clue	Diagnosis
Hypotension, distended neck veins and absent breath sounds on the left after a crash	Tension pneumothorax
Low BP, raised JVP, muffled heart sounds after a stab wound to the chest	Cardiac tamponade
Shock with a dull right hemithorax and 1.8 L of blood from the chest drain	Massive haemothorax -thoracotomy
Chest segment moving inwards on breathing in	Flail chest
Widened mediastinum after a high-speed deceleration crash	Blunt aortic injury
Bowel loops in the left chest on X-ray after a crash	Diaphragmatic rupture
Left shoulder tip pain and shock after a fall onto the left side	Splenic injury (Kehr's sign)
Bruising across the lower abdomen from a seatbelt with a lumbar fracture	Chance fracture -look for bowel injury
Shock with a shortened leg and perineal bruising after a motorbike crash	Pelvic fracture -binder
Brief knockout, talking normally, then drowsiness 2 hours later	Extradural haematoma
Fluctuating confusion 3 weeks after a minor fall in a man on warfarin	Chronic subdural haematoma
Panda eyes, Battle's sign and clear fluid from the nose	Basal skull fracture
Coma with a near-normal CT after a high-speed crash	Diffuse axonal injury
Rising BP, falling pulse and irregular breathing with a head injury	Cushing's response -raised ICP
Arms weaker than legs after a fall onto the face in a 75-year-old	Central cord syndrome
Same-side weakness and opposite-side loss of pain sensation after a stab to the back	Brown-Séquard syndrome
BP 80/40 and HR 50 with warm peripheries after a neck injury	Neurogenic shock
Hypoxia, confusion and petechiae 2 days after a femoral fracture	Fat embolism syndrome
Pregnant woman at 32 weeks with abdominal pain, vaginal bleeding and a tender uterus after a crash	Placental abruption
Glove-like scald with clear edges and no splash marks in a toddler	Forced immersion -safeguarding
White, leathery, painless burn	Full-thickness burn
Hoarse voice and soot in the mouth after a house fire	Inhalation injury -early intubation
Headache and confusion with SpO2 99% after a faulty boiler	Carbon monoxide poisoning
Persistent high lactate after a house fire despite fluids	Cyanide poisoning -hydroxocobalamin
Rising ventilator pressures with a circumferential chest burn	Needs escharotomy
Small skin wound but dark urine and high CK after a high-voltage shock	Deep tissue damage and rhabdomyolysis
J waves on the ECG of a man found outdoors in winter	Hypothermia

Exam-style Scenarios

1. A 24-year-old motorcyclist hits a car at 50 mph. He is agitated, RR 34, SpO₂ 86% on oxygen, HR 135, BP 78/40. The trachea is deviated to the left, the right chest is hyper-resonant with absent breath sounds, and neck veins are distended.
Answer: Right tension pneumothorax.

• Immediate decompression -needle or finger thoracostomy (4th/5th intercostal space, mid-axillary line) -before any X-ray.
• Then a chest drain; continue the primary survey (C -bleeding sources, major haemorrhage protocol, tranexamic acid).
• Whole-body CT once stable; look for other injuries (pelvis, femur, head, spine).

2. A 45-year-old woman is crushed by a lorry. HR 140, BP 70/40, GCS 14. Chest X-ray is clear; FAST shows no free fluid; pelvic X-ray shows an open-book pelvic fracture.
Answer: Haemorrhagic shock from a pelvic fracture.

• Pelvic binder at the level of the greater trochanters (if not already on); major haemorrhage protocol with balanced blood products; tranexamic acid 1 g within 3 hours.
• Permissive hypotension (no head injury evident); prevent hypothermia; check fibrinogen and calcium.
• Stop the bleeding -interventional radiology embolisation or pre-peritoneal packing ± external fixation; don't catheterise if blood at the meatus.

3. A 19-year-old man is hit on the side of the head with a bat. He was briefly knocked out, then chatted with paramedics. One hour later his GCS has dropped to 9 and his right pupil is dilated.
Answer: Extradural haematoma with raised intracranial pressure.

