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318
O. R. Pulido and T. Egodage
in a trauma patient. Obstructive shock in chest trauma
may kill someone very quickly and should also be recognized. Adequate exposure to this type of injury is imperative. Most importantly, ensure you have not missed injury
by using the ATLS algorithm. This will help you to identify concomitant injuries aside from your prior presentation. DO NOT get caught taking an unstable patient to
CT scan.
Bonus Points
• Resuscitate patients prior to intubation (induction may
cause circulatory collapse).
• The true indication for a FAST exam is in patients who
are hemodynamically unstable and have a blunt
mechanism.
• Subclavian exposure can be seen via clamshell
thoracotomy.
Words ofWisdom
Prior knowledge of the anatomy of the chest is imperative to
dealing with thoracic trauma successfully. The ASSET
course is a great tool for surgeons wishing to maintain their
skills of subclavian and thoracic exposure.
Ensure that patients are resuscitated when considering
intubation, or intubate intraoperatively with the patient
prepared.
Bibliography
Demetrides D, Zakaluzny S.Emergency room resuscitative thoracot-
omy. In: Demetriades D, Inaba K, Velmahos G, editors. Atlas of sur-
gical techniques in trauma. Cambridge: University Printing House;
2015. p.50–69.
Ghanta R, Wall M Jr, Mattox K.Trauma thoracotomy: principles and
techniques. In: Feliciano D, Mattox K, Moore E, editors. Trauma.
9th ed. NewYork: McGraw Hill; 2021. p.561–6.
Slater LA, Garcia LJ, Cartolano T, Velopulos CG, Farnejad F, Haut
ER. Trauma critical care. In: Neff MA, editor. Passing the gen-
eral surgeon oral board exam. 2nd ed. NewYork: Springer; 2014.
p.129–31.
The SCORE Portal [Internet]. https://www.surgicalcore.org.
Coagulopathy ofTrauma
VictoriaSharp andAnnHutchison
97
Concept
Most questions will start with the initial assessment of a
trauma patient that requires operative intervention. Be prepared to discuss the initial assessment and management of a
trauma patient prior to moving into the details of coagulopathy. Coagulopathy of trauma is thought to have four main
components. First, trauma-induced coagulopathy is impairment of hemostasis and early brinolysis activation after
injury prior to the onset of the subsequent three components.
The remaining factors are acidosis, hypothermia, and
hemodilution.
Acidosis is secondary to inadequate tissue perfusion (lactic acidosis) leading to clotting dysfunction at a pH <7.2.
This is exacerbated by iatrogenic coagulopathy induced by
large volumes of crystalloid (excess chloride) and unbalanced component transfusion. Finally, hypothermia occurs
with exposure at the time of injury, transport, initial assessment, and can be worsened by administration of cold uids
or blood products. The effect of hypothermia on hemostasis
manifests as platelet dysfunction and impaired enzymatic
function.
Resuscitation can be guided by thromboelastography
(TEG). TEG allows for real-time assessment of clot strength
in whole blood through clot formation, propagation, stabilization, and dissolution. The various measurements allow for
guided resuscitation to correct coagulopathy. Delayed initial
formation of clot (prolonged R time) indicates a deciency
of coagulation factors and is managed with the administration of FFP. Prolonged time until the clot reaches a xed
strength (K time) and decreased speed of brin accumulation
(Alpha angle) both indicate a lack of brinogen and are
treated with Cryoprecipitate. A decreased maximum ampli-
V. Sharp
Acute Care Surgery, Ypsilanti, MI, USA
e-mail: Victoria_sharp@ihacares.com
A. Hutchison (
Surgical Critical Care, Little Rock, AR, USA
*)
tude (MA) indicates decreased clot strength and is managed
with platelet transfusion. Lastly, excess brinolysis is demonstrated by an increased lysis at 30 min (LY30) and is
treated with tranexamic acid.
Way Question May BeAsked?
“A 65-year-old female presents to the emergency department
as a Level 1 trauma after a motor vehicle collision. Primary
survey is notable for an intact airway, bilateral breath sounds,
and hypotension with palpable femoral pulses. Adjuncts to
the primary survey are notable for a positive FAST exam in
the LUQ and given persistent hypotension the decision is
made to proceed to the operating room. The abdomen is
opened, packed, and splenectomy is performed as well as
splenic exure colon resection for a perforation. During continued resuscitation you note the blood appears thin and is
not forming clot well. You place an ABThera to allow a second look and further operative management.”
