9.6 Trauma, Burns, Supportive Care, and End-of-Life Pharmacotherapy

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1 Chapter 1: Pathophysiology and Recognition of Critical Illness

1.1 Pathophysiology of Shock and Sepsis 1.2 Respiratory Failure and ARDS Pathophysiology 1.3 ICU-Acquired Weakness and Post-Intensive Care Syndrome 1.4 Chronic Disease States and Risk Factors for Critical Illness

2 Chapter 2: Medical Devices and Circulatory Support

2.1 Hemodynamic Monitoring and Interpretation 2.2 Mechanical Circulatory Support 2.3 Mechanical Ventilation Modes and Settings 2.4 Continuous Renal Replacement Therapy 2.5 Lines, Tubes, and Drains in Critical Care

3 Chapter 3: Fluid, Electrolyte, and Acid-Base Management

3.1 Resuscitation Fluids: Crystalloids vs. Colloids 3.2 Electrolyte Disorders in the ICU 3.3 Acid-Base Disorders and Interpretation

4 Chapter 4: Vasoactive and Inotropic Therapy in Shock

4.1 Vasopressors in Distributive Shock 4.2 Inotropes and Vasopressors in Cardiogenic and Obstructive Shock

5 Chapter 5: Sedation, Analgesia, and Delirium (PADIS)

5.1 Pain and Analgesia in the ICU 5.2 Sedation Strategies and Medication Selection 5.3 Delirium Assessment, Prevention, and Treatment 5.4 Neuromuscular Blockade in Critical Illness

6 Chapter 6: Cardiovascular Emergencies

6.1 Acute Coronary Syndromes in ICU Patients 6.2 Acute Decompensated Heart Failure 6.3 Hypertensive Emergencies and Arrhythmias

7 Chapter 7: Pulmonary and Infectious Diseases in the ICU

7.1 Severe Sepsis and Septic Shock Antimicrobial Selection 7.2 Pharmacotherapy for Mechanical Ventilation and ARDS 7.3 Severe Infections in the ICU

8 Chapter 8: Neurocritical Care

8.1 Ischemic and Hemorrhagic Stroke Management 8.2 Intracranial Hypertension and Brain Edema 8.3 Status Epilepticus and Sedation in Brain Injury

9 Chapter 9: Toxicology, Endocrine, and Hematologic Emergencies

9.1 Toxicology and Antidote Therapy in the ICU 9.2 Endocrine Emergencies 9.3 Hematologic Emergencies, Anticoagulant Reversal, and Transfusions 9.4 Gastrointestinal and Hepatic Emergencies in the ICU 9.5 Dermatologic and Immunologic Conditions in the ICU 9.6 Trauma, Burns, Supportive Care, and End-of-Life Pharmacotherapy

10 Chapter 10: Special Populations, Pharmacokinetics, and Nutrition

10.1 Altered Pharmacokinetics in Critically Ill Patients 10.2 Therapeutic Drug Monitoring in the ICU 10.3 Nutrition Support: Enteral vs. Parenteral

11 Chapter 11: Quality, Safety, and Clinical Guidelines

11.1 Medication Safety and Error Prevention in the ICU 11.2 Antimicrobial Stewardship and Infection Prevention 11.3 Implementation of Clinical Practice Guidelines 11.4 Healthcare Regulations, Standards, and Drug Interactions

12 Chapter 12: Practice Management, Biostatistics, and Evidence-Based Medicine

12.1 ICU Formulary Management and Cost-Effectiveness 12.2 Biostatistics and Literature Evaluation 12.3 Clinical Trial Interpretation in Critical Care 12.4 Professional Development, Precepting, and ICU Pharmacy Services 12.5 Alternative ICU Delivery Models and Disaster Healthcare Management

13 Chapter 13: Treatment Planning and Care Coordination

13.1 Goals of Care, Perioperative Care, and Transitions of Care 13.2 Medication Delivery Routes and Devices in Critical Illness 13.3 Social Determinants of Health and Patient/Caregiver Education

9.6 Trauma, Burns, Supportive Care, and End-of-Life Pharmacotherapy

Key Takeaways Explain This Topic AI

Severe burns require the Parkland formula (4 mL x kg x %BSA lactated Ringer's in first 24h, half in first 8h) and aggressive pain control, with subsequent high-volume crystalloid needs driving renally-cleared antibiotic dosing (augmented renal clearance is common).

