5.2 Trauma Management (ATLS Protocol) & Burns

Trauma Management (ATLS Protocol) & Burn Care

Trauma evaluation follows the standardized Advanced Trauma Life Support (ATLS) sequence: Airway, Breathing, Circulation, Disability, and Exposure (ABCDE). Life-threatening conditions identified during the primary survey are treated immediately before progressing to subsequent steps.

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ATLS Primary Survey & Resuscitation (ABCDE)

A – Airway with Cervical Spine Protection

• Assume cervical spine injury in all blunt trauma patients. Maintain inline manual stabilization or rigid cervical collar.
• Canadian C-Spine Rule: Clinical decision tool to determine the need for cervical spine radiography in alert, stable trauma patients. Radiographs are mandatory if high-risk factors exist (age $\ge 65$, dangerous mechanism, paresthesias) or if low-risk factors allowing range-of-motion testing are absent.
• Indications for Definitive Airway (Endotracheal Intubation):
  • Severe head injury with Glasgow Coma Scale (GCS) $\le 8$
  • Apnea or respiratory failure
  • Impending airway compromise (inhalation injury, facial/neck trauma, expanding hematoma)
  • Inability to maintain airway patency or oxygenation

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B – Breathing & Ventilation

Immediate identification and intervention for five lethal thoracic injuries during the primary survey:

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C – Circulation & Hemorrhage Control

Evaluate pulse, capillary refill, skin color, mental status, and blood pressure. Identify internal vs. external bleeding.

Hemorrhagic Shock Classification

• Class I ($< 15\%$ blood loss, $< 750\text{ mL}$): Normal BP, normal HR ($< 100$), minimal anxiety.
• Class II (15–30% blood loss, 750–1500 mL): Normal BP, tachycardia ($100\text{--}120$), narrowed pulse pressure.
• Class III (30–40% blood loss, 1500–2000 mL): Hypotension, marked tachycardia ($120\text{--}140$), oliguria, confusion.
• Class IV ($> 40\%$ blood loss, $> 2000\text{ mL}$): Severe hypotension, severe tachycardia ($> 140$), anuria, lethargy.

Resuscitation Principles

• Place two large-bore peripheral IV lines ($16\text{-gauge}$ or $14\text{-gauge}$) or intraosseous (IO) access.
• Initiate Permissive Hypotension (target SBP 80–90 mmHg in non-TBI patients) until surgical hemorrhage control is achieved.
• Massive Transfusion Protocol (MTP): Activated when Class III/IV shock occurs. Administer uncrossmatched Type O-negative packed red blood cells (PRBCs), plasma (FFP), and platelets in a 1:1:1 balanced ratio.
• Tranexamic Acid (TXA): Administer $1\text{ g}$ IV bolus over 10 minutes within 3 hours of injury, followed by $1\text{ g}$ IV infusion over 8 hours.
• Pelvic Fractures: Hemodynamically unstable pelvic ring disruptions (open-book fractures) require immediate application of a pelvic binder centered over the greater trochanters (NOT the iliac crests) to reduce pelvic volume and tamponade venous hemorrhage.
• FAST Exam (Focused Assessment with Sonography for Trauma): Evaluates 4 windows: Pericardial, Right Upper Quadrant (Morison's pouch), Left Upper Quadrant (splenorenal recessed space), and Pelvis (suprapubic space). In an unstable blunt trauma patient, a positive FAST mandates immediate laparotomy.

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D & E – Disability & Exposure

• Disability: Assess Glasgow Coma Scale (GCS = Eye [4] + Verbal [5] + Motor [6]), pupil size and reactivity, and lateralizing motor deficits.
• Exposure / Environment: Completely undress patient to inspect back and perineum (log-roll with C-spine control). Prevent hypothermia using warmed IV fluids, warm blankets, and elevated ambient room temperature.

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Burn Management & Inhalation Trauma

Assessment of Burn Depth & Total Body Surface Area (TBSA)

Include only partial-thickness (2nd degree) and full-thickness (3rd degree) burns when calculating %TBSA. Superficial erythema (1st degree / sunburn) is excluded.

Wallace Rule of Nines (Adults)

• Head and Neck: 9%
• Each Upper Extremity: 9% (Front 4.5%, Back 4.5%)
• Anterior Trunk: 18%
• Posterior Trunk: 18%
• Each Lower Extremity: 18% (Front 9%, Back 9%)
• Perineum / Genitalia: 1%

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Burn Resuscitation: The Parkland Formula

Burn injury causes systemic capillary leak and massive hypovolemic shock. Fluid resuscitation uses Ringer's Lactate (RL).

$$\text{Total 24-Hour Fluid Requirement (mL)} = 4\text{ mL} \times \text{Body Weight (kg)} \times \text{\%TBSA}$$

• Administration Schedule:
  • Administer 50% of the calculated fluid volume over the FIRST 8 HOURS post-burn injury (calculated from time of burn, NOT time of hospital arrival).
  • Administer the remaining 50% of fluid volume over the SUBSEQUENT 16 HOURS.
• Resuscitation Endpoint: Adjust infusion rates dynamically to maintain target urine output:
  • Adults: $0.5\ \text{mL/kg/h}$ ($30\text{--}50\text{ mL/h}$)
  • Pediatric ($< 30\text{ kg}$): $1.0\ \text{mL/kg/h}$

💡 Calculation Example: A 70 kg male suffers 40% TBSA burns at 12:00 PM and arrives at the ER at 2:00 PM. Total 24h RL volume $= 4 \times 70 \times 40 = 11,200\text{ mL}$. First 8h volume $= 5,600\text{ mL}$. Since 2 hours elapsed before arrival, the remaining $5,600\text{ mL}$ must be infused over the next 6 hours ($933\text{ mL/h}$). The remaining $5,600\text{ mL}$ is infused over the final 16 hours ($350\text{ mL/h}$).

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Inhalation Injury & Surgical Emergencies

• Inhalation Injury: Suspect in closed-space fires, facial burns, singed nasal hairs, carbonaceous sputum, or hoarseness. Early prophylactic endotracheal intubation is mandatory before airway edema causes complete occlusion.
• Carbon Monoxide (CO) Poisoning: Carboxyhemoglobin $> 10\%$ (or $> 3\%$ in non-smokers). Normal pulse oximetry is falsely reassuring! Treat with 100% normobaric oxygen via non-rebreather mask (reduces half-life from 320 to 80 minutes) or hyperbaric oxygen.
• Circumferential Burns & Escharotomy: Full-thickness circumferential burns on extremities or torso act as a non-yielding band. Extremity edema causes compartment syndrome (loss of distal Doppler signals, paresthesias); chest burns cause severe compliance failure and asphyxia. Treatment is emergency bedside escharotomy extending through the rigid eschar into subcutaneous fat.