1.5 Major Trauma, Head Injury, Burns & Environmental Emergencies

Major Trauma, Head Injury, Burns & Environmental Emergencies

Trauma is the leading cause of death in people under 40 in the UK. PLAB 1 questions focus on the order of priorities in the primary survey, recognising immediately life-threatening injuries, and applying NICE head injury and burns rules correctly.

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The Trauma Primary Survey (cABCDE)

• c – Catastrophic haemorrhage: direct pressure, haemostatic dressings and a tourniquet for exsanguinating limb bleeding; pelvic binder for suspected pelvic fracture.
• A – Airway with cervical spine protection: jaw thrust (not head tilt), suction, airway adjuncts; definitive airway (rapid sequence induction) if GCS is 8 or less or the airway is threatened (burns, facial trauma). Use manual in-line stabilisation; imaging decisions follow the Canadian C-spine rule in NICE NG232.
• B – Breathing: look for the life-threatening chest injuries below.
• C – Circulation: two large-bore cannulae, bloods including crossmatch and venous gas, and activation of the major haemorrhage protocol (red cells and plasma given in a balanced ratio, with platelets and cryoprecipitate guided by tests). Give tranexamic acid 1 g IV over 10 minutes, then 1 g over 8 hours, within 3 hours of injury. Use permissive hypotension (a palpable radial pulse) until bleeding is controlled, except in traumatic brain injury where cerebral perfusion matters more.
• D – Disability: GCS, pupils, glucose.
• E – Exposure: full examination with log roll, while preventing hypothermia.

Life-Threatening Chest Injuries

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Head Injury (NICE NG232, 2023)

The Glasgow Coma Scale scores eyes (1–4), verbal (1–5) and motor (1–6); the total is 3–15.

CT Head Within 1 Hour (adults, 16 and over)

Any of: GCS below 13 on initial assessment in the emergency department; GCS below 15 at 2 hours after the injury; suspected open or depressed skull fracture; any sign of basal skull fracture (haemotympanum, "panda" eyes, CSF leak from ear or nose, Battle's sign); post-traumatic seizure; focal neurological deficit; more than one episode of vomiting.

CT Head Within 8 Hours

For adults with loss of consciousness or amnesia plus a risk factor: age 65 or over, a bleeding or clotting disorder, a dangerous mechanism (pedestrian or cyclist hit by a vehicle, ejection from a vehicle, fall from more than 1 metre or 5 stairs), or more than 30 minutes' retrograde amnesia. For people taking anticoagulants or antiplatelets other than aspirin alone with no other indication, NICE advises considering a CT within 8 hours (or within the hour if they present more than 8 hours after injury).

Intracranial Haematomas

Signs of raised intracranial pressure include falling GCS, a dilated pupil on the side of the lesion (third nerve compression) and Cushing's response (hypertension, bradycardia, irregular breathing), which is a late sign of impending herniation.

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Burns

• Stop the burning and cool: remove clothing and jewellery, then cool the burn with cool running water for 20 minutes (useful up to 3 hours after injury) and cover loosely with cling film. Keep the patient warm.
• Airway: singed nasal hair, soot in the mouth, hoarseness, stridor or burns in an enclosed space suggest inhalation injury, which needs early senior anaesthetic review and intubation before swelling makes it impossible. Consider carbon monoxide and cyanide poisoning (high-flow oxygen; hydroxocobalamin for cyanide).
• Size: estimate % total body surface area (TBSA) with the Wallace rule of nines in adults (head 9, each arm 9, front of trunk 18, back 18, each leg 18, perineum 1), the Lund and Browder chart in children, and the patient's palm with fingers as about 1% for small burns. Erythema alone is not counted.
• Depth: superficial (red, painful, no blisters); partial thickness (blisters, painful, moist); full thickness (white, leathery or charred, painless).
• Fluids: for burns over about 15% TBSA in adults (10% in children), the Parkland formula gives 4 mL x weight (kg) x %TBSA of Hartmann's solution over 24 hours, half in the first 8 hours from the time of the burn; titrate to a urine output of 0.5 mL/kg/h in adults (1 mL/kg/h in children).
• Escharotomy is needed for circumferential full-thickness burns of the chest or limbs.
• Refer to a burns service for large burns, burns of the face, hands, feet, genitalia, perineum or major joints, circumferential burns, inhalation, electrical or chemical burns, and any burn with suspected non-accidental injury.

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Environmental Emergencies

• Hypothermia (core temperature below 35°C): shivering is lost as it deepens; ECG may show bradycardia and J (Osborn) waves. Handle gently (ventricular fibrillation risk), remove wet clothing and rewarm (passive, active external, or extracorporeal for severe cases). In cardiac arrest, Resuscitation Council UK advises withholding adrenaline below 30°C, doubling the interval between doses at 30–35°C, and giving no more than 3 shocks until the core temperature exceeds 30°C.
• Heat stroke: core temperature above 40°C with CNS dysfunction (confusion, seizures, coma). Start rapid cooling immediately (cold-water immersion or evaporative cooling); antipyretics do not work. Watch for rhabdomyolysis, AKI and DIC.
• Drowning: hypoxia is the cause of arrest, so give 5 initial rescue breaths before compressions.