Trauma patients frequently develop augmented renal clearance (ARC), requiring higher doses of beta-lactams, vancomycin, and anticoagulants; massive transfusion mandates calcium replacement due to citrate-induced hypocalcemia.

Supportive ICU care includes DVT prophylaxis (LMWH preferred over UFH in trauma per EAST guidelines), stress ulcer prophylaxis in mechanically ventilated patients, and bowel regimen for opioid-induced constipation.

End-of-life pharmacotherapy prioritizes symptom control: opioid and benzodiazepine infusions for dyspnea and anxiety, anticholinergics for secretions, and palliative sedation with midazolam/propofol for refractory symptoms.

Last updated: October 2026

Trauma, Burns, Supportive Care, and End-of-Life Pharmacotherapy
Severe Burn Pharmacotherapy
Initial Resuscitation (Parkland Formula)

4 mL x kg x %BSA of lactated Ringer's in first 24 hours (from time of burn, not admission).

Half in first 8 hours post-burn; remainder over 16 hours.

Titrate to urine output 0.5-1.0 mL/kg/hour.

Brooke and modified Brooke formulas are alternatives; Parkland is most common in US practice.

Pharmacotherapy Considerations in Burns

Issue Implication

Augmented renal clearance (ARC) Burn hypermetabolism produces CrCl >130 mL/min; need higher doses of vancomycin (target AUC 400-600), beta-lactams (extended or continuous infusion), anticoagulants

Volume of distribution Massive fluid shifts increase Vd; initial loading doses often need to be 1.5-2x standard

Protein binding Hypoalbuminemia increases free fraction of highly-bound drugs; titrate to clinical effect
Escharotomy Compartment syndrome may require fasciotomy; analgesia with ketamine preferred
Inhalation injury High-dose heparin/N-acetylcysteine/bronchodilators nebulized; monitor for ARDS

Infection Burn wound sepsis: empiric antipseudomonal + anti-MRSA; topical silver sulfadiazine for partial-thickness (avoid if sulfonamide allergy)

Nutrition Early enteral feeding within 24h reduces infection; high protein (1.5-2 g/kg/day), high calorie needs

Trauma Pharmacotherapy
Massive Transfusion Protocol

1:1:1 ratio (PRBC:FFP:platelets) for trauma-induced coagulopathy.

Calcium replacement critical: each unit PRBC contains ~3 g citrate; ionized calcium drops precipitating hypotension, prolonged QT, coagulopathy. Replace with calcium gluconate 1-2 g IV q1-2h or calcium chloride 1 g IV (central line preferred) guided by ionized calcium.

TXA within 3 hours of injury (CRASH-2): 1 g IV bolus over 10 min, then 1 g IV over 8 hours. Beyond 3 hours, may increase mortality.

Reversal of anticoagulants per agent (see 9.3).

Trauma-Specific Pharmacotherapy

Pain: multimodal — acetaminophen, ketamine (sub-dissociative 0.1-0.3 mg/kg/hour for opioid-sparing), regional anesthesia, opioid sparing.

DVT prophylaxis: LMWH (enoxaparin 30 mg SC q12h or 40 mg daily) preferred over UFH in trauma (EAST practice guidelines); start within 24-72h if no contraindication. Considerate IVC filter only if anticoagulation contraindicated.

Stress ulcer prophylaxis: indicated if mechanical ventilation >48h or coagulopathy; pantoprazole 40 mg IV daily.

Antibiotic prophylaxis: not routine; single dose pre-operative for open fractures.

Traumatic Brain Injury Pharmacotherapy

Avoid hypotension (SBP <100 or MAP <65) and hypoxia.

Hyperosmolar therapy: mannitol 0.25-1 g/kg IV or 3% hypertonic saline 250 mL bolus for elevated ICP.