How toAnswer?
History
• Obtain prehospital history from EMS including accident
details, prehospital interventions, and any known patient
history, specically any anticoagulant use or history of
bleeding disorders.
Physical Examination
• Conduct the primary survey (ABCDEs) including vital
signs.
• Be prepared to discuss adjuncts to the primary survey
including FAST exam.
• Perform a secondary survey when appropriate.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_97
319
320
V. Sharp and A. Hutchison
Diagnostic Tests
• Chest X-ray, Pelvic X-ray, eFAST.
• Laboratory tests including CBC, PT/INR, PTT, brinogen, type and screen, arterial blood gas, viscoelastic
hemostatic arrays (TEG and ROTEM).
Treatment
• Damage control surgery with control of anatomic
hemorrhage.
• Correcting acidosis by treating the underlying shock with
hemorrhage control and blood product
• Resuscitation.
• Avoiding iatrogenic coagulopathy by avoiding excess
crystalloid administration and focusing on balanced
resuscitation with red blood cells, plasma, and platelet
transfusion in a 1:1:1 fashion.
• Avoiding and correcting hypothermia with warm blankets, forced air warmers, uid, and blood product warming prior to transfusion.
Common Curveballs
• Delayed evidence of coagulopathy after arriving at the
ICU.
• Transient responder to crystalloid/blood that may allow
for CT scan evaluation.
• Persistent hypotension in the trauma bay with negative
FAST exam.
• Specic anticoagulant use reported by EMS and its reversal agent of choice.
Clean Kills
• Failure to recognize the need for surgical control of
bleeding.
• Failure to recognize the progression of coagulopathy in
the operating room.
• Failure to correct hypothermia.
• Using crystalloid alone for volume resuscitation.
• Using nonbalanced resuscitation for product
administration.
• Proceeding to CT scan with an unstable patient.
Summary
Trauma remains a leading cause of death in the adult
population and trauma cases are frequently complicated
by coagulopathy. Patients with coagulopathy have a
three- to four-fold greater mortality and are eight times
more likely to die within the rst 24h after injury. It is
critical to recognize this phenomenon and employ measures to prevent the progression early on. This includes
immediately warming trauma patients, correcting acidosis, avoiding excess crystalloid, and ensuring balanced
resuscitation with blood product administration.
Bibliography
Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopa-
thy. J Trauma. 2003;54(6):1127–30. https://doi.org/10.1097/01.
TA.0000069184.82147.06.
Chang R, Cardenas JC, Wade CE, Holcomb JB. Advances
in the understanding of trauma-induced coagulopathy. Blood. 2016;128(8):1043–9. https://doi.org/10.1182/
blood- 2016- 01- 636423.
Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y,
Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, Hoyt DB,
Bouillon B. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008;65(4):748–54. https://doi.org/10.1097/
TA.0b013e3181877a9c.
Hirshberg A, Dugas M, Banez EI, Scott BG, Wall MJ Jr, Mattox
KL. Minimizing dilutional coagulopathy in exsanguinating hemorrhage: a computer simulation. J Trauma. 2003;54(3):454–63.
https://doi.org/10.1097/01.TA.0000053245.08642.1F.
Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA,
Schreiber MA, Gonzalez EA, Pomper GJ, Perkins JG, Spinella PC,
Williams KL, Park MS.Increased plasma and platelet to red blood
cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248(3):447–58. https://doi.
org/10.1097/SLA.0b013e318185a9ad.
MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M.Early coag-
ulopathy predicts mortality in trauma. J Trauma. 2003;55(1):39–44.
https://doi.org/10.1097/01.TA.0000075338.21177.EF.
Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T,
Simanski C, Neugebauer E, Bouillon B, AG Polytrauma of the
German Trauma Society (DGU). Early coagulopathy in multiple injury: an analysis from the German trauma registry on 8724
patients. Injury. 2007;38(3):298–304. https://doi.org/10.1016/j.
injury.2006.10.003.