• Airway -intubate and ventilate (target PaCO₂ 4.5–5.0 kPa), SpO₂ over 94%, systolic BP 110 or more.
• Urgent CT head and immediate neurosurgical referral for craniotomy; head up 30°; hypertonic saline or mannitol as a bridge.
• Treat seizures; avoid hypotension, hypoxia and fever.

4. A 70 kg man has 30% TBSA partial- and full-thickness burns from a house fire 2 hours ago. He has soot around his mouth and a hoarse voice.
Answer: Major burn with inhalation injury.

• Early intubation by an experienced anaesthetist (uncut tube); 100% oxygen; check carboxyhaemoglobin and lactate (cyanide -hydroxocobalamin if severe acidosis).
• Fluids -Parkland: 4 × 70 × 30 = 8,400 mL of Hartmann's in 24 hours from the time of the burn -about 4,200 mL in the first 8 hours (already 2 hours in, so give it over the next 6) -titrate to urine output 0.5 mL/kg/hour; many units start lower.
• Cool and cover with cling film, keep warm, analgesia, catheter, tetanus; refer to a burns centre; escharotomy if circumferential chest or limb burns.

5. An 82-year-old woman on apixaban trips at home and hits her head. She has no loss of consciousness, a GCS of 15, and a small scalp bruise.
Answer: Head injury in an anticoagulated older patient.

• CT head (within 8 hours per NICE for anticoagulated patients; many units scan sooner) -she should not go home without imaging.
• If bleeding is found -urgent anticoagulant reversal (local policy) and neurosurgical advice; neuro observations.
• Look for the cause of the fall (syncope, ECG, postural BP), assess cervical spine (age 65 or over -imaging if neck pain), frailty and falls review.

Key Points

• Treat the greatest threat to life first -<C>ABCDE -control catastrophic bleeding before the airway.
• Tension pneumothorax is a clinical diagnosis -decompress before X-ray.
• Beck's triad -low BP, raised JVP, muffled heart sounds -tamponade.
• Shock in trauma is bleeding until proven otherwise -chest, abdomen, pelvis, long bones, the floor.
• Tranexamic acid 1 g within 3 hours of injury.
• Balanced blood products, limit crystalloid, prevent the lethal triad (cold, acidosis, coagulopathy).
• Permissive hypotension -except in head injury (keep systolic 110 or more).
• Pelvic binder at the greater trochanters; don't spring the pelvis.
• Unstable with positive FAST -laparotomy; stable solid organ injury -often non-operative.
• CT head within 1 hour for GCS under 13 (or under 15 at 2 hours), skull fracture signs, seizure, focal deficit, or more than one vomit.
• Extradural -lucid interval, lens-shaped; subdural -crescent, older people and anticoagulants.
• Prevent secondary brain injury -oxygen, BP, CO₂, glucose, sodium, temperature.
• Neurogenic shock -low BP with bradycardia and warm skin.
• Always do a tertiary survey -missed injuries are common.
• Burns -cool for 20 minutes, cover with cling film, keep warm.
• Rule of nines; palm and fingers = 1%; Lund and Browder for children; don't count erythema.
• Parkland -4 mL × kg × %TBSA, half in the first 8 hours from the burn; titrate to urine output.
• Inhalation injury -intubate early; CO poisoning gives normal SpO₂.
• Hypothermic arrest -not dead until warm and dead.

Guidelines and Further Reading

• American College of Surgeons: Advanced Trauma Life Support (ATLS)
• NICE NG39: Major trauma -assessment and initial management
• NICE NG40: Major trauma -service delivery
• NICE NG41: Spinal injury -assessment and initial management
• NICE NG232: Head injury -assessment and early management
• NICE NG37: Fractures (complex) -assessment and management
• Royal College of Emergency Medicine: Tranexamic acid in trauma; Silver trauma guidance
• Resuscitation Council UK: Special circumstances (traumatic cardiac arrest, hypothermia, drowning, pregnancy)
• British Burn Association: National Burn Care Referral Guidance; First aid clinical practice guidelines
• Difficult Airway Society: Guidelines for management of unanticipated difficult intubation
• UKHSA / TOXBASE: Carbon monoxide and cyanide poisoning
• BNF -for current doses