Inhalation injury can occur when the respiratory tract suffers direct damage from heat or smoke, or when a patient develops systemic pathology following inhalation of toxins. This module covers the assessment and management of upper and lower airway inhalation injury and subsequent complications. It also addresses the clinical consequences of inhaled toxins and their specific management.

As the largest organ in the body, the skin is vitally important to maintaining homeostasis. Skin loss due to burn injury therefore gives rise to a host of systemic sequelae. In this module, we discuss the acute physiological disturbances that follow burn injury and require judicious organ support within the intensive care unit. We also consider common complications, which occur across multiple systems and timeframes of hours to years.

Burn injuries are a major cause of morbidity and mortality globally and can lead to significant physio-logical insult and organ dysfunction. In addition to describing the epidemiology of burns injuries, this module provides an overview of the pathophysiology of burns, an approach to the initial assessment and management of the patient with burn injury. A burn injury should be described in terms of the depth of injury (superficial, dermal or full thickness) and the size of the injured area expressed as a percentage of the total body surface area affected. In addition, initial assessment should include a comprehensive ABCDE approach, as these patients often have disturbances to physiology and co-existing pathology. Special consideration should be given to circumferential burns (of either digits, limb or torso) as these injuries may require decompressive escharotomy. Early fluid resuscitation is imperative to counteract the fluid losses and shifts experienced following burn injury and is most commonly determined using the Parklands formula.

During the acute early phase, trauma care is particularly challenging and requires a structured approach. The Advanced Trauma Life Support (ATLS) programme is the most widely used trauma course worldwide. It was established under the initiative of James Styner, an orthopaedic surgeon, after a tragic plane crash devastated his family. He was horrified by the treatment his family received at a local hospital in rural Nebraska. Together with several colleagues and university endorsement, he founded the ATLS course which was held for the first time in 1978 in Auburn, Nebraska. As international reference for trauma actors around the globe, ATLS allows to speak the same language, and to structure trauma care in different environments with different organisations.

In severely injured trauma patients, several cells (endothelial and macrophages mainly) are damaged and activated by massive tissue disruption and microcirculatory hypoperfusion. This leads to the release of “alarm” molecules named “alarmins” or DAMPs (Damage or Danger Associated Molecular Patterns). Like PAMPs (Pathogen Associated Molecular Patterns), molecules are released after pathogen attacks. Several of these molecules are passively released from dying cells; others are actively secreted. Similar proteins will be released after a cellular injury during bacterial infection or traumatic injury because the genetic background of the bacteria and the cells’ mitochondria involved in the injury response is very similar. An insult triggers the release of PAMPs and/or DAMPs. 

Pulmonary contusion is present when a direct pulmonary injury is generating hypoxemia through the formation of a pulmonary shunt. Injury to the lung parenchyma results in alveolo-capillary rupture, bleeding, secretions and cellular debris, leading to inadequate ventilation in the injured areas. This is followed by a two-stage evolution with a primitive injury and a gradual worsening in the first 48 hours.

In hospital, the primary survey is a structured clinical and ultra-sonographic examination aiming at identifying acute life-threatening injuries that require immediate resuscitation, and constructing a therapeutic and diagnostic sequence. This phase has to follow a protocol known by all team members. It must be simple but systematic to avoid missing injuries, from head to toe, targeting A/B, C, D, E assessments (see below). Whenever an A/B, C, D, E pathology is identified, a corresponding intervention is carried out without delay. It is crucial for the success of resuscitation, that the team performs primary survey and immediate interventions simultaneously without losing structure and focus, and with no delay to assess and address other vital problems. An intrahospital trauma team is able to manage several problems simultaneously.

Trauma affects productive members of society, often leading to long-term disability and dependency in survivors. Every year more than five million people die worldwide due to traumatic events. In USA, unintentional injury caused 200,955 deaths, being the fourth cause of mortality after heart disease, cancer, and COVID-19. According to WHO, road traffic accidents are the leading cause of death for people aged 15–29, and the seventh cause of disability. Almost 60% of road traffic deaths are among people aged 15–44. Half of the world’s road traffic deaths occur among motorcyclists (23%), pedestrians (22%) and cyclists (4%).

Poisoning episodes may be classified as:

• Accidental (unintentional)
  
• Intentional
  
• Homicidal