Whiting D, DiNardo JA. TEG and ROTEM: technology and clini-
cal applications. Am J Hematol. 2014;89(2):228–32. https://doi.
org/10.1002/ajh.23599.
Damage Control Surgery
ClaireLe Guen andChristinaL.Jacovides
98
Concept
You will likely be asked to run through a trauma scenario,
which results in a patient arriving in the operating room and
undergoing a surgical procedure during which they become
coagulopathic, acidotic, or cold prior to denitive repair.
Alternative scenarios could present as unstable blunt abdominal trauma with a positive focused assessment with sonography for trauma (FAST) exam, or even elective surgery with
unexpected hemorrhagic complications. It is less wellestablished to perform damage control surgery in the setting
of emergency general abdominal surgery in the absence of
hemorrhage, but this also may present in an emergency general surgery case.
Way Question May BeAsked?
A 30-year-old man presents to the emergency department
following a single gunshot wound to the abdomen.
You run through the case and the following scenario
unfolds:
The patient’s airway is intact, and he has bilateral breath
sounds. His pulses are intact, but he is hypotensive (70/40)
and tachycardic (140). You obtain two large-bore IVs and
activate a massive transfusion protocol. The patient’s
Glasgow Coma Scale (GCS) is 15, and he is moving all four
extremities. You identify a bullet wound in the right upper
quadrant and the patient is peritonitic. Chest X-ray (CXR) is
clear. Abdominal X-ray (AXR) demonstrates a retained foreign body in the left lower quadrant. The FAST exam is posi-
C. Le Guen
Department of Surgery, Temple University Hospital,
Philadelphia, PA, USA
e-mail: Claire.LeGuen@tuhs.temple.edu
C. L. Jacovides (
Division of Trauma, Surgical Critical Care, and Burn Surgery,
Department of Surgery, Temple University Hospital,
Philadelphia, PA, USA
e-mail: christina.jacovides@tuhs.temple.edu
*)
tive. The patient is transported to the operating room for
emergency laparotomy. In the operating room, he is intubated and you perform an exploratory laparotomy. There is
evidence of hemoperitoneum, and all four quadrants are
packed. You explore the zones of the retroperitoneum and
identify an inframesocolic Zone 1 hematoma extending
toward Zone 2 on the right but no Zone 3 hematoma. You
identify a liver laceration which you pack. You perform a
right medial visceral rotation (Cattell Braasch maneuver)
and expose the inferior vena cava and right renal hilum.
There is a destructive injury to the right renal hilum with
active hemorrhage. You perform a right nephrectomy. You
run the bowel and identify multiple small bowel injuries
clustered in two segments of small bowel. You resect them.
You identify a destructive injury to the proximal hepatic exure and perform a right hemicolectomy.
The patient begins to ooze from all raw surfaces and your
anesthesiologist comments that the patient’s pH is 7.15 and
his temperature is 32°C. What is your next step?
How toAnswer?
Initial Evaluation
As described above, in a trauma scenario, always begin with
Advanced Trauma Life Support (ATLS) algorithms (Merrick
2018)
(a) Airway—Is the patient protecting their airway? If not,
consider intubation but remember that this may precipitate cardiovascular collapse in a patient in hemorrhagic
shock.
(b) Breathing—Does the patient have bilateral breath
sounds and lung sliding on extended FAST (eFAST)? If
not, consider tube thoracostomy to evacuate hemothorax
or pneumothorax.
(c) Circulation—Does the patient have pulses? What is their
heart rate and blood pressure? Obtain adequate vascular
access with a minimum of two large-bore IVs for vol-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_98
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322
C. Le Guen and C. L. Jacovides
ume resuscitation. Consider emergency central access
placement, as well as intraosseous lines for patients with
difcult access, not uncommon in the intravascularly
depleted patient in hemorrhagic shock.
(d) Disability—What is the patient’s GCS score? Patients
who are in shock or hypoxic often present with agitation,
combativeness, or with a depressed GCS score.
(e) Exposure—Does the patient have external signs of
trauma? Fully expose the patient to identify all external
signs of trauma.
Early Decision-Making
• Massive transfusion should begin in the trauma bay for
patients in hemorrhagic shock, allowing for permissive
hypotension, maintaining balanced blood product resuscitation, and limiting crystalloid administration.
