14.1 Trauma & Burns

The Primary Survey — the ABCDE Sequence

Trauma resuscitation follows a fixed priority order adapted from Advanced Trauma Life Support (ATLS): Airway, Breathing, Circulation, Disability, Exposure. The CCRN rewards the candidate who treats the greatest immediate threat first, so when a stem stacks several abnormalities together, address the earliest letter that is compromised before moving on. You do not proceed to B until A is secured.

A — Airway with Cervical-Spine Protection

Assess patency while maintaining in-line cervical stabilization — assume a C-spine injury in any blunt multi-trauma patient. Stridor, gurgling, and inability to phonate signal obstruction. A definitive airway (endotracheal intubation) is indicated for a Glasgow Coma Scale (GCS) of 8 or less, an expanding neck hematoma, or airway burns. Reposition with a jaw-thrust (not head-tilt) to protect the spine.

B — Breathing and Ventilation

Expose the chest, watch for symmetric rise, and auscultate. Immediately life-threatening chest injuries include tension pneumothorax, open ('sucking') pneumothorax, and massive hemothorax. Tension pneumothorax is a clinical diagnosis — tracheal deviation, absent breath sounds, distended neck veins, hypotension — and is treated with immediate needle or finger decompression followed by a chest tube. Do not wait for a chest x-ray.

C — Circulation with Hemorrhage Control

Apply direct pressure or a tourniquet to external bleeding, place two large-bore IVs, and identify the source of shock. The classic sites of major occult blood loss are 'blood on the floor and four more': chest, abdomen, pelvis, retroperitoneum/long bones, and external. A positive Focused Assessment with Sonography for Trauma (FAST) plus hypotension points to intra-abdominal hemorrhage and hemorrhagic (hypovolemic) shock requiring operative control.

D — Disability

Rapid neuro exam: GCS, pupil size and reactivity, gross motor movement. A unilateral fixed, dilated pupil with declining consciousness suggests uncal herniation.

E — Exposure / Environment

Fully undress the patient to find every injury, then immediately cover with warm blankets. The trauma bay is a leading source of iatrogenic hypothermia, which feeds the lethal triad below.

The Secondary Survey

Only after the primary survey is complete and resuscitation is underway does the team perform the head-to-toe secondary survey. Take an AMPLE history — Allergies, Medications, Past history/Pregnancy, Last meal, Events of injury — and inspect and palpate every region, including the back via log-roll, the perineum, and all orifices. Adjuncts include labs, imaging, gastric decompression, and a urinary catheter — but avoid the urinary catheter if urethral injury is suspected (blood at the meatus, high-riding prostate, scrotal hematoma).

Damage-Control Resuscitation and the Lethal Triad

Damage-control resuscitation (DCR) limits crystalloid, starts blood products early, and tolerates a lower blood pressure until bleeding is controlled — permissive hypotension, targeting a systolic of roughly 80-90 mmHg or a palpable radial pulse. The key exception is traumatic brain injury, where even brief hypotension worsens secondary brain injury, so a normal MAP is maintained.

The lethal triad is hypothermia, metabolic acidosis, and coagulopathy — a self-reinforcing spiral. Hypothermia impairs the enzymatic clotting cascade and platelet function; acidosis from hypoperfusion and lactate inhibits clotting factors; and the resulting coagulopathy causes more bleeding, deeper shock, and worse acidosis. Interrupting it means active rewarming, warmed blood and fluids, hemorrhage control, and balanced transfusion — not additional crystalloid, which dilutes clotting factors and drops core temperature further.

Massive Transfusion — the 1:1:1 Ratio

Massive transfusion is generally defined as 10 or more units of packed red blood cells (PRBCs) in 24 hours (or 4 units in 1 hour). A balanced 1:1:1 ratio of plasma : platelets : PRBCs approximates whole blood and limits dilutional and consumptive coagulopathy. Give tranexamic acid (TXA) within 3 hours of injury. Watch for citrate-induced hypocalcemia — rapidly transfused blood binds ionized calcium, producing perioral tingling and a prolonged QT; replace with IV calcium. Also monitor for hyperkalemia and hypothermia from cold products.

Burns

Estimating TBSA — the Rule of Nines

Burn size drives fluid resuscitation. The rule of nines divides the adult body into multiples of 9% total body surface area (TBSA): head 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, and perineum 1%. The patient's palm (with fingers) equals roughly 1% TBSA for scattered burns. Count only partial-thickness (second-degree) and full-thickness (third-degree) burns — never superficial (first-degree) erythema.

The Parkland Formula — Worked Example

The Parkland formula estimates the first 24-hour crystalloid (lactated Ringer's) need:

4 mL x body weight (kg) x %TBSA burned.

Give half in the first 8 hours from the time of injury (not from arrival) and the remaining half over the next 16 hours. Worked example — an 80 kg adult with 40% TBSA burns:

• 4 x 80 x 40 = 12,800 mL over 24 hours
• First 8 hours: 6,400 mL, about 800 mL/hr
• Next 16 hours: 6,400 mL, about 400 mL/hr

Parkland is only a starting estimate — titrate to urine output of 0.5 mL/kg/hr (roughly 30-50 mL/hr in adults), the best bedside marker of adequate resuscitation. In the first 24-48 hours, massive capillary leak causes hypovolemic (burn) shock, so under-resuscitation risks acute kidney injury while over-resuscitation ('fluid creep') risks pulmonary edema and abdominal compartment syndrome.

Inhalation Injury, Airway, and Carbon Monoxide

Intubate early for facial burns, singed nasal hairs, carbonaceous sputum, hoarseness, or stridor — airway edema worsens over hours, and a delayed attempt may be impossible. Carbon monoxide (CO) is the classic pitfall: standard pulse oximetry reads falsely normal because it cannot distinguish carboxyhemoglobin from oxyhemoglobin. Diagnose with co-oximetry (COHgb level) and treat with 100% oxygen, which cuts the CO half-life from about 4-5 hours on room air to 60-90 minutes; consider hyperbaric oxygen for severe poisoning, pregnancy, or neurologic signs. Suspect cyanide toxicity from enclosed-space fires (persistent lactic acidosis) and treat with hydroxocobalamin.

Escharotomy

Circumferential full-thickness burns form a rigid, inelastic eschar. On a limb the eschar acts as a tourniquet (loss of distal pulses, paresthesias, pallor); on the chest or torso it restricts ventilation (rising peak inspiratory pressures). Escharotomy — a surgical incision through the eschar — restores perfusion and chest-wall excursion. Distinguish it from fasciotomy, which decompresses a true compartment syndrome of the muscle compartments.