Trauma, burns and environmental emergencies

Trauma resuscitation (primary survey, damage-control resuscitation, massive transfusion, TXA), chest and abdominal injuries, burns with inhalation injury, heat stroke, drowning, hypothermia and electrical injury, with Indian context (road traffic injuries, heat waves, monsoon drowning).

6 topics

01
Primary survey and massive transfusion
ATLS primary survey (<C>ABCDE), damage-control resuscitation, tranexamic acid and activating the massive transfusion protocol.
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02
Chest and abdominal trauma
Recognising and treating the immediately life-threatening chest injuries, and decision-making for blunt and penetrating abdominal trauma.
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03
Burns: resuscitation and inhalation injury
TBSA estimation, Parkland/ABA fluid resuscitation, airway and inhalation injury, CO and cyanide, escharotomy and early ICU care.
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04
Heat stroke
Rapid recognition and cooling of classic and exertional heat stroke, and ICU management of its multi-organ complications.
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05
Drowning
Resuscitation with early ventilation, ICU management of drowning lung injury and prognosis.
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06
Hypothermia and electrical injury
Staging and rewarming accidental hypothermia, hypothermic cardiac arrest, and ICU care after electrical and lightning injuries.
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Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Tranexamic acid

Antifibrinolytic

Indications: Trauma haemorrhage within 3 h of injury; PPH; (not for GI bleeding)
Adult dose: 1 g IV over 10 min, then 1 g IV over 8 h. Give within 3 h of injury; do not start after 3 h.
Preparation (India): 500 mg/5 mL ampoules (Indian brands widely available). Loading: 1 g in 100 mL NS over 10 min; maintenance: 1 g in 500 mL NS at ~62 mL/h over 8 h.
Renal / hepatic: Reduce maintenance in severe renal impairment.
Cautions: Starting > 3 h after injury increased bleeding deaths in CRASH-2. Seizures at high doses.

Packed red blood cells (PRBC)

Blood component

Indications: Haemorrhagic shock; symptomatic anaemia
Adult dose: Massive haemorrhage: 1 unit PRBC : 1 unit FFP : 1 unit platelets (or 1 apheresis platelet per 6 units). Target Hb 7-9 g/dL once bleeding is controlled.
Preparation (India): ~250-350 mL per unit; 1 unit raises Hb by ~1 g/dL in a 70 kg adult. Use O-negative (women of child-bearing age) or O-positive uncrossmatched in emergencies.
Cautions: Warm all products; monitor ionised calcium, potassium and temperature.

Cryoprecipitate / fibrinogen concentrate

Blood component / factor concentrate

Indications: Fibrinogen < 1.5 g/L (or functional fibrinogen deficit on ROTEM/TEG) in bleeding
Adult dose: Cryoprecipitate 1 unit per 10 kg (typically 6-10 units in adults) OR fibrinogen concentrate 3-4 g IV; repeat guided by fibrinogen level.
Preparation (India): Single-donor cryo units (~15-20 mL, ~150-250 mg fibrinogen each) from blood banks; fibrinogen concentrate has limited availability in India.

Calcium chloride 10% / calcium gluconate 10%

Electrolyte

Indications: Hypocalcaemia during massive transfusion; hyperkalaemia; CCB toxicity
Adult dose: Massive transfusion: 10 mL calcium chloride 10% (or 30 mL calcium gluconate 10%) IV, repeat to keep ionised Ca > 1.1 mmol/L.
Preparation (India): Calcium gluconate 10% 10 mL ampoules are most common in India (2.2 mmol Ca each); calcium chloride 10% contains 6.8 mmol per 10 mL (central line preferred).
Cautions: Calcium chloride is a vesicant; do not mix with bicarbonate.

Ringer lactate

Isotonic crystalloid

Indications: Burns resuscitation; volume replacement
Adult dose: Burns: 2-4 mL/kg/%TBSA over 24 h from time of burn (half in first 8 h), then titrate hourly to urine output. Trauma: limit crystalloid; switch early to blood.
Preparation (India): 500 mL / 1 L bags.
Cautions: Fluid creep (> 6 mL/kg/%TBSA) causes compartment syndromes and ARDS.

Oxygen

Medical gas

Indications: Hypoxaemia; carbon monoxide poisoning; drowning
Adult dose: CO poisoning: 100% (FiO2 1.0) via non-rebreather or ventilator. Otherwise titrate to SpO2 94-98%.
Preparation (India): Pipeline or cylinder; non-rebreather mask delivers FiO2 ~0.6-0.8 at 15 L/min.
Cautions: SpO2 unreliable in CO poisoning.

Hydroxocobalamin

Cyanide antidote

Indications: Suspected cyanide poisoning in smoke inhalation (coma, shock, lactate > 8 mmol/L)
Adult dose: 5 g IV over 15 min; may repeat 5 g once.
Preparation (India): Cyanokit 5 g vial; limited availability in India (import/tertiary centres). Sodium thiosulphate 12.5 g IV is an alternative.
Cautions: Turns skin and urine red; interferes with colorimetric lab tests and dialysis machine blood-leak alarms.

Benzodiazepine (diazepam / midazolam)

Benzodiazepine

Indications: Shivering or agitation during active cooling of heat stroke; seizures
Adult dose: Midazolam 1-2 mg IV, repeat; or diazepam 5-10 mg IV for shivering/seizure.
Preparation (India): Midazolam 1 mg/mL and 5 mg/mL ampoules; diazepam 10 mg/2 mL.
Cautions: Respiratory depression; airway support ready.

Warmed IV fluids (0.9% saline or RL at 38-42 °C)

Crystalloid

Indications: Volume replacement during rewarming of hypothermia
Adult dose: Boluses of 250-500 mL warmed to 38-42 °C as needed for hypotension during rewarming.
Preparation (India): Use a fluid warmer or warming cabinet.
Cautions: Rewarming causes vasodilation and hypotension (rewarming shock); give boluses with haemodynamic monitoring.

6 topics

Primary survey and massive transfusion

Chest and abdominal trauma

Burns: resuscitation and inhalation injury

Heat stroke

Drowning

Hypothermia and electrical injury

Drugs in this module

Module references (14)