• Patients who remain hemodynamically unstable and have
thoracic or abdominal penetrating or blunt trauma require
operative intervention.
• Consider early in the course of your treatment whether
the patient would benet from a damage control procedure: (Liao etal. 2020; Shapiro etal. 2000)
– Physiologic Reasons
Hypothermia (temperature<35°C)
Acidosis (pH < 7.20, base decit > 8)
Coagulopathy
Sustained hypotension or pressor requirement
– Injury Patterns (not exhaustive):
Multi Compartment injury
Inaccessible major venous injuries
Vascular injuries with concomitant visceral
injuries
Complex injuries requiring protracted procedures
(i.e., hepatobiliary or pancreaticoduodenal
injuries)
Multisystem trauma requiring staged procedures/
prioritization from multiple different specialties or
with extra-abdominal life-threatening injuries
Need for reassessment of intra-abdominal contents
Inability to bring the fascia together due to visceral
edema
Patients with limited physiologic reserve (e.g., geriatric patients)
Patients with injuries that require care beyond the
capabilities of the treating facility
Intraoperative Considerations toMinimize
theNeed forDamage Control
• Prevent hypothermia with forced-air heating devices,
warm blankets, warmed uid/blood products, and warmed
supplemental oxygen.
• If the patient is requiring massive transfusion, maintain as
close to a 1:1:1 ratio of red blood cells (RBC), fresh frozen plasma (FFP), and platelets as feasible (Holcomb
etal. 2015)
• Consider using tranexamic acid (TXA) (CRASH-2 Trial
Collaborators etal. 2010) or prothrombin complex concentrate (PCC) (although a recent trial suggested this
may be associated with increased risk for thromboembolic disease without a signicant reduction in transfusion requirement) (Bouzat etal. 2023; Tanaka etal. 2021;
Zeeshan et al. 2019) in a patient requiring massive
transfusion.
Damage Control Surgery
Initial Phase
Damage control surgery should be considered for a patient
who is unstable due to signicant blood loss. Its major goal
is to control life-threatening hemorrhage, minimize contamination, and stabilize the patient sufciently to allow for
transfer to the intensive care unit (ICU) for additional resuscitation. Once the patient’s tissue perfusion has improved,
they can be brought back to the operating room for denitive
treatment.
The major techniques used in damage control surgery are
as follows:
• For major arterial injuries in an unstable patient, consider
shunting over denitive repair (Tung etal. 2021; Feliciano
and Subramanian 2013)
• For major venous injuries in an unstable patient, consider
ligation over denitive repair (Savage and Fabian 2016)
– Most veins can be ligated, including the iliac veins and
left renal vein.
– Ligation of the infrarenal inferior vena cava (IVC) is
well-described. Ligation of the suprarenal IVC is possible but poorly tolerated in the absence of existing
collateral circulation. Ligation of the IVC above the
liver is typically fatal.
– Additionally, ligation of the portal vein, superior mes-
enteric vein, and right renal vein are similarly poorly
tolerated.
• For solid organ injuries or pelvic bleeding, consider packing for hemostasis with consideration for postoperative
endovascular embolization or planned second-look laparotomy after resuscitation and stabilization of coagulopathy in the ICU.
• For hollow viscus injuries, consider temporary closure of
the organ versus limited resection to prevent contamination. In the setting of damage control, it is acceptable to
leave the patient in discontinuity rather than to perform a
denitive repair at the index operation.
98 Damage Control Surgery
323
• For complex biliary and pancreatic injuries, drain the
injury widely and plan to reevaluate once the patient is
otherwise stabilized.
• Perform temporary abdominal closure, typically with
vacuum dressing or other dressing that minimizes injury
to or exposure of the underlying viscera, sometimes with
temporary skin closure.
• Communicate closely with the anesthesia team throughout
the procedure so that you remain aware of signicant physiologic derangements. This will allow you to tailor the
extent of the operation according to the patient’s stability
(e.g., transition from a plan to denitively repair injuries to
a plan for damage control and ICU resuscitation).
Resuscitative Phase
• Patients who are coagulopathic, cold, and acidotic, in
whom surgical bleeding and contamination have been
controlled and there is no immediate indication for
another operative intervention, should go to the ICU for
resuscitation.