Propofol for sedation (preserves neuro exam, lowers ICP, but watch for PRIS).

Seizure prophylaxis (levetiracetam 1 g IV) for 7 days post-severe TBI with intracranial hemorrhage.

Avoid corticosteroids (worsen mortality in TBI per CRASH trial).

Supportive Care in the ICU
DVT Prophylaxis

Per PADIS and CHEST guidelines:

Medical ICU: enoxaparin 40 mg SC daily or UFH 5000 units SC q8-12h.

Surgical/trauma ICU: enoxaparin 30 mg SC q12h (start 24-72h post-op once hemostasis).

Renal dysfunction (CrCl <30): enoxaparin 30 mg SC daily or UFH, dalteparin 5000 IU daily; avoid fondaparinux; DOACs contraindicated.

Mechanical prophylaxis (SCDs) as adjunct; not monotherapy.

Stress Ulcer Prophylaxis

Indicated for: mechanical ventilation >48h, coagulopathy, major burns (>35% BSA), traumatic brain injury, major trauma with spinal cord injury, history of GI bleed within 1 year.

Pantoprazole 40 mg IV daily preferred; H2 blockers alternative.

Discontinue when ICU risk factors resolve.

Bowel Regimen

Opioid-induced constipation is universal:

Scheduled stimulant (senna); adding docusate offers no further benefit.

Osmotic laxative (PEG, lactulose) for constipation.

Methylnaltrexone 8-12 mg SC q48h for refractory opioid-induced constipation (does not cross blood-brain barrier, no analgesia reversal).

Naloxegol 12.5-25 mg PO daily alternative.

End-of-Life Pharmacotherapy (Palliative Care in ICU)
Symptom-Based Approach

Symptom First-Line

Pain Morphine 1-5 mg IV q1h or continuous infusion 0.5-2 mg/hour; hydromorphone 0.2-1 mg q2h if renal dysfunction

Dyspnea Low-dose opioid (morphine 2-5 mg IV PRN or infusion); benzodiazepines for anxiety
Anxiety/agitation Lorazepam 0.5-2 mg IV q1h PRN; midazolam infusion 1-5 mg/hour for palliative sedation
Delirium Haloperidol 0.5-2 mg IV q1h PRN; avoid benzodiazepines unless alcohol withdrawal

Secretions (death rattle) Glycopyrrolate 0.2 mg IV q4-6h or scopolamine patch 1 mg/72h; hyoscine butylbromide alternative

Nausea Haloperidol 0.5-2 mg IV q8h; ondansetron 4 mg IV q8h; metoclopramide 5-10 mg IV q6h (avoid if bowel obstruction)

Palliative Sedation

For refractory symptoms in actively dying patients:

Midazolam infusion 1-10 mg/hour titrated to comfort.

Propofol infusion 10-50 mcg/kg/min as alternative.

Ethical principles: proportional sedation, informed consent, team agreement, family discussion.

Goals of Care and Caregiver Education

Family meetings within 72h of ICU admission improve outcomes and reduce non-beneficial treatment.

Pharmacist role: deprescribe unnecessary medications (statins, antihypertensives, antibiotics) when prognosis <2 weeks.

Caregiver education for terminal discharge includes home opioid administration, sublingual routes, anticipatory prescribing.

Clinical Scenario

A 25-year-old with 50% BSA burns develops febrile septic shock on day 4. He has CrCl 175 mL/min by 8-hour measured urine creatinine. Vancomycin and piperacillin-tazobactam are ordered. How should dosing be adjusted, and what is the monitoring strategy?

Answer: This patient has augmented renal clearance (ARC) from burn hypermetabolism. Standard vancomycin and beta-lactam doses will fail PD targets. Use extended-infusion piperacillin-tazobactam 4.5 g q6h over 4 hours and vancomycin 25-30 mg/kg load then 1.5-2 g q8-12h targeting AUC 400-600 with Bayesian or peak-trough monitoring. Consider continuous infusion beta-lactam in severe ARC. Re-dose after CRRT if initiated, accounting for circuit clearance.