• If another procedure is required, this should be done
promptly.
• The goal of this phase is the normalization of tissue perfusion. Correct hypothermia, coagulopathy, and acidosis.
Resuscitate judiciously to avoid volume overload. Utilize
lung-protective ventilation with judicious volume resuscitation to minimize the risk of resuscitation-related lung
injury (Liao etal. 2020)
Denitive Repair Phase
• Once the patient’s physiology normalizes, plan to return
to the operating room for denitive repair of injuries.
• Attempt to close the fascia primarily if possible. This may
not be feasible due to swelling of the abdominal compartments and loss of domain. Your options at this point are:
– to attempt partial closure, return to the ICU, and plan
to return to the operating room (OR) later to reattempt
fascial closure or
– to secure an interposition mesh to the fascial edges to
close the abdomen and prevent evisceration. Over
time, granulation tissue will form over this mesh, and
a skin graft can be placed. Abdominal wall reconstruction may be performed later.
Common Curveballs
• Vascular surgery is unavailable for repair of a major vascular injury—know how/when to shunt.
• A major vein is injured—know when it is reasonable to
ligate a venous injury.
• Patient has a major injury to the head of the pancreas—
drain the injury and plan to return after full diagnostic
evaluation and ideally with input from hepatobiliary specialists. It is rarely indicated to perform an index pancreaticoduodenectomy in a trauma patient.
Clean Kills
• Not following ABCs in trauma bay.
• Not verbalizing steps of resuscitation (establishing IV
access, calling for blood).
• Not obtaining adjuncts in the trauma bay (FAST, CXR).
• Obtaining a CT scan in a hemodynamically unstable
patient or a patient with a clear indication for operative
intervention.
• Ignoring signs of coagulopathy, acidosis, and hypothermia and proceeding with denitive repair of complex
injuries requiring long procedure times.
Bonus Points
• Recognize when the scenario involves a patient whose
injury complex is too signicant to allow for denitive
repair at the index operation and consider the option for
damage control surgery early in the operative course.
• Ask for adjuncts to transfusion alongside your massive
transfusion protocol—e.g., TXA±PCC in patients requiring large volume transfusions.
• While in the OR, comment on how you will maintain
close lines of communication with the anesthesia team,
specically focusing on ongoing transfusion requirements, patient temperature, and physiologic derangements such as acid-base imbalance.
Words ofWisdom
• Patients may still develop abdominal compartment syndrome with an open abdomen.
• Damage control surgery is typically described as it
relates to abdominal injury, but it may also be used in any
patient with the indications listed above, regardless of the
site of injury; after the abdomen, it is most commonly
discussed in the context of thoracic injury (Rotondo and
Bard 2004)
• Communication is critical in damage control surgery.
Involve the anesthesia team, the OR nursing staff, the
ICU team, and any specialists in discussion of the
patient’s course. If the surgeon completes a rapid damage
control surgery but waits for an ICU bed for an hour,
some of the benets of rapid operative intervention have
been lost.
324
C. Le Guen and C. L. Jacovides
Summary
In the unstable patient, damage control surgery enables
swift control of hemorrhage and contamination to allow
for continued resuscitation and stabilization in the
ICU. Early recognition of patients that would benet
from an abbreviated surgery with temporary closure is
key to avoiding severe acidotic, hypothermic, and coagulopathic states from which patients cannot recover.
Bibliography
Bouzat P, Charbit J, Abback PS, Huet-Garrigue D, Delhaye N, Leone
M, et al. Efcacy and safety of early administration of 4-factor
prothrombin complex concentrate in patients with trauma at risk
of massive transfusion: the PROCOAG randomized clinical trial.
JAMA. 2023;329(16):1367–75.
CRASH-2 Trial Collaborators, Shakur H, Roberts I, Bautista R,
Caballero J, Coats T, et al. Effects of tranexamic acid on death,
vascular occlusive events, and blood transfusion in trauma patients
with signicant haemorrhage (CRASH-2): a randomised, placebocontrolled trial. Lancet. 2010;376(9734):23–32.
Feliciano DV, Subramanian A. Temporary vascular shunts. Eur J
Trauma Emerg Surg. 2013;39(6):553–60.
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski
JM, et al. Transfusion of plasma, platelets, and red blood
cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with
severe trauma: the PROPPR randomized clinical trial. JAMA.
2015;313(5):471–82.
Liao L, Eastridge BJ, Rotondo M.Damage control surgery. In: Peitzman
AB, Yealy DM, Fabian TC, Schwab CW, Guyette FX, Seamon MJ,
etal., editors. The trauma manual: trauma and acute care surgery.
5th ed. Philadelphia: Wolters Kluwer; 2020. p.57–63.
Merrick C, editor. American College of Surgeons Committee on
Trauma. Advanced trauma life support (ATLS), 10th ed. American
College of Surgeons; 2018.
Rotondo MF, Bard MR.Damage control surgery for thoracic injuries.
Injury. 2004;35(7):649–54.
Savage SA, Fabian TC.Chapter 12—Inferior vena cava, portal, and
mesenteric venous systems. In: Rasmussen TE, Tai NRM, editors.
Rich’s vascular trauma [Internet], 3rd ed. Philadelphia: Elsevier;
2016 [cited 2023 Oct 11]. p. 126–38. https://www.sciencedirect.
com/science/article/pii/B9781455712618000126.
Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF.Damage control:
collective review. J Trauma. 2000;49(5):969–78.
Tanaka KA, Shettar S, Vandyck K, Shea SM, Abuelkasem E.Roles of
four-factor prothrombin complex concentrate in the management of
critical bleeding. Transfus Med Rev. 2021;35(4):96–103.
Tung L, Leonard J, Lawless RA, Cralley A, Betzold R, Pasley JD, etal.
Temporary intravascular shunts after civilian arterial injury: a prospective multicenter Eastern Association for the Surgery of Trauma
study. Injury. 2021;52(5):1204–9.
Zeeshan M, Hamidi M, Kulvatunyou N, Jehan F, O’Keeffe T, Khan M,
etal. 3-factor versus 4-factor PCC in coagulopathy of trauma: four
is better than three. Shock. 2019;52(1):23–8.
Burns
TheresaL.Chin, WendyY.Rockne, andMalloryJebbia
99
Concept
Similar to trauma resuscitation, begin with the primary and
secondary survey in a burn resuscitation as per Advanced
Trauma Life Support (ATLS). Burn resuscitation is managed
with higher hourly intravenous uid rates rather than uid
boluses. A hypotensive burn patient usually needs additional
intravascular uids; however, other causes of hypotension
should be ruled out, including other causes of trauma and
shock. The scenario may include burn resuscitation, surgical
management of the burn injury, possibly including escharotomy or fasciotomy, management of inhalation injury and
acute respiratory distress syndrome, or burn sepsis.
Way theQuestion May BeAsked
“A 55-year-old female was cooking when the stove burst into
ames and the rest of the kitchen caught on re. She was
unable to leave the house until she was rescued by reghters 20 mins later. Per the medics, she was given oxygen en
route but she was awake and talking. She has burns to the
face, chest, bilateral arms, and legs. Her vital signs are BP
110/85, P 100, O2 sat 94% on NRB.She has one 18 gauge IV
in her left AC”.
How toAnswer
Start with Primary Survey as per ATLS (ABCs) and then
move to secondary survey. Be cognizant for signs of respiratory distress and intubate early for respiratory distress
T. L. Chin (*) · W. Y. Rockne · M. Jebbia
Division of Trauma, Burns and Surgical Critical Care, Department
of Surgery, University of California Irvine Medical Center,
Orange, CA, USA
e-mail: chintl1@hs.uci.edu; Wendy.Y.Rockne@uth.tmc.edu;
mjebbia@hs.uci.edu
(tachypnea, hoarseness, difculty breathing) as the vocal
cords can swell. If you cannot intubate, perform a surgical
airway.
History
• Potential and duration of closed space smoke exposure
(concern for inhalation injury).
• Details of the mechanism to determine if there may be
additional traumatic injuries such as blast injury or fall
from height.
• Past medical history (Note pulmonary, cardiac, and renal
history)
Physical Exam
• Airway: Ensure the patient can talk without hoarseness.
• Breathing: Place the patient on 100% oxygen (to treat
potential carbon monoxide and cyanide toxicity). Evaluate
for breath sounds. Place chest tube if there is concern for
pneumothorax from trauma.
• Circulation: Obtain intravenous or intraosseous access.
• Disability: Assess their mental status and Glasgow Coma
Scale (GCS) especially prior to intubation.
• Exposure: Identify areas of burns and other signs of
trauma.
• Secondary survey: Estimate severity/depth of burns and
Total Body Surface Area (TBSA). The rule of nines will
allow for a fast estimation. (Rule of nines picture for
TBSA estimation). Include only partial and full thickness
burns (Fig.99.1).
• Start uid resuscitation with Lactated Ringers using
2–4cc/kg/TBSA.LR is preferred over normal saline (NS)
because large volumes of NS can lead to a hyperchloremic metabolic acidosis (Table99.1).
• For pediatric patients, add maintenance IV uid with dextrose since children have less glycogen stores and are vulnerable to develop hypoglycemia.
• Place Foley catheter and monitor urine output.
• Neurovascular exam and monitoring for distal perfusion
of extremities, especially in circumferential burns.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_99
325
326
Fig. 99.1 Rule of nines for
TBSA estimation
T. L. Chin et al.
Table 99.1 Lactated Ringers resuscitation uid rate calculation
Lactate Ringers resuscitation uid rate calculation
X=2–4mL/kg/%TBSA for estimated uid needs in the rst 24h
Y=X/2 for estimated uid needs in rst 8h
Z=Y/8 for estimated uid needs in the rst hour and the starting
hourly uid rate
Diagnostic Tests
• Carboxyhemoglobin (evaluate for carbon monoxide toxicity, but do not wait for the result to start oxygen therapy)
• CBC (patient may be hemoconcentrated from third spacing of uid)
• BMP (evaluate for acute kidney injury) or any other electrolyte derangements
• Lactic acidosis/base decit (should be overall improving
during your resuscitation)
• Possible bronchoscopy to evaluate severity of inhalation
injury, if suspected
Treatment
• Fluid resuscitation with hourly adjustments based on urineoutput (UOP) of about 1 cc/kg/h for pediatrics and
30–50cc/h (0.5cc/kg/h) for adults.
• Mechanical ventilation and oxygen support; consider
hydroxocobalamin for cyanide toxicity if there is concern
for prolonged smoke exposure/inhalation injury or concomitant carbon monoxide toxicity.
• Coverage of burns with clean dry sheet until a topical
antimicrobial can be applied.
• Consider early excision of burn to reduce inammatory
response to burn injury.
• Maintain normothermia.
• Elevate extremities to reduce swelling. Consider
escharotomies.
Curveballs
• Be cognizant of signs of respiratory distress in your primary survey and intubate early for respiratory distress
(tachypnea, hoarseness, difculty breathing) as the vocal
cords can swell. If you cannot intubate, perform a surgical
airway.
• If you lose distal pulses or the patient develops paresthesias, evaluate the need for escharotomy or fasciotomy.
• If the patient develops hypotension during resuscitation,
consider additional traumatic injuries. Reassess the primary and secondary surveys to methodically identify and
treat additional injuries. Also, consider over-resuscitation
and abdominal compartment syndrome indicating the
need for decompressive laparotomy
• If urine output drops, consider increasing intravenous
uid rate, continuous renal replacement therapy to remove
inammatory mediators, and/or removal of burn eschar to
reduce inammatory burden.
• If an electrical burn/injury, consider evaluating for rhabdomyolysis and need for additional uid resuscitation. or
higher UOP.
99 Burns
327
Clean Kills
• Not addressing primary survey (airway, breathing, and
circulation) before burn size and severity estimation.
• Not starting uid resuscitation.
• Not starting oxygen therapy in someone with a ame burn
or smoke exposure (potential carbon monoxide or cyanide toxicity).
Bibliography
Advanced burn life support manual 2023. American Burn Association;
2023.
Pham TN, Cancio LC, Gibran NS, American Burn Association
practice guidelines burn shock resuscitation. J Burn
Care Res. 2008;29(1):257–66. https://doi.org/10.1097/
BCR.0b013e31815